assignment nursing journal

Writing Tips for Nursing School Students

• Nursing School Writing Types
• Writing a Nursing Essay
• Citations Guide
• Common Writing Mistakes
• Writing Resources

Are you ready to earn your online nursing degree?

Writing is an essential skill nurses should achieve proficiency in early in their career. It is a crucial part of the profession, as nurses need to be able to effectively communicate with patients, families, and other healthcare professionals.

While verbal communication also plays a vital role in nursing, being able to write well builds the nurse’s ability to provide better care.

Being able to accurately detail a patient’s personal history, symptoms, and diagnosis allows for the execution of a precise treatment plan that is clearly communicated to all parties involved, both professional and personal.

From registered nurses to clinical nurses and beyond, being able to communicate effectively and efficiently is a critical soft skill that will help nurses in any role increase their ability to treat their patients.

This guide provides an overview of the types of writing nurses will experience throughout their educational training. Utilize the following tips and tricks to help strengthen your writing skills, which will ultimately help in the development of transferable career skills .

Types of Writing Nurses Will Do in School

Personal statements for nursing school.

Nursing schools want candidates who meet academic and professional requirements. They also want a candidate who demonstrates a sincere passion for patient care and individual connections. You should always craft a personal statement, even when the application doesn’t explicitly require one. Personal statements allow you to describe your goals, characteristics, credentials, volunteer work, and meaningful life experiences. A well-crafted essay can help you stand out among other qualified applicants. And, as with any piece of writing, you must take the time to revise.

In your personal statement, you should portray yourself as determined and empathetic, with characteristics, goals, work ethic, and healthcare philosophy that align with a program’s values. Some nursing schools ask for a general personal statement, while others require a specific prompt. Colleges commonly ask students to describe a hardship they overcame, a difficult task they accomplished, or a professional goal they hope to achieve through the program. Many schools also ask students to detail previous experiences in healthcare. You may decide to write about how you connect with patients or how you provide practical and emotional support to loved ones.

You will also encounter writing prompts during examinations, including standardized tests like the GRE or MCAT, nursing school entrance exams , and course-specific evaluations. You may also take exams to get state licensure or professional certification. In most of these instances, you will need to write one or several long-form essays. Proper planning is key. Though you won’t know what specific prompt the test will require, you can expect certain common topics. You can search online or use study guides to determine which prompts usually appear on each test.

On test day, you should begin by creating an outline that lists three main points in response to the prompt. Using these points, work backwards to write a central thesis to guide the essay’s structure. Review what you’ve written to ensure that the essay actually responds to the prompt at hand. Be sure to leave time to correct spelling, grammar, and stylistic errors.

Research Papers

Like essays, research papers follow a long-form structure. Unlike an essay, which heavily relies on the writer’s point of view, a research paper presents an in-depth investigation of a topic using data, expert opinions, and insights. While an essay evaluates general critical thinking and writing skills, a research paper tests your knowledge, research skills, and original contributions. Research papers also allow you to prove you understand what has been argued and discovered about a topic. Research papers, especially at the graduate and doctoral levels, require independent research and analyses. These papers sometimes take months or years to complete.

To write a successful research paper, you should pick a topic relevant to your interests and the nursing field. Possibilities include elderly care challenges, patient safety and ethics, mental health treatment and regulations in the U.S., and nursing shortages and possible solutions. Whatever your choice, you must plan accordingly. Advanced papers such as dissertations may require funding or help from professors. Research papers often consist of the following sections: abstract, introduction, literature review, methods, results, discussion, conclusion, and references. You should keep this general structure in mind as you prepare notes and outlines.

How Do You Write a Nursing Essay?

In nursing school, essay writing includes academic papers, personal narratives, and professional compositions. You should become familiar with each of the five major forms below. There are many similarities between these essay types, such as an overarching thesis and a supportive, logical structure. You should support claims with factual, statistical, anecdotal, and rhetorical evidence. However, each form requires distinct skills to achieve specific results.

Comparative

Cause and effect, citations guide for nursing students.

Citations allow readers to know where information came from. By citing sources, you avoid plagiarizing or stealing another person’s ideas, research, language, and analyses. Whether intentional or unintentional, plagiarism is one of the most egregious errors one can make. Consequences for plagiarism include automatic course failure, disciplinary actions from the university, and even legal repercussions. You should take special care to ensure you properly cite sources.

American Psychological Association (APA) Style

APA is the most commonly used style among natural scientists, social scientists, educators, and nurses. Like other citation styles, APA emphasizes clarity of font style, font size, spacing, and paragraph structure. APA citations focus on publication date, and in most cases, the date comes right after the author’s name. This order makes the style particularly useful for scientists, who value new research and updates on current findings. For more information on APA style, visit this official website .

