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What Is Nursing Theory?

3 min read • July, 05 2023

Nursing theories provide a foundation for clinical decision-making. These theoretical models in nursing shape nursing research and create conceptual blueprints, ultimately determining the how and why that drive nurse-patient interactions.

Nurse researchers and scholars naturally develop these theories with the input and influence of other professionals in the field.

Why Is Nursing Theory Important?

Nursing theory concepts are essential to the present and future of the profession. The first nursing theory — Florence Nightingale's Environmental Theory — dates back to the 19th century. Nightingale identified a clear link between a patient's environment (such as clean water, sunlight, and fresh air) and their ability to recover. Her discoveries remain relevant for today's practitioners. As health care continues to develop, new types of nursing theories may evolve to reflect new medicines and technologies.

Education and training showcase the importance of nursing theory. Nurse researchers and scholars share established ideas to ensure industry-wide best practices and patient outcomes, and nurse educators shape their curricula based on this research. When nurses learn these theories, they gain the data to explain the reasoning behind their clinical decision-making. Nurses position themselves to provide the best care by familiarizing themselves with time-tested theories. Recognizing their place in the history of nursing provides a validating sense of belonging within the greater health care system. That helps patients and other health care providers better understand and appreciate nurses’ contributions.

Types of Nursing Theories

Nursing theories fall under three tiers: grand nursing, middle-range, and practical-level theories . Inherent to each is the nursing metaparadigm , which focuses on four components:

• The person (sometimes referred to as the patient or client)
• Their environment (physical and emotional)
• Their health while receiving treatment
• The nurse's approach and attributes

Each of these four elements factors into a specific nursing theory.

Grand Nursing Theories

Grand theories are the broadest of the three theory classifications. They offer wide-ranging perspectives focused on abstract concepts, often stemming from a nurse theorist’s lived experiences or nursing philosophies. Grand nursing theories help to guide research in the field, with studies aiming to explore proposed ideas further.

Hildegard Peplau's Theory of Interpersonal Relations is an excellent example of a grand nursing theory. The theory suggests that for a nurse-patient relationship to be successful, it must go through three phases: orientation, working, and termination. This grand theory is broad in scope and widely applicable to different environments.

Middle-Range Nursing Theories

As the name suggests, middle-range theories lie somewhere between the sweeping scope of grand nursing and a minute focus on practice-level theories. These theories are often phenomena-driven, attempting to explain or predict certain trends in clinical practice. They’re also testable or verifiable through research.

Nurse researchers have applied the concept of Dorothea E. Orem's Self-Care Deficit Theory to patients dealing with various conditions, ranging from hepatitis to diabetes. This grand theory suggests that patients recover most effectively if they actively and autonomously perform self-care.

Practice-Level Nursing Theories

Practice-level theories are more specific to a patient’s needs or goals. These theories guide the treatment of health conditions and situations requiring nursing intervention. Because they’re so specific, these types of nursing theories directly impact daily practices more than other theory classifications. From patient education to practicing active compassion, bedside nurses use these theories in their everyday responsibilities.

Nursing Theory in Practice

Theory and practice inform each other. Nursing theories determine research that shapes policies and procedures. Nurses constantly apply theories to patient interactions, consciously or due to training. For example, a nurse who aims to provide culturally competent care — through a commitment to ongoing education and open-mindedness — puts Madeleine Leininger's Transcultural Nursing Theory into effect. Because nursing is multifaceted, nurses can draw from multiple theories to ensure the best course of action for a patient.

Applying theory in nursing practice develops nursing knowledge and supports evidence-based practice. A nursing theoretical framework is essential to understand decision-making processes and to promote quality patient care.

Images sourced from Getty Images

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Case Studies in Nursing Theory

Winstead-Fry, Patricia

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Here you will find books, both eBooks and Print books, that are collections of nursing theories/mid range theories/social theories.  These books are designed to inform the user about the theorist and their theories.  These books are not primary or original sources for nursing theories.  

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• OJIN Homepage
• Table of Contents
• Volume 21 - 2016
• Number 2: May 2016
• Integrating Lewin’s Theory with Lean’s System Approach

A Case Review: Integrating Lewin’s Theory with Lean’s System Approach for Change

Elizabeth Wojciechowski is a doctorally prepared APN in mental health nursing with 25 years of experience in clinical management, strategic planning, graduate-level education, and qualitative and quantitative research. Her most recent professional experience as Education Program Manager and Project Consultant includes collaborating with professionals on hospital-wide change management projects; developing a website and hospital-wide patient and family education system; project lead for strategic planning for a new cancer rehabilitation center; and leading the inception of the nursing research committee. Former experience as an associate professor of nursing and a nurse manager includes serving on a university IRB board; teaching epidemiology, research, leadership and management at the graduate school level; developing and administering an outpatient dual-diagnosis program servicing children and families; and securing outside funding to pursue clinical research projects that resulted in publications in peer-reviewed journals and awards.

Tabitha Pearsall received a business degree in Seattle, WA and has 25 years operations experience, 11 years of experience utilizing Lean or Six Sigma improvement methodologies, with the last eight years focused in healthcare. She is Lean Certified through John Black & Associates, whose method is modeled after the Toyota Production System. She has implemented improvement programs in three organizations, two of which are in healthcare focused on Lean. Currently, Director of Performance Improvement at a large acute rehabilitation hospital, creating structure and implementing plan for integrating Lean methods and facilitating improvements hospital wide.

Patricia J. Murphy has over 30 years of experience in nursing leadership and education. She currently is the Associate Chief Nurse at a large acute inpatient rehabilitation institute where she is responsible for the operations of seven inpatient-nursing units, the nursing supervisors, radiology, respiratory therapy, laboratory services, dialysis, and chaplaincy. In this leadership role, she identifies, facilitates, implements, supports, and monitors evidence based nursing practices, projects and nursing development initiatives in order to improve nurse sensitive patient outcomes and add to the body of knowledge of rehabilitation nursing practice. Former experience includes Director of Oncology Services and Hospice; strategic planning of a new cancer center; leading quality projects in oncology and within the stem cell transplant unit; designing and implementing an oncology support program; and developing and implementing a complementary therapy program to support inpatients, outpatients, and the community.

Eileen French received a BSN from Northern Illinois University and an MSN from Loyola University. She is certified in rehabilitation nursing and has worked for over 30 years at a large acute inpatient rehabilitation institute, as a direct care nurse, clinical educator, clinical nurse consultant, and nurse manager. She is currently Manager of Nursing Outcomes, and has led a group of nurses responsible for planning and initiating bedside shift report in this rehabilitation setting.

• Figures/Tables

The complexity of healthcare calls for interprofessional collaboration to improve and sustain the best outcomes for safe and high quality patient care. Historically, rehabilitation nursing has been an area that relies heavily on interprofessional relationships. Professionals from various disciplines often subscribe to different change management theories for continuous quality improvement. Through a case review, authors describe how a large, Midwestern, rehabilitation hospital used the crosswalk methodology to facilitate interprofessional collaboration and develop an intervention model for implementing and sustaining bedside shift reporting. The authors provide project background and offer a brief overview of the two common frameworks used in this project, Lewin’s Three-Step Model for Change and the Lean Systems Approach. The description of the bedside shift report project methods demonstrates that multiple disciplines are able to utilize a common framework for leading and sustaining change to support outcomes of high quality and safe care, and capitalize on the opportunities of multiple views and discipline-specific approaches. The conclusion discusses outcomes, future initiatives, and implications for nursing practice.

Key words: Outcomes, quality improvement, interprofessional collaboration, Lewin, Lean, crosswalk, case review, outcomes

Providing today’s healthcare requires professional collaboration among disciplines to address complex problems and implement new practices, processes, and workflows.  Providing today’s healthcare requires professional collaboration among disciplines to address complex problems and implement new practices, processes, and workflows ( AACN, 2011 ; Bridges, Davidson, Odegard, Maki, &Tomkowski, 2011 ; IOM, 2011 ).   Often this collaboration magnifies competing or alternative discipline specific theories, language, and strategies to lead and sustain change management and to implement and support Continuous Quality Improvement (CQI) projects. Initially, professionals may perceive these differing views as mutually exclusive.

Lewin’s Three-Step Model Change Management is highlighted throughout the nursing literature as a framework to transform care at the bedside ( Shirey, 2013 ). One criticism of Lewin’s theory is that it is not fluid and does not account for the dynamic healthcare environment in which nurses function today ( Shirey, 2013 ). With the need to streamline resources and provide quality and safe healthcare, nurse leaders have focused on a rapid cycle approach to lead and sustain quality improvement changes at the bedside. One specific approach that is gaining rapid attention in healthcare is the “Lean System” for transformation. Experts assert that Lewin’s theory provides the fundamental principles for change, while the Lean system also provides the particular elements to develop and implement change, including accountability, communication, employee engagement, and transparency. The purpose of this case review is to describe how one large, Midwestern, rehabilitation facility used a crosswalk methodology to promote interprofessional collaboration and to design an intervention model comes to implement and sustain bedside shift reporting.

Project Background: Setting, Theoretical Bases, and Topic of Interest

Founded in the mid-1950s, this 182-bed, acute, inpatient rehabilitation facility (IRF) is located in a large Midwestern city and known for its commitment to promoting interprofessional and collaborative patient care. Rehabilitation is an interprofessional practice by nature that requires physiatrists, nurses, occupational therapists, speech therapists, physical therapists, and ancillary departments to collaborate to identify and achieve patient goals and outcomes. In early spring of 2017, the IRF will open a new research hospital to replace the current building. The new research hospital, a private, not-for-profit acute in-patient and outpatient rehabilitation facility, will expand patient care and combine research activities that translate directly to patient care in real time to improve patient outcomes.

This evolving research hospital environment requires that nurse executives demonstrate collaborative problem solving across the spectrum of care. Nurse leaders and executives’ formal training supports frequent use of Lewin’s Three-Step Model for Change Management. Meanwhile, healthcare institutions’ performance improvement departments often institute the Lean Systems Approach to quality improvement ( Toussaint & Berry, 2013 ; Toussaint & Gerad, 2010 ).

Integrating language from the Lean model within the theoretical basis of change theories used by the IRF healthcare culture would likely be a key factor for success continuous quality improvement activities.  The IRF executive leadership team identified that the organization was reliable in initiating improvements, but was challenged to sustain and spread improvements throughout the organization. The Lean model had been adapted as the improvement system for the IRF. Integrating language from the Lean model within the theoretical basis of change theories used by the IRF healthcare culture would likely be a key factor for success continuous quality improvement activities. The Director of Performance Improvement gained leadership team approval to lead an effort to connect the Lean System tools with concepts that were common to several change management theories or frameworks, such as Diffusion of Innovations Theory; Donabedian’s Structure, Process, and Outcomes Framework; and the Institute for Healthcare Improvement (IHI) Rapid Cycle Improvement Model, including Lewin ( Donabedian, 2003 ; IHI, 2001 ; Lewin, 1951 ; Rogers, 2003 ).

Concurrently, the manager of nursing outcomes met with her clinical nursing team to plan a pilot project for bedside shift reporting (BSR). Ultimately, this project serves to coalesce the aforementioned simultaneous events of the new research environment of the facility and the combination of change theory and Lean model concepts into a workable framework for interprofessional collaboration. While the BSR is not the focus of this case review, this project served as a catalyst for the interprofessional collaboration among executives; mid-level and staff nurses; performance improvement professionals; the patient-family education resource center; and director of ethics. The purpose of this article is to discuss an interprofessional collaboration that sought consensus among members of different disciplines who typically utilized different theoretical approaches to problem solving. We selected the crosswalk method to further collaboration and to create an intervention model for BSR. As BSR happened to be a substantive topic of interest to the organization, a natural opportunity emerged to display the utility of a crosswalk method as a tool to developing an intervention model.

Brief Overview: Lewin’s Model for Planned Change and the Lean Systems Approach

Inherent in interprofessional collaboration is a requisite that each discipline shares an understanding of the similarities and a common language of the change process...  With the current emphasis on interprofessional problem-solving approaches for CQI in mind, collaboration becomes an essential part in delivering quality care and leading CQI projects ( AACN, 2011 ; Bridges et al., 2011 ; IOM, 2011 ). Inherent in interprofessional collaboration is a requisite that each discipline shares an understanding of the similarities and a common language of the change process it proposes to use to develop an intervention model. Because the language and perspectives differ, professionals often struggle to find common ground for understanding so that each discipline maintains an influence. Historically, many nurses have subscribed to Lewin’s Three-Step Model for Change ( Shirley 2013 ). For the past 10 years, the Lean System Approach has been at the forefront of efforts to implement and sustain change in healthcare delivery organizations (D'Andreamatteo, Lappi, Lega, & Sargiacomo, 2015 ). This section provides a brief overview of Lewin’s Three-Step Model for Change and the Lean System Approach to change.

Lewin’s Three-Step Model for Change Healthcare organizations are complex adaptive systems where change is a complex process with varying degrees of complexity and agreement among disciplines.  The Change Model. Complex adaptive systems require that, in order for organizations to maintain equilibrium and survive, the organizations must respond to an ever-changing environment. Healthcare organizations are complex adaptive systems where change is a complex process with varying degrees of complexity and agreement among disciplines ( Plsek & Greenhalgh, 2001 ; Porter-O’Grady & Malloch, 2011 ). Lewin’s Change Management Theory ( Lewin, 1951 ) is a common change theory used by nurses across specialty areas for various quality improvement projects to transform care at the bedside ( Chaboyer, McMurray, & Wallis, 2010 ; McGarry, Cashin & Fowler, 2012 ; Shirey, 2013 ; Suc, Prokosch & Ganslandt, 2009 ; Vines, Dupler, Van Son, & Guido, 2014 ).

