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Evidence-Based Practice and Nursing Research

Evidence-based practice is now widely recognized as the key to improving healthcare quality and patient outcomes. Although the purposes of nursing research (conducting research to generate new knowledge) and evidence-based nursing practice (utilizing best evidence as basis of nursing practice) seem quite different, an increasing number of research studies have been conducted with the goal of translating evidence effectively into practice. Clearly, evidence from research (effective innovation) must be accompanied by effective implementation, and an enabling context to achieve significant outcomes.

As mentioned by Professor Rita Pickler, “nursing science needs to encompass all manner of research, from discovery to translation, from bench to bedside, from mechanistic to holistic” ( Pickler, 2018 ). I feel that The Journal of Nursing Research must provide an open forum for all kind of research in order to help bridge the gap between research-generated evidence and clinical nursing practice and education.

In this issue, an article by professor Ying-Ju Chang and colleagues at National Cheng Kung University presents an evidence-based practice curriculum for undergraduate nursing students developed using an action research-based model. This “evidence-based practice curriculum” spans all four academic years, integrates coursework and practicums, and sets different learning objectives for students at different grade levels. Also in this issue, Yang et al. apply a revised standard care procedure to increase the ability of critical care nurses to verify the placement of nasogastric tubes. After appraising the evidence, the authors conclude that the aspirate pH test is the most reliable and economical method for verifying nasogastric tube placement at the bedside. They subsequently develop a revised standard care procedure and a checklist for auditing the procedure, conduct education for nurses, and examine the effectiveness of the revised procedure.

I hope that these two studies help us all better appreciate that, in addition to innovation and new breakthrough discoveries, curriculum development and evidence-based quality improvement projects, though may not seem so novel, are also important areas of nursing research. Translating evidence into practice is sound science and merits more research.

Cite this article as: Chien, L. Y. (2019). Evidence-based practice and nursing research. The Journal of Nursing Research, 27 (4), e29. https://doi.org/10.1097/jnr.0000000000000346

• Pickler R. H. (2018). Honoring the past, pursuing the future . Nursing Research , 67 ( 1 ), 1–2. 10.1097/NNR.0000000000000255 [ PubMed ] [ CrossRef ] [ Google Scholar ]

A nurses' guide to the hierarchy of research designs and evidence

• Australian Journal of Advanced Nursing 33(3):38-43
• 33(3):38-43

• University of New England (Australia)

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Evidence-Based Practice for Nursing: Evaluating the Evidence

• What is Evidence-Based Practice?
• Asking the Clinical Question
• Finding Evidence
• Evaluating the Evidence
• Articles, Books & Web Resources on EBN

Evaluating Evidence: Questions to Ask When Reading a Research Article or Report

For guidance on the process of reading a research book or an article, look at Paul N. Edward's paper,  How to Read a Book  (2014) . When reading an article, report, or other summary of a research study, there are two principle questions to keep in mind:

1. Is this relevant to my patient or the problem?

• Once you begin reading an article, you may find that the study population isn't representative of the patient or problem you are treating or addressing. Research abstracts alone do not always make this apparent.
• You may also find that while a study population or problem matches that of your patient, the study did not focus on an aspect of the problem you are interested in. E.g. You may find that a study looks at oral administration of an antibiotic before a surgical procedure, but doesn't address the timing of the administration of the antibiotic.
• The question of relevance is primary when assessing an article--if the article or report is not relevant, then the validity of the article won't matter (Slawson & Shaughnessy, 1997).

2. Is the evidence in this study valid?

• Validity is the extent to which the methods and conclusions of a study accurately reflect or represent the truth. Validity in a research article or report has two parts: 1) Internal validity--i.e. do the results of the study mean what they are presented as meaning? e.g. were bias and/or confounding factors present? ; and 2) External validity--i.e. are the study results generalizable? e.g. can the results be applied outside of the study setting and population(s) ?
• Determining validity can be a complex and nuanced task, but there are a few criteria and questions that can be used to assist in determining research validity. The set of questions, as well as an overview of levels of evidence, are below.

For a checklist that can help you evaluate a research article or report, use our checklist for Critically Evaluating a Research Article

• How to Critically Evaluate a Research Article

How to Read a Paper--Assessing the Value of Medical Research

Evaluating the evidence from medical studies can be a complex process, involving an understanding of study methodologies, reliability and validity, as well as how these apply to specific study types. While this can seem daunting, in a series of articles by Trisha Greenhalgh from BMJ, the author introduces the methods of evaluating the evidence from medical studies, in language that is understandable even for non-experts. Although these articles date from 1997, the methods the author describes remain relevant. Use the links below to access the articles.

• How to read a paper: Getting your bearings (deciding what the paper is about) Not all published research is worth considering. This provides an outline of how to decide whether or not you should consider a research paper. more... less... Greenhalgh, T. (1997b). How to read a paper. Getting your bearings (deciding what the paper is about). BMJ (Clinical Research Ed.), 315(7102), 243–246.
• Assessing the methodological quality of published papers This article discusses how to assess the methodological validity of recent research, using five questions that should be addressed before applying recent research findings to your practice. more... less... Greenhalgh, T. (1997a). Assessing the methodological quality of published papers. BMJ (Clinical Research Ed.), 315(7103), 305–308.
• How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests This article and the next present the basics for assessing the statistical validity of medical research. The two articles are intended for readers who struggle with statistics more... less... Greenhalgh, T. (1997f). How to read a paper. Statistics for the non-statistician. I: Different types of data need different statistical tests. BMJ (Clinical Research Ed.), 315(7104), 364–366.
• How to read a paper: Statistics for the non-statistician II: "Significant" relations and their pitfalls The second article on evaluating the statistical validity of a research article. more... less... Greenhalgh, T. (1997). Education and debate. how to read a paper: Statistics for the non-statistician. II: "significant" relations and their pitfalls. BMJ: British Medical Journal (International Edition), 315(7105), 422-425. doi: 10.1136/bmj.315.7105.422
• How to read a paper. Papers that report drug trials more... less... Greenhalgh, T. (1997d). How to read a paper. Papers that report drug trials. BMJ (Clinical Research Ed.), 315(7106), 480–483.
• How to read a paper. Papers that report diagnostic or screening tests more... less... Greenhalgh, T. (1997c). How to read a paper. Papers that report diagnostic or screening tests. BMJ (Clinical Research Ed.), 315(7107), 540–543.
• How to read a paper. Papers that tell you what things cost (economic analyses) more... less... Greenhalgh, T. (1997e). How to read a paper. Papers that tell you what things cost (economic analyses). BMJ (Clinical Research Ed.), 315(7108), 596–599.
• Papers that summarise other papers (systematic reviews and meta-analyses) more... less... Greenhalgh, T. (1997i). Papers that summarise other papers (systematic reviews and meta-analyses). BMJ (Clinical Research Ed.), 315(7109), 672–675.
• How to read a paper: Papers that go beyond numbers (qualitative research) A set of questions that could be used to analyze the validity of qualitative research more... less... Greenhalgh, T., & Taylor, R. (1997). Papers that go beyond numbers (qualitative research). BMJ (Clinical Research Ed.), 315(7110), 740–743.

Levels of Evidence

In some journals, you will see a 'level of evidence' assigned to a research article. Levels of evidence are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. The combination of these attributes gives the level of evidence for a study.  Many systems for assigning levels of evidence exist.  A frequently used system in medicine is from the  Oxford Center for Evidence-Based Medicine .  In nursing, the system for assigning levels of evidence is often from Melnyk & Fineout-Overholt's 2011 book,  Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice .  The Levels of Evidence below are adapted from Melnyk & Fineout-Overholt's (2011) model.  

Uses of Levels of Evidence : Levels of evidence from one or more studies provide the "grade (or strength) of recommendation" for a particular treatment, test, or practice. Levels of evidence are reported for studies published in some medical and nursing journals. Levels of Evidence are most visible in Practice Guidelines, where the level of evidence is used to indicate how strong a recommendation for a particular practice is. This allows health care professionals to quickly ascertain the weight or importance of the recommendation in any given guideline. In some cases, levels of evidence in guidelines are accompanied by a Strength of Recommendation.

About Levels of Evidence and the Hierarchy of Evidence : While Levels of Evidence correlate roughly with the hierarchy of evidence (discussed elsewhere on this page), levels of evidence don't always match the categories from the Hierarchy of Evidence, reflecting the fact that study design alone doesn't guarantee good evidence. For example, the systematic review or meta-analysis of randomized controlled trials (RCTs) are at the top of the evidence pyramid and are typically assigned the highest level of evidence, due to the fact that the study design reduces the probability of bias  ( Melnyk , 2011),  whereas the weakest level of evidence is the  opinion from authorities and/or reports of expert committees.  However, a systematic review may report very weak evidence for a particular practice and therefore the level of evidence behind a recommendation may be lower than the position of the study type on the Pyramid/Hierarchy of Evidence.

About Levels of Evidence and Strength of Recommendation : The fact that a study is located lower on the Hierarchy of Evidence does not necessarily mean that the strength of recommendation made from that and other studies is low--if evidence is consistent across studies on a topic and/or very compelling, strong recommendations can be made from evidence found in studies with lower levels of evidence, and study types located at the bottom of the Hierarchy of Evidence. In other words, strong recommendations can be made from lower levels of evidence.

For example: a case series observed in 1961 in which two physicians who noted a high incidence (approximately 20%) of children born with birth defects to mothers taking thalidomide resulted in very strong recommendations against the prescription and eventually, manufacture and marketing of thalidomide. In other words, as a result of the case series, a strong recommendation was made from a study that was in one of the lowest positions on the hierarchy of evidence.

Hierarchy of Evidence for Quantitative Questions

The pyramid below represents the hierarchy of evidence, which illustrates the strength of study types; the higher the study type on the pyramid, the more likely it is that the research is valid. The pyramid is meant to assist researchers in prioritizing studies they have located to answer a clinical or practice question. 

For clinical questions, you should try to find articles with the highest quality of evidence. Systematic Reviews and Meta-Analyses are considered the highest quality of evidence for clinical decision-making and should be used above other study types, whenever available, provided the Systematic Review or Meta-Analysis is fairly recent. 

As you move up the pyramid, fewer studies are available, because the study designs become increasingly more expensive for researchers to perform. It is important to recognize that high levels of evidence may not exist for your clinical question, due to both costs of the research and the type of question you have.  If the highest levels of study design from the evidence pyramid are unavailable for your question, you'll need to move down the pyramid.

While the pyramid of evidence can be helpful, individual studies--no matter the study type--must be assessed to determine the validity.

Hierarchy of Evidence for Qualitative Studies

Qualitative studies are not included in the Hierarchy of Evidence above. Since qualitative studies provide valuable evidence about patients' experiences and values, qualitative studies are important--even critically necessary--for Evidence-Based Nursing. Just like quantitative studies, qualitative studies are not all created equal. The pyramid below  shows a hierarchy of evidence for qualitative studies.

Adapted from Daly et al. (2007)

Help with Research Terms & Study Types: Cut through the Jargon!

• CEBM Glossary
• Centre for Evidence-Based Medicine|Toronto
• Cochrane Collaboration Glossary
• Qualitative Research Terms (NHS Trust)
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Evidence-Based Nursing Research Guide: Evidence Levels & Types

• Key Resources
• Evidence-Based Nursing Definitions
• Evidence Levels & Types
• PICO Search Strategy
• Systematic Reviews This link opens in a new window
• Books & eBooks
• Background Information
• Organizations

Evidence Pyramid

Depending on their purpose, design, and mode of reporting or dissemination, health-related research studies can be ranked according to the strength of evidence they provide, with the sources of strongest evidence at the top, and the weakest at the bottom:

Secondary Sources: studies of studies

Systematic Review

• Identifies, appraises, and synthesizes all empirical evidence that meets pre-specified eligibility criteria
• Methods section outlines a detailed search strategy used to identify and appraise articles
• May include a meta-analysis, but not required (see Meta-Analysis below)

Meta-Analysis

• A subset of systematic reviews: uses quantitative methods to combine the results of independent studies and synthesize the summaries and conclusions
• Methods section outlines a detailed search strategy used to identify and appraise articles; often surveys clinical trials
• Can be conducted independently, or as a part of a systematic review
• All meta-analyses are systematic reviews, but not all systematic reviews are meta-analyses

Evidence-Based Guideline

• Provides a brief summary of evidence for a general clinical question or condition
• Produced by professional health care organizations, practices, and agencies that systematically gather, appraise, and combine the evidence
• Click on the 'Evidence-Based Care Sheets' link located at the top of the  CINAHL  screen to find short overviews of evidence-based care recommendations covering 140 or more health care topics.

Meta-Synthesis or Qualitative Synthesis (Systematic Review of Qualitative or Descriptive Studies)

• a systematic review of qualitative or descriptive studies, low strength level

Primary Sources: original studies

Randomized Controlled Trial

• Experiment where individuals are randomly assigned to an experimental or control group to test the value or efficiency of a treatment or intervention

Non-Randomized Controlled Clinical Trial (Quasi-Experimental)

• Involves one or more test treatments, at least one control treatment, specified outcome measures for evaluating the studied intervention, and a bias-free method for assigning patients to the test treatment

Case-Control or Case-Comparison Study (Non-Experimental)

• Individuals with a particular condition or disease (the cases) are selected for comparison with individuals who do not have the condition or disease (the controls)

Cohort Study (Non-Experimental)

• Identifies subsets (cohorts) of a defined population
• Cohorts may or may not be exposed to factors that researchers hypothesize will influence the probability that participants will have a particular disease or other outcome
• Researchers follow cohorts in an attempt to determine distinguishing subgroup characteristics

Further Reading

• Levels of Evidence - EBP Toolkit Winona State University
• Levels of Evidence Northern Virginia Community College
• Types of Evidence University of Missouri - St Louis
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• Next: PICO Search Strategy >>
• Last Updated: May 28, 2024 8:43 AM
• URL: https://libguides.depaul.edu/ebp

• Levels of Evidence

When searching for evidence-based information, one should select the highest level of evidence  available. Clinicians must understand the types of evidence and their relative quality in the hierarchy of research evidence. The Levels of Evidence pyramid below represents the relative quality of types of evidence with the  least clinically relevant at the bottom and the most clinically relevant at the top .  

                                          LEVELS OF EVIDENCE

Image adapted from:  Murad MH, Asi N, Alsawas M, &Alhadab, F. (2016). New evidence pyramid.  BMJ Evidence-Based Medicine,  (English Ed.) ,  21 (4), 125–127. https://doi.org/10.1136/ebmed-2016-110401

• OpenMD Levels of Evidence An overview of the Levels of Evidence pyramid including study types.