(Author and year of publication, page number) “Punishment, then, will tend to become the most hidden part of the penal process” (Foucault, 1977, p. 9).

Chicago Manual of Style (CMS)

CMS (also known as CMOS or, simply, Chicago) features two citation systems, the notes and bibliography, and the author and date. This style is used primarily by historians, who place high importance on a text’s origin. The notes and bibliography include a superscript number with a corresponding footnote or endnote. Scientific professionals use the author and date citation, a generic parenthetical system with similarities to other citation styles. The CMS official website provides additional information, including changes to citation systems in the current edition.

“Punishment, then, will tend to become the most hidden part of the penal process”. 1 1. Michel Foucault, trans. Alan Sheridan, Discipline and Punish: The Birth of the Prison (New York: Pantheon Books, 1977), 9.

(Author and year of publication, page number) “Punishment, then, will tend to become the most hidden part of the penal process” (Foucault 1977, 9).

Modern Language Association (MLA) Format

MLA format traces its history to 1951 when it was first published as a thin booklet. Today, MLA is the primary format used by academics and professionals in humanities, English, literature, media studies, and cultural studies. To adapt to the rapid growth of new mediums over the past few decades, MLA updates its citation system. Visit the MLA Style Center for in-depth information on new guidelines and ongoing changes. In general, in text citations consist of author and page number, or just page number if the author’s name appears in the text.

(Author and page number) “Punishment, then, will tend to become the most hidden part of the penal process” (Foucault 9).

Associated Press (AP) Style

Published in 1952, the original AP Stylebook was marketed to journalists and other professionals related to the Associated Press. AP now stands as the go-to style for professionals in business, public relations, media, mass communications, and journalism. AP style prioritizes brevity and accuracy. The style includes specific guidelines regarding technological terms, titles, locations, and abbreviations and acronyms. Unlike the previous styles, AP does not use parenthetical or in-text citations. Rather, writers cite sources directly in the prose. For more information, including style-checking tools and quizzes, visit the Associated Press Stylebook .

In the book, “Discipline and Punish: The Birth of the Prison,” first published in English in 1977, philosopher Michel Foucault argues that “Punishment, then, will tend to become the most hidden part of the penal process”.

Which Style Should Nursing Students Use?

Because nurses rely on scientific terms and information, professionals in the field usually use APA style. Regardless of the purpose and specific genre of your text, you should always strive for concise, objective, and evidenced-based writing. You can expect to learn APA style as soon as you enroll in a major course. However, you should also prepare to learn other styles as part of your academic training. For example, freshman composition classes tend to focus on MLA guidelines.

Common Writing Mistakes Students Make

Active vs. passive voice.

Active and passive voice represent two different ways to present the same piece of information. Active voice focuses on the subject performing an action. For example, the dog bites the boy. This format creates clear, concise, and engaging writing. Using active voice, nurses might write, I administered patient care at 11:00. Passive voice, on the other hand, focuses on the object of the sentence or the action being performed. For example, the boy was bitten by the dog. A passive sentence is usually one that contains the verb “to be.” Using passive voice, you might write, patient care was administered at 11:00.

Professionals in the sciences often use passive voice in their writing to create an objective tone and authorial distance. Passive voice can prioritize specific terms, actions, evidence, or research over the writer’s presence. Additionally, nurses use passive voice because it is usually clear that the reported thoughts, actions, and opinions come from them. However, you must also learn how to use active voice.

Punctuation

There are 14 punctuation marks in the English language, each with multiple and sometimes overlapping uses. Additionally, certain punctuation marks only make sense in highly specific and nuanced grammatical instances. To master punctuation, you must learn through practice, particularly by revising your own writing.

For example, colons and semicolons are often used interchangeably, when they actually serve distinct purposes. Generally used before itemized lists, colons stand in for the phrases “here is what I mean” or “that is to say.” For example, I am bringing three things to the picnic: applesauce, napkins, and lemonade. Semicolons separate two independent clauses connected through topic or meaning. For example, It was below zero; Ricardo wondered if he would freeze to death. Comma splices, which create run on sentences, are another common mistake. You can identify a comma splice by learning the differences between an independent and dependent clause.

Grammar refers to the rules of a particular language system. Grammar determines how users can structure words and form sentences with coherent meaning. Aspects include syntax (the arrangement of words to convey their mutual relations in a sentence) and semantics (how individual words and word groups are understood). Unless you major in writing, literature, etymology, or another related field, you generally won’t examine English grammar deeply. Through years of cognitive development and practice, native users implicitly understand how to effectively employ the language.

Distinct grammatical systems exist for each language and, sometimes, even within a single language. For example, African American Vernacular English uses different syntactic rules than General American English. You should learn grammatical terms and definitions. Common errors include subject/verb agreement, sentence fragments, dangling modifiers, and vague or incorrect pronoun usage. Hasty writers can also misuse phonetically similar words (your/you’re, its/it’s, and there/their/they’re).