Lewin’s theory proposes that individuals and groups of individuals are influenced by restraining forces, or obstacles that counter driving forces aimed at keeping the status quo, and driving forces, or positive forces for change that push in the direction that causes change to happen. The tension between the driving and restraining maintains equilibrium. Changing the status quo requires organizations to execute planned change activities using his three-step model. This model consists of the following steps ( Lewin 1951 ; Manchester, et al., 2014 ; Vines, et al., 2104 ).

• Unfreezing, or creating problem awareness, making it possible for people to let go of old ways/patterns and undoing the current equilibrium (e.g., educating, challenging status quo, demonstrating issues or problems)
• Changing/moving, which is seeking alternatives, demonstrating benefits of change, and decreasing forces that affect change negatively (e.g., brainstorming, role modeling new ways, coaching, training)
• Refreezing, which is integrating and stabilizing a new equilibrium into the system so it becomes habit and resists further change (e.g., celebrating success, re-training, and monitoring Key Performance Indicators [KPIs])

Other Considerations . Criticisms of Lewin’s change theory are lack of accountability for the interaction of the individual, groups, organization, and society; and failure to address the complex and iterative process of change ( Burnes, 2004 ). Figure 1 depicts this change model as a linear process.

Figure 1. Lewin’s Three-Step Model for Planned Change

However, in addition to change theory, healthcare has also shifted to a robust system for change called the Lean Systems Approach.

Lean Systems Approach

The Lean Model. The Lean Systems Approach (Lean) is a people-based system, focusing on improving the process and supporting the people through standardized work to create process predictability, improved process flow, and ways to make defects and inefficiencies visible to empower staff to take action at all levels ( Liker, 2004 ; Toussaint & Gerard, 2010 ). To that end, Lean creates value for internal and external customers through eliminating waste (e.g., time, defects, motion, inventory, overproduction, transportation, processing). To create value and meet customer needs, Lean resources are provided in a robust toolkit. Value stream mapping is a tool to identify process relating to material and information and people flow. It is useful to identify value added and non-value added actions. Value stream mapping is then used to create a plan to eliminate waste, create transparency (visual management), implement standard work, improve flow, and sustain change.

...Lean is a way of thinking about improvement as a never-ending journey.  Overall, Lean is a way of thinking about improvement as a never-ending journey. Lean starts as a top-down, bottom-up approach, requiring leadership support. Over time, the goal is for all staff to contribute to problem solving and designing improvements to add value as defined by the customer. Value is defined as the services that the customer is willing to purchase ( Toussaint &Gerard, 2010 ).

In healthcare, adding value or meeting the customer or patient needs often occurs at the bedside, and nurses who provide care are closest to the bedside. Lean offers a common system, philosophy, language, and tool kit for improvement. Many quality improvement approaches have parallels and one well known is Deming’s Improvement Model of Plan, Do, Check, Act ( Deming Institute, 2015 ). Deming’s model is also utilized in the Lean approach as a structure to make and sustain improvements. The IHI refers to this as Plan, Do, Study, Act-Rapid Cycle Improvement Model ( Scoville & Little, 2014 ). Both models, like Lean, strive for structure, methods, and improvement that never ends – continuous improvement, or Kaizen, in Lean terms. For an organization to reap the full benefit of the Lean approach, it is necessary to integrate a system-wide approach ( D’Andreamatteo et al., 2015 ; Liker, 2004 ; Toussaint, 2015 ). Lean tools are designed to work together to maximize improvements within an organization and create a culture that embraces the journey of continuous quality improvement.

...the Lean System exemplifies a culture where each staff member is empowered to make change.  To this end, the Lean System exemplifies a culture where each staff member is empowered to make change. This culture focuses on creating value, supporting staff, and improving process flow to increase quality, reduce costs, and increase efficiency. Interprofessional collaboration is a necessary component to make improvements that involve going to the gemba (i.e., where the work is done or patient floor), to observe with our own eyes, ask questions, and learn. Other aspects of Lean are the importance of utilizing data and identifying root cause (5 Why’s, or asking why five times). Becoming a learning organization by creating a safe environment to make mistakes (taking into account patient safety) is key in Lean; it is better to try, fail, learn, adjust, than to not try at all ( Simon & Canacari, 2012 ). The Lean tools provide a medium for staff to break down problems, eliminate non-value added activities, and not only implement a new standard process, but sustain it as well ( Kimsey, 2010 ; Liker, 2004 ; Mann, 2010 ).

Kaizen, or continuous improvement, means adjusting how healthcare organizations operate to create value.  Other Considerations . Incorporating Lean into the healthcare industry has been met with barriers. A common reaction to Lean within healthcare is that it only applies to manufacturing cars (e.g., the Toyota Production System) ( Liker, 2004 ; Toussaint & Gerad, 2010 ; Toussaint & Berry, 2013 ). This reaction, in itself, becomes a barrier to apply and incorporate Lean into the healthcare industry. The interpretation of standard work being inflexible is also a barrier within healthcare. Standard work can be made flexible to adjust to unique patient scenarios and change according to changes in the healthcare environment, technology, and patient needs. Kaizen, or continuous improvement, means adjusting how healthcare organizations operate to create value. Many hospitals have been applying Lean, such as Virginia Mason Medical Center, ThedaCare, Mayo Clinic, and Seattle Children’s Hospital ( Toussaint & Berry, 2013 ). Furthermore, regulatory changes, such as those from the Centers for Medicare & Medicaid Services (CMS), and pressure on healthcare organizations to deliver high quality, safe and cost-effective care ( Toussaint & Berry, 2013 ).

[A no-blame culture] creates an environment whereby any member(s) of the organization can take action to improve performance and outcomes.  Healthcare can often be a shame and blame culture, which is very different than Lean ( Simon & Canacari, 2012 ; Toussaint & Gerad, 2010 ). A fundamental principle of Lean is that it attacks the process rather than the person or people to create a no-blame culture. The Lean Systems Approach is designed to build trust, engage staff to trystorm (try ideas rapidly to see if they work), measure improvement, and implement and sustain. The Lean System is designed for problems to rise to the surface and become transparent so that they can be addressed. This transparency (visual management), along with clear measures and coaching, keeps important concerns in view of staff. This creates an environment whereby any member(s) of the organization can take action to improve performance and outcomes ( Mann, 2010 ).

Considering concepts from both Lewin’s Three-Step Model for change and the Lean Systems Approach opens the possibility of using the best of each of these models to facilitate interprofessional collaboration and a problem-solving approach. Through interprofessional collaboration, nursing and other disciplines can continue to improve processes and outcomes for the greater good of patient outcomes and the healthcare industry ( Brooks, Rhodes & Tefft, 2014 ). The next section offers a short explanation of the concept of interprofessional collaboration, which served as the problem-solving basis of our project to develop an intervention model for bedside shift reporting.

Interprofessional Collaboration: A Problem Solving Approach

...collaboration can enhance collegial relationships and collapse professional silos, as well as improve patient outcomes.  In one of the more widely-cited definitions of collaboration, Gray ( 1989 ) describes "a process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their own limited vision of what is possible” ( p. 5 ). Collaboration involves multiple disciplines that span across individual professional silos, hence the term interprofessional is used for this case review. Collaboration is based on a naturalistic inquiry process, whereby each party takes on the teacher role, educating others, and the learner role, an openness and willingness to receive information from others, relinquishing power and control to move beyond their own perspectives for benefit of change ( Denzin & Lincoln, 2011 ; Gray, 1989 ).

Communication serves as a mechanism for sharing knowledge and is the hallmark for improving working relationships ( Gray, 1989 ). Collaborative efforts create spaces where connections are made, ideas are shared, opportunities for innovation flourish, and strategies for change to transpire ( London, 2012 ). Today, healthcare associations and committees work diligently to ensure that interprofessional collaboration is part of their educational curriculum and practice standards.

The American Nurses Association ( ANA, 2009 ) lists “collaboration” as a standard of practice for nursing administration. Similarly, the Institute of Medicine ( IOM, 2011 ) recommends that “nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States” ( p. 32 ).

Nursing driven improvement projects and change initiatives that require interprofessional collaboration are common in redesigning healthcare delivery. However, simply grouping healthcare professionals from differing disciplines together to work on a project does not always cultivate collaboration ( Kotecha et al., 2015 ). Effective interprofessional collaboration is a blending of professional cultures that arises from sharing knowledge and skills to improve patient care, and exhibits accountability, coordination, communication, cooperation, and mutual respect among its members ( Bridges et al., 2011 ; Reber, et al., 2011 ). Such collaboration can enhance collegial relationships and collapse professional silos, as well as improve patient outcomes ( Kotecha et al., 2015 .).

There are facilitating and hindering factors for interprofessional collaboration associated with nursing driven projects ( Tviet, Belew, & Noble, 2015 ). Facilitating factors cited include: identifying key roles and individuals; soliciting early involvement and commitment from individuals and the group; and continuing to monitor progress and compliance well after implementation, including follow up with staff whose compliance is low. Hindering factors cited include: difficulty coordinating meeting times among multiple professions; bias of each profession as to what would work for them; discipline specific professional jargon; and the ability of one person or group to resist change and stop the project from moving forward ( Ellison, 2014 ).

Interprofessional collaboration lessens discipline-specific perspectives, thus improving quality of care and patient outcomes, and increasing efficiency and reducing healthcare resources.  Interprofessional collaboration lessens discipline-specific perspectives, thus improving quality of care and patient outcomes, and increasing efficiency and reducing healthcare resources ( Patton, Lim, Ramlow, & White, 2015 ). An initial effort by all parties to visually display alignments and confront differences may minimize frustration and miscommunication among professionals. As we considered the synergy of concepts from both the Lewin Three-Step Model for Change and Lean Systems Approach, our idea was to use crosswalk methodology to begin collaboration with an interprofessional perspective.

Crosswalk Methodology

The crosswalk is a robust qualitative method, often associated with theory building and inductive reasoning, which provides a compressed display or visual of meaningful information ( Miles & Huberman, 1994 ). Table 1 demonstrates the utility of the crosswalk method across domains, with examples from various domains to make comparative evaluations among programs, assessment tools, and theories to determine alignments and misalignments. Advantages of conducting a crosswalk are that it elucidates key connections and critical opportunities for growth and knowledge expansion, equitable resource allocation, and inquiry; and it depicts a large amount of information in a clear and concise manner. Disadvantages of the crosswalk method are that it often lacks the rigor and depth necessary to make causal links or provide generalizable information ( Miles & Huberman, 1994 ). However, since the goals of qualitative methods are not causal links or generalizability, crosswalks can offer an intentional, systematic method to consider complex information in a meaningful way.

Table 1. Examples: Utility of Crosswalk Across Domains

Bedside Shift Report Project Methods

Through a case review, we will describe how this IRF implemented a CQI process that integrated theory into practice via both Lewin’s theory and a Lean Systems Approach. We used crosswalk methodology to compare Lewin’s Theory and Lean, a process that ultimately led to collaboration and the creation of an intervention model for BSR. For this case, the crosswalk was used to visually examine the relationships, concepts, and language used within two approaches to change and quality improvement. Team members visualized the similarities and dissimilarities and adopted the teacher and learner role necessary to move the BSR project forward.

Our Team Initially, an interprofessional team of six consisting of executives; mid-level and staff nurses; performance improvement professionals; the patient-family education and resource center; and director of ethics convened through semi-monthly work sessions from early spring 2015 to early fall 2015 for the purpose of BSR. During interprofessional work sessions, the language used among team members when discussing the improvement process differed, which resulted in confusion among members and became a barrier to collaboration.

What the team experienced was similar to what Andersen and Rovik ( 2015 ) described as the many interpretations of lean thinking. Different definitions or interpretations of concepts were being made, prolonging the improvement and sustaining process. D'Andreamatteo et al. ( 2015 ) suggested that “...a common definition should be established to distinguish what is Lean and what is not…” ( p. 10 ). The team wanted all participants of the various disciplines to see the commonalities of approach, to create a better known definition of each concept, and to continue to build collaboration and understanding for better outcomes.

Visually showing theoretical connections helped improve the understanding of all team members and thus our process became more adoptable to the group.  Team members identified the translation barrier very early when they conducted a crosswalk of concepts and language from Lewin’s Change Theory to the language of Lean tools and principles. Lean, being both a system and a way of thinking, and not just a quick process to make point improvements, was linked with Lewin’s, three-step model of planned change. This crosswalk, demonstrated in Table 2, launched the connection to understand improvement theory and techniques. Visually showing theoretical connections helped improve the understanding of all team members and thus our process became more adoptable to the group.

Our Process and Crosswalk Once we determined a topic of interest (bedside reporting) our interprofessional team used the following process to problem solve:

• Convened an interprofessional working group consisting of executive, mid-level and staff nursing, performance improvement, the patient-family education resource center, and director of ethics;
• Reviewed literature on BSR to familiarize team with evidence-based practice for BSR;
• Reviewed Lewin Three-Step Model for Planned Change;
• Reviewed Lean System Approach for CQI;
• Created a crosswalk;
• Refined crosswalk based on team feedback;
• Finalized crosswalk ( See Table 2 );
• Presented to nursing staff-at-large to spread understanding.