Study Types

Systematic Reviews summarize the results of a systematic literature search on a specific clinical question to develop clinical recommendations. The studies are reviewed, assessed, and the results are summarized according to the predetermined criteria of the review question. They assess the methodology, sample size, and quality of the studies, using the highest quality data available to answer specific clinical questions and develop practice recommendations.

Meta-Analysis takes this process one-step further, reviewing a clinical question for which multiple systematic reviews exist and combining all the results using accepted statistical methodology  

Randomized, Controlled Clinical Trial - A prospective, analytical, experimental study using primary data generated in the clinical environment. Individuals who are similar at the beginning are randomly allocated to two or more groups (treatment and control) and the outcomes of the groups are compared after sufficient follow-up time.

A study that shows the efficacy of a diagnostic test is called a prospective, blind comparison to a gold standard study. This is a controlled trial that looks at patients with varying degrees of an illness and administers both diagnostic tests -- the test under investigation and the "gold standard" test -- to all of the patients in the study.

Cohort Studies  identify a large population who already has a specific exposure or treatment, follows them over time (prospective), and compares outcomes with another group that has not been affected by the exposure or treatment being studied. Cohort studies are observational and not as reliable as randomized controlled studies, since the two groups may differ in ways other than in the variable under study.

Case Control Studies  are studies in which patients who already have a specific condition or outcome are compared with people who do not. Researchers look back in time (retrospective) to identify possible exposures. They often rely on medical records and patient recall for data collection. These types of studies are often less reliable than randomized controlled trials and cohort studies because showing a statistical relationship does not mean than one factor necessarily caused the other.

Case Series and Case Reports  consist of collections of reports on the treatment of individual patients or a report on a single patient. Because they are reports of cases and use no control groups with which to compare outcomes, they have no statistical validity.

Background Information / Expert Opinion  use varied evidence to present information that ranges from expert opinion to providing summaries of well-known information with established evidence. They are good resources to begin understanding a topic, learning definitions, and clinical parameters. However, when answering an EBP question, look for information with statistically significant data from resources higher-up in the pyramid.

Source: Duke University Medical Center Library: Evidence-Based Medicine Resources

Filtered Information vs Unfiltered Information

Filtered Information - Information that has been collected and aggregated by expert analysis and review. The quality of the studies has already been appraised and recommendations for practice may have already been made. Examples include systematic reviews and meta-analyses .

Unfiltered Information - Primary or original research studies. Original research studies that have not yet been synthesized or aggregated such as randomized controlled trials (RCTs), cohort studies and case-control studies, which are often published in peer-reviewed journals. These studies have not undergone additional analysis and review beyond that of the peer review process for each study.

• << Previous: Finding the Evidence
• Next: Systematic Reviews and Meta Analyses >>
• Evidence-Based Medicine/Evidence-Based Practice
• Evidence-Based Practice in Nursing
• EBP in Nursing: More Resources
• Question Types
• Systematic Reviews and Meta Analyses
• Study Types & Terminology
• Quantitative vs. Qualitative Research
• Critical Appraisal: Evaluating Studies
• Conducting a Systematic Review
• Research Study Design
• Selected Print and Electronic Reference Books for EBP
• Finding a Book on the Shelf by Call Number
• Finding EBP Articles in the Databases
• Selected Evidence Based Practice Journals
• Finding the Full Text of an Article from a Citation
• Intro to Nursing Databases
• Databases for EBP
• Intro to Nursing Resources
• Citation Management Programs
• Sample Annotated Bibliography
• Last Updated: Jun 7, 2024 4:03 PM
• URL: https://libguides.adelphi.edu/evidence-based-practice

Levels of Evidence and Study Design: Levels of Evidence

Levels of evidence.

• Study Design
• Study Design by Question Type
• Rating Systems

This is a general set of levels to aid in critically evaluating evidence. It was adapted from the model presented in the book, Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice  (Melnyk & Fineout-Overholt, 2019). Some specialties may have adopted a slightly different and/or smaller set of levels.

Evidence from a clinical practice guideline based on systematic reviews or meta-analyses of randomized controlled trials. Is this is not available, then evidence from a systematic review or meta-analysis of random controlled trials.

Evidence from randomized controlled studies with good design.

Evidence from controlled trials that have good design but are not randomized.

Evidence from case-control and cohort studies with good design.

Evidence from systematic reviews of qualitative and descriptive studies.

Evidence from qualitative and descriptive studies.

Evidence from the opinion of authorities and/or the reports of expert committees. 

Evidence Pyramid

The pyramid below is a hierarchy of evidence for quantitative studies. It shows the hierarchy of studies by study design; starting with secondary and reappraised studies, then primary studies, and finally reports and opinions, which have no study design. This pyramid is a simplified, amalgamation of information presented in the book chapter “Evidence-based decision making” (Forest et al., 2019) and book Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice  (Melnyk & Fineout-Overholt, 2019).

Evidence Table for Nursing

Advocate Health - Midwest provides system-wide evidence based practice resources. The Nursing Hub* has an Evidence-Based Quality Improvement (EBQI) Evidence Table , within the Evidence-Based Practice (EBP) Resource. It also includes information on evidence type, and a literature synthesis table.

*The Nursing Hub requires access to the Advocate Health - Midwest SharePoint platform.

Forrest, J. L., Miller, S. A., Miller, G. W., Elangovan, S., & Newman, M. G. (2019). Evidence-based decision making. In M. G. Newman, H. H. Takei, P. R. Klokkevold, & F. A. Carranza (Eds.),  Newman and Carranza's clinical periodontology  (13th ed., pp. 1-9.e1). Elsevier.

• Melnyk, B. M., & Fineout-Overholt, E. (2019).  Evidence-based practice in nursing and healthcare: A guide to best practice  (4th ed.). Wolters Kluwer. 
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• Last Updated: Dec 29, 2023 2:03 PM
• URL: https://library.aah.org/guides/levelsofevidence

Nursing-Johns Hopkins Evidence-Based Practice Model

Jhebp model for levels of evidence, jhebp levels of evidence overview.

• Levels I, II and III

Evidence-Based Practice (EBP) uses a rating system to appraise evidence (usually a research study published as a journal article). The level of evidence corresponds to the research study design. Scientific research is considered to be the strongest form of evidence and recommendations from the strongest form of evidence will most likely lead to the best practices. The strength of evidence can vary from study to study based on the methods used and the quality of reporting by the researchers. You will want to seek the highest level of evidence available on your topic (Dang et al., 2022, p. 130).

The Johns Hopkins EBP model uses 3 ratings for the level of scientific research evidence 

• true experimental (level I)
• quasi-experimental (level II)
• nonexperimental (level III) 

The level determination is based on the research meeting the study design requirements  (Dang et al., 2022, p. 146-7).

You will use the Research Appraisal Tool (Appendix E) along with the Evidence Level and Quality Guide (Appendix D) to analyze and  appraise research studies . (Tools linked below.)

N onresearch evidence is covered in Levels IV and V.

• Evidence Level and Quality Guide (Appendix D)
• Research Evidence Appraisal Tool (Appendix E)

Level I Experimental study

randomized controlled trial (RCT)

Systematic review of RCTs, with or without meta-analysis

Level II Quasi-experimental Study

Systematic review of a combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis.

Level III Non-experimental study

Systematic review of a combination of RCTs, quasi-experimental and non-experimental, or non-experimental studies only, with or without meta-analysis.

Qualitative study or systematic review, with or without meta-analysis

Level IV Opinion of respected authorities and/or nationally recognized expert committees/consensus panels based on scientific evidence.

Clinical practice guidelines

Consensus panels

Level V Based on experiential and non-research evidence.

Literature reviews

Quality improvement, program, or financial evaluation

Case reports

Opinion of nationally recognized expert(s) based on experiential evidence

These flow charts can also help you detemine the level of evidence throigh a series of questions.

Single Quantitative Research Study

Summary/Reviews 

These charts are a part of the Research Evidence Appraisal Tool (Appendix E) document.

Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International

• << Previous: Start Here
• Next: Levels I, II and III >>
• Last Updated: Feb 8, 2024 1:24 PM
• URL: https://bradley.libguides.com/jhebp

Nursing - Systematic Reviews: Levels of Evidence

• Levels of Evidence
• Meta-Analyses
• Definitions
• Citation Search
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"How would I use the 6S Model while taking care of a patient?" .cls-1{fill:#fff;stroke:#79a13f;stroke-miterlimit:10;stroke-width:5px;}.cls-2{fill:#79a13f;} The 6S Model is designed to work from the top down, starting with Systems - also referred to as computerized decision support systems (CDSSs). DiCenso et al. describes that, “an evidence-based clinical information system integrates and concisely summarizes all relevant and important research evidence about a clinical problem, is updated as new research evidence becomes available, and automatically links (through an electronic medical record) a specific patient’s circumstances to the relevant information” (2009). Systematic reviews lead up to this type of bio-available level of evidence.

What are systematic reviews, polit–beck evidence hierarchy/levels of evidence scale for therapy questions.

"Figure 2.2 [in context of book] shows our eight-level evidence hierarchy for Therapy/intervention questions. This hierarchy ranks sources of evidence with respect the readiness of an intervention to be put to use in practice" (Polit & Beck, 2021, p. 28). Levels are ranked on risk of bias - level one being the least bias, level eight being the most biased. There are several types of levels of evidence scales designed for answering different questions. "An evidence hierarchy for Prognosis questions, for example, is different from the hierarchy for Therapy questions" (p. 29).

Advantages of Levels of Evidence Scales

"Through controls imposed by manipulation, comparison, and randomization, alternative explanations can be discredited. It is because of this strength that meta-analyses of RCTs, which integrate evidence from multiple experiments, are at the pinnacle of the evidence hierarchies for Therapy questions" (p. 188).

"Tip: Traditional evidence hierarchies or level of evidence scales (e.g., Figure 2.2), rank evidence sources almost exclusively based on the risk of internal validity threats" (p. 217).

Systematic reviews can provide researchers with knowledge that prior evidence shows. This can help clarify established efficacy of a treatment without unnecessary and thus unethical research. Greenhalgh (2019) illustrates this citing Dean Fergusson and colleagues (2005) systematic review on a clinical surgical topic (p. 128).

Limits of Levels of Evidence Scales

Regarding the importance of real-world clinical practice settings, and the conflicting tradeoffs between internal and external validity, Polit and Beck (2021) write, "the first (and most prevalent) approach is to emphasize one and sacrifice another. Most often, it is external validity that is sacrificed. For example, external validity is not even considered in ranking evidence in level of evidence scales" (p. 221). ... From an EBP perspective, it is important to remember that drawing inferences about causal relationships relies not only on how high up on the evidence hierarchy a study is (Figure 2.2), but also, for any given level of the hierarchy, how successful the researcher was in managing study validity and balancing competing validity demands" (p. 222).

Polit and Beck note Levin (2014) that an evidence hierarchy "is not meant to provide a quality rating for evidence retrieved in the search for an answer" (p. 6), and as the Oxford Center for Evidence-Based Medicine concurs that evidence scales are, 'NOT intended to provide you with a definitive judgment about the quality of the evidence. There will inevitably be cases where "lower-level" evidence...will provide stronger than a "higher level" study (Howick et al., 2011, p.2)'" (p. 30).

Level of evidence (e.g., Figure 2.2) + Quality of evidence = Strength of evidence .

The 6S Model of Levels of Evidence

"The 6S hierarchy does not imply a gradient of evidence in terms of quality , but rather in terms of ease in retrieving relevant evidence to address a clinical question. At all levels, the evidence should be assessed for quality and relevance" (Polit & Beck, 2021, p. 24, Tip box).

The 6S Pyramid proposes a structure of quantitative evidence where articles that include pre-appraised and pre-synthesized studies are located at the top of the hierarchy (McMaster U., n.d.).

It can help to consider the level of evidence that a document represents, for example, a scientific article that summarizes and analyses many similar articles may provide more insight than the conclusion of a single research article. This is not to say that summaries can not be flawed, nor does it suggest that rare case studies should be ignored. The aim of health research is the well-being of all people, therefore it is important to use current evidence in light of patient preferences negotiated with clinical expertise.

Other Gradings in Levels of Evidence

While it is accepted that the strongest evidence is derived from meta-analyses, various evidence grading systems exist. for example: The Johns Hopkins Nursing Evidence-Based Practice model ranks evidence from level I to level V, as follows (Seben et al., 2010): Level I: Meta-analysis of randomized clinical trials (RCTs); experimental studies; RCTs Level II: Quasi-experimental studies Level III: Non-experimental or qualitative studies Level IV: Opinions of nationally recognized experts based on research evidence or an expert consensus panel Level V: Opinions of individual experts based on non-research evidence (e.g., case studies, literature reviews, organizational experience, and personal experience) The American Association of Critical-Care Nurses (AACN) evidence level system , updated in 2009, ranks evidence as follows (Armola et al., 2009): Level A: Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment Level B: Well-designed, controlled randomized or non-randomized studies with results that consistently support a specific action, intervention, or treatment Level C: Qualitative, descriptive, or correlational studies, integrative or systematic reviews, or RCTs with inconsistent results Level D: Peer-reviewed professional organizational standards, with clinical studies to support recommendations Level E: Theory-based evidence from expert opinion or multiple case reports Level M: Manufacturers’ recommendations (2017)

EBM Pyramid and EBM Page Generator

Unfiltered are resources that are primary sources describing original research. Randomized controlled trials, cohort studies, case-controlled studies, and case series/reports are considered unfiltered information.

Filtered are resources that are secondary sources which summarize and analyze the available evidence. They evaluate the quality of individual studies and often provide recommendations for practice. Systematic reviews, critically-appraised topics, and critically-appraised individual articles are considered filtered information.

Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L., ... Medina, J. (2009). AACN levels of evidence. What's new? Critical Care Nurse , 29 (4), 70-73. doi:10.4037/ccn2009969

DiCenso, A., Bayley, L., & Haynes, R. B. (2009). Accessing pre-appraised evidence: Fine-tuning the 5S model into a 6S model. BMJ Evidence-Based Nursing , 12 (4) https://ebn.bmj.com/content/12/4/99.2.short

Fergusson, D., Glass, K. C., Hutton, B., & Shapiro, S. (2005). Randomized controlled trials of Aprotinin in cardiac surgery: Could clinical equipoise have stopped the bleeding?. Clinical Trials , 2 (3), 218-232.

Glover, J., Izzo, D., Odato, K. & Wang, L. (2008). Evidence-based mental health resources . EBM Pyramid and EBM Page Generator. Copyright 2008. All Rights Reserved. Retrieved April 28, 2020 from https://web.archive.org/web/20200219181415/http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_psych_resources.html Note. Document removed from host. Old link used with the WayBack Machine of the Internet Archive to retrieve the original webpage on 2/10/21 http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_psych_resources.html

Greenhalgh, T. (2019). How to read a paper: The basics of evidence-based medicine and healthcare . (Sixth ed.). Wiley Blackwell.

Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: The “4S” evolution of services for finding current best evidence. BMJ Evidence-Based Medicine , 6 (2), 36-38.

Haynes, R. B. (2006). Of studies, syntheses, synopses, summaries, and systems: the “5S” evolution of information services for evidence-based healthcare decisions. BMJ Evidence-Based Medicine , 11 (6), 162-164.

McMaster University (n.d.). 6S Search Pyramid Tool https://www.nccmt.ca/capacity-development/6s-search-pyramid

Polit, D., & Beck, C. (2019). Nursing research: Generating and assessing evidence for nursing practice . Wolters Kluwer Health.

Schub, E., Walsh, K. & Pravikoff D. (Ed.) (2017). Evidence-based nursing practice: Implementing [Skill Set]. Nursing Reference Center Plus

Seben, S., March, K. S., & Pugh, L. C. (2010). Evidence-based practice: The forum approach. American Nurse Today , 5 (11), 32-34.

• Systematic Review from the Encyclopedia of Nursing Research by Cheryl Holly Systematic reviews provide reliable evidential summaries of past research for the busy practitioner. By pooling results from multiple studies, findings are based on multiple populations, conditions, and circumstances. The pooled results of many small and large studies have more precise, powerful, and convincing conclusions (Holly, Salmond, & Saimbert, 2016) [ references in article ]. This scholarly synthesis of research findings and other evidence forms the foundation for evidence-based practice allowing the practitioner to make up-to-date decisions.

Standards & Guides

• Cochrane Handbook for Systematic Reviews of Interventions The Cochrane Handbook for Systematic Reviews of Interventions is the official guide that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.
• Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) PRISMA is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. PRISMA focuses on the reporting of reviews evaluating randomized trials, but can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions.
• Systematic Reviews by The Centre for Reviews and Dissemination "The guidance has been written for those with an understanding of health research but who are new to systematic reviews; those with some experience but who want to learn more; and for commissioners. We hope that experienced systematic reviewers will also find this guidance of value; for example when planning a review in an area that is unfamiliar or with an expanded scope. This guidance might also be useful to those who need to evaluate the quality of systematic reviews, including, for example, anyone with responsibility for implementing systematic review findings" (CRD, 2009, p. vi, "Who should use this guide")

• Carrying out systematic literature reviews: An introduction by Alan Davies Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making (Davies, 2019, Abstract)
• Papers that summarize other papers (systematic reviews and meta-analyses) by Trisha Greenhalgh ... a systematic review is an overview of primary studies that: contains a statement of objectives, sources and methods; has been conducted in a way that is explicit, transparent and reproducible (Figure 9.1) [ Table found in book chapter ]. The most enduring and reliable systematic reviews, notably those undertaken by the Cochrane Collaboration (discussed later in this chapter), are regularly updated to incorporate new evidence (Greenhalgh, 2020, p. 117, Chapter 9).
• A PRISMA assessment of the reporting quality of systematic reviews of nursing published in the Cochrane Library and paper-based journals by Juxia Zhang et al. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was released as a standard of reporting systematic reviewers (SRs). However, not all SRs adhere completely to this standard. This study aimed to evaluate the reporting quality of SRs published in the Cochrane Library and paper-based journals (Zhang et al., 2019, Abstract).

Cochrane [Username]. (2016, Jan 27). What are systematic reviews? YouTube. https://www.youtube.com/watch?v=egJlW4vkb1Y

Davies, A. (2019). Carrying out systematic literature reviews: An introduction. British Journal of Nursing , 28 (15), 1008–1014. https://doi-org.ezproxy.simmons.edu/10.12968/bjon.2019.28.15.1008

Greenhalgh, T. (2019). Papers that summarize other papers (systematic reviews and meta-analyses). In How to read a Paper : The basics of evidence-based medicine and healthcare . (Sixth ed., pp. 117-136). Wiley Blackwell.

Holly, C. (2017). Systematic review. In J. Fitzpatrick (Ed.), Encyclopedia of nursing research (4th ed.). Springer Publishing Company. Credo Reference.

Zhang, J., Han, L., Shields, L., Tian, J., & Wang, J. (2019). A PRISMA assessment of the reporting quality of systematic reviews of nursing published in the Cochrane Library and paper-based journals. Medicine , 98 (49), e18099. https://doi.org/10.1097/MD.0000000000018099

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Example of a Table of Evidence

• Evidence table

Assessing the evidence and Building a Table

• EBM-Assessing the Evidence, Critical Appraisal

One of the most important steps in writing a paper is showing the strength and rationale of the evidence you chosen.  The following document discusses the reasoning, grading and creation of a "Table of Evidence."  While table of evidences can differ, the examples given in this article are a great starting point.

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• Volume 20, Issue 3
• Mixed methods research: expanding the evidence base
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• Allison Shorten 1 ,
• Joanna Smith 2
• 1 School of Nursing , University of Alabama at Birmingham , USA
• 2 Children's Nursing, School of Healthcare , University of Leeds , UK
• Correspondence to Dr Allison Shorten, School of Nursing, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294, USA; [email protected]; ashorten{at}uab.edu

https://doi.org/10.1136/eb-2017-102699

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Introduction

‘Mixed methods’ is a research approach whereby researchers collect and analyse both quantitative and qualitative data within the same study. 1 2 Growth of mixed methods research in nursing and healthcare has occurred at a time of internationally increasing complexity in healthcare delivery. Mixed methods research draws on potential strengths of both qualitative and quantitative methods, 3 allowing researchers to explore diverse perspectives and uncover relationships that exist between the intricate layers of our multifaceted research questions. As providers and policy makers strive to ensure quality and safety for patients and families, researchers can use mixed methods to explore contemporary healthcare trends and practices across increasingly diverse practice settings.

What is mixed methods research?

Mixed methods research requires a purposeful mixing of methods in data collection, data analysis and interpretation of the evidence. The key word is ‘mixed’, as an essential step in the mixed methods approach is data linkage, or integration at an appropriate stage in the research process. 4 Purposeful data integration enables researchers to seek a more panoramic view of their research landscape, viewing phenomena from different viewpoints and through diverse research lenses. For example, in a randomised controlled trial (RCT) evaluating a decision aid for women making choices about birth after caesarean, quantitative data were collected to assess knowledge change, levels of decisional conflict, birth choices and outcomes. 5 Qualitative narrative data were collected to gain insight into women’s decision-making experiences and factors that influenced their choices for mode of birth. 5

In contrast, multimethod research uses a single research paradigm, either quantitative or qualitative. Data are collected and analysed using different methods within the same paradigm. 6 7 For example, in a multimethods qualitative study investigating parent–professional shared decision-making regarding diagnosis of suspected shunt malfunction in children, data collection included audio recordings of admission consultations and interviews 1 week post consultation, with interactions analysed using conversational analysis and the framework approach for the interview data. 8

What are the strengths and challenges in using mixed methods?

Selecting the right research method starts with identifying the research question and study aims. A mixed methods design is appropriate for answering research questions that neither quantitative nor qualitative methods could answer alone. 4 9–11 Mixed methods can be used to gain a better understanding of connections or contradictions between qualitative and quantitative data; they can provide opportunities for participants to have a strong voice and share their experiences across the research process, and they can facilitate different avenues of exploration that enrich the evidence and enable questions to be answered more deeply. 11 Mixed methods can facilitate greater scholarly interaction and enrich the experiences of researchers as different perspectives illuminate the issues being studied. 11

The process of mixing methods within one study, however, can add to the complexity of conducting research. It often requires more resources (time and personnel) and additional research training, as multidisciplinary research teams need to become conversant with alternative research paradigms and different approaches to sample selection, data collection, data analysis and data synthesis or integration. 11

What are the different types of mixed methods designs?

Mixed methods research comprises different types of design categories, including explanatory, exploratory, parallel and nested (embedded) designs. 2   Table 1 summarises the characteristics of each design, the process used and models of connecting or integrating data. For each type of research, an example was created to illustrate how each study design might be applied to address similar but different nursing research aims within the same general nursing research area.

• View inline

Types of mixed methods designs*

What should be considered when evaluating mixed methods research?

When reading mixed methods research or writing a proposal using mixed methods to answer a research question, the six questions below are a useful guide 12 :

Does the research question justify the use of mixed methods?

Is the method sequence clearly described, logical in flow and well aligned with study aims?

Is data collection and analysis clearly described and well aligned with study aims?

Does one method dominate the other or are they equally important?

Did the use of one method limit or confound the other method?

When, how and by whom is data integration (mixing) achieved?

For more detail of the evaluation guide, refer to the McMaster University Mixed Methods Appraisal Tool. 12 The quality checklist for appraising published mixed methods research could also be used as a design checklist when planning mixed methods studies.

• Elliot AE , et al
• Creswell JW ,
• Plano ClarkV L
• Greene JC ,
• Caracelli VJ ,
• Ivankova NV
• Shorten A ,
• Shorten B ,
• Halcomb E ,
• Cheater F ,
• Bekker H , et al
• Tashakkori A ,
• Creswell JW
• 12. ↵ National Collaborating Centre for Methods and Tools . Appraising qualitative, quantitative, and mixed methods studies included in mixed studies reviews: the MMAT . Hamilton, ON : BMJ Publishing Group , 2015 . http://www.nccmt.ca/resources/search/232 (accessed May 2017) .

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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• Open access
• Published: 05 June 2024

Assessing nurses’ professional competency: a cross-sectional study in Palestine

• Rasha Abu Zaitoun 1 , 2  

BMC Nursing volume  23 , Article number:  379 ( 2024 ) Cite this article

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Evaluating nurses’ professional competence is critical for ensuring high-quality patient care. Therefore, this study aimed to evaluate the nurses’ professional competence level and to identify differences based on demographics in three West Bank hospitals.

A cross-sectional design was used, and a convenient sample of 206 nurses participated in the study. The Nurse Professional Competence (NPC) Scale was used to assess the competency level. The investigator distributed the questionnaire and explained the aim of the research. Consent forms were signed before the data collection.

The average competency level was 79% (SD = 11.5), with 90% being professionally competent nurses. The average “nursing care” competency was 79% (SD = 12.98), and the competency level in providing value-based care was 80% (SD = 13.35). The average competency level in technical and medical care was 78% (SD = 13.45), whereas 79% (SD = 12.85) was the average competence level in “Care Pedagogics” and “Documentation and Administration “. The average competence level in the development and leadership subscale was 78% (SD = 12.22). Nurses who attended three to five workshops had a higher level of Nursing Care Competency, (H = 11.98, p  = 0.003), and were more competent in value-based care (H = 9.29, p  = 0.01); in pedagogical care and patient education (H = 15.16, P  = 0.001); and in providing medical and technical care (H = 12.37, p  = 0.002). Nurses attending more than five workshops were more competent in documentation and administration (H = 12.55, p  = 0.002), and in development and leadership subscale ( H = 7.96, p  = 0.20).

The study revealed that participants lacked development and leadership skills. Engagement in workshops positively impacted the level of competencies among nurses. Notably, those attending more than five workshops exhibited greater competence in documentation, administration, development, and leadership in nursing care.

Implications

This study emphasized the role of continuing education in improving nurses’ competencies and highlighted the need to conduct the study at a wider aspect to involve more hospitals with various affiliations to help structure more sensitive professional development and adopt the competencies as an integral part of staff development.

Peer Review reports

In the contemporary world, scholars prioritize the significance and function of human resources in the progress of nations; furthermore, they assert that an organization’s most critical asset is its human capital [ 1 ]. Nurses play a critical role as the primary and most valuable human resource in healthcare organizations [ 2 ]. With significant advancements in science and technology, cost control measures, and limited time for building therapeutic patient relationships, nurses are increasingly concerned about patient safety and quality of care and are committed to improving and maintaining their competencies [ 3 ].

Contemporary perspectives on professionalism underscore that enhancing the quality of healthcare is a moral and professional obligation of all medical practitioners, especially nurses. Thus, they must exhibit dedication to professional competence, transparency with patients, and improvement of care quality [ 4 ]. Professional competency is crucial in providing nursing care, and it involves adhering to professional standards [ 5 ]. The literature extensively addresses nursing competency in terms of patient safety and the quality of care provided [ 6 ].

The Novice to Expert Theory by Patricia Benner emphasizes the importance of nursing competency. Benner’s theory supports the formation of competent and trained nurses who can address the various problems of modern healthcare by offering a developmental framework, encouraging experiential learning, promoting mentorship, and improving patient safety.

skilled and knowledgeable nurses who provide high-quality care, advance patient safety, and influence good outcomes in healthcare delivery. This study is supported by Benner’s theory that emphasizes the effect of nurses’ competency on patient outcomes [ 7 ] Identifying the level of professional competency could help categorize nurses based on their level of practice and determine the proper approach to move nurses from novice to expert.

Professional competency in nurses is defined as a combination of skills, knowledge, attitudes, values, and abilities that facilitate effective performance in occupational and professional roles [ 8 ]. It involves using knowledge, technical skills, clinical reasoning, communication, emotions, and values and rethinking daily activities to provide services to individuals and society, reflecting sound judgment and habits [ 9 ].

Globally, the professional empowerment and competency of nurses are a focus of human resource management in healthcare systems, and the World Health Organization mandates that member countries report and implement plans to strengthen nurses’ competencies [ 10 ]. Nursing competency leads to improving the quality of care, increasing patient satisfaction, enhancing nursing education, and promoting nursing as a profession [ 11 ]. Patients expect competent behavior from nurses, and following the high prevalence of medical incidents, the public and media have become concerned about clinicians’ competency [ 12 ]. Thus, professionals must demonstrate their clinical competence to perform specific roles [ 13 ]. Neglecting nursing competency can cause problems for organizations, resulting in frustration, job dissatisfaction, and attrition [ 14 ].

Professional skills and competency have an impact on job attitudes, including organizational commitment and professional affiliations [ 15 ]. To achieve the goals of the healthcare system, manpower requires not only expertise, empowerment, and competency but also high levels of organizational attachment and commitment, as well as a willingness to participate in activities beyond their predetermined duties; hence, the levels of attachment and commitment of nurses to their affiliated organizations can affect the promotion of their clinical competency [ 1 ].

Nursing competency is a fundamental skill that is essential for meeting nursing obligations; hence, it is crucial to have a clear understanding of the nursing competency level to establish the basis for nursing education programs, and professional development planning and it is vital to recognize the process of nursing competency development to ensure ongoing professional growth following the acquisition of a nursing license [ 5 ]. The fundamental concept of professional competency in nursing has a direct correlation with enhancing patient care quality and safety [ 1 ].