Writing Resources for Nursing Students

Apa style central, reviewed by:.

Shrilekha Deshaies, MSN, RN

Shri Deshaies is a nurse educator with over 20 years of experience teaching in hospital, nursing school, and community settings. Deshaies’ clinical area of expertise is critical care nursing and she is a certified critical care nurse. She has worked in various surgical ICUs throughout her career, including cardiovascular, trauma, and neurosurgery.

Shri Deshaies is a paid member of our Healthcare Review Partner Network. Learn more about our review partners here .

Page last reviewed November 30, 2021

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Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion

Peter griffiths.

a University of Southampton, Health Sciences, United Kingdom

b National Institute for Health Research Applied Research Collaboration (Wessex), United Kingdom

c Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden

Christina Saville

Jeremy jones, natalie pattison.

d University of Hertfordshire, School of Health and Social Work, United Kingdom

e East & North Hertfordshire NHS Trust, United Kingdom

Thomas Monks

f University of Exeter, College of Medicine and Health, United Kingdom

Associated Data

The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.

We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.

The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.

Conclusions

Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.

Tweetable abstract

Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

What is already known about the topic?

• • There are many studies showing adverse effects of low nurse staffing on patient outcomes.
• • There has been a longstanding interest in developing systems to determine the required staffing level.
• • Despite decades of research and a large number of tools, previous reviews have highlighted limited evidence about their use.

What this paper adds

• • Recent years continue to see reports of new staffing tools and systems.
• • Important sources of variability are neglected in published reports.
• • Benefits are associated with increased staffing levels but the costs and benefits of using a tool, as opposed to simply increasing staffing, remain unknown.

1. Introduction

Multiple reviews of research have established that higher registered nurse staffing levels in hospitals are associated with better patient outcomes and improved care quality, including lower risks of in-hospital mortality, shorter lengths of stay and fewer omissions of necessary care (e.g. Brennan et al., 2013 ; Griffiths et al., 2016 , 2018b ; Kane et al., 2007 ; Shekelle, 2013 ). However, beyond providing an injunction to invest in ‘more’ staff, such studies rarely indicate directly how many staff are required. The ability to determine the ‘right’ number of staff, both to employ and to deploy on any given shift, is an imperative from the perspective of both quality and efficiency of care ( Saville et al., 2019 ). In this paper, we consider the evidence base for approaches to measuring nursing workload and tools used to determine the number of nurses that are required for general acute-care hospital wards.

1.1. Nurse staffing levels and outcomes

Low nurse staffing is associated with omissions of essential nursing care ( Griffiths et al., 2018b ), identified as a key mechanism leading to adverse patient outcomes ( Recio-Saucedo et al., 2018 ). Building on the extensive evidence from cross-sectional studies, recent studies have shown associations at a patient- rather than hospital- or unit-level ( Griffiths et al., 2018a , 2019 ; Needleman et al., 2011b ). These include studies involving direct observation of care delivery ( Bridges et al., 2019 ) and studies showing that omissions in care mediate associations between staffing levels and outcomes ( Ball et al., 2018 ; Bruyneel et al., 2015 ; Griffiths et al., 2018a ). While cause and effect cannot be directly inferred from observational studies, the case for a conclusion that low nurse staffing causes harm to patients is increasingly compelling. Perhaps the case is best made by considering the alternative proposition. It seems highly unlikely that there are no adverse outcomes caused by low nurse staffing levels.

Partly as a response to this evidence, policies of mandatory staffing minimums have been much discussed and implemented in a number of jurisdictions, most notably California, USA ( Donaldson and Shapiro, 2010 ; Mark et al., 2013 ; Royal College of Nursing, 2012 ). Yet, even where mandatory staffing policies are implemented, patient care needs that cannot be met by the minimum must be identified, and staffing adjusted accordingly. The question of how best to identify the required nurse staffing level remains unanswered.

1.2. Staffing tools and methodologies

Determination of appropriate nurse staffing levels and measurement of workload have been studied since the earliest days of research into nursing (e.g. Lewinski-Corwin, 1922 ). Over the years, there have been many reviews focussing on methods for determining nurse staffing requirements. All have highlighted major deficits in the evidence. The problem is not a simple lack of published literature. One early review of nurse staffing methodologies, published in 1973, included a bibliography of over 1000 studies ( Aydelotte, 1973 ). However, finding no evidence concerning the relative costs or effectiveness of different staffing methods and little evidence for validity or reliability, the authors concluded “Although the intent of the methodologies is admirable, all are weak” (p. 57) ( Aydelotte, 1973 ).