The final crosswalk led to two outcomes, described below.

Table 2. Crosswalk: Lewin Change Theory and Lean Concepts

Our Outcomes This case review illustrates two outcomes. The first outcome of our project was enriched interprofessional collaboration and the second outcome was an intervention model BSR ( see Figure 2 ). These are briefly described below.

The rich interprofessional collaboration that resulted in our final crosswalk illustrated the compatibility between Lewin’s Theory and Lean, operationalized the stages of change, and provided tangible strategies and tools to implement and sustain a BSR project. This project will be implemented in 2016.

During a debriefing, the primary author (E.W) asked team members to comment about their experience with this CQI project. Anecdotal information illustrates furthered collaboration within this IRF. Team members verified the accuracy of the anecdotal information by reviewing its written form and gave permission for publication in this article.

The following remarks display three themes related to collaboration:

…the teacher-learner process where members move between educating others, and gaining knowledge by being open and willing to understand others; I came to the team with one idea about how to change systems for the benefit of patient care. …Initially, I felt the team was polarized due to their differing ways of thinking or points of view about change. Once we conducted the crosswalk between Lean and Lewin, I could visualize how we were saying similar things, but in a different way. I learned from my team members and I believe they learned from me. ... I listened and I also felt heard. [I] loved this experience and would use the crosswalk early in any interprofesssional project. …the opportunity for innovative problem solving that transpired above your own world view for the common good; Nurses first came to the team with the feeling that Lean was just a passing fancy that would attempt to improve sustaining change and would fail and soon be forgotten. [However], they came away with useful tools to support their on-going challenges to continually improve patient care and nursing outcomes. …the promotion for enhanced partnerships among professionals. Finding commonality in the Lewin and Lean languages and approach provided a way for our broader group to connect and discuss improvements in a proactive way. Recognizing we were not against one another but working towards the same goal for quality of care. Since this took crosswalk took place, our partnerships are tighter due to a better understanding of each other’s disciplines and perspective. We have a point of reference to go back to for discussion. Mutual respect was enhanced allowing us to have different conversations now with better focus on solutions.

As noted previously, the manager of nursing quality and her clinical staff had done preliminary work on BSR. The second outcome of our subsequent team work, the intervention model in Figure 2 , assimilated and utilized Lean and Lewin tools and principles that comprise the Standard Work Sequence (i.e,, the BSR protocol). Examples of this protocol included:

• The design and target population of intervention
• Process measures, such as measures of the intended delivery of the intervention (e.g., survey assessing on thoroughness, accuracy and efficiency of the BSR, patient interviews, and staff coaching and feedback tool)
• Outcome measures, which included measures for the intended response or results of the intervention (e.g., pain control, patient falls, pressure ulcers, availability of RNs, staff addressing [patients’] concerns, and staff keeping patient informed)

Figure 2. Intervention Model for Beside Shift Reporting

This article describes the two outcomes resulting from our interprofessional collaborative team effort to address the topic of interest using an intentional theoretical approach. As the intervention model is implemented, baseline and follow-up data will be obtained on the process and outcomes measures listed above.

Developing and utilizing our crosswalk to educate nurses on the Lean philosophy and tools adopted by this organization for CQI also familiarized non-nursing members of the interprofessional team with Lewin’s work and the common nursing culture and language for change. It was the “aha” moment for all team members. This breakthrough led to further collaboration and demonstrated the commonalities between Lewin’s Three-Step Model for Change and the Lean Systems Approach philosophy for CQI. Collaboration enhanced nursing buy-in to this process and a better understanding of the application of Lean principles.

Critical to collaboration is that parties realize that talking about and planning collaboration does not mean that it will happen quickly and easily.  Barriers to communicating and understanding the process were greatly reduced. At the conclusion, nurses could quickly and easily see the benefits of using this adaptive model to implement and sustain change. Critical to collaboration is that parties realize that talking about and planning collaboration does not mean that it will happen quickly and easily. Ultimately, the crosswalk offered two positive outcomes. The first was that it furthered interprofessional collaboration by engaging team members to clarify language and mental models of management approaches. The second outcome was the development of the intervention model for BSR project, taking preliminary work on a project by the Manager of Nursing Outcomes and her team to the next level, with an end product that is being implemented in 2016.

Future directions for our team are to determine the usefulness of the crosswalk for multi-discipline initiatives, such as the “patient up and ready” program, a joint initiative between nursing and allied health to ensure that patients are available and ready for each scheduled therapy session. In sum, the initial outcomes of this case review demonstrate willingness among providers in multiple disciplines to seek consensus in understanding and utilize a shared framework to lead and sustain change for high quality and safe patient care. Doing so capitalizes on the expanded knowledge and expertise of multiple views and discipline-specific approaches to change management.

Elizabeth Wojciechowski, PhD, PMHCNS-BC Email: [email protected]

Tabitha Pearsall, AAB, Lean Certification Email:  [email protected]

Patricia Murphy, MSN, RN, NEA-BC Email:  [email protected]

Eileen French, MSN, RN, CRRN Email: [email protected]

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May 31, 2016

DOI : 10.3912/OJIN.Vol21No02Man04

https://doi.org/10.3912/OJIN.Vol21No02Man04

Citation: Wojciechowski, E., Murphy, P., Pearsall, T., French, E., (May 31, 2016) "A Case Review: Integrating Lewin’s Theory with Lean’s System Approach for Change" OJIN: The Online Journal of Issues in Nursing Vol. 21 No. 2, Manuscript 4.

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Cognitive load theory in workplace-based learning from the viewpoint of nursing students: application of a path analysis

• Shakiba Sadat Tabatabaee 1 ,
• Sara Jambarsang 2 &
• Fatemeh Keshmiri 3  

BMC Medical Education volume  24 , Article number:  678 ( 2024 ) Cite this article

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The present study aimed to test the relationship between the components of the Cognitive Load Theory (CLT) including memory, intrinsic and extraneous cognitive load in workplace-based learning in a clinical setting, and decision-making skills of nursing students.

This study was conducted at Shahid Sadoughi University of Medical Sciences in 2021–2023. The participants were 151 nursing students who studied their apprenticeship courses in the teaching hospitals. The three basic components of the cognitive load model, including working memory, cognitive load, and decision-making as the outcome of learning, were investigated in this study. Wechsler’s computerized working memory test was used to evaluate working memory. Cognitive Load Inventory for Handoffs including nine questions in three categories of intrinsic cognitive load, extraneous cognitive load, and germane cognitive load was used. The clinical decision-making skills of the participants were evaluated using a 24-question inventory by Lowry et al. based on a 5-point scale. The path analysis of AMOS 22 software was used to examine the relationships between components and test the model.

In this study, the goodness of fit of the model based on the cognitive load theory was reported (GIF = 0.99, CFI = 0.99, RMSEA = 0.03). The results of regression analysis showed that the scores of decision-making skills in nursing students were significantly related to extraneous cognitive load scores ( p -value = 0.0001). Intrinsic cognitive load was significantly different from the point of view of nursing students in different academic years ( p  = 0.0001).

The present results showed that the CLT in workplace-based learning has a goodness of fit with the components of memory, intrinsic cognitive load, extraneous cognitive load, and clinical decision-making skill as the key learning outcomes in nursing education. The results showed that the relationship between nursing students’ decision-making skills and extraneous cognitive load is stronger than its relationship with intrinsic cognitive load and memory Workplace-based learning programs in nursing that aim to improve students’ decision-making skills are suggested to manage extraneous cognitive load by incorporating cognitive load principles into the instructional design of clinical education.

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Introduction

Cognitive load was introduced as a key theory in medical education [ 1 ] This theory guides the components of human cognitive architecture concerning learning and education to create a correct understanding of the characteristics and conditions of education and learning [ 2 ].

Cognitive load theory (CLT)

The CLT was first proposed in the 1980s by John Sweller [ 3 ]. This theory explains learning according to three important aspects including types of memory (working and long-term memory), learning process, and forms of cognitive load that affect learning [ 4 ].

The cognitive architecture assumed by CLT includes long-term memory (LTM) and working memory (WM). The key subsystem of memory in the CLT is working memory [ 5 ].

• Cognitive load

Cognitive load is defined as the load that a specific task imposes on the learner’s cognitive system [ 6 ]. In the CLT, three types of cognitive load are proposed, including intrinsic cognitive load (ICL), extraneous cognitive load (ECL), and germane cognitive load (GCL) [ 7 , 8 ]. ICL is related to the complexity of educational materials rather than their quantity [ 9 ]. ICL depends on several factors, including the individual’s skill, the number of information elements, and the degree of interaction of different elements of the tasks. ECL caused by the training format includes training strategies, training design, and teaching-learning methods [ 4 , 10 , 11 ]. GCL refers to the load imposed by the mental processes necessary for learning (such as the formation of schemata) [ 11 ]. Germane load means trying to build and modify learning schemata, which is mainly under the control of job components such as motivation, effort, and the learner’s metacognitive skills [ 7 ]. Also, the level of learner’s proficiency can moderate the ICL arising from the interaction of elements. This means that the availability and automaticity of the learner’s schemata can moderate intrinsic load [ 11 ].

Learning process

Education in medical science systems is a complex and multidimensional process that is affected by many factors [ 12 ]. In the process of clinical education, students need to learn several professional tasks and activities and apply them in the provision of health care services by simultaneously integrating a set of knowledge, skills, and behaviors [ 11 ]. These characteristics of clinical education can impose a high cognitive load on students and harm their effective learning [ 11 , 13 ].

CLT in health professions education

The CLT has emerged as one of the foremost models in educational psychology considered in different fields such as health professions education. The goal of CLT has been to improve learning at the individual student level in different environments including the classroom, and complex professional learning environments [ 14 ]. Sweller and colleagues showed there have been main developments in CLT and instructional design over the last 20 years. The ‘cognitive theory of multimedia learning’ focusing on the design of multimedia educational materials and the ‘four-component instructional design (4 C/ID)’ focusing on the design of whole-task courses and curricula have been built based on the CLT [ 15 ]. In addition, the CLT provides principles that are recommended to apply to the design of instructional messages and instructional units, such as lessons, written materials consisting of text and pictures, and educational multimedia (instructional animations, videos, simulations, games) [ 15 ].

The theoretical scope of the cognitive load has been expanded by including the physical environment as a key factor affecting cognitive load. Physical environments that evoke stress, emotions, and/or uncertainty raise new questions about how to deal with cognitive load. The questions require examining the human cognitive architecture of educational design in environments that are accompanied by uncertainty and stress [ 15 ]. Likewise, Paas et al. (2020) introduced variables affecting cognitive load and introduced factors including instructional design and learning environment as an effective factor that affects students’ learning process. They stated that the learning environment can affect cognitive load and suggested a way of managing it [ 5 ].

Advances in CLT have set the trends for future developments in different learning environments such as workplace-based learning, simulation, and games [ 15 ]. Most studies used the CLT principles in instructional design in simulation, virtual reality, and game settings in nursing education [ 1 , 16 , 17 , 18 ]. Yiin et al., (2023) indicated the multi-media interactive learning materials and an active learning mechanism reduced nursing students’ intrinsic and extrinsic cognitive load and encouraged the students to learn [ 19 ]. Takhdat et al., (2024) showed that mindfulness meditation practice optimizes cognitive load, and decreases the anxiety of nursing students in a simulation setting [ 20 ].

Clinical education in the workplace is defined as a main educational setting where students improve their competencies and prepare for their future careers. Sewell and colleagues (2019) in a BEME guide (Best Evidence in Medical Education guide) discussed cognitive load in workplace-based learning in the real environment [ 21 ]. The workplace-based learning in clinical education imposes high levels of cognitive load that negatively impact on learning of learners and their performances. Sewell et al. indicated the factors of, complex tasks, settings, and novice learners mostly predispose the students to high levels of cognitive load. They stated aspects of workplace environments contribute to extraneous load, and adversely impact capacity for engaging in tasks that enhance germane load and learning [ 15 ]. Further studies are recommended to understand the manner and the extent of the impact of cognitive load on different learning outcomes in various learning environments in systems of health professions education [ 1 , 16 , 17 ].

The present study aimed to test the relationship between the components of the Cognitive Load Theory (CLT) including memory, intrinsic and extraneous cognitive load in workplace-based learning, and decision-making skills of nursing students in clinical settings.

Materials and methods

This cross-sectional study was conducted in 2021–2023 at Shahid Sadoughi University of Medical Sciences, Yazd, Iran. In the present study, the path analysis was used to predict a defined theoretical model that posits hypothesized linear relations among variables and decreases to the solution of one or more multiple regression analyses.

The present university has conducted a four-year nursing degree curriculum. The students have participated in workplace-based learning in the clinical setting from the second semester. They contributed to care processes as team members from the third semester of the academic course. In the present nursing curriculum, there is no reasoning and decision-making training course. The decision-making skills have been learned by the students in the process of workplace-based learning in the clinical environment. The stages of experiential learning, including observation, practice and repetition, feedback, and self-reflection, have been implemented in the nursing clinical education program. In clinical education courses, the students have used study guides nursing flowcharts, and clinical guidelines.

Participants

Undergraduate nursing students of the faculties affiliated with Shahid Sadoughi University of Medical Sciences participated in this study. The inclusion criteria were nursing students who had completed at least six months of apprenticeship courses in their field in the hospital. Students with working experience as health technicians ( Behvarz ) were excluded from the study. This exclusion criterion aims to control for potential confounding variables that could influence the study’s outcomes, such as previous professional experience impacting cognitive load assessments and decision-making skills [ 22 , 23 ].