Currently, in Palestine, there exist various levels of nurses who have graduated from a variety of nursing schools within and outside the country. Consequently, there is a diversity in their practices both at an individual and institutional level, posing a challenge to both evaluating the quality of care delivered and standardizing nursing practices nationwide. One proposed strategy to address these obstacles involves conducting an initial assessment of nurses’ competencies to establish a foundation, followed by devising a standardized professional development scheme informed by the gathered data. Unfortunately, there is a notable absence of studies that have investigated the professional competencies of nurses across different nursing specialties, leading to the absence of a comprehensive national framework for appraising nursing competencies and a lack of a standardized approach for assessing competencies.

Given that nurses are frontline healthcare providers delivering population-based health services and gatekeepers for maintaining patient safety their competency level is critical to ensure their ability to perform their daily duties effectively and efficiently to maintain high-quality care also it is an important objective method to help the nursing administrative to assess their employees level of practices and set suitable improvement plans Therefore, it is essential to measure nurses’ competency and, once measured, to establish a standard against which practice domain and performance can be evaluated. This approach provides a framework for ensuring nurses possess the necessary knowledge and skills to carry out their responsibilities effectively.

The Joint Commission Accreditation requires measuring different types of competencies based on the main patient safety goals such as infection control practices and recommends health institutions align with an organization’s strategies, business objectives, and culture for success [ 16 ]. Most commonly measured competencies verify specific nursing skills and practices and tho, but, there are limited efforts to assess the overall nursing professional competence level.

To the best of our knowledge, this study represents the first attempt to assess the level of professional competence among nurses. The choice was made to carry out this investigation within a tertiary hospital that holds accreditation from JCI. This decision was based on the premise that nurses in such settings have been immersed in a system of competency-based evaluation, potentially yielding more insightful responses compared to their counterparts in non-JCI-accredited hospitals. Furthermore, JCI-accredited hospitals typically offer ongoing professional development initiatives. The advancement of these programs requires a thorough understanding of the overall professional competence level, which is essential for structuring purposeful developmental activities.

Therefore, this study aimed to assess the level of professional competence among nurses in a tertiary hospital in the West Bank using the Nurse Professional Competence (NPC) Scale, which evaluates self-reported professional competence.

Study design and settings

A cross-sectional descriptive-analytic design was used to recruit the targeted participants from academic, private, and Ministry of Health hospitals. The data were collected from April to July 2023.

Research procedure and sample

The sample was convenient to reach nurses in their place of work easily during their working time. The sample size was calculated using a Raosoft calculator ( http://www.raosoft.com/samplesize.html ) with a confidence level of 95%, a marginal error of 5%, and a response distribution of 50%. The estimated sample size was 286, with an attrition rate of 5%. The sample included registered nurses who provided direct patient care and had at least one year of experience in their current workplace. Head nurses, nurses who worked in the administrative field, nurses on maternal, annual, and unpaid leave, and aid nurses were excluded. Questionnaires that were completed by less than 60% of the participants were excluded from the study according to the recommendation of the original author of the tool [ 17 ]. A total of 206 nurses responded and were actively engaged in the study.

Data were gathered over a single month through the use of a self-reported, paper-based questionnaire. The questionnaire was administered in the English language because the intended participants consisted of nurses who predominantly used English for documentation and communication purposes. The questionnaires were directly distributed to the participants, allowing them to peruse the consent form, research objectives, and ethical considerations while simultaneously being encouraged to submit any inquiries they may have had. The initial page of the instrument included a description of the research aim, a consent form, and the contact information of the author.

Research instrument

The data collection questionnaire consisted of two parts: the first part included demographic and workplace information, and the second part included the short version of the Nurse Professional Competence Scale (NPC), which was utilized to assess self-reported professional competence among nurses [ 18 ]. The Nurse Professional Competence Scale was developed by Jan Nilsson and colleagues [ 17 ] in Sweden based on Swedish national guidelines and the World Health Organization’s European Strategy for Nursing and Midwifery [ 19 ]. The original NPC scale comprises eight competency domains and a total of 88 items grouped into eight competence areas, namely, nursing care, value-based nursing care, medical and technical care, teaching/learning and support, documentation and information technology, legislation in nursing and safety planning, leadership in and development of nursing care, and education. For this study, the short version of the NPC was used [ 17 ]. The reliability and validity of the NPC Scale have been confirmed in previous studies, and the Cronbach’s alpha values of all the domains were > 0.70 [ 18 ]. .

The Nurse Professional Competence Scale has been validated and shown to have good reliability and validity in various studies conducted in the Swedish language version [ 20 ]. Responses are given on a seven-point scale ranging from a very low degree (1) to a very high degree (7), with “either high or low degree” coded as (4) [ 21 ]. The competency levels were classified into four categories based on the average score of the scale and subscales: low level (0–25), rather good level (> 25–50), good level (> 50–75), and very good level (> 75–100) [ 22 ].

For this study, Permission was obtained from the authors to use the instrument and they gave instructions to analyze the scale the instrument was piloted on 10 nurses who were excluded from the study. Some modifications were made based on the results to enhance the readability and readability of the study. The needed completion time was from 10 to 15 min.

The Statistical Package for the Social Sciences (SPSS) version 21 was used to analyze the data. Descriptive statistics in terms of percentage, mean and standard deviation were used to describe the demographic and work environment factors. The competency subscale scores were calculated following the formulas recommended by the author of the short version of the NPC. The nursing care competence level was calculated by summing item numbers one through 5 divided by 25 and multiplied by 100. The value-based nursing care competence level was obtained by summing the items ranging from six to ten divided by 35 and multiplied by 100. The medical and technical care competence level was estimated by summing the results of items 11 to 16 divided by 42 and multiplied by 100. The competence level in the care pedagogic was the result of summing the items ranging from 17 to 21 divided by 35 and multiplied by 100. The documentation and administrative competence level was calculated by summing the items ranging from 22 to 29 dividing by 56 and multiplying by 100; finally, the leadership and organization subscale was assessed by summing the items from 30 to 35 dividing by 42, and multiplying by 100 [ 17 ]. Moreover, the data were not normally distributed; thus, the Mann‒Whitney test and the Kruskal‒Wallis test were used to analyze the associations between demographic information and professional competency subscale scores. A p -value < 0.05 was considered to indicate statistical significance.

Ethical considerations

The institutional review board of the Arab American University (AAUP) IRB NO. 2023/A/59. All nurses were given both verbal and written information about the aim and objectives of the study, and informed consent was obtained from all participants. Participants were assured that their confidentiality and anonymity would be preserved, that their participation was voluntary, and that they could withdraw at any time without any penalties.

Demographics and work environment factors

A total of 206 nurses, with a response rate of 72%, participated in this study to assess their professional competence level. The mean age of the participants was 29.5 years, with a minimum of 21 years and a maximum of 45 years. Male nurses represented 52.4% of the participants ( n  = 108). The majority held a bachelor’s degree in nursing ( n  = 168), and 22 (10.7%) nurses held postgraduate certificates. 57% of the nurses earned a monthly income of 500–1000 JD ( n  = 57.8). 94% of the respondents received up to five courses per year. Nearly half ( n  = 94) of the participants worked as instructors for nursing students. Among those with less than six years of experience, 97 (47.1%) and 11.7% ( n  = 24) had 12 or more years of experience, respectively (Table  1 ).

The professional competence level and subscales

Table  2 showed that the average professional competence level was 79% (SD = 11.5), with a median of 80, a minimum of 45% and a maximum of 100%. A total of 90% of the nurses were professionally competent, while 15 nurses had a competence level of less than 60%. The average “nursing care” competency was 79% (SD = 12.98), with a minimum of 34% and a maximum of 100%. The competency level of providing value-based care was 80% (SD = 13.35), with a minimum of 20% and a maximum of 100%. An average of 78% (SD = 13.45) of the participants were competent at providing technical and medical care, for a minimum of 21%. The nurses also showed an average competence level of 79% (SD = 12.85) in “Care Pedagogics”, with a minimum score of 34% and a maximum of 100%. Similarly, 79% (SD = 12.15) of the participants had an average competence level in “documentation and administration of nursing care”, for a minimum of 39%. Finally, the average competence level of the “Development, leadership and organization of Nursing Care” factor was 78% (SD = 12.22), with a minimum score of 48% and a maximum of 100% (see Table  2 ).

The difference in competency subscale scores among nurses

A significant relationship was found between the number of workshops attended by nurses and their level of competence in all competency areas. In Nursing Care, nurses who attended between three and five in-service education workshops had a higher level of Nursing Care Competency, with a mean rank of 122.39 (H = 11.98, p  = 0.003) (see Table  3 ). Table  4 indicated that nurses who attended three to five workshops had a higher level of competency in applying value-based care, with a mean rank = 119.65 (H = 9.29, p  = 0.01); in pedagogical care and patient education, with a mean rank of 123.1 (H = 15.16, P  = 0.001) (see Table  5 ); and in providing medical and technical care, with a mean rank of 121.88 (H = 12.37, p  = 0.002) (see Table  6 ).

Table  7 revealed that nurses who attended more than five workshops were more competent in documenting and administering nursing care, with a mean rank of 130.0 (H = 12.55, p  = 0.002), and in developing and leading nursing care (mean rank = 121.7, H = 7.96, p  = 0.20) (see Table  8 ). Similarly, Table nine shows that attending three to five workshops was associated with a higher total professional competence level, with a mean rank of 121.05 (H = 12.11, p  = 0.002). However, there were no significant differences in the total professional competency level or other professional competency subscale scores among other demographic and work environment factors (see Table  9 ). The reliability of the short version of the questionnaire in this study was excellent, with a Cronbach’s alpha of 97%.

This study aimed to assess the level of professional nursing competency of nurses who work at a tertiary hospital. Using the NPC Scale, the study’s findings shed light on the degree of self-reported professional competence among nurses working in a tertiary hospital in the West Bank. The results could be applied to raise the standard of patient care and healthcare services by pointing out areas that need improvement in the nursing clinical field, education, and training programs. This study contributes to the existing body of knowledge on the level of professional competence among nurses on the West Bank.

A total of 206 nurses participated in the study. Most of the respondents were male. The study showed no significant differences between males and females in terms of their level of professional competence; this was also noted in a study in which gender was not significantly related to professional competence [ 23 ]. In contrast, a study conducted on nurses’ competency in the Saudi Arabian healthcare context showed that male participants demonstrated superior self-reported competency assessment compared to female participants [ 24 ].

On the other hand, this study showed that years of experience do not affect the competency level, in contrast to a Japanese study in which the nursing competence levels are affected by the clinical experience. high competency level among newly hired nurses and junior nurses [ 25 ]. Also, a systematic review in Iran indicated that clinical experience of more than nine years affects the competency level [ 26 ].

The educational level of nurses in this study revealed no discernible relationship with their competence, and this is supported by the study of S-O Kim and Y-J Choi [ 27 ] contradicting the study of Z Nabizadeh-Gharghozar, NM Alavi and NM Ajorpaz [ 28 ] that correlates the educational level with competence level This discrepancy in results underscores the necessity for further exploration to understand the nuanced relationship between education levels and nursing competencies [ 29 ]. While a notable correlation emerged in this study between the number of workshops attended by nurses and their competence levels across all competency domains, a recent study in Japan showed that attending a two-day international outreach seminar provided participants with valuable and current knowledge regarding the competency of nurse educators. They developed a heightened awareness of the shifts in their self-efficacy as educators [ 30 ]. Additionally, Egyptian studies concluded that workshops had a beneficial impact on enhancing the knowledge, collaboration skills, and overall performance of both head and staff nurses [ 31 ].

According to our study, nurses exhibited a very good level of the total professional competency level. This result was supported by a study conducted in Iran which reported that nurses had a very good competency level [ 32 ]. Delving into the assessment of competency sub scores our study excelled in evaluating the competency of providing nursing care and helping patients was very good and the same with the result of a Turkish study that assessed the caring and helping competency level of 243 nurses in a university hospital [ 33 ],. Similarly, participants showed a very good competency level in handling technology and advanced medical machines, which affirms the growing integration of technology in nursing practice [ 34 ]. The “Care Pedagogics” competency underscores the crucial role of nurses in educating and supporting patients and their families, which is consistent with the findings of other related research [ 32 , 35 ] These results emphasize the ongoing need to prioritize clinical proficiency in nursing education and practice [ 17 ].

Moving into the sphere of “Documentation and Administration of Nursing Care”, nurses in our study had a very good competency level in developing a collaborative care plan and documentation skills echoing the significance of nursing documentation and administration for ensuring high-quality patient care [ 36 ], Additionally, the participant’s had very good competency in “Development, Leadership, and Organization of Nursing Care” which underscored the nursing abilities to lead and supervise teamwork and prioritize care aligning with the findings of various studies supporting this notion [ 37 , 38 , 39 ].

According to the study’s findings, nurses generally do well in areas including nursing care, value-based nursing care, technical and medical treatment, and administration and documentation. In contrast, a study highlighting possible areas for focused improvement in nursing practice and education found that nurses tended to report lower competence scores in the areas of development, leadership, organization of nursing care, and care pedagogy [ 40 ].

Furthermore, it’s critical to stress how important it is for nurses to maintain quality of life. To guarantee that high-quality care is provided, initiatives to enhance the quality of life for nurses must be initiated. When creating projects and programs to improve nurses’ competence, nurse managers should take the results into account [ 41 ] and use reflective learning, which can help both new and novice nurses because it will help them develop a good self-perception of their competence [ 42 ].

Theoretical implication

The results of this study contributed to the theoretical understanding of factors affecting the professional competencies of nurses. The notable correlation between the number of continuing education activities attended by nurses and the level of nurses’ performance implies that professional development programs have a pivotal role in enhancing and improving nurses’ competency in several domains. This result goes in alignment with the “ Novice to Expert” theory of Benner and empirically supports the crucial role of ongoing education in improving and supporting nurses to advance their professional competencies and growth. On the other hand, the multidimensional aspects of the applied professional competency in this study such as the documentation, value-based, and technical aspects all act as factors that shape the wholistic approach to nursing care and the nature of the nurse’s practices which require more wholistic evaluation method for nurses competencies.

Managerial implications

The majority of nurses in this study were professionally competent which indicates that available ongoing educational activities were valuable and effective opportunities to promote nurses’ competencies. However, having 15 nurses with a 60% competency level highlights the importance of structuring more need-sensitive ongoing education programs and interventions. On the other side, the strong relationship between attending continuing education activities and a higher level of nurses competencies across various domains underscores the pivotal role of offering equal and efficient opportunities for attending and joining the available activities, also health care institutions may need to invest more effectively in promoting and supporting goal-based, and need-sensitive professional development programs in their setting to get more competent and qualified nurses and subsequently high-quality patient care.