Subsequent reviews have had to embrace an ever-growing body of research and an increasing number of systems. A review undertaken for the then Department of Health and Social Services (DHSS) in the UK in 1982 identified over 400 different systems for determining staffing requirements ( DHSS Operational Research Service, 1982 ). Despite the volume of writing, evidence to judge the merits of these systems has remained elusive. Writing in 1994, Edwardson and Giovanetti noted the absence of published scientific evidence for a number of systems, such as GRASP or Medicus, which were in widespread use in North America ( Edwardson and Giovannetti, 1994 ). They also noted that although different systems tended to produce results that were highly correlated, they could nonetheless produce substantially different estimates of the required level of nursing staff for a given patient or unit ( Edwardson and Giovannetti, 1994 ).

Fasoli and Haddock reviewed 63 sources (primary research, theoretical articles and reviews) and again found that there was insufficient evidence for the validity of many current systems for measuring nursing workload and staffing requirements, concluding that systems are not sufficiently accurate for resource allocation or decision-making ( Fasoli et al., 2011 ; Fasoli and Haddock, 2010 ). Other reviews reinforce this pervasively negative picture of the evidence ( Arthur and James, 1994 ; Butler et al., 2011 ; Hurst, 2002 ; Twigg and Duffield, 2009 ). The field is dominated by descriptive reports of locally developed approaches and none of these reviews found any evidence for the impact of implementation of a tool on outcomes for quality of care, patients or staff ( Griffiths et al., 2016 ).

However, the topic remains important. Identifying low staffing as a significant contributor to “conditions of appalling care ”, a key recommendation of the Francis Inquiry into the failings of the Mid Staffordshire General Hospital in the United Kingdom was the development of guidance for nurse staffing including:

“…evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix.”(p. 1678) ( Francis, 2013 )

In this paper we aim to give an overview of approaches to measuring nurse staffing requirements for general acute hospital wards, drawing primarily on existing reviews, before presenting a more comprehensive overview of more recent primary research to determine whether (and how) evidence has changed in recent years.

2. Review methods and scope

2.1. search strategy and approach to review.

The sheer volume of material and unanswered questions identified in other reviews makes this a daunting area to summarise. We describe the current review as systematic in the sense that we aim to be explicit about the approach to identification and selection of literature. However, as we primarily aim to map the literature, identifying recent developments, key features and areas of relative strength and weakness, without necessarily giving each study an in-depth critical appraisal, we consider this a scoping review, serving to summarise findings and identify gaps in the knowledge ( Arksey and O'Malley, 2005 ).

We draw selectively on older authoritative sources and reviews to give a general overview and background to the evidence (including the reviews already cited), using the results of our comprehensive searches and review of reviews undertaken for the National Institute for Health and Care Excellence, NICE ( Griffiths et al., 2014 ) as a key source.

In order to identify more recent studies, we searched Medline, CINAHL (key word only) and The Cochrane Library using the terms “Workload”[key word, MESH] or “Patient Classification”[key word] AND “Personnel Staffing and Scheduling” AND “Nurs*”[key word] or “Nursing”[MESH] and limited results using the OVID Medline sensitive limits for reviews, therapy, clinical prediction guides, costs or economics. We checked the sensitivity of this search, which was designed to be specific, using the results of our earlier more comprehensive search ( Griffiths et al., 2014 ) as a test set. We performed additional searches for citations to existing reviews and for other works by the authors of those reviews (since such reviews might be conducted as a prelude to new empirical research). We also undertook focussed searches on databases for works by key authors and searched the World Wide Web using the names of widely used tools. Searches were completed in mid-December 2018. We looked specifically for new reviews published after 2014 (when searches for our 2014 review of reviews were completed) and primary studies published from 2008 onwards, because the most recent review in our review of reviews was published in 2010 ( Fasoli and Haddock, 2010 ). After removing duplicates, we had 392 recent sources to consider.

2.2. Selection of primary research

Consistent with the aims of a scoping review, we took a liberal approach to inclusion for material to review. We included primary studies that described the development, reliability or validity testing of systems/ tools for measuring nursing workload/ predicting staffing requirements; studies that compared the workload as assessed by different measures, or which used a tool as part of a wider study in such a way that it might provide some insight into the validity of tools or another aspect of the determination of nurse staffing requirements; and studies that reported the costs and/or consequences of using a tool, including the impact on patient outcomes. We also included descriptive papers that might not merit the label ‘study’, provided that they included some data. We only included studies that were of direct relevance to staffing on general acute adult inpatient units and so excluded studies focussing exclusively on (for example) intensive or maternity care. However, had we identified material that demonstrated a significant methodological advance or other insight we were open to including it for illustrative purposes.

3.1. Overview of approaches to determining nurse staffing levels

There are many methods for determining nurse staffing requirements described in the literature. They are generally classified into several broad types