The rule of thumb is to have at least 10–15 observations per parameter (i.e., 10–15 cases for each independent variable and the dependent variable) to have reliable estimates of the model parameters [ 24 ]. Thus, a total of 151 eligible students were randomly selected in this study.

Data collection

To conduct the examination, the researcher explained the objectives of the research, the instruments of data collection, the duration of the examinations, and the confidentiality of data. The participants were asked to perform the Wechsler computerized working memory test and fill the Questionnaires of Cognitive Load Inventory for Handoffs and Clinical Decision-making in a calm environment and away from disturbing side factors. The informed consent form was completed by the students.

Study tools

Working memory measurement tool: Wechsler’s computerized working memory test was used to evaluate working (active) memory [ 25 , 26 ]. In this test, two sections of forward and backward recall of digits are used to measure the memory span. The total working memory score is obtained from the sum of the scores of the two parts of forward and backward recall with a maximum score is 28. For the correct evaluation of the subject, the soft table is used for the desired ages. In this software, the score of memory span (auditory and visual) is also provided. This score represents the number of items memorized by the examinee.

The cognitive Load Inventory for Handoffs (CLIH) was compiled by Yang et al., (2016) [ 27 ] to assess the cognitive load of students in their clinical education. The questionnaire includes 9 questions in three domains of ICL, ECL, and GCL which is based on a 10-point Likert. The validity of the tool was confirmed in the present study. The qualitative content validity of the Persian version of the questionnaire was confirmed from the viewpoints of 15 experts. To determine content validity quantitatively, two indices “Content Validity Ratio (CVR)” and “Content Validity Index (CVI)” were used. The findings of the quantitative content validity assessment indicated that the CVR for all items was higher than the minimum acceptable value (= 0.49), and the CVI values of all items were above 0.79. According to the indices, all items were kept in the questionnaire. S-CVI/Ave was 0.94, which was desirable. The internal consistency of the tool was reported as Cronbach’s alpha coefficient = 0.86.

Clinical decision-making as a learning outcome of nursing students in clinical education was evaluated using the 24-item questionnaire designed by Lauri et al. (2001) which is based on a 5-point scale [ 12 ]. The reliability and validity were confirmed in the Karimi et al. study (2013) (Cronbach’s alpha coefficient of intrinsic consistency = 0.8) [ 28 ].

Data analysis

Demographic information of the participants (including gender, age, level of education, and the last externship/internship period of the students) was collected. Descriptive statistics (including frequency percentage, mean, and standard deviation) and analytical statistics (ANOVA) were used to investigate the variables. SPSS statistical software (Ver. 24) was used for data analysis.

This study employed path analysis as the primary statistical analysis method due to its ability to examine the relationships between multiple variables, including the direct and indirect effects of predictor variables on the outcome variable. Specifically, path analysis was used to investigate the relationships between memory, internal and external cognitive load, and decision-making skill, as well as the indirect effects of these variables on learning outcomes. Moreover, path analysis is suited for examining the relationships among the variables in this study due to the capability of path analysis to handle complex models and multiple relationships simultaneously. The use of path analysis was further justified by the need to examine the causal relationships between variables, as well as to account for measurement error and unexplained variance in the data. Path analysis allows for the estimation of standardized regression coefficients, which can be used to interpret the magnitude and direction of the relationships between variables.

In terms of model evaluation, this study employed several indices to assess the goodness-of-fit of the proposed model. The goodness-of-fit index (GFI) was also used to evaluate the model’s fit relative to a baseline model, with a value of 0.95 or higher indicating a good fit [ 29 ]. In addition, acceptable levels of indices of the path analysis include Adjusted Goodness-of-Fit Index (AGFI) > 0.8, Tucker-Lewis Index (TLI) > 0.9, the Incremental Fit Index (IFI) > 0.8. Regarding the Comparative Fit Index (CFI) with a value of greater than 0.90 is very good fit, 0.80 to 0.89 is adequate but marginal fit, 0.60 to 0.79 is poor fit, a and lower than 0.60 very poor fit. Finally, the root mean square error of approximation (RMSEA) was used to evaluate the model’s fit to the data, with a value of 0.05 or less indicating a good fit [ 30 ]. These results indicate that the proposed model provided an adequate representation of the relationships among the variables studied. In the present study, AMOS 22 software was used to assess the fitness of this model.

In total, 151 nursing students participated in this study, 77 of them (51%) were women and 74 (49%) were men. The mean age of the participants was 21.97 ± 2.20. The demographic information of the participants is shown in Table  1 .

The mean score of decision-making of nursing students was 78.37 ± 11.30 and the mean score of cognitive load perceived by students in the workplace-based learning process of clinical setting was 45.26 ± 8.84. Table  2 shows the mean score of the students in the studied variables.

The results of regression analysis showed that the students’ scores of nursing students in decision-making skills were significantly related to the ECL scores ( P  = 0.0001). By increasing one ECL score, the score of students’ clinical decision-making skill increased by 1.2.

The mean scores of ICL and ECL of the students according to their academic year are reported in Table  3 . ANOVA showed that ICL was significantly different from the point of view of nursing students in different academic years ( P  = 0.0001). The results of the Bonferroni test showed that ICL in novice (second-year) students was significantly lower than in third-year ( P  = 0.0001) and fourth-year students ( P  = 0.004). Figure  1 illustrate the path analysis model of CLT in the workplace-based leaning. Table  4 show a report of indices of goodness-of-fit in the model.

Path analysis model: standardized coefficient estimates

ICL: Intrinsic cognitive load, ECL: Extraneous cognitive load

The current study reported a statistically significant fit for the proposed path analysis model indicating a good fit in the data collected from the nursing students in the workplace-based learning at clinical setting.

The development of clinical decision-making skills is a main competency of nursing students in clinical education courses. Learning the decision-making skill is considered a complex and multi-dimensional process that is influenced by various factors for instance personal features, task experience, and situational awareness ability [ 22 ]. Moreover, educational factors such as instructional design, learning environments, and teaching methods direct the cognitive load and learning process of students [ 12 , 31 ]. The present results showed that nursing students’ decision-making skills have a significant positive relationship the capacity of the working memory of learners and ECL in workplace-based learning environments. In line with our results, the findings of studies confirmed management of ECL that depended on the characteristics of the instructional material, the instructional design, and the prior knowledge of learners in the process of clinical education have a positive relationship with learning [ 5 , 21 , 23 ]. The effect of cognitive load as a mediating relationship on clinical reasoning as the key outcome of learning was shown in the Jung et al. study (2022) [ 32 ]. In a review, Josephsen et al. (2015) showed that there is a positive relationship between the cognitive architecture of learners and educational design in nursing. Their results indicated that learners must be aware of cognitive architecture and educational processes in nursing to manage cognitive load and effective learning [ 16 ].

The present results showed that the decision-making scores of the nursing students had a significant positive relationship with ECL in workplace-bead learning. The students have experienced the experiential learning process in clinical nursing education. They learned through observing, exercising, receiving feedback, and reflecting in action and on action at the workplace-based learning in the clinical setting. In addition, nursing students used supportive resources such as a nursing flowchart, a study guide, and structured constructive feedback in clinical education. The use of CLT principles in the instructional design of workplace-based learning of nursing clinical education effects on the ECL. Many learning tasks, especially complex clinical activities, require memorizing and applying a large amount of information [ 11 ]. According to the CLT, the educational environment provides a trigger to use the information stored in LTM to determine the appropriate action in the environment according to the environmental-and-organizing linking principle. Moreover, specialized performance is developed through the creation of a large number of more complex schemata by combining elements consisting of lower-level schemata with higher-level schemata [ 5 ]. The schemata facilitate the decision-making process. The significant relationship between the ECL and learning has also been confirmed in the study of Sawicka et al. (2008) [ 9 ]. The application of strategies for ECL management is recommended by Sawicka et al. The tailored strategies with the workplace-based education were conducted in the clinical setting. These strategies include presenting educational materials from simple to complex and presenting familiar examples in the experiential learning process in clinical setting. The students were experienced the nursing care plan form simple cases to complex cases. The supplementary questions and diverse assignments were conducted in the clinical education by students. They experienced self-explanatory and supporting information in the feedback and reflection process. The use of the strategies in the clinical education of the nursing students in workplace-based learning may effect on our findings. Similarly, Skulmowski et al., (2022) acknowledged the use of aspects of constructive alignment, a strategy to balance the cognitive load and an approach of fostering deep forms of learning improved the learning outcomes [ 33 ].

In the CLT, the features of working memory including its capacity and time limitations were introduced as a key component that plays an important role in learning. This issue is emphasized in cognitive models [ 5 , 34 ]. The present results showed that the relationship between memory and ICL is stronger than ECL. Kilic et al. (2010) model indicated that working memory plays an effective role in providing information necessary for complex cognitive activities such as learning and clinical reasoning [ 34 ]. So, if the learning material is too difficult, the ICL imposed on learners may exceed their working memory capacity and hinder learning [ 9 ]. In line with our results, the relationship of working memory with ICL was stranger than ECL. Sawicka (2008) stated that the insufficiency of working memory resources to expand schemata hinders learning [ 9 ].

The present results showed that the fit of the model was favorable by considering working memory scores, cognitive load, and learning, but no significant relationship was observed between working memory and decision-making scores. Also, no significant relationship between ICL and learning was observed in the present study. In line with our results, Szulewski et al., (2021) presented a new model for medical education systems based on CLT. They stated the relationship between the working memory of healthcare workers cannot be discussed directly in the model. They expressed this as a limitation of their model and acknowledged that the capacity of working memory in complex medical education systems is affected by stress, emotions, and uncertainties, which can affect the performance of healthcare workers [ 14 ]. Although the significant relationship between the components was not approved in the present study, the good fit of the proposed path analysis model, indicated that these components interact with each other and require consideration as a coherent structure in instructional design of the workplace-based learning by planners.

Emotions, stress, and uncertainty are integrated with the learning process and environment in the educational systems of health professions. The educational systems of health professions integrate emotions, stress, and uncertainty into the learning process and environment. According to Sweller, emotions that are considered undesirable for learning result in extraneous load that can be reduced by preventing them. If emotion, stress, and uncertainty are seen as an integral element of the task that learners require to learn, they contribute to intrinsic cognitive load and must be dealt with in another way. Therefore, it is necessary to consider multi-faceted planning by using different components and systematically examining different aspects of cognitive load before formulating educational designs for workplace-based learning in the clinical setting [ 5 ].

Garvey et al. study (2017) introduced a model in which, in addition to the cognitive load components, the individual maturity component based on the years of education was also included in the model [ 35 ]. In the present study, individual maturity was considered in different academic years. The present results showed that there is a significant relationship between the learning maturity of individuals and ICL components. ICL is related to the complexity caused by training and depends on factors such as the individual’s skill, the number of information elements, and the degree of interaction of elements in the learning process. Our findings indicated the ICL of the second-year students was significantly lower compared to the third-year and the fourth-year. The results can be due to less work experience in the hospital, the smaller amount of material learned, and dealing with the limited clinical complexities of the students in the second year. Sewell’s results confirmed a negative relationship between GCL and ICL with the level of experience and performance of students [ 21 ]. These results were also aligned with the present results. Our results are in contrast to Schlairet’s findings (2015) which indicated that a negative relationship between the performance of novice nursing students and cognitive load was observed, although this relationship was not significant [ 36 ]. The difference in the level of students and the difference in the measured learning outcome (decision-making skills versus performance) and considering the cognitive load score without separating ICL and ECL can affect the results.

The results showed that the current model does not have a good fit considering the GCL. The current limitation can be due to measuring the GCL using only one question in CLIH [ 27 ]. Measuring the GCL as a mental process of learning is difficult and requires the measurement of supporting components such as motivation, effort, and metacognitive skills [ 7 ]. In a meta-analysis, Lapierre (2022) found that cognitive load measurement is one of the concerns of studies in the field of CLT. He stated that appropriate tools and the use of self-expression are among the concerns of studies in this field [ 1 ]. Therefore, it is recommended to use different tools to measure the desired cognitive load component in future studies [ 5 , 17 ]. Moreover, it is suggested that influential components such as factors affecting the GCL, learning maturity, and educational strategies should be taken into consideration in future studies.

CLT is a key theory in the purposeful guidance of the process of education, which can guide the educational processes to more effective learning in medical science education systems. The current results showed that CLT had a good fit with the components of memory, ICL, ECL, and clinical decision-making as the key learning outcomes in workplace-based learning in clinical settings. The results showed that the relationship between nursing students’ decision-making skills and extraneous cognitive load is stronger than its relationship with intrinsic cognitive load and memory. Workplace-based learning programs in nursing that aim to improve students’ decision-making skills are suggested to manage extraneous cognitive load by incorporating cognitive load principles into the instructional design of clinical education.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of the data of participants but are available from the corresponding author at reasonable request.

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Acknowledgements

The authors appreciate the cooperation of Amir Houshang Mehrparvar. We would like to thank all the participants for their contribution.

The Shahid Sadoughi University of Medical Sciences, Yazd, Iran funded this project (ID: 16139). The grant supported the data collection process. The funders had no role in the design of the study and collection, analysis, interpretation of data, or preparation of the manuscript. The report of the study’s findings is sent by the authors to the funder at the end of the study.

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F.K. and SH.T. conceptualized and designed the study and SH.T. collected the data. S.J analyzed the data. F.K. and SH.T wrote the main manuscript text. The authors have met the criteria for authorship and had a role in preparing the manuscript. Also, all authors approved the final manuscript.