Additionally, the study findings highlight that subdomains and sub-dimensions of nurses’ practices such as care and value-based aspects and documentation and administration have essential roles in formulating the overall professional competency level of nurses. This guides the nurse managers and leaders to establish a more uniform performance appraisal process to evaluate nurses’ practices. This would enable nurse leaders to effectively identify any practice gaps and areas for improvement and this helps them to efficiently utilize resources to provide the required learning activities and offer equal chances for improving nurses’ performance. Determining a nurse’s areas of competence can serve as a reference to guide the hiring process of new staff.

The outcome of this study can steer the adoption of robust ongoing education such as mentorship and preceptorship programs, cross-training programs, in-service clinical training, and other professional development opportunities to facilitate the rapid transition of newly hired nurses from beginner level to more competent and proficient nurses.

A trustworthy tool that recognizes a nurse’s level of professional competency can assist policymakers, managers, and nurse educators in defining the skills, knowledge, and attitude necessary for nurses to perform their jobs. The findings of this research can also be used to create more customized and goal-oriented professional development programs, pinpointing areas of best practices that require improvement and investigating the necessary methods and resources to improve nurses’ competencies while emphasizing evidence-based practices. Additional research examining the relationships between nursing competence and patient outcomes may be beneficial in enhancing best practices for nurses.

Limitations

The sample was convenient with 206 nurses participating in the study, which potentially limits the generalizability of the findings to a broader nursing population. Additionally, the overrepresentation of male respondents might skew the results and not accurately reflect the gender balance in nursing.

The data primarily relied on self-reported measures, which might introduce response bias and subjectivity. Objective assessments or external evaluations of competence could enhance the validity of the findings.

The study utilized a cross-sectional design, providing a snapshot of competence at a specific time. Longitudinal studies tracking nurses’ competence over time could offer a more comprehensive understanding of competence development.

The study did not comprehensively explore other potential influencing factors, such as workload, staffing ratios, or specific training programs attended by participants. These factors can significantly impact nursing competence and have not been thoroughly investigated.

Conclusions

In this study, we meticulously evaluated the professional competence levels of 206 nurses employed in a tertiary hospital setting. The findings revealed that the professional competence level was moderately high among the participants. However, it is noteworthy that while a significant portion of nurses demonstrated high levels of competency, a considerable number still exhibited competence levels below the desired threshold, with 15 nurses scoring below 60%.

Our comprehensive assessment encompassed various competency areas, shedding light on specific domains where nurses warrant focused attention. Notably, the domain of “Development, Leadership, and Organization of Nursing Care” exhibited a slightly lower average competency level (78%). Therefore, it is important to promote nurse’s knowledge and skills in the domain of leadership and management principles.

Attending workshops plays a significant role in improving nurses’ competencies, especially the competency in documentation, management, and leadership skills. So, investments in providing a well-designed workshop with a clear outcome are essential to affect the level of competence among nurses. Moreover, the findings underscored the importance of continuing education and training programs to foster nurses’ competency, and subsequently, improve the quality of patient care.

In conclusion, this study provides valuable insights into the nuanced landscape of nursing competence, highlighting both areas of strength and opportunities for improvement. Moving forward, healthcare institutions and educational bodies must prioritize ongoing education and targeted interventions aimed at fortifying nursing competencies for the betterment of patient care.

Recommendations

Healthcare institutions should invest in continuous training programs, and make sure they are goal-directed and have outcomes related to improving the staff knowledge as well as the skills and contributing to improving the competency level.

More emphasis needs to be placed on the development of leadership and management abilities. The ongoing educational initiatives should arrange more organized and impactful workshops and training programs to enhance this particular aspect, which in turn will have a direct impact on the competencies of nurses.

Encourage collaboration between academia and healthcare institutions to conduct research focused on nursing competence to disseminate competency development to regional policymakers and initiate training programs and the potential implementation of a “clinical ladder” system for nurses.

Future studies should involve larger and more diverse samples across various healthcare settings to capture a more representative picture of nursing competence. Ensuring a balanced gender representation among participants would yield more comprehensive insights.

Complementing self-reported measures with objective assessments or observations of nursing practices could enhance the robustness and validity of the findings. Qualitative interviews or focus groups might provide richer insights into the factors affecting nursing competence.

Conducting longitudinal studies to track nurses’ competence development over time would offer a deeper understanding of competency growth and fluctuations throughout a nurse’s career trajectory.

Future research should further explore the various factors influencing nursing competence, including workload, staffing, continuing education programs, and the impact of specific training initiatives on competence levels.

Implementing targeted interventions or training programs and evaluating their impact on nursing competence could provide valuable insights into effective strategies for enhancing nursing competency.

Collaborating with multiple healthcare facilities or employing a multicenter approach would provide a more extensive dataset and facilitate comparisons between institutions, enriching the understanding of nursing competence on a broader scale.

Data availability

Primary research article or the corresponding author are the sources of all data. Data that supports the results of the manuscript is provided within the manuscript.

Abbreviations

Arab American University

Institutional Review Board

An-Najah-National University Hospital

Nurse Professional Competence Scale

Statistical Package for the Social Sciences

World Health Organization

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Acknowledgements

I would like to express my gratitude and acknowledgment to the Research Centre especially Prof. Saed Zyoud and Prof. Ramzi Shawahneh for their support in providing resources and facilitating the research process.

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Determining the level of evidence

Nonresearch evidence.

Glasofer, Amy DNP, RN, NE-BC; Townsend, Ann B. DRNP, RN, ANP-C, CNS-C

Amy Glasofer is a nurse scientist at Virtua Center for Learning in Mt. Laurel, N.J., and Ann B. Townsend is an adult NP with The NP Group, LLC.

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This article was first published as: Glasofer A, Townsend AB. Determining the level of evidence: nonresearch evidence. Nurs Crit Care . 2020;15(2):22-26.

To support evidence-based nursing practice, the authors provide guidelines for nonresearch evidence, which includes clinical practice guidelines, consensus or position statements, literature review, expert opinion, organizational experience, case reports, community standards, clinician experience, and consumer preferences. This is the third in a three-part series.

In the final installment of a three-part series, the authors provide guidelines for evaluating nonresearch evidence, which includes clinical practice guidelines, consensus or position statements, literature reviews, expert opinion, and more.

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The effect of spaced E-Learning on knowledge of basic life support and satisfaction of nursing students: a quasi-experimental study

• Fataneh Ranjbar 1 ,
• Hamid Sharif-Nia 2 , 3 ,
• Maryam Shiri 4 , 5 &
• Pardis Rahmatpour 5  

BMC Medical Education volume  24 , Article number:  537 ( 2024 ) Cite this article

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Cardiopulmonary resuscitation (CPR) training is essential for all students, especially nursing students. One of the educational approaches to creating long-term learning in inclusive is spaced learning. Spaced learning consists of three or more training sessions in which information is presented over time and at intervals. The present study was conducted to investigate the effect of basic life support (BLS) training through spaced E-learning on the knowledge and satisfaction of nursing students.

In this quasi-experimental study with two groups, 106 undergraduate nursing students of Alborz University of Medical Sciences in Iran participated. The control group ( n  = 47) received BLS training with massed E-learning in one three-hour session, and the intervention group ( n  = 59) received spaced E-learning in three one-hour sessions. An electronic questionnaire including demographic information and a pre-test of BLS knowledge were sent to both groups. Also, immediately after receiving the training, two weeks later and one month later, they completed a post-test of BLS knowledge. Students were asked to indicate their level of satisfaction with the provided education by completing the SLS-OLE.

The post-test scores immediately after, two weeks later, and one month later of the intervention group were higher than the control group. The results of repeated measurement ANOVA showed that the score changes of knowledge are significant over time ( p  < 0.001), the number of sessions ( p  < 0.001), and the interactive effect of them ( p  < 0.001). There was no statistically significant difference in the level of satisfaction with education in both groups.

Based on the results, BLS training in both groups increased the knowledge of BLS. however, the increase in knowledge and its retention was higher in the intervention group that received the training in spaced learning.

Peer Review reports

Introduction

Cardiopulmonary resuscitation (CPR) stands as an indispensable skill for nurses and nursing students, wielding a direct impact on patient survival rates. The prompt initiation of basic cardiopulmonary resuscitation (BLS) remains pivotal in determining client survival [ 1 , 2 ].

With nursing students being a common presence in healthcare institutions, one would expect them to possess ample and up-to-date knowledge and skills [ 3 ]. Although BLS is introduced during high school education, reinforcing this training at the university level becomes essential due to the unique demands of nursing. In Iran, BLS is currently integrated into the curriculum during the 6th semester of undergraduate nursing programs. However, nursing students engage with patients from the second semester onwards, both inside and outside the hospital setting. Consequently, CPR knowledge and skills assume a paramount role in their education [ 4 ].

Recent studies present a divergence in opinions regarding the most effective method for CPR training. Some have highlighted the efficacy of virtual reality simulation, educational videos, and gamification in teaching BLS [ 5 , 6 , 7 , 8 , 9 ]. Students exposed to CPR training across multiple sessions, incorporating diverse educational technologies, exhibit increased motivation and self-confidence in executing this life-saving procedure [ 10 ]. They also demonstrate superior self-efficacy and long-term retention of CPR knowledge and skills [ 11 ]. Repetition emerges as a crucial element in minimizing errors and boosting learners’ self-assurance, with the frequency of CPR training sessions correlating with students’ self-confidence and willingness to learn [ 12 , 13 ].

Despite the numerous methods available, CPR training continues to be predominantly delivered in the traditional “mass education” format, where all content is typically covered in a single day. However, contemporary research underscores the effectiveness of the Spaced Learning method, underpinned by the “Encoding Variability Theory”.

The encoding variability theory

Research has shed light on the diminishing efficacy of extended, monotonous lectures exceeding 50 min, leading to students’ boredom, waning concentration, and dissatisfaction [ 14 ]. The “Spacing Effect” underscores that disseminating content at intervals within a specified timeframe yields more effective learning outcomes than presenting it all at once. The “Encoding Variability Theory” posits that varying learning conditions activate distinct areas of the brain, facilitating improved information retrieval from memory [ 15 ]. This theory underscores the importance of repeating stimuli at longer intervals, fostering effective information assimilation and retention while enhancing memory recall and information retrieval [ 16 ].

• Spaced learning

Spaced learning, an approach informed by the “Encoding Variability Theory,” champions knowledge retention by spacing out learning sessions. This method, also employed in online education, reduces students’ stress and cultivates an enjoyable learning experience. It is defined by incorporating three or more sessions that offer information over time at intervals. Spacing formats may vary in terms of timing, with some researchers implementing sessions over several days, while others structure them across hours, weeks, or months [ 17 , 18 ].

This method boasts several advantages, including reducing learner distraction by introducing breaks and spacing between sessions, making it ideal for comprehending complex concepts by allowing learners to digest information before proceeding to the next segment. Additionally, each session concludes with a recap of the material covered, fortifying retention [ 19 , 20 , 21 ].

Several studies have explored the application of the spaced learning method in CPR training, yielding promising results. A systematic review conducted by Yeung et al. (2020), encompassing basic and advanced CPR, found that 15 out of 17 studies reported enhanced learner performance through spaced learning [ 22 ]. In a study by Oermann et al. (2020) investigating the ideal interval for CPR training, daily and weekly intervals were found to be conducive to effective learning [ 23 ]. In line with the literature, content tailored to students’ needs, comprehensive and well-designed, delivered continuously, bolsters student satisfaction [ 24 , 25 ]. Given the critical importance of CPR training for nursing students and the demonstrable benefits of Spaced Learning in knowledge retention, this study endeavors to evaluate the impact of BLS Spaced E-learning on the knowledge and satisfaction of first-year undergraduate nursing students in Iran.

Study design

This study adopts a quasi-experimental design involving two groups, conducted among first-year undergraduate nursing students at Alborz University of Medical Sciences, Iran, 2022.

Participants

Among 120 eligible undergraduate nursing students,106 students participated in this study, selected through a convenience sampling method. Inclusion criteria encompassed a willingness to participate, first-year nursing students with no prior CPR knowledge, no previous participation in CPR workshops, and no involvement in similar CPR research. Exclusion criteria included unwillingness to continue participation, irregular class attendance, and incomplete questionnaire responses. Invitation posters were distributed to students, and volunteers were enrolled. Eligibility criteria were verified by the researcher, and participants were randomly divided into two groups of control group ( n  = 47) and intervention group ( n  = 59). The intervention and control groups were homogeneous in terms of age, grade point average, academic semester and interest in nursing. ( p  > 0.05).

Questionnaires

The study employed an online questionnaire comprising three forms: demographic and educational information, BLS knowledge assessment, and student satisfaction with online learning. The questionnaire was hosted on the Persian online platform ( www.porsline.ir ), and students were provided with a link through their Telegram groups.

Demographic and Educational Information: This form gathered data on participants’ year of birth, gender, academic semester, GPA of the last semester, and their level of interest in nursing (one question).

BLS Knowledge: This section contained 15 multiple-choice questions based on the BLS guidelines of the American Heart Association (AHA 2020), textbooks, and National Council Licensure Examination (NCLEX RN) tests. Ten faculty members in the field of medical emergency and nursing evaluated the questions for face and content validity. Professors who had the experience of teaching emergency medicine in class and internships were selected. They assessed grammar, word usage, clarity, and question relevance. Necessary revisions were made based on their feedback and CVI and CVR ratings.

Student Learning and Satisfaction in Online Learning Environments Instrument (SLS-OLE): This questionnaire consisted of 34 questions across six domains: “course structure, learner interaction, student engagement, instructor presence, student satisfaction, perceived learning,” using a seven-point Likert scale ranging from strongly disagree (1) to strongly agree (7). After obtaining permission from the scale’s developer [ 26 ], the questionnaire was translated into Persian by the researcher and underwent face and content validity evaluation by ten professors in nursing and medical education. The items’ Content Validity Index (CVI) and Content Validity Ratio (CVR) were calculated, and the items were deemed valid (CVI > 0.7, CVR > 0.62). In this study, the internal consistency of SLS-OLE was assessed using Cronbach’s alpha, resulting in values of 0.78 for course structure, 0.82 for learner interaction, 0.72 for student engagement, 0.78 for instructor presence, 0.94 for student satisfaction, and 0.88 for perceived learning.

Research procedure

In this study, Synchronous online teaching sessions were approximately 3 h. The control group received BLS training through massed learning in a single three-hour session, while the intervention group received spaced learning across three one-hour sessions (Fig.  1 ). Both groups were added on the Telegram groups. A message was sent to both groups, detailing the research objectives, confidentiality, participants’ freedom to engage or withdraw, and the research steps.

Tracking diagram of study procedure

The BLS online course was taught by the researcher, a master’s student in emergency nursing with seven years of experience in the emergency field, and prior participation in CPR workshops, remaining updated on the latest AHA guidelines (BLS-AHA 2020 Guideline). The course content comprised PowerPoint presentations, videos, and images, all reviewed by two nursing professors.

The date and time for the online classes were scheduled based on student input, avoiding conflicts with their class schedules and the 2022 World Cup matches. The control group received instruction on November 24, while the intervention group received training from November 26 to 28, 2022. Both groups completed a demographic questionnaire and pre-test before commencing the class. After the sessions, both groups undertook a post-test immediately. Students were given a CPR scenario as an assignment and asked to outline the BLS steps for this scenario. Subsequently, they completed the SLS-OLE questionnaire, as well as post-tests two weeks and one month after the course.

Finally, educational materials, including AHA guidelines, CPR videos, and info-graphics, were distributed to both groups. Correctly completed assignments were rewarded with gifts, and all participants received a certificate of workshop participation from the nursing school’s scientific association.

Data analysis

Data analysis involved descriptive statistics (frequency, mean, standard deviation) and analytical statistics. The Shapiro-Wilk test confirmed the assumption of normal data distribution. An independent t-test was employed to compare variances between the two groups, and repeated-measures ANOVA was used to evaluate changes in measurements over time. Data analysis was carried out using SPSS v.23 and MedCalc v.22 software.

Ethical consideration

Online informed consent was obtained from all participants. The participants were informed that they have no obligation to answer the questionnaire, confidential and anonymous information will be published as a group. Participants could not view the online questionnaire items until they clicked the agree button. All methods were carried out in accordance with relevant guidelines and regulation under the Ethics approval and consent to participate. This study is part of a Master’s degree dissertation and was approved by the ethics committee of the Alborz University of Medical Sciences [Ethic code: IR.ABZUMS.REC.1401.080].

In this study, 106 nursing students of 120, with a mean age of 21.00 ± 2.1 years, participated. Table  1 presents the demographic and educational information of the nursing students involved in the study.

Comparing the pretest scores between the two groups revealed no significant difference ( p  = 0.35), indicating that the two groups were equivalent in terms of their baseline BLS knowledge. Post-training, knowledge scores improved in both groups, with the intervention group showing a higher increase. Table  2 displays the BLS knowledge scores at different measurement points. Furthermore, the results highlighted that the changes in knowledge scores in both groups were influenced by time ( p  < 0.001), the number of sessions ( p  < 0.001), and their interactive effect ( p  < 0.001) (Fig.  2 ).

The trend of changing the BLS scores in the different measuring times. X axis: times of assessing BLS score Y axis: BLS score

Table  3 provides the scores for the SLS-OLE domains in both groups. The results show no statistically significant differences between the two groups. Notably, the highest score was in the perceived learning domain, while the lowest score was in the learner interaction domain.

This study aimed to explore the impact of spaced E-learning on Basic Life Support (BLS) knowledge and the satisfaction of nursing students. Spaced learning was chosen as the intervention method, believed to be superior to mass learning [ 15 ]. Spaced learning has demonstrated its effectiveness in various fields, including medical sciences [ 27 ], mathematics [ 28 ], and has been associated with improved knowledge acquisition, retention, skills, competencies, and overall student satisfaction [ 29 , 30 ] .

The results of this study indicated that BLS training improved in both groups, with the intervention group (spaced learning) showing a greater increase in knowledge, in line with similar studies investigating CPR training. Patocka et al. (2019) compared spaced learning with massed learning in teaching CPR to emergency medical service (EMS) providers, showing improved three-month retention of skills in the spaced learning group [ 29 ]. Similarly, in a study by Ferguson et al. (2019), atrial fibrillation training through Mobile spaced education led to higher knowledge and awareness scores among nurses [ 31 ]. Beyond CPR, other studies explored the efficacy of spaced learning in various medical fields, such as laparoscopy training [ 32 ], microsurgery methods for medical students [ 33 ] anesthesia in neurosurgery among anesthesia students [ 34 ] and symptom management among nursing students [ 35 ]. These studies collectively demonstrate the acceptability and efficacy of mobile distance learning, enhancing both learning outcomes and the ability to apply knowledge in clinical practice.

The not significant increase in BLS knowledge observed in the control group between time 2 and time 3, in contrast to the decrease in knowledge seen in the intervention group during the same period, can be attributed to the spacing effect and the dynamics of memory retention.

The spacing effect, a well-documented cognitive phenomenon, suggests that spreading out learning over time leads to better long-term retention compared to cramming information in a single session. In this study, the control group underwent massed learning in a single three-hour session, likely resulting in a more immediate but less enduring increase in knowledge. On the other hand, the intervention group engaged in spaced learning across three one-hour sessions, allowing for more effective encoding and retention of information over time.

The impact of time and the number of sessions on students’ knowledge scores suggests that knowledge repetition through content review and multiple post-tests enhances retention. Moreover, conducting sessions in multiple segments allows students to better understand the content and seek clarification on unclear topics, as supported by previous research [ 15 , 23 ]. Longitudinal studies have emphasized the need for repeated CPR training throughout nursing education to maintain knowledge and skills [ 36 ]. In this study, spaced learning consisted of three one-hour sessions, with the duration of classes directly influencing learning outcomes. Shorter sessions of 10 to 20 min appear to be more effective, aligning with students’ preferences for shorter, frequent classes over lengthy sessions [ 37 ]. This a suggestion for further research to examine the effects of shorter class duration.

Furthermore, the study revealed a high level of student satisfaction with the online course in both groups, with no significant difference between them. Also, Teo et al. study reported no significant differences in satisfaction scores between the two groups of mass and spaced learning in microsurgical procedures [ 33 ]. Studies by Dabiri et al. (2019) and Watchmaker et al. (2019) corroborated this finding, highlighting high satisfaction with spaced learning [ 38 , 39 ]. Reasons for this satisfaction include reduced mental fatigue, enhanced comprehension, more engaging learning experiences, and improved long-term retention [ 19 ]. The utilization of various teaching methods and new approaches by instructors also contributes to student satisfaction. After COVID-19 pandemic, the effectiveness of alternative educational methods, such as simulation, educational videos, and games, in teaching clinical topics was highlighted [ 5 ].

Data were collected from one center, so it affects the findings’ generalizability. In December, we encountered the challenge of coordinating the training days of our online course with the schedule of the 2022 FIFA World Cup. We devised polls in collaboration and coordination with students to determine the most suitable time for conducting classes in Telegram groups. The final limitation was we measured the BLS knowledge of nursing students, not their skills. So, comparing the knowledge application in the real clinical environment between the two groups is suggested.

Implications

The findings of this study carry several practical and educational implications for the field of nursing education and beyond:

Enhancing CPR Training: The use of spaced E-learning for CPR training offers a promising avenue for improving the quality and effectiveness of training for nursing students. Implementing this approach in nursing curricula can help ensure that students acquire and retain essential life-saving skills.

Long-Term Retention: The study underscores the importance of regular CPR training sessions throughout the nursing education journey. Institutions should consider incorporating spaced learning approaches to promote long-term retention of knowledge and skills.

Online Education Integration: In the post-COVID-19 era, online education has gained prominence. Nursing schools and institutions should explore the integration of spaced E-learning methodologies to enhance students’ learning experiences, irrespective of whether classes are conducted in person or online.

Effectiveness of Spaced Learning: This study reaffirms the efficacy of spaced learning as a teaching methodology. Educators and instructional designers can adopt this method in various academic disciplines, particularly for complex topics requiring knowledge retention.

Student Satisfaction: The high levels of student satisfaction with spaced E-learning emphasize the importance of using innovative teaching methods that not only facilitate learning but also create engaging and enjoyable educational experiences. Instructors should consider diversifying their teaching strategies.

Use of Technology: The study underscores the role of technology in modern education. Institutions should continue to invest in and promote the use of online platforms and digital resources to support spaced learning initiatives.

Research and Innovation: The study highlights the value of research and innovation in education. Future research can delve deeper into the impact of spaced learning on various topics and different educational contexts, contributing to the advancement of teaching and learning practices. In addition, it is recommended that future studies investigate the effects of spaced learning over different time durations of classes and intervals between sessions; explore differences based on gender, ethnicity, etc.; and focus on skills-based content. The adoption of spaced learning is recommended for face-to-face classes and various theoretical and practical subjects in nursing education.

In conclusion, this study provides valuable insights into the potential benefits of spaced E-learning in nursing education. By considering the implications outlined above, nursing schools, educators, and institutions can embrace innovative approaches to curriculum design, teaching methodologies, and technology integration, ultimately enhancing the quality of education and, most importantly, the quality of patient care.

CPR training is a critical skill for all students, particularly nursing students. This study found that students who underwent spaced learning exhibited greater knowledge acquisition at various measurement points compared to the control group (mass learning). Interestingly, both groups reported similar levels of satisfaction. Considering the significance and increasing prominence of online education, spaced E-learning emerges as an effective approach for teaching and enhancing knowledge retention among nursing students. Teaching content in multiple sessions proves to be more effective than massed learning in promoting nursing students’ learning and knowledge retention.

Data availability

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

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Acknowledgements

The study was extracted from the dissertation for the Master degree of emergency nursing in Alborz University of medical sciences. The protocol of study was approved by the ethics committee of Alborz University of Medical Sciences with code IR.ABZUMS.REC.1401.080. The researcher here by thanks the Deputy of Research and Technology of Alborz University of Medical Sciences for supporting the current research. The authors would also like to acknowledge Dr. Kamrani and Mrs. Taher for their guidance and support.

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Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

Department of Medical Education, Alborz University of Medical Sciences, Karaj, Iran

Maryam Shiri

School of Nursing, Alborz University of Medical Sciences, Karaj, Iran

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all authors were involved in designing the present study. F.R and P.R carried out the study and collected data. H.S analyzed, and interpreted data. M.S provided guidance for accuracy. All authors wrote the present manuscript, read and approved the final manuscript.

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Ranjbar, F., Sharif-Nia, H., Shiri, M. et al. The effect of spaced E-Learning on knowledge of basic life support and satisfaction of nursing students: a quasi-experimental study. BMC Med Educ 24 , 537 (2024). https://doi.org/10.1186/s12909-024-05533-9

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The way to relieve college students’ academic stress: the influence mechanism of sports interest and sports atmosphere

• Mengfan Liu 1 ,
• Bo Shi 2 &

BMC Psychology volume  12 , Article number:  327 ( 2024 ) Cite this article

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Metrics details

Background and research objectives

Given the enduring popularity of higher education, there has been considerable attention on the correlation between college students’ engagement in sports and their academic stress levels. This study seeks to delve deeply into how university physical education fosters academic performance by influencing students’ sports interests, particularly in enhancing their psychological resilience to mitigate academic pressure. Through this investigation, the aim is to offer both theoretical underpinnings and empirical evidence to support the holistic enhancement of higher education.

Research methods

Initially, this study undertakes an analysis of the fundamental relationship between college students’ physical activities and their experience of academic stress. Subsequently, utilizing a structural equation model, specific research models and hypotheses are formulated. These are then examined in detail through the questionnaire method to elucidate the mechanism by which college sports interests alleviate academic stress.

Research findings

The study reveals a significant positive correlation between psychological resilience and academic stress, indicating that a robust psychological resilience can effectively diminish academic pressure. Furthermore, both the sports atmosphere and sports interest are found to exert a notable positive impact on academic stress, mediated by the variable of psychological toughness. This underscores the pivotal role of physical education in fostering positive psychological traits and enhancing academic achievement.

This study underscores the central importance of cultivating and nurturing college students’ sports interests, as well as fostering a conducive sports atmosphere, in fortifying psychological resilience and mitigating academic pressure. By offering novel perspectives and strategies for alleviating the academic stress faced by college students, this study contributes valuable theoretical insights and practical experiences to the broader development of higher education.

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Introduction

In the context of the rapid evolution of higher education, there is a growing focus on enhancing academic resilience to stress [ 1 ]. Numerous studies have demonstrated that physical activity serves as a positive psychological intervention, with significant effects on fostering learning, alleviating academic pressure, and reducing psychological anxiety. Given that college students represent the future workforce, their academic stress has garnered widespread concern [ 2 ]. Thus, investigating the link between college students’ sports interests and academic pressure holds considerable practical significance and social value. Research on the correlation between sports interests and academic stress has made considerable strides in recent decades. However, most studies have primarily examined their direct relationship, overlooking potential additional factors and complex interactive mechanisms [ 3 ]. In recent years, researchers have increasingly turned their attention to the moderating role of mediating variables in the relationship between sports interests and academic stress, such as self-esteem, self-efficacy, and body image. These variables are viewed as pivotal factors influencing the impact of sports interests on academic stress. This study aims to construct a comprehensive theoretical framework and delve deeply into the mechanisms of these mediating variables in the relationship between college students’ sports interests and academic pressure. The goal is to offer more effective strategies and recommendations for alleviating academic pressure among college students.

With the proliferation of higher education and the intensifying social competition, the academic pressure confronting college students has become increasingly pronounced. This pressure not only jeopardizes their mental well-being but also has the potential to impede their academic performance and future career prospects. In recent years, physical activities have garnered widespread attention as an effective means of alleviating academic stress. Research conducted by Karagiorgakis and Blaker [ 4 ] underscores the efficacy of sports participation in relieving academic stress among college students. Their findings reveal a significant reduction in anxiety and depression levels among students engaging in sports activities, particularly for those with sustained participation. This discovery presents a positive coping strategy for students to mitigate the psychological stress induced by academic studies through sports engagement. Further evidence from Dexter et al. [ 5 ] corroborates the beneficial impact of physical activity in managing academic stress. Their study indicates that students who regularly partake in physical activities demonstrate heightened mental resilience when confronted with academic pressure. This enhanced mental fortitude enables them to confront challenges more adeptly and mitigate negative emotions associated with stress. Approaching the issue from a different angle, O’Connor [ 6 ] explores the psychological benefits of sports engagement in alleviating academic stress. He contends that participation in sports fosters feelings of enjoyment and accomplishment, thereby mitigating negative emotions stemming from academic pressure. This sense of fulfillment contributes to heightened life satisfaction and self-confidence among college students, empowering them to confront academic challenges proactively. Storm and Eske [ 7 ] emphasize the role of physical activities in nurturing college students’ capacity to cope with challenges and stress. They argue that sports participation equips students with essential coping skills, vital not only for navigating current academic pressures but also for addressing future life and work challenges. From a social standpoint, Green et al. [ 8 ] highlight the role of sports participation in fostering social connections among college students. Their research indicates that engagement in sports facilitates the formation of friendships and social networks, providing crucial social and emotional support. This support network aids in mitigating feelings of isolation and helplessness, thereby bolstering students’ psychological resilience in the face of academic stress. Despite the considerable role of physical activity in mitigating academic stress among college students, current research on the relationship between sports interest and academic stress remains limited. Berdida and Grande [ 9 ] underscore the growing societal concern regarding the pressure faced by college students, emphasizing the importance of delving deeper into the impact and mechanisms of sports interest on academic stress. Moreover, Basri et al. [ 10 ] emphasize the significance of mental health issues among college students, particularly those facing financial hardships, who may experience elevated stress levels and associated psychological challenges. In conclusion, physical activities serve as a potent positive psychological intervention in alleviating the academic stress experienced by college students. Future research endeavors should further explore the impact and mechanisms of sports interest on academic stress, providing both theoretical foundations and practical guidance for mental health education and psychological intervention among college students. This concerted effort will facilitate a better understanding and management of academic stress issues, promoting holistic development and well-being among college students.