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Tabatabaee, S.S., Jambarsang, S. & Keshmiri, F. Cognitive load theory in workplace-based learning from the viewpoint of nursing students: application of a path analysis. BMC Med Educ 24 , 678 (2024). https://doi.org/10.1186/s12909-024-05664-z

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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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Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country

Vidya seshan.

1 Maternal and Child Health Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Gerald Amandu Matua

2 Fundamentals and Administration Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Divya Raghavan

Judie arulappan, iman al hashmi, erna judith roach, sheeba elizebath sunderraj, emi john prince.

3 Griffith University, Nathan Campus, Queensland 4111

Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills. Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program. Methodology: A descriptive qualitative research design using focus group discussion method guided the study. The sample included undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018. The researcher used a purposive sampling technique and a total of 22 students participated in the study, through five (5) focus groups, with each focus group comprising between four to six nursing students. Results: In total, nine subthemes emerged from the three themes. The themes were “Knowledge development”, “Critical thinking and Problem solving”, and “Communication and Collaboration”. Regarding “Knowledge development”, the students perceived case study analysis method as contributing toward deeper understanding of the course content thereby helping to reduce the gap between theory and practice especially during clinical placement. The “Enhanced critical thinking ability” on the other hand implies that case study analysis increased student's ability to think critically and aroused problem-solving interest in the learners. The “Communication and Collaboration” theme implies that case study analysis allowed students to share their views, opinions, and experiences with others and this enabled them to communicate better with others and to respect other's ideas which further enhanced their team building capacities. Conclusion: This method is effective for imparting professional knowledge and skills in undergraduate nursing education and it results in deeper level of learning and helps in the application of theoretical knowledge into clinical practice. It also broadened students’ perspectives, improved their cooperation capacity and their communication with each other. Finally, it enhanced student's judgment and critical thinking skills which is key for their success.

Introduction/Background

Recently, educators started to advocate for teaching modalities that not only transfer knowledge ( Shirani Bidabadi et al., 2016 ), but also foster critical and higher-order thinking and student-centered learning ( Wang & Farmer, 2008 ; Onweh & Akpan, 2014). Therefore, educators need to utilize proven teaching strategies to produce positive outcomes for learners (Onweh & Akpan, 2014). Informed by this view point, a teaching strategy is considered effective if it results in purposeful learning ( Centra, 1993 ; Sajjad, 2010 ) and allows the teacher to create situations that promote appropriate learning (Braskamp & Ory, 1994) to achieve the desired outcome ( Hodges et al., 2020 ). Since teaching methods impact student learning significantly, educators need to continuously test the effectives of their teaching strategies to ensure desired learning outcomes for their students given today's dynamic learning environments ( Farashahi & Tajeddin, 2018 ).

In this study, the researchers sought to study the effectiveness of case study analysis as an active, problem-based, student-centered, teacher-facilitated strategy in a baccalaureate-nursing program. This choice of teaching method is supported by the fact that nowadays, active teaching-learning is preferred in undergraduate programs because, they not only make students more powerful actors in professional life ( Bean, 2011 ; Yang et al., 2013 ), but they actually help learners to develop critical thinking skills ( Clarke, 2010 ). In fact, students who undergo such teaching approaches usually become more resourceful in integrating theory with practice, especially as they solve their case scenarios ( Chen et al., 2019 ; Farashahi & Tajeddin, 2018 ; Savery, 2019 ).

Review of Literature

As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios ( Farashahi & Tajeddin, 2018 ; Hermens & Clarke, 2009). Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to experience teamwork and interpersonal relations as “they learn by doing” thus benefiting from possibilities that traditional lectures hardly create ( Farashahi & Tajeddin, 2018 ; Garrison & Kanuka, 2004 ).

Another merit associated with case study method of teaching is the fact that students can apply and test their perspectives and knowledge in line with the tenets of Kolb et al.'s (2014) “experiential learning model”. This model advocates for the use of practical experience as the source of one's learning and development. Proponents of case study-based teaching note that unlike passive lectures where student input is limited, case studies allow them to draw from their own experience leading to the development of higher-order thinking and retention of knowledge.

Case scenario-based teaching also encourages learners to engage in reflective practice as they cooperate with others to solve the cases and share views during case scenario analysis and presentation ( MsDade, 1995 ).

This method results in “idea marriage” as learners articulate their views about the case scenario. This “idea marriage” phenomenon occurs through knowledge transfer from one situation to another as learners analyze scenarios, compare notes with each other, and develop multiple perspectives of the case scenario. In fact, recent evidence shows that authentic case-scenarios help learners to acquire problem solving and collaborative capabilities, including the ability to express their own views firmly and respectfully, which is vital for future success in both professional and personal lives ( Eronen et al., 2019 ; Yajima & Takahashi, 2017 ). In recognition of this higher education trend toward student-focused learning, educators are now increasingly expected to incorporate different strategies in their teaching.

This study demonstrated that when well implemented, educators can use active learning strategies like case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. This study is significant because the findings will help educators in the country and in the region to incorporate active learning strategies such as case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. Besides, most studies on the case study method in nursing literature mostly employ quantitative methods. The shortage of published research on the case study method in the Arabian Gulf region and the scanty use of qualitative methods further justify why we adopted the focus group method for inquiry.

A descriptive qualitative research design using focus group discussion method guided the study. The authors chose this method because it is not only inexpensive, flexible, stimulating but it is also known to help with information recall and results in rich data ( Matua et al., 2014 ; Streubert & Carpenter, 2011 ). Furthermore, as evidenced in the literature, the focus group discussion method is often used when there is a need to gain an in-depth understanding of poorly understood phenomena as the case in our study. The choice of this method is further supported by the scarcity of published research related to the use of case study analysis as a teaching strategy in the Middle Eastern region, thereby further justifying the need for an exploratory research approach for our study.

As a recommended strategy, the researchers generated data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and cased-based teaching approaches. The focus group interviews allowed the study participants to express their experiences and perspectives in their own words. In addition, the investigators integrated participants’ self-reported experiences with their own observations and this enhanced the study findings ( Morgan & Bottorff, 2010 ; Nyumba et al., 2018 ; Parker & Tritter, 2006 ).

Eligibility Criteria

In order to be eligible to participate in the study, the participants had to:

• be a baccalaureate nursing student in College of Nursing, Sultan Qaboos University
• register for Maternity Nursing Course in 2017 and 2018.
• attend all the Case Study Analysis sessions in the courses before the study.
• show a willingness to participate in the study voluntarily and share their views freely.

The population included the undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018.

The researcher used a purposive sampling technique to choose participants who were capable of actively participating and discussing their views in the focus group interviews. This technique enabled the researchers to select participants who could provide rich information and insights about case study analysis method as an effective teaching strategy. The final study sample included baccalaureate nursing students who agreed to participate in the study by signing a written informed consent. In total, twenty-two (22) students participated in the study, through five focus groups, with each focus group comprising between four and six students. The number of participants was determined by the stage at which data saturation was reached. The point of data saturation is when no new information emerges from additional participants interviewed ( Saunders et al., 2018 ).Focus group interviews were stopped once data saturation was achieved. Qualitative research design with focus group discussion allowed the researchers to generate data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and case-based teaching approaches. The focus group interviews allowed the study participants to express their perspectives in their own words. In addition, the investigators enhanced the study findings by integrating participants’ self-reported experiences with the researchers’ own observations and notes during the study.

The study took place at College of Nursing; Sultan Qaboos University, Oman's premier public university, in Muscat. This is the only setting chosen for the study. The participants are the students who were enrolled in Maternal Health Nursing course during 2017 and 2018. The interviews occurred in the teaching rooms after official class hours. Students who did not participate in the study learnt the course content using the traditional lecture based method.

Ethical Considerations

Permission to conduct the study was granted by the College Research and Ethics Committee (XXXX). Prior to the interviews, each participant was informed about the purpose, benefits as well as the risks associated with participating in the study and clarifications were made by the principal researcher. After completing this ethical requirement, each student who accepted to participate in the study proceeded to sign an informed consent form signifying that their participation in the focus group interview was entirely voluntary and based on free will.

The anonymity of study participants and confidentiality of their data was upheld throughout the focus group interviews and during data analysis. To enhance confidentiality and anonymity of the data, each participant was assigned a unique code number which was used throughout data analysis and reporting phases. To further assure the confidentiality of the research data and anonymity of the participants, all research-related data were kept safe, under lock and key and through digital password protection, with unhindered access only available to the research team.

Research Intervention

In Fall 2017 and Spring 2018 semesters, as a method of teaching Maternal Health Nursing course, all students participated in two group-based case study analysis exercises which were implemented in the 7 th and 13 th weeks. This was done after the students were introduced to the case study method using a sample case study prior to the study. The instructor explained to the students how to solve the sample problem, including how to accomplish the role-specific competencies in the courses through case study analysis. In both weeks, each group consisting of six to seven students was assigned to different case scenarios to analyze and work on, after which they presented their collective solution to the case scenarios to the larger class of 40 students. The case scenarios used in both weeks were peer-reviewed by the researchers prior to the study.

Pilot Study

A group of three students participated as a pilot group for the study. However, the students who participated in the pilot study were not included in the final study as is general the principle with qualitative inquiry because of possible prior exposure “contamination”. The purpose of piloting was to gather data to provide guidance for a substantive study focusing on testing the data collection procedure, the interview process including the sequence and number of questions and probes and recording equipment efficacy. After the pilot phase, the lessons learned from the pilot were incorporated to ensure smooth operations during the actual focus group interview ( Malmqvist et al., 2019 .

Data Collection

The focus group interviews took place after the target population was exposed to case study analysis method in Maternal Health Nursing course during the Fall 2017 and Spring 2018 semesters. Before data collection began, the research team pilot tested the focus group interview guide to ensure that all the guide questions were clear and well understood by study participants.

In total, five (5) focus groups participated in the study, with each group comprising between four and six students. The focus group interviews lasted between 60 and 90 min. In addition to the interview guide questions, participants’ responses to unanswered questions were elicited using prompts to facilitate information flow whenever required. As a best practice, all the interviews were audio-recorded in addition to extensive field notes taken by one of the researchers. The focus group interviews continued until data saturation occurred in all the five (5) focus groups.

Credibility

In this study, participant's descriptions were digitally audio recorded to ensure that no information was lost. In order to ensure that the results are accurate, verbatim transcriptions of the audio recordings were done supported by interview notes. Furthermore, interpretations of the researcher were verified and supported with existing literature with oversight from the research team.

Transferability

The researcher provided a detailed description about the study settings, participants, sampling technique, and the process of data collection and analyses. The researcher used verbatim quotes from various participants to aid the transferability of the results.

Dependability

The researcher ensured that the research process is clearly documented, traceable, and logical to achieve dependability of the research findings. Furthermore, the researcher transparently described the research steps, procedures and process from the start of the research project to the reporting of the findings.

Confirmability

In this study, confirmability of the study findings was achieved through the researcher's efforts to make the findings credible, dependable, and transferable.

Data Analysis

Data were analyzed manually after the lead researcher integrated the verbatim transcriptions with the extensive field notes to form the final data set. Data were analyzed thematically under three thematic areas of a) knowledge development; b) critical thinking and problem solving; and (c) communication and collaboration, which are linked to the study objectives. The researchers used the Six (6) steps approach to conduct a trustworthy thematic analysis: (1) familiarization with the research data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes, (6) writing the report ( Nowell et al., 2017 ).

The analysis process started with each team member individually reading and re-reading the transcripts several times and then identifying meaning units linked to the three thematic areas. The co-authors then discussed in-depth the various meaning units linked to the thematic statements until consensus was reached and final themes emerged based on the study objectives.

A total of 22 undergraduate third-year baccalaureate nursing students who were enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018 participated in the study, through five focus groups, with each group comprising four to six students. Of these, 59% were females and 41% were males. In total, nine subthemes emerged from the three themes. Under knowledge development, emerged the subthemes, “ deepened understanding of content ; “ reduced gap between theory and practice” and “ improved test-taking ability ”. While under Critical thinking and problem solving, emerged the subthemes, “ enhanced critical thinking ability ” and “ heightened curiosity”. The third thematic area of communication and collaboration yielded, “ improved communication ability ”; “ enhanced team-building capacity ”; “ effective collaboration” and “ improved presentation skills ”, details of which are summarized in Table 1 .

Table 1.

Objective Linked Themes and Student Perceptions of Outcome Case Study Analysis.

Theme 1: Knowledge Development

In terms of knowledge development, students expressed delight at the inclusion of case study analysis as a method during their regular theory class. The first subtheme related to knowledge development that supports the adoption of the case study approach is its perceived benefit of ‘ deepened understanding of content ’ by the students as vividly described by this participant:

“ I was able to perform well in the in-course exams as this teaching method enhanced my understanding of the content rather than memorizing ” (FGD#3).

The second subtheme related to knowledge development was informed by participants’ observation that teaching them using case study analysis method ‘ reduced the gap between theory and practice’. This participant's claim stem from the realization that, a case study scenario his group analyzed in the previous week helped him and his colleagues to competently deal with a similar situation during clinical placement the following week, as articulated below:

“ You see when I was caring for mothers in antenatal unit, I could understand the condition better and could plan her care well because me and my group already analyzed a similar situation in class last week which the teacher gave us, this made our work easier in the ward”. (FGD#7).