Hence, this study endeavors to furnish both theoretical groundwork and practical directives for alleviating academic stress among college students by conducting a systematic review and meta-analysis of extant research. Additionally, it aims to furnish references and insights for prospective investigations in this domain. The primary focus of this inquiry encompasses two key aspects: (1) scrutinizing the relationship between college students’ engagement in sports activities and their academic stress levels, and (2) exploring the moderating variables that influence this relationship. Through a comprehensive examination of pertinent literature and the adoption of both quantitative and qualitative methodologies, this study aims to elucidate these facets. Consequently, it not only furnishes valuable support for ameliorating academic stress among university students but also constitutes a substantial contribution to the advancement of higher education.

Relationship between college students’ sports interest and academic stress

Factors influencing academic stress.

Academic stress represents a primary challenge encountered by college students, emanating from diverse sources including coursework demands, examinations, paper submissions, internships, and employment responsibilities [ 11 ]. Prolonged exposure to excessive academic stress can precipitate a range of issues such as anxiety, depression, insomnia, and physical discomfort, exerting adverse effects on the mental and physical well-being of college students. Consequently, it is imperative to comprehend the factors contributing to academic stress and to institute tailored coping mechanisms accordingly [ 12 ].

Currently, research on academic stress primarily examines individual and environmental factors. Individual factors encompass abilities, interests, and self-expectations, while environmental factors encompass familial, school, and societal pressures. Additionally, factors such as sports interest, sports atmosphere, and psychological resilience play crucial roles in influencing academic stress [ 13 ]. Sports interest refers to an individual’s favorable disposition and inclination towards participating in sports activities [ 14 ]. College students who harbor sports interests are more predisposed to actively partake in sports, thereby mitigating stress and alleviating anxiety. Research indicates a noteworthy positive correlation between sports interest and mental health status—heightened sports interest correlates with improved mental well-being. Sports atmosphere pertains to the milieu and ambiance surrounding sports activities, encompassing both school and community environments. A conducive sports atmosphere can invigorate college students’ enthusiasm for engaging in sports, thereby enhancing their sports interest and involvement. Studies suggest that an enhanced school sports atmosphere correlates with better mental health among students [ 15 ]. Psychological resilience refers to an individual’s capacity to adapt and cope effectively with setbacks, stressors, and adversity [ 16 ]. College students endowed with higher levels of psychological resilience demonstrate adeptness in managing academic stress and other pressures, thereby sustaining a positive outlook and fostering good mental health. Research indicates that psychological resilience exerts a significant ameliorative effect on academic stress.

In summary, academic stress emerges as a complex issue influenced by various factors. Among these, sports interest, sports atmosphere, and psychological resilience play pivotal roles in shaping the academic stress experienced by college students. The study advocates for the implementation of strategies aimed at enhancing college students’ sports interests, fostering a positive sports atmosphere, and nurturing psychological resilience. These measures are deemed effective in alleviating academic stress and enhancing the mental and physical well-being of college students. Consequently, within the realm of higher education, emphasis should be placed on cultivating students’ sports interests and psychological resilience, while also fostering a conducive sports environment and atmosphere. Figure  1 illustrates the interrelationships between the variables examined in this study.

Schematic diagram of the relationship between college students’ mental health and sports activities

Figure  1 depicts the positive impact pathway of sports activities on the mental health of college students. Firstly, sports activities contribute to stress relief by triggering the release of substances such as endorphins and dopamine, thereby alleviating anxiety, depression, and fostering positive emotions [ 17 ]. Secondly, participation in sports bolsters college students’ self-esteem and confidence. Through showcasing their abilities and achieving success, students garner recognition and affirmation of their self-worth. Additionally, forging close connections with fellow athletes facilitates the formation of a supportive social network, offering emotional reinforcement and encouragement. Consequently, this diminishes feelings of social isolation and loneliness, augmenting happiness and mental well-being [ 18 ]. Moreover, engagement in sports endeavors can enhance body image and satisfaction, fostering increased self-acceptance and contentment with one’s physical appearance, thereby mitigating anxiety and stress associated with appearance. Importantly, the relationship between college students’ sports activities and mental health is reciprocal: active involvement in sports enhances mental well-being, while robust mental health status further motivates students to participate actively in sports. Hence, actively promoting campus sports activities emerges as a potent means to nurture the mental health of college students [ 19 ].

Application of structural equation models

Structural equation models (SEMs) stand as a robust statistical technique extensively employed in social science research, particularly for elucidating intricate causal relationships and latent variables. In this study, SEMs are utilized to delve deeply into the interplay between college students’ sports interests, sports atmosphere, and academic stress, while also examining the potential role of psychological resilience. Through SEMs, interactions among multiple variables can be simultaneously estimated, encompassing the direct effects of independent variables (e.g., sports interest and sports atmosphere) on dependent variables (e.g., academic stress), as well as their indirect effects mediated through latent variables (e.g., psychological resilience) [ 20 ]. This comprehensive analytical approach fosters a more precise comprehension of the complex relationships among these variables and their collective impact on college students’ academic stress and mental health. It is noteworthy that although sports interest and sports atmosphere serve as independent variables, they do not directly function as moderators. Moderating factors typically denote variables that can influence the relationship between independent and dependent variables, such as gender, age, or cultural background. For instance, gender can be regarded as a moderating factor in research aimed at exploring disparities between different gender groups regarding the influence of sports interest and sports atmosphere on academic stress. By introducing gender as a moderator, researchers can attain a more holistic understanding of whether the relationship between college students’ sports interest, sports atmosphere, and academic stress varies across genders. This, in turn, facilitates the development of tailored educational and intervention measures to better cater to the diverse needs of different gender groups and promote their holistic development [ 21 ].

Figure  2 illustrates the design of variable relationships in this study, based on the preceding discussion.

Relationship of study variables

The research hypotheses for this study are as follows:

Sports interest has a direct positive impact on psychological resilience.

Sports interest has an indirect positive impact on academic stress through psychological resilience.

Sports atmosphere has a direct positive impact on psychological resilience.

Sports atmosphere has an indirect positive impact on academic stress through psychological resilience.

Through the utilization of SEMs, this study can effectively test these hypotheses and estimate the effects of each pathway [ 22 ]. This facilitates a comprehensive understanding of the intricate relationships among sports interest, sports environment, psychological resilience, and academic stress. Moreover, it furnishes a theoretical foundation for intervening and preventing psychological health issues among college students [ 23 ].

While SEMs offer a potent tool for investigating complex relationships, they are not without challenges and limitations [ 24 ]. For example, SEMs can solely manage known and pre-defined variables and are unable to accommodate unknown or undefined variables [ 25 ]. Additionally, the hypothesis-testing nature of SEMs necessitates cautious interpretation of the results in this study. To mitigate these limitations and ensure the reliability of results, this study employs an appropriate sample size and relied on reliable measurement tools for assessing variables [ 26 ].

This study predominantly employs a questionnaire survey method to gather data to thoroughly investigate the relationship between college students’ sports interests, sports atmosphere, psychological resilience, and academic pressure. The questionnaire design encompasses four primary sections: basic information of college students, sports interests, sports atmosphere, and psychological resilience, and academic pressure.

(1) Questionnaire design

To ensure the scientific rigor and validity of the questionnaire, this study opted for four widely validated scales:

Athletic Climate Scale: Developed by Jackson and Marsh in 1996, this scale evaluates college students’ experiences in athletic environments. It comprises 8 single-dimensional indicators and is scored on a 10-point scale [ 27 ].

Intrinsic Motivation Scale: This scale, devised by Ryan and Deci in 2000, gauges college students’ interest in physical activities. It consists of 8 indicators and is scored on a 7-point scale [ 28 ].

Connor-Davidson Resilience Scale: Developed by Connor and Davidson in 2003, this scale assesses an individual’s psychological resilience. It encompasses 25 indicators and is scored on a 5-point scale [ 29 ].

Academic Stress Scale: Based on Lefcott’s 1981 study, this scale is utilized to evaluate college students’ experience of academic stress. It includes 15 indicators, also scored on a 5-point scale [ 30 ].

(2) Sampling method

To ensure the breadth and representativeness of the sample, this study meticulously designs and implements the sampling strategy. Initially, the target groups are meticulously segmented based on multiple dimensions such as geographical location, school type, and subject area, thereby forming multiple levels or subgroups with distinct characteristics. This segmentation facilitates a more comprehensive coverage of college students from diverse backgrounds, thereby ensuring the diversity of the sample. Subsequently, within each subpopulation, a random sampling method is employed to ensure that individuals in each subgroup have an equal opportunity of being selected. This randomness effectively mitigates sampling errors and enhances the representativeness of the sample. Through random sampling, it is ensured that individuals in the sample are sufficiently dispersed across geographical locations, school types, and subject areas, thus authentically reflecting the overall scenario of the target group. Furthermore, clear inclusion criteria are established to ensure homogeneity of the sample and the reliability of the study. Specifically, survey participants are required to be full-time college students, ensuring uniformity in educational backgrounds and experiences. This inclusion criterion serves to control for confounding factors within the sample and bolster the internal validity of the study. By employing stratified random sampling and setting explicit inclusion criteria, this study successfully constructs a broad and representative sample, laying a robust foundation for subsequent data analysis and the dissemination of research findings.

(3) Data collection and processing

Through meticulously planned online survey initiatives, 725 questionnaires are successfully distributed across major online survey platforms. These questionnaires are widely circulated among university students from diverse regions, age groups, and academic backgrounds, ensuring the diversity and representativeness of respondents. Following the collection of questionnaires, rigorous screening and sorting procedures are implemented to eliminate incomplete or erroneous responses, as well as those that do not meet the predefined inclusion criteria, thereby ensuring the validity and reliability of the data. Subsequently, after this thorough screening and sorting process, a total of 706 valid questionnaires are retained, yielding an effective rate of 97.38%. This high retention rate underscores the rationality of the questionnaire design and the active cooperation of the respondents. The respondents to these valid questionnaires hail from various regions across the country, spanning diverse age groups and academic disciplines. Their responses furnish a rich database, facilitating a comprehensive and in-depth understanding of college students’ sports interests, sports atmosphere, psychological resilience, and academic pressure, among other aspects. Upon completion of data collection, the collected data undergo detailed analysis utilizing SPSS statistical software. Initially, descriptive statistics are conducted to delineate the distribution of each variable, providing a preliminary insight into the overall sample characteristics. Subsequently, correlation analysis is performed to explore the interrelationships between variables, laying the groundwork for subsequent regression analysis. Finally, regression analysis and other analytical techniques are employed to delve deeply into the relationships and influencing mechanisms among variables such as sports interest, sports atmosphere, psychological resilience, and academic pressure, furnishing robust evidence for understanding the intricate interplay among these variables. The specific outcomes of the statistical analysis are elucidated in Fig.  3 .

Sample statistical results

As depicted in Fig.  3 , the research sample of this study comprises 706 college students, 363 girls and 343 boys. Furthermore, the sample encompasses students from all academic years within the university, indicating that the research sample encompasses the entire student body on campus. This comprehensive coverage of the student population imbues the research findings with significant practical relevance and applicability.

The defined results of variables in this study are as follows:

Sports atmosphere comprises three subclassifications: Cooperation (M1), Input (M2), and Sense of belonging (M3). Sports interests contains 3 subclassifications: Self(I1), Mode (I2), and Participate (I3). Psychological resilience contains 4 subclassifications: Self-regulation (R1), Help from others (R2), and Ability dictates (R3), Learning effect (R4). Academic stress contains 4 subclassifications: Influence of others (P1), Competitive Impact (P2), Ability Impact (P3), and Environmental impact (P4).

In summary, this study process meticulously defines key variables, including sports interest, sports atmosphere, mental toughness, and academic stress. Sports interest is gauged through pertinent questions in the questionnaire, reflecting individuals’ preferences and willingness to engage in sports activities. The sports climate is evaluated using a specialized sports climate scale, elucidating the extent to which an individual’s sports environment or community fosters and supports sports participation. Mental toughness is assessed employing the well-established Resilience Scale, capturing an individual’s capacity to adapt and rebound amidst challenges and adversity. Academic stress is quantified using the Academic Stress Scale, focusing on the intensity of pressure and tension experienced by students during the learning process. To ensure the accuracy and reliability of these variables, the study conducts a thorough literature review, selects validated scales, and performs factor analysis as necessary to delve deeper into the structure and dimensions of the variables. These variables play pivotal roles in the study, and understanding their interactions and collective influence on an individual’s psychological state and academic performance constitutes the core content of the investigation. Research inquiries centers on elucidating the interrelationships among these variables and how they synergistically shape an individual’s holistic development. Drawing from theoretical analysis and literature review, the research team formulates a series of hypotheses to be tested through data collection and analysis. By meticulously measuring and analyzing these variables, this study aims to offer a nuanced understanding of the nexus between sports interest, sports atmosphere, mental toughness, and academic pressure, furnishing valuable insights for both research and practical applications in related fields.

Analysis of the impact of college students’ sports on mental health

Questionnaire reliability analysis.

Reliability pertains to the consistency and stability of measurement results obtained from a questionnaire, constituting a crucial criterion for evaluating questionnaire quality. Various methods exist for assessing reliability, with test-retest reliability, split-half reliability, and Cronbach’s Alpha being commonly utilized tools. Among these, Cronbach’s Alpha coefficient method has emerged as one of the most prevalent reliability analysis techniques due to its simplicity and effectiveness. It assesses the internal consistency of a questionnaire by computing the correlation between all items within the questionnaire. Typically, a Cronbach’s Alpha coefficient exceeding 0.7 signifies good reliability of the questionnaire.

In this study, the reliability of the questionnaire is evaluated using Cronbach’s Alpha coefficient method. The analysis reveals a Cronbach’s Alpha coefficient of 0.961, significantly surpassing the generally accepted threshold for good reliability (0.7). This outcome unequivocally indicates that the questionnaire employed here exhibits exceptionally high internal consistency, implying that each item within the questionnaire demonstrates strong consistency when measuring the same construct. Thus, the questionnaire can be deemed to possess good reliability.