Another student added that:

“ It was useful as what is taught in the theory class could be applied to the clinical cases.”

This ‘theory-practice’ connection was particularly useful in helping students to better understand how to manage patients with different health conditions. Interestingly, the students reported that they were more likely to link a correct nursing care plan to patients whose conditions were close to the case study scenarios they had already studied in class as herein affirmed:

“ …when in the hospital I felt I could perceive the treatment modality and plan for [a particular] nursing care well when I [had] discussed with my team members and referred the textbook resource while performing case study discussion”. (FGD#17).

In a similar way, another student added:

“…I could relate with the condition I have seen in the clinical area. So this has given me a chance to recall the condition and relate the theory to practice”. (FGD#2) .

The other subtheme closely related to case study scenarios as helping to deepen participant's understanding of the course content, is the notion that this teaching strategy also resulted in ‘ improved test taking-ability’ as this participant's verbatim statement confirms:

“ I could answer the questions related to the cases discussed [much] better during in-course exams. Also [the case scenarios] helped me a great deal to critically think and answer my exam papers” (FGD#11).

Theme 2: Critical Thinking and Problem Solving

In this subtheme, students found the case study analysis as an excellent method to learn disease conditions in the two courses. This perceived success with the case study approach is associated with the method's ability to ‘ enhance students’ critical thinking ability’ as this student declares:

“ This method of teaching increased my ability to think critically as the cases are the situations, where we need to think to solve the situation”. (FGD#5)

This enhanced critical thinking ability attributed to case study scenario analysis was also manifested during patient care where students felt it allowed them to experience a “ flow of patient care” leading to better patient management planning as would typically occur during case scenario analysis. In support of this finding, a participant mentioned that:

“ …I could easily connect the flow of patient care provided and hence was able to plan for [his] management as often required during case study discussion” (FGD#12)

Another subtheme linked with this theme is the “ heightened curiosity” associated with the case scenario discussions. It was clear from the findings that the cases aroused curiosity in the mind of the students. This heightened interest meant that during class discussion, baccalaureate nursing students became active learners, eager to discover the next set of action as herein affirmed:

“… from the beginning of discussion with the group, I was eager to find the answer to questions presented and wanted to learn the best way for patient management” (FGD#14)

Theme 3: Communication and Collaboration

In terms of its impact on student communication, the subtheme revealed that case study analysis resulted in “ improved communication ability” among the nursing students . This enhanced ability of students to exchange ideas with each other may be attributed to the close interaction required to discuss and solve their assigned case scenarios as described by the participant below:

“ as [case study analysis] was done in the way of group discussion, I felt me and my friends communicated more within the group as we discussed our condition. We also learnt from each other, and we became better with time.” (FGD#21).

The next subtheme further augments the notion that case study analysis activities helped to “ enhance team-building capacity” of students as this participant affirmatively narrates:

“ students have the opportunity to meet face to face to share their views, opinion, and their experience, as this build on the way they can communicate with each other and respect each other's opinions and enhance team-building”. (FGD#19).

Another subtheme revealed from the findings show that the small groups in which the case analysis occurs allowed the learners to have deeper and more focused conversations with one another, resulting in “ an effective collaboration between students” as herein declared:

“ We could collaborate effectively as we further went into a deep conversation on the case to solve”. (FGD#16).

Similarly, another student noted that:

“ …discussion of case scenarios helped us to prepare better for clinical postings and simulation lab experience” (FGD#5) .

A fourth subtheme related to communication found that students also identified that case study analysis resulted in “ improved presentation skills”. This is attributed in part to the preparation students have to go through as part of their routine case study discussion activities, which include organizing their presentations and justifying and integrating their ideas. Besides readying themselves for case presentations, the advice, motivation, and encouragement such students receive from their faculty members and colleagues makes them better presenters as confirmed below:

“ …teachers gave us enough time to prepare, hence I was able to present in front of the class regarding the finding from our group.” (FGD#16).

In this study, the researches explored learner's perspectives on how one of the active teaching strategies, case study analysis method impacted their knowledge development, critical thinking, and problem solving as well as communication and collaboration ability.

Knowledge Development

In terms of knowledge development, the nursing students perceived case study analysis as contributing toward: (a) deeper understanding of content, (b) reducing gap between theory and practice, and (c) improving test-taking ability. Deeper learning” implies better grasping and retention of course content. It may also imply a deeper understanding of course content combined with learner's ability to apply that understanding to new problems including grasping core competencies expected in future practice situations (Rickles et al., 2019; Rittle-Johnson et al., 2020 ). Deeper learning therefore occurs due to the disequilibrium created by the case scenario, which is usually different from what the learner already knows ( Hattie, 2017 ). Hence, by “forcing” students to compare and discuss various options in the quest to solve the “imbalance” embedded in case scenarios, students dig deeper in their current understanding of a given content including its application to the broader context ( Manalo, 2019 ). This movement to a deeper level of understanding arises from carefully crafted case scenarios that instructors use to stimulate learning in the desired area (Nottingham, 2017; Rittle-Johnson et al., 2020 ). The present study demonstrated that indeed such carefully crafted case study scenarios did encourage students to engage more deeply with course content. This finding supports the call by educators to adopt case study as an effective strategy.

Another finding that case study analysis method helps in “ reducing the gap between theory and practice ” implies that the method helps students to maintain a proper balance between theory and practice, where they can see how theoretical knowledge has direct practical application in the clinical area. Ajani and Moez (2011) argue that to enable students to link theory and practice effectively, nurse educators should introduce them to different aspects of knowledge and practice as with case study analysis. This dual exposure ensures that students are proficient in theory and clinical skills. This finding further amplifies the call for educators to adequately prepare students to match the demands and realities of modern clinical environments ( Hickey, 2010 ). This expectation can be met by ensuring that student's knowledge and skills that are congruent with hospital requirements ( Factor et al., 2017 ) through adoption of case study analysis method which allows integration of clinical knowledge in classroom discussion on regular basis.

The third finding, related to “improved test taking ability”, implies that case study analysis helped them to perform better in their examination, noting that their experience of going through case scenario analysis helped them to answer similar cases discussed in class much better during examinations. Martinez-Rodrigo et al. (2017) report similar findings in a study conducted among Spanish electrical engineering students who were introduced to problem-based cooperative learning strategies, which is similar to case study analysis method. Analysis of student's results showed that their grades and pass rates increased considerably compared to previous years where traditional lecture-based method was used. Similar results were reported by Bonney (2015) in an even earlier study conducted among biology students in Kings Borough community college students, in New York, United States. When student's performance in examination questions covered by case studies was compared with class-room discussions, and text-book reading, case study analysis approach was significantly more effective compared to traditional methods in aiding students’ performance in their examinations. This finding therefore further demonstrates that case study analysis method indeed improves student's test taking ability.

Critical Thinking and Problem Solving

In terms of critical thinking and problem-solving ability, the use of case study analysis resulted in two subthemes: (a) enhanced critical thinking ability and (b) heightened learner curiosity. The “ enhanced critical thinking ability” implies that case analysis increased student's ability to think critically as they navigated through the case scenarios. This observation agrees with the findings of an earlier questionnaire-based study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh, that showed 81% of respondents agree that case study analysis develops critical thinking ability and enables students to do better problem analysis ( Muhiuddin & Jahan, 2006 ). This observation agrees with the findings of an earlier study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh. The study showed that 81% of respondents agreed that case study analysis facilitated the development of critical thinking ability in the learners and enabled the students to perform better with problem analysis ( Muhiuddin & Jahan, 2006 ).

More recently, Suwono et al. (2017) found similar results in a quasi-experimental research conducted at a Malaysian university. The research findings showed that there was a significant difference in biological literacy and critical thinking skills between the students taught using socio-biological case-based learning and those taught using traditional lecture-based learning. The researchers concluded that case-based learning enhanced the biological literacy and critical thinking skills of the students. The current study adds to the existing pedagogical knowledge base that case study methodology can indeed help to deepen learner's critical thinking and problem solving ability.

The second subtheme related to “ heightened learner curiosity” seems to suggest that the case studies aroused problem-solving interest in learners. This observation agrees with two earlier studies by Tiwari et al. (2006) and Flanagan and McCausland (2007) who both reported that most students enjoyed case-based teaching. The authors add that the case study method also improved student's clinical reasoning, diagnostic interpretation of patient information as well as their ability to think logically when presented a challenge in the classroom and in the clinical area. Jackson and Ward (2012) similarly reported that first year engineering undergraduates experienced enhanced student motivation. The findings also revealed that the students venturing self-efficacy increased much like their awareness of the importance of key aspects of the course for their future careers. The authors conclude that the case-based method appears to motivate students to autonomously gather, analyze and present data to solve a given case. The researchers observed enhanced personal and collaborative efforts among the learners, including improved communication ability. Further still, learners were more willing to challenge conventional wisdom, and showed higher “softer” skills after exposure to case analysis based teaching method. These findings like that of the current study indicate that teaching using case based analysis approach indeed motivates students to engage more in their learning, there by resulting in deeper learning.

Communication and Collaboration

Case study analysis is also perceived to result in: (a) improved communication ability; (b) enhanced team -building capacity, (c) effective collaboration ability, and (d) enhanced presentation skills. The “ improved communication ability ” manifested in learners being better able to exchange ideas with peers, communicating their views more clearly and collaborating more effectively with their colleagues to address any challenges that arise. Fini et al. (2018) report comparable results in a study involving engineering students who were subjected to case scenario brainstorming activities about sustainability concepts and their implications in transportation engineering in selected courses. The results show that this intervention significantly improved student's communication skills besides their higher-order cognitive, self-efficacy and teamwork skills. The researchers concluded that involving students in brainstorming activities related to problem identification including their practical implications, is an effective teaching strategy. Similarly, a Korean study by Park and Choi (2018) that sought to analyze the effects of case-based communication training involving 112 sophomore nursing students concluded that case-based training program improved the students’ critical thinking ability and communication competence. This finding seems to support further the use of case based teaching as an effective teaching-learning strategy.

The “ enhanced team-building capacity” arose from the opportunity students had in sharing their views, opinions, and experiences where they learned to communicate with each other and respect each other's ideas which further enhance team building. Fini et al. (2018) similarly noted that increased teamwork levels were seen among their study respondents when the researchers subjected engineering students to case scenario based-brainstorming activities as occurs with case study analysis teaching. Likewise, Lairamore et al. (2013) report similar results in their study that showed that case study analysis method increased team work ability and readiness among students from five health disciplines in a US-based study.

The finding that case study analysis teaching method resulted in “ effective collaboration ability” among students manifested as students entered into deep conversation as they solved the case scenarios. Rezaee and Mosalanejad (2015) assert that such innovative learning strategies result in noticeable educational outcomes, such as greater satisfaction with and enjoyment of the learning process ( Wellmon et al., 2012 ). Further, positive attitudes toward learning and collaboration have been noted leading to deeper learning as students prepare for case discussions ( Rezaee & Mosalanejad, 2015 ). This results show that case study analysis can be utilized by educators to foster professional collaboration among their learners, which is one of the key expectations of new graduates today.

The finding associated with “improved presentation skills” is consistent with the results of a descriptive study in Saudi Arabia that compared case study and traditional lectures in the teaching of physiology course to undergraduate nursing students. The researchers found that case-based teaching improved student’ overall knowledge and performance in the course including facilitating the acquisition of skills compared to traditional lectures ( Majeed, 2014 ). Noblitt et al. (2010) report similar findings in their study that compares traditional presentation approach with the case study method for developing and improving student's oral communication skills. This finding extends our understanding that case study method improves learners’ presentation skills.

The study was limited to level third year nursing students belonging to only one college and the sample size, which might limit the transferability of the study findings to other settings.

Implications for Practice

These study findings add to the existing body of knowledge that places case study based teaching as a tested method that promotes perception learning where students’ senses are engaged as a result of the real-life and authentic clinical scenarios ( Malesela, 2009 ), resulting in deeper learning and achievement of long-lasting knowledge ( Fiscus, 2018 ). The students reported that case scenario discussions broadened their perspectives, improved their cooperation capacity and communication with each other. This teaching method, in turn, offers students an opportunity to enhance their judgment and critical thinking skills by applying theory into practice.

These skills are critically important because nurses need to have the necessary knowledge and skills to plan high quality care for their patients to achieve a speedy recovery. In order to attain this educational goal, nurse educators have to prepare students through different student- centered strategies. The findings of our study appear to show that when appropriately used, case-based teaching results in acquisition of disciplinary knowledge manifested by deepened understanding of course content, as well as reducing the gap between theory and practice and enhancing learner's test-taking-ability. The study also showed that cased based teaching enhanced learner's critical thinking ability and curiosity to seek and acquire a deeper knowledge. Finally, the study results indicate that case study analysis results in improved communication and enhanced team-building capacity, collaborative ability and improved oral communication and presentation skills. The study findings and related evidence from literature show that case study analysis is well- suited approach for imparting knowledge and skills in baccalaureate nursing education.

This study evaluated the usefulness of Case Study Analysis as a teaching strategy. We found that this method of teaching helps encourages deeper learning among students. For instructors, it provides the opportunity to tailor learning experiences for students to undertake in depth study in order to stimulate deeper understanding of the desired content. The researchers conclude that if the cases are carefully selected according to the level of the students, and are written realistically and creatively and the group discussions keep students well engaged, case study analysis method is more effective than other traditional lecture methods in facilitating deeper and transferable learning/skills acquisition in undergraduate courses.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

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• Open access
• Published: 18 June 2024

Nurses’ intention to care of COVID-19 patients in hospitals dedicated to infectious disease in South Korea: application of the theory of planned behavior and verification of the moderating effect of ethical nursing competence

• Mira Mo   ORCID: orcid.org/0000-0002-5802-0333 1 ,
• Seongmi Moon   ORCID: orcid.org/0000-0003-4384-0088 2 &
• Eun Kyeung Song   ORCID: orcid.org/0000-0002-9854-537X 2  

BMC Nursing volume  23 , Article number:  410 ( 2024 ) Cite this article

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Metrics details

The theory of planned behavior is a conceptual framework of recent studies to identify and explain nurses’ intentions to care for patients with emerging infectious diseases. However, correlations between behavioral intentions and variables that explain them have been inconsistent in previous studies. The influence of new variables might be considered in this case. This study aimed to determine moderating effects of ethical nursing competence on nurses’ intention to care for COVID-19 patients in hospitals dedicated to infectious diseases based on the theory of planned behavior.

A cross-sectional survey was conducted. Data on intention to care for COVID-19 patients, perceived behavioral control, attitude toward the behavior, subjective norm, and ethical nursing competence were obtained from 190 nurses in three hospitals dedicated to infectious diseases in South Korea. The moderating effect of ethical nursing competence was analyzed using model I of PROCESS Macro. Ethical considerations: This study was approved by the Institutional Review Board of Ulsan University Hospital, South Korea. Written informed consent was obtained from each subject.

The ethical nursing competence was a significant moderator in the relation between perceived behavioral control and the intention to care (B = 0.36, t = 2.16, p  = 0.032). Ethical nursing competence did not have a significant interaction with attitude toward behavior or subjective norm.

Conclusions

This study showed that the higher the ethical nursing competence level, the greater the effect of perceived behavioral control on nurses’ intention to care for COVID-19 patients. Promoting ethical nursing competence is necessary for nurses who would take care of patients at the frontline of the infectious disease pandemic. Nursing managers should include ethical nursing competence in the assessment of nurses’ competence and design educational programs to enhance ethical nursing competence for efficient nursing staffing during a pandemic.

Peer Review reports

Due to the pandemic of infectious diseases caused by Coronavirus Disease 2019 (COVID-19), the Korean government has designated hospitals dedicated to infectious diseases for treating patients infected with COVID-19. As a result, many COVID-19 patients were sent to hospitals dedicated to infectious diseases. Proportion of COVID-19-related tasks and roles of nurses are increased. The work experience of nurses caring for COVID-19 patients in Korea shows that fear and concern about the spread of infection coexist with responsibility for patient care [ 1 ]. From the beginning of the 2020 COVID-19 pandemic to this point, nurses caring for patients with COVID-19 have had difficulty caring for patients due to limited information, unpredictable work, new challenges, insufficient support, family concerns, and emotional stress [ 2 ].

In a disaster caused by disease, the public expects healthcare providers to respond at the frontline. The most important ethical decision for healthcare providers at this time is whether to remain in hospitals to fight infectious diseases, which is a matter for each healthcare provider to decide for themselves [ 3 ]. After the COVID-19 pandemic, many research studies have been conducted on ethical issues that nurses face. An integrated analysis of these studies shows that nurses are required to work in situations where person protection equipment is scarce with their health endangered. They also experience moral distress due to the need to provide safe and high-quality care for patients [ 4 ]. Therefore, nurses’ intention to care for COVID-19 patients at hospitals dedicated to infectious diseases is important for ethical decision-making of nurses.

Nurses’ intention to care refers to their intention to perform nursing activities independently according to nurses’ intention to care for patients. In a situation where there are possibilities of emerging infectious diseases pandemic such as COVID-19, it is important to identify nurses’ intention to care [ 5 ]. Among theories that explain intentions to behavior, the theory of planned behavior (TPB) [ 6 ] is the conceptual framework of recent studies [ 5 , 7 , 8 , 9 , 10 ] to identify and explain nurses’ intentions to care for patients with emerging infectious diseases. According to the TPB, perceived behavioral control (PBC), attitude toward the behavior (ATT), and subjective norm (SN) are three factors that can predict behavior intention [ 6 ]. In one study [ 5 ], all these three factors had a significant effect on the intention to care for patients with infectious diseases. However, there were cases in which ATT was not significant [ 8 ] or SN was not significant [ 8 , 9 ]. In addition, one study [ 10 ] that investigated correlations among variables of TPB in nursing students reported that only PBC had a significant relationship with intention to care. As such, when correlations between behavior intention and variables that explain it are not consistent in previous studies, the influence of a new variable can be considered. In particular, the moderating action of the new variable can be verified [ 11 ]. The moderating action of the new variable could influence the direction or intensity of the relationship between PBC, ATT, and SN and intention to care. This means that the relationship varies according to the level of the new variable [ 11 ].

As mentioned earlier, when nurses’ intention to care for COVID-19 patients in a hospital dedicated to infectious diseases involves ethical decision-making, it can be thought that the influence of factors related to intention to care will vary depending on ethical decision-making abilities of nurses. According to a study [ 12 ] that investigated whether ethical characteristics of nurses could have a moderating effect in the model explaining nurses’ behaviors when the level of ethical leadership of nurses was high, the intention of eco-friendly behavior had a significant effect on actual eco-friendly behavior. In this study, ethical leadership showed a significant moderating effect when nurses’ intention to eco-friendly behavior was linked to actual eco-friendly behavior. Since nurses’ ethical leadership showed a moderating effect on the behavior- intention to behavior relationship, it is necessary to examine whether ethical characteristics could act as moderating variables in the relationship between PBC, ATT, and SN and intention to care based on TPB.

It is possible to add a new factor predicting intention to TPB. This predictive factor should be a factor that is conceptually independent of existing factors and a factor that can be widely applied to behavioral research conducted in social behavior science [ 13 ]. Ethical nursing competency, a concept that includes ethical decision-making of nurses, is a concept in which not only ethical decision-making but also ethical sensitivity, knowledge, reflection, behavior, and attitude are interdependently integrated. It develops in various ways depending on an individual’s situation regarding ethical problems and dilemmas [ 14 ]. Therefore, this study intends to apply TPB to explain nurses’ intentions to care for COVID-19 patients in hospitals dedicated to infectious diseases. The purpose of this study was to investigate the moderating effect of ethical nursing competency under the assumption that PBC, ATT, and SN have different effects on intention to care according to the level of ethical nursing competency. Results of this study suggest an expanded explanation of TPB and provide basic data for recognizing the importance of ethical nursing competency development of nurses by confirming the moderating effect of ethical nursing competency.

Conceptual framework

In this study, we tried to confirm the moderating effect of ethical nursing competency based on TPB (Fig.  1 ) [ 6 ]. TPB is a theory proposed to predict complex human behavior and intention to behavior. PBC, ATT, and SN are key variables that can directly predict behavior intention. In this study, we will investigate whether ethical nursing competency can act as a moderating effect in the relationship between PBC-intention to care, ATT-intention to care, and SN-intention to care, respectively.

Conceptual framework of this study

This was a cross-sectional, correlational, descriptive study to identify the moderating effect of ethical nursing competency in the relationship between PBC, ATT, and SN and the care intention of nurses taking care of patients with COVID-19 at hospitals dedicated to infectious disease.

Setting and sample

The participants in this study were nurses who worked at three general hospitals in the southeastern area of South Korea. These hospitals were specifically dedicated to infectious diseases. One hospital was situated in Ulsan Metropolitan City, while the other two were in Changwon City. Convenience sampling was used to select these hospitals. The study included nurses who had been directly caring for COVID-19 patients in isolated wards for more than 6 months. Nursing managers and nurses with administrative duties were not included in the study.

To calculate the sample size, regression analysis criteria were applied using the G*power program 3.1.9.2. At a significance level of 0.05 and a power of 90% with a median effect size and 15 predictors (11 general characteristics, 3 independent variables, and 1 moderating variable) as input, the required number of samples was calculated to be 171. Considering that previous studies have reported dropout rates of either 7% [ 5 ] or 8% [ 7 ], a sample of 190 nurses was conveniently recruited for this study, taking into account a projected dropout rate of 10%. All 190 questionnaires were analyzed.

Measurements

Tpb related variables.

Instruments were developed to measure nurses’ intention to care, PBC, ATT, and SN in the care of patients with Severe Acute Respiratory Syndrome (SARS) based on the TPB [ 15 ]. These instruments were modified specifically for nurses caring for emerging infectious diseases. To ensure their validity, items were selected with high content validity index by a panel of five experts. This panel consisted of two nursing professors, one infection control nurse specialist, and two nurses with experience in caring for emerging infectious diseases [ 9 ].

We used the modified version. Instruments had a 7-point Likert-type rating from − 3 (strongly disagree) to 3 (strongly agree). We used the average value divided by the number of items by summing up scores of the items for each variable for analysis, with a higher score indicating a higher level of the variable.

Nurses’ intention to care was measured as a nurse’s willingness to care for COVID-19 patients using three items asking about their willingness to voluntarily perform nursing care. The Cronbach’s alpha in this study was 0.89.

The PBC consisted of two items asking whether a nurse felt confident in caring for COVID-19 patients and perceives ease in performing nursing care. The Cronbach’s alpha in this study was 0.87. The ATT consisted of three items asking whether caring for COVID-19 patients was wise, must-do, or worthwhile. The Cronbach’s alpha in this study was 0.83. The SN consisted of two items asking how much a nurse felt social pressure to care for patients with COVID-19. The Cronbach’s alpha in this study was 0.79.

Ethical nursing competency

Ethical nursing competency is a concept that interdependently integrates not only ethical decision-making, but also ethical sensitivity, knowledge, reflection, behavior, and attitude based on ethical knowledge and sensitivity in ethical conflict situations that occur during nursing work [ 14 ]. We used the ethical nursing competency measurement tool developed by Kang and Oh [ 16 ]. It consisted of a total of 20 items in five factors, including four items of ethical sensitivity, two items of ethical knowledge, two items of ethical reflection, six items of ethical decision-making and action, and six items of ethical behavior. The Cronbach’s alpha in this study was 0.88.

Data collection

Data collection was conducted from August 10, 2021 to September 01, 2021. We reached out to the nursing departments of our target hospitals to provide them with an explanation of the purpose and methodology of our study. Once we received permission, the nursing department then notified the nurses about the survey through their respective nursing managers. To ensure maximum participation, we personally visited each department and handed out structured questionnaires to the nurses who willingly agreed to take part in the study. Once the questionnaires were completed, they were sealed and collected at the nursing department. We subsequently visited the nursing department to retrieve the questionnaires. In total, we collected 65 questionnaires from a hospital in Ulsan, and 85 and 40 questionnaires from two hospitals in Changwon, respectively.

Data analysis

Data were analyzed using the SPSS 24.0 program. PROCESS Macro version 4.0 was used to analyze the moderating effect of ethical nursing competency. For general characteristics, frequency and percentage were calculated. Intention to care, PBC, ATT, SN, and ethical nursing competency were analyzed. Results are presented as mean and standard deviation. Differences in intention to care by participants’ general characteristics were analyzed using an independent t-test and one-way analysis of variance. Correlations between intention to care, PBC, ATT, SN, and ethical nursing competency were analyzed using Pearson’s correlation coefficient. To verify the moderating effect of ethical nursing competency, PROCESS Macro model 1 was used [ 17 ].

General characteristics of participants

Table  1 shows general characteristics of participants. Of all participants, 86.3% were women, 85.3% were under 40 years old, 75.8% were unmarried, and 81.1% were staff nurses. Among these participants, 91.6% worked in wards and 8.4% worked in intensive care units. As for the number of patients in charge, 42.1% had 20 or less, and 39.5% had 40–60 patients. Among participants, 96.3% had experience in education related to infectious diseases, 71.6 had experience in education related to ethics, and 81.6% had no experience of caring for patients with emerging infectious diseases. Regarding perceived work intensity, ‘upper-middle’ was the most at 56.8%, followed by ‘upper’ at 25.3% (48 persons), ‘middle’ at 16.8%, and ‘middle-lower’ at 1.1%.

Intention to care, PBC, ATT, SN, and ethical nursing competency

Means and standard deviations of intention to care, PBC, ATT, SN, and ethical nursing competency are shown in Table  2 .

Differences in intention to care by participants’ general characteristics

Participants’ intention to care was significantly different by age. Intention to care for those in their 40s or older had a score of 1.54 ± 1.50, which was significantly higher than that (0.96 ± 1.13) in those under 40 years (t = -2,37, p  = 0.019). In the case of charge nurses or head nurses, intention to care had a score of 1.37 ± 1.33, higher than that of staff nurses at 0.97 ± 1.17, although the difference was not statistically significant (t = 1.82, p  = 0.071). For those working in general wards rather than intensive care units (t = 0.73, p  = 0.467), for those whose number of patients in charge was relatively small (t = 2.16, p  = 0.118), and for those who perceived work intensity as ‘middle-lower’ (t = 0.68, p  = 0.568), their intention to care was higher, although there were no significant differences.

Intention to care was almost the same regardless of whether or not they had received education on infectious diseases. Intention to care was higher in those who had received education on ethics (t = 0.76, p  = 0.448) and revious experience of caring for patients with emerging infectious diseases (t = 0.97, p  = 0.336), although there were no statistically significant differences (Table  1 ).