Furthermore, to ascertain the suitability of the questionnaire for further factor analysis, a Kaiser-Meyer-Olkin (KMO) test is conducted. The KMO test evaluates the adequacy of raw data for factor analysis by assessing the ratio of partial correlations to simple correlations between variables. A KMO value approaching 1 signifies strong correlation between variables, rendering the original variables more conducive for factor analysis. Conversely, a KMO value nearing 0 suggests weak correlation between variables, rendering the original variables unsuitable for factor analysis.

In this study, the KMO test yields a result of 0.975, indicating a very high value close to 1, signifying robust correlation between variables in the questionnaire. Consequently, it can be inferred that the questionnaire utilized in this study is highly suitable for factor analysis, thereby further validating the reliability and applicability of the questionnaire. In summary, based on the aforementioned analysis, it can be concluded that the questionnaire employed in this study exhibits both good reliability and good validity.

Influence of personal factors

When assessing the influence of gender, grade, place of origin, and academic performance on college students’ engagement in physical exercise and mental health, this study employs the following statistical methods:

For examining the relationship between categorical variables such as gender, grade, place of origin, participation in physical exercise, and mental health level, a Chi-square test is utilized. This method is employed to ascertain whether the observed frequency distribution across different categories significantly differs from the expected frequency distribution, thereby determining the presence of a correlation between two categorical variables.

Moreover, one-way ANOVA is employed for assessing the relationship between the continuous variable of academic performance and physical exercise participation and mental health levels. This statistical method is utilized to examine the effect of one or more independent variables (in this study, academic performance) on a continuous dependent variable (such as physical activity participation or mental health levels). Through the application of the aforementioned statistical methods, the results presented in Table  1 are obtained. This table provides a comprehensive overview of the statistical analysis outcomes concerning gender, grade, place of origin, academic performance, physical exercise participation, and mental health level.

The findings depicted in Table  1 reveal that only gender demonstrates a significant correlation with psychological resilience, while grade level exhibits a noteworthy relationship with sports interest. Moreover, throughout the testing process, the influence of gender, grade level, hometown, and academic performance on the variables under investigation in this study is deemed insignificant. These results suggest that external factors exert minimal impact on the study, thereby affirming its reliability.

Correlation analysis

This study analyzes the relationship between various variables using the Pearson correlation coefficient to examine the linear relationships within the model. The Pearson correlation coefficient is a statistic that measures the strength and direction of the linear relationship between two variables, ranging from − 1 to 1. A correlation coefficient close to 1 indicates a strong positive correlation, close to -1 indicates a strong negative correlation, and close to 0 indicates almost no linear relationship between the variables. By calculating the Pearson correlation coefficient for the relevant variables in the dataset, the intensity and direction of the linear relationship between them are obtained. The results are summarized in Table  2 , providing an important basis for further analysis of interactions between variables and the construction of statistical models.

The results presented in Table  2 from the linear correlation test shed light on the relationships between sports interest, psychological resilience, academic pressure, and psychological well-being. While sports atmosphere is not directly listed, its impact on psychological well-being is discussed based on the provided description. These tests offer crucial insights into how these variables interrelate. The unstandardized coefficient for sports interest is -0.042, indicating that increased sports interest is associated with a small yet significant positive effect on psychological well-being. Although the standardized coefficient Beta is -0.087 and the t value is -0.709 (low), the p value is 0.480 (greater than 0.05 significance level), suggesting that the direct correlation between sports interest and psychological well-being is not strong. However, this doesn’t undermine the importance of sports interests. Conversely, the unstandardized coefficient for psychological resilience is 0.078, indicating that enhancements in psychological resilience are linked to significant positive effects on psychological well-being. With a standardized coefficient Beta of 0.177, a t value of 1.773, and a p value of 0.079 (close to the significance level of 0.05), the role of mental toughness in bolstering mental health is underscored. Moreover, the unstandardized coefficient for academic stress is -0.041, indicating that heightened academic stress is associated with negative effects on psychological well-being. Although the standardized coefficient Beta is -0.139, the t value is -1.141, and the p value is 0.257 (greater than 0.05 significance level), implying that the direct negative impact of academic stress on psychological well-being is not significant, its negative impact trend is noteworthy. Regarding sports atmosphere, although its coefficient is not listed, the p-value is 0.480, indicating its insignificant impact on psychological well-being. This warrants further exploration in future research to discern the potential influence of sports atmosphere on psychological well-being. In terms of analysis of variance, the model’s R² value is 0.087, indicating that sports interest, mental toughness, and academic stress jointly explain approximately 8.7% of the variation in psychological well-being. Though modest, this proportion holds significance given the multifaceted nature of psychological well-being. The adjusted R² value is 0.058, showing a slight decrease in the model’s explanatory power after accounting for the number of variables. With an F statistic value of 3.042 and a corresponding p-value of 0.033 (less than the 0.05 significance level), the entire model is statistically significant in predicting psychological well-being. The Durbin-Watson (D-W) value of 1.710 indicates no evident autocorrelation between residuals, ensuring the model’s data independence. In conclusion, this study elucidates the intricate relationships between sports interest, psychological resilience, academic stress, and psychological well-being. While the direct effect of sports interest on psychological well-being may not be significant, it likely plays a significant role alongside other variables. The substantial positive impact of psychological resilience on psychological well-being offers novel insights into enhancing mental health. Conversely, the negative trend of academic stress on psychological well-being underscores its potential harm. Future research can delve deeper into the interaction mechanisms between these variables and devise interventions to enhance college students’ psychological well-being.

Effects of sports on academic stress in the SEMs

Indeed, correlation analysis and SEMs are robust analytical tools that are wisely chosen for this study to comprehensively evaluate research hypotheses and explore relationships between variables. Correlation analysis serves as an initial step to ascertain statistical correlations between variables, providing a foundation for deeper investigation. By assessing the strength and direction of these correlations, researchers gain insights into potential associations and can identify variables that warrant further examination. SEMs, on the other hand, offers a sophisticated approach to analyze complex relationships among multiple variables simultaneously. It allows researchers to construct models that incorporate both observed variables and latent variables, providing a more nuanced understanding of their interactions and overall impact. SEMs serve as an efficacious statistical approach for probing the association between sports activities and academic stress. This methodology facilitates the examination of both the direct and indirect impacts of various types of sports activities on academic stress, while also considering the influence of individual differences on this nexus. Such an approach not only enhances comprehension of the mechanisms by which sports activities influence academic stress but also furnishes valuable insights for ameliorating academic stress. Table  3 ; Fig.  4 illustrate the research findings pertaining to the influence of sports activities on academic stress, as explored through SEMs in this study.

The path analysis results presented in Table  3 ; Fig.  4 provide strong support for the research hypotheses, confirming the significant impact of sports interest and sports atmosphere on college students’ psychological resilience and academic stress. Let’s break down these findings based on each hypothesis:

The path coefficient of 0.47, with a t value of 5.26 and a p value of less than 0.001, indicates a significant positive relationship between sports interest and mental toughness. This result confirms the hypothesis, suggesting that higher levels of sports interest are associated with greater psychological resilience among college students.

The path coefficient of 0.36, with a t value of 4.15 and a p value of less than 0.001, supports the indirect effect of sports interest on academic stress through psychological resilience. Thus, not only does sports interest directly enhance psychological resilience, but it also indirectly reduces academic stress by bolstering psychological toughness.

The path coefficient of 0.58, with a t value of 5.14 and a p value of less than 0.001, indicates a significant positive impact of sports atmosphere on psychological resilience. This finding corroborates the hypothesis, suggesting that a positive sports environment fosters greater psychological resilience among college students.

The path coefficient of 0.49, with a t value of 4.56 and a p value of less than 0.001, provides evidence for the indirect effect of sports atmosphere on academic stress via psychological resilience. Therefore, a conducive sports atmosphere not only enhances psychological resilience but also indirectly mitigates academic stress by bolstering mental toughness.

Absolutely, interpreting path coefficients in SEMs requires careful consideration of various factors that may influence their reliability and validity. Sample size, measurement error, model specification, and data characteristics can all impact the accuracy of path coefficients and the overall fit of the model to the data. Sample size plays a crucial role in the statistical power of SEMs. Larger sample sizes generally provide more reliable estimates of path coefficients and increase the likelihood of detecting significant relationships. Measurement error can introduce bias into path coefficient estimates, leading to potential inaccuracies in model interpretation. Therefore, it is essential to use validated measurement tools and carefully consider the reliability and validity of the measures used in the study. Furthermore, model fit statistics, such as the comparative fit index and root mean square error of approximation, are critical for assessing the overall goodness of fit of the SEM to the data. Poor model fit may indicate discrepancies between the proposed theoretical model and the observed data, highlighting the need for model refinement or reconsideration of data processing methods. Figure  4 provides a visual representation of the path analysis results, offering an intuitive understanding of the relationships between sports atmosphere, sports interest, mental toughness, and academic pressure among college students. This visualization aids in interpreting the complex interplay between these variables and facilitates communication of the study findings. In conclusion, addressing issues related to sports atmosphere, sports interest, mental toughness, and academic pressure among college students requires a multifaceted approach. Strategies such as strengthening physical education programs, providing mental toughness training, optimizing curriculum design, and improving teaching methods can contribute to promoting the physical and mental well-being of college students and equipping them with the skills to navigate the challenges of modern society.

This study delves into the influence of physical exercise on academic stress among college students, with a specific focus on how it shapes students’ psychological resilience and consequently impacts their academic stress levels. In today’s university milieu, characterized by escalating competition, academic stress emerges as a formidable challenge for college students. Hence, investigating the efficacy of physical exercise as a stress-relief mechanism assumes paramount significance in safeguarding the psychological well-being of students. While extant literature extensively examines the correlation between physical exercise and physical health, scant attention has been paid to its ramifications on academic stress and psychological resilience. This study bridges this gap by employing SEMs to meticulously scrutinize the intricate interplay among physical exercise, psychological resilience, and academic stress. This methodological approach not only offers a novel research perspective but also sheds light on the pivotal roles played by sports interest and the sports atmosphere in shaping college students’ psychological resilience and mitigating academic stress. The findings underscore the substantial mediating role of psychological resilience between physical exercise and academic stress. Moreover, they reveal that both sports interest and the sports atmosphere wield a significant positive influence on psychological resilience, and bolstering psychological resilience effectively diminishes academic stress levels among college students. These findings underscore the multifaceted significance of sports in higher education, extending beyond mere physical health promotion to encompass a distinctive role in safeguarding psychological well-being and alleviating academic stress.

This study makes a significant contribution by explicitly elucidating the inherent connections among interest in sports, the sports atmosphere, psychological resilience, and academic stress, thereby underscoring the positive role of sports in maintaining the psychological well-being of college students. This finding not only enriches theoretical understanding in relevant fields but also provides practical strategies and recommendations for schools and educational institutions. Firstly, schools and relevant departments should further recognize the importance of sports in alleviating academic stress and promoting psychological health, intensifying efforts to promote sports activities. By offering diverse sports programs and facilities and encouraging active participation in sports activities among college students, schools can nurture their interest in sports and cultivate healthy sports habits. Secondly, educational institutions and educators should integrate sports into daily educational teaching, making it an essential means of promoting students’ comprehensive development and enhancing psychological resilience. By creating a positive sports atmosphere through various forms such as sports classes, sports clubs, and sports events, educators can help students establish healthy lifestyles. Finally, future research could further explore other factors that may influence the relationship between interest in sports, psychological resilience, and academic stress, such as individual traits, family background, and social environment. This will contribute to a more comprehensive understanding of the role of sports in the growth of college students, providing scientific evidence for the development of more effective intervention measures. In conclusion, this study offers a new perspective on understanding the regulatory mechanism of college students’ psychological health by deeply exploring the relationship between physical exercise, psychological resilience, and academic stress. By fostering interest in sports, enhancing psychological resilience, and creating a positive sports environment, academic stress among college students can be effectively alleviated, promoting their comprehensive development and psychological health. These findings hold significant practical implications for schools, society, and families alike.

With societal development and the acceleration of life’s pace, academic pressure has garnered widespread attention. Sports interest and a favorable sports atmosphere are increasingly recognized as effective methods for alleviating academic pressure. This study aims to explore the influence of physical activities and psychological resilience among college students on academic stress, offering valuable insights for addressing the academic stress levels of college students. Through a literature review and SEM analysis, this study presents significant conclusions and contributions. Firstly, it establishes a notable relationship between psychological resilience and academic stress, demonstrating that the sports atmosphere and sports interest significantly impact academic stress through psychological resilience. This underscores the importance of fostering sports interests and cultivating a positive sports atmosphere among college students to enhance psychological resilience, consequently alleviating academic pressure. This finding provides vital guidance for college educators, highlighting the importance of organizing and promoting sports activities. Secondly, through SEM analysis, this study identifies psychological toughness as a mediating factor in the relationship between sports interest and academic stress. This underscores the positive impact of physical activity on mental health, specifically in reducing academic stress by enhancing psychological toughness. This contribution enriches the theoretical framework surrounding the interplay of academic stress and physical activity and offers novel perspectives and strategies for mental health education in higher education institutions. Finally, this study validates its research hypotheses through empirical data analysis and offers specific recommendations and future prospects. However, certain limitations exist, including potential subjectivity in self-reporting and memory constraints inherent in the questionnaire method. Thus, future research endeavors may focus on diversifying samples and expanding coverage to enhance the reliability and representativeness of research outcomes. In summary, this study provides valuable insights and strategies for ameliorating the academic stress experienced by college students by delving into the influence of physical activities and psychological resilience on academic stress. This not only aids university educators in better addressing students’ mental health concerns but also serves as a significant reference for future related research.

Data availability

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

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Acknowledgements

We sincerely appreciate every participant in our survey.

This research was funded by the General Project of Jilin Provincial Education Science Plan during the 14th Five-Year Plan Period, 2022, with the project titled “Research on the Impact of New Era National Defense Physical Education on Enhancing College Students’ Physical Literacy.” The project number is GH22169.

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School of Psychology, Northeast Normal University, Changchun, China

Mengfan Liu

School of Physical Education, Northeast Normal University, Changchun, China

Bo Shi & Xu Gao

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BS contributed to the conception and design of the study and wrote sections of the manuscript. ML organized the database, performed the statistical analysis, and wrote the first draft of the manuscript. XG made careful revisions to the first draft of the manuscript. All authors contributed to the manuscript revision, read, and approved the submitted version.

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Correspondence to Bo Shi .

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The studies involving human participants were reviewed and approved by the Academic Ethics Committee of the School of Psychology at Northeast Normal University. The patients/participants provided their written informed consent to participate in this study.

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Liu, M., Shi, B. & Gao, X. The way to relieve college students’ academic stress: the influence mechanism of sports interest and sports atmosphere. BMC Psychol 12 , 327 (2024). https://doi.org/10.1186/s40359-024-01819-1

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Received : 20 January 2024

Accepted : 27 May 2024

Published : 04 June 2024

DOI : https://doi.org/10.1186/s40359-024-01819-1

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