Relationships among Intention to care, PBC, ATT, SN, and ethical nursing competency

Intention to care was significantly related to PBC ( r  = 0.50, p  < 0.001), ATT ( r  = 0.51, p  < 0.001), SN ( r  = 0.35, p  < 0.001), and ethical nursing competency ( r  = 0.26, p  < 0.001) (Table  2 ).

Moderating effect of ethical nursing competency

To construct a model of moderating effect of ethical nursing competency, the variable ‘age’ among general characteristics which had significant association with intention to care was included in the model (Table  3 ). In model 1 (F = 18.690, p  < 0.001), in which ethical nursing competency played a moderating role in the relationship between PBC and intention to care, PBC affected intention to care only by its interaction with ethical nursing competency with a significant effect (t = 2.16, p  = 0.032). ATT independently had a significant effect on intention to care (t = 4.81, p  < 0.001). In model 2 (F = 17.61, p  < 0.001), in which ethical nursing competency had a moderating effect on the relationship between ATT and intention to care, the interaction between ATT and nursing ethical competency was insignificant (t = 0.76, p  = 0.451). Only PBC independently had a significant effect on intention to care (t = 4.51, p  < 0.001). In model 3 (F = 17.48, p  < 0.001), in which ethical nursing competency had a moderating effect on the relationship between SN and intention to care, the interaction between SN and ethical nursing competency was insignificant (t = 0.20, p  = 0.843). PBC (t = 4.56, p  < 0.001) and ATT (t = 5.12, p  < 0.001) each independently had a significant effect on intention to care.

In model 1, in which the moderating effect of ethical nursing competency was significant, the relationship between PBC and intention to care in the group with a low level of ethical nursing competency (-1 standard deviation) and the group with a high level (+ 1 standard deviation) according to the pick-a-point approach is shown in Fig.  2 . In the case of the group with a low level of ethical nursing competency, the effect size of PBC affecting intention to care was 0.30. In the group with a high level of ethical nursing competency, the effect size was 0.51 (Table  4 ). In other words, the higher the ethical nursing competency, the greater the influence of PBC on intention to care. According to Johnson-Neyman analysis, the moderating effect of ethical nursing competency was significant when the ethical nursing competency exceeded 2.52 points (Fig.  3 ).

Effect of perceived behavioral control on intention to care at values of moderator ethical nursing competence

Conditional effect of perceived behavioral control on intention to care depending on moderator ethical nursing competence

In this study, we tried to explain the intention to care of nurses who cared for COVID-19 patients in hospitals dedicated to infectious diseases. The intion to care had a score of 1.04 points. In a previous study [ 18 ] in which data were collected one year earlier than this study, the intention to care of nurses caring for patients with COVID-19 also had a score of 1.04 points. In studies conducted in Korea, nurses who had experience caring for COVID-19 patients during the COVID pandemic had a higher intention to care than nurses who did not [ 18 , 19 ]. In addition, nurses’ intention to care during the COVID pandemic was higher than that of patients with new infectious diseases investigated before the pandemic [ 5 , 9 ].

Ehtical nursing competency is as a comprehensive concept that reflects various ethical attributes, such as ethical knowledge, attitudes, sensitivity, reflection, decision-making, and behavior. It can be considered as a new concept that expands TPB to explain intention behind actions [ 13 ]. Among ethical issues that nurses experience and feel confusion and conflict in Korea, priorities are ‘patient care situations that can threaten nurses’ health’ and ‘staffing that restricts nursing care’. Accordingly, there is also a high demand for ethics education on situations that can threaten nurses’ health [ 20 ]. In the COVID-19 pandemic, nurses are experiencing ethical conflicts on a daily basis. Lack of understanding of COVID-19 transmission mode and characteristics, pathophysiology, and susceptibility profile along with insufficient personal protective equipment placed nurses at significant and uncertain risks. Nonetheless, nurses strive to balance their duty of benevolence with duty of caring for patients [ 21 ]. They believe that all patients have the right to receive optimal treatment regardless of age or health status [ 22 ]. Most nurses showed intention to participate in the care of patients with COVID-19 [ 23 ]. Although the level of stress is high while nursing patients with COVID-19, there is also a report that stress does not affect nursing intention because of professional ethics of nurses who are aware of their responsibility and obligation to care for patients [ 24 ]. In this study, these ethical characteristics of nurses were measured as ethical nursing competency. It showed a significant moderating effect in the relationship between PBC and intention to care in TPB. At this time, PBC itself did not influence the intention to care significantly. Results of this study confirm that despite perceived confidence and ease in caring for COVID-19 patients, the level of ethical nursing competence determines the extent to which PBC influences intention to care, ultimately demonstrating the importance of ethical nursing competence in determining intention to care.

Several studies have shown moderating effects of ethical factors in models explaining behaviors. One study has shown a moderating effect of ethical leadership on the relationship between nurses’ intention to engage in green behavior and actual green behavior [ 12 ]. In the field of management, researches have shown that the impact of public service motivation on organizational commitment is greater when there is a higher ethical leadership [ 25 ]. In addition, groups with high ethical leadership experienced an increased task commitment as cooperation increases, while groups with low ethical leadership experienced decreased task commitment even when cooperation increased [ 26 ]. Moderators are variables that can modify the strength or direction of a causal relationship. They are characterized as relatively stable personal characteristics or relatively unchanging environmental variables [ 27 ]. Further research is needed to determine whether ethical nursing competencies, which are ethical characteristics of nurses, such as ethical leadership, could serve as moderators in explaining nurses’ behavioral intentions and behaviors. Furthermore, the development and practical application of education and training programs to promote ethical nursing competence are needed.

Among variables presented in the TPB in this study, SN was the only variable that did not have a significant effect on the intention to care for COVID-19 patients. SN was 0.99, which was slightly higher than tjpse in previous studies [ 8 , 19 ]. In Korean studies explaining the intention to care for patients with infectious diseases, including this study, results of no significant effect of SN [ 8 , 9 , 19 ] are more common than the results of significant effects [ 5 , 7 ]. SN is known to be the variable least related to intention in the TPB [ 28 , 29 ]. SN refers to the degree to which a person feels social pressure. There has been a consistent need to redefine this concept because social pressure is not so direct or explicit [ 28 ]. However, for behaviors that most people perceive as clearly necessary, such as vaccination and social distancing during the COVID-19 pandemic, SN has been shown to significantly influence behavior intentions [ 30 , 31 ].

In the TPB, PBC has been studied as a variable that independently affects intention to behavior. According to Ajzen [ 13 ], PBC theoretically plays a moderating role in relationships between ATT- behavior intentions and SN-behavior intentions. In one study to identify this aspect [ 29 ], PBC was used as a moderating variable to explain intentions for three behaviors: voting, reducing food waste, and reducing energy consumption, with interaction effects of PBC and SN being found to be consistent. Given these results, the importance of SN is that it interacts with PBC to influence behavior intention. In this study, PBC is treated as an independent variable as it has been widely studied in previous studies. In this study, PBC was 0.86, which was high compared to previous studies [ 8 , 19 ]. Models 2 and 3, which examined the interaction of ethical nursing competence with ATT and SN, showed that higher levels of PBC were associated with higher intention to care. Previous studies have consistently shown that PBC could independently influence intention to care [ 5 , 7 , 8 , 9 , 19 ]. On the other hand, in this study, PBC had a significant interaction effect with ethical nursing competence. As suggested by Ajzen [ 13 ], to verify the moderating role of PBC, it is necessary to continue to explore interactions between PBC and other variables in future studies.

According to the TPB, ATT can influence behavior intention. In this study, ATT was 1.50, which was similar to or higher than those in previous studies [ 8 , 19 ]. Also, model 1 and model 3 used to examine the interaction of ethical nursing competence with PBC and SN found that more positive ATT was associated with a higher intention to care. In studies exploring the experience of caring for patients with COVID-19, nurses report feeling supported, recognized, respected, and proud by those around them and the public, which has led to a greater sense of mission and pride [ 1 , 32 , 33 , 34 , 35 ]. A systematic review of qualitative studies on nurses’ experiences working in acute care hospitals during the respiratory pandemic [ 36 ] has found that nurses are willing to work together because they experience a sense of professional camaraderie, caring for and protecting their colleagues by sharing tasks. It can be inferred that the support, respect, recognition, and professional camaraderie that society has shown for nurses since the pandemic have led to an attitude that caring for COVID-19 patients is a worthwhile endeavor, which might have increased their intention to care. However, in this study, ethical nursing competencies did not have a significant moderating effect on the relationship between ATT and intentions to care, i.e., ATT influenced intentions to care regardless of the level of ethical nursing competencies. Thus, to increase intentions to care for COVID-19 patients, it is necessary for society to recognize and appreciate nurses’ contributions [ 23 ] as well as for nurses themselves to value their behaviors through supportive words from nursing managers [ 37 ] and financial rewards [ 9 , 37 ].

Because this study included nurses working in infectious disease hospitals, it is important to be cautious when applying findings of this study to nurses who are not caring for patients with COVID-19 or have never cared for patients with COVID-19. In addition, this study used a convenience sample from three hospitals. Thus, caution should be exercised in generalizing results.

This study extended the TPB to include ethical nursing competence as a moderating variable to explain nurses’ intention to care for COVID-19 patients in an infectious disease hospital. Nurses’ intention to care for COVID-19 patients was high. Ethical nursing competence had a significant moderating effect on the relationship between PBC and intention to care: the higher the level of ethical nursing competence, the greater the effect of PBC on intention to care. Based on findings of this study, it is necessary to explore various ways to enhance ethical nursing competence for nurses on the frontline of the emerging infectious disease pandemic.

Data availability

The data and materials of this study are available from the corresponding author upon reasonable request.

Abbreviations

Attitude toward the behavior

Coronavirus Disease 2019

Perceived behavioral control

Severe Acute Respiratory Syndrome

Subjective norm

Theory of planned behavior

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M.M performed conceptualization of this study, data collection, data analysis, and preparation of the manuscript. S.M performed conceptualization of this study, data curation and analysis, interpretation of results, preparation of the manuscript, and revision of the manuscript. E.K.S performed data curation and analysis, interpretation of results, preparation of the manuscript, and revision of the manuscript.

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Mo, M., Moon, S. & Song, E.K. Nurses’ intention to care of COVID-19 patients in hospitals dedicated to infectious disease in South Korea: application of the theory of planned behavior and verification of the moderating effect of ethical nursing competence. BMC Nurs 23 , 410 (2024). https://doi.org/10.1186/s12912-024-02072-y

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Election latest: Labour to 'simplify' transitioning process; betting scandal hangs over Tories

Labour have plans to "simplify" the transitioning process, which will streamline the procedure of acquiring a gender recognition certificate. Elsewhere today, Sky News is interviewing Northern Ireland party leaders and will broadcast live from the nation at 8pm.

Monday 24 June 2024 07:09, UK

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• Labour to 'simplify' transitioning process
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The Conservative Party has been quick off the mark to reply to Labour's plans to simplify the transitioning process.

Kemi Badenoch, the women and equalities minister, said: "These proposals unravel all the protections in the current system designed to protect women and girls.

"This change creates more loopholes for predators and bad faith actors to infiltrate women-only spaces and put us at risk.

"Labour have never understood or cared about this issue or the vulnerable women impacted by their policies. 

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"Labour's promise of change is definitely change for the worse."

Labour are planning to simplify the process for people to transition, if they enter government.

The party wants to ditch the current two-year waiting period for people to acquire a gender recognition certificate (GRC) - instead implementing a similar length "cooling-off period" after applying for a GRC, Sky News understands.

This echoes similar policies the party proposed earlier in the year.

It follows JK Rowling's intervention on Friday night, when she attacked Labour over its position ( read more here ).

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The DUP will be launching their manifesto later this morning.

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Speaking to us this morning on behalf of the Conservative Party will be Northern Ireland Secretary Chris Heaton-Harris at 7.15am .

Labour's shadow health secretary Wes Streeting will be on at 8.15am .

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Veterans minister Johnny Mercer has tonight offered further details of an "awkward" hustings in Plymouth, after which he claimed his Labour rival was "bloating" his military service.

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Labour has said Mr Thomas is unable to discuss much of his role in the armed forces because of its "sensitive" nature.

Now, in a lengthy social media post, Mr Mercer described the event, which he said "descended into anarchy".

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By Adam Boulton , Sky News commentator

Have you ever taken part in an opinion poll? I was about to say I haven't and then a dim memory surfaced from decades ago of a nice lady with a clipboard asking me questions in the Berkshire town of Pangbourne.

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In this election, there are at least 18 separate companies publishing voting intention polls. They are busier than ever now the campaign is under way.

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A flurry of general elections since 2015 has brought an unprecedented churn in our parliamentary representatives.

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An unparalleled total of 23% of Conservative MPs are calling it a day in 2024, more than the previous high of 22% of Tories who quit in 1997, another year of boundary changes.

In contrast, only 15% of Labour MPs are resigning.

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This is the question asked by our political correspondent Darren McCaffrey ...

In 2019, Liz Truss was once again elected MP for South West Norfolk - her fourth election win.

The then international trade secretary and later prime minister romped home to victory with nearly 70% of the vote.

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• Earl Elvis of East Anglia - The Official Monster Raving Loony Party • James Bagge - Independent • Gary Conway - Heritage Party • Pallavi Devulapalli - Green Party • Lorraine Douglas - Communist Party of Great Britain • Terry Jermy - Labour Party • Toby McKenzie - Reform UK • Josie Ratcliffe - Liberal Democrats • Liz Truss - Conservative and Unionist Party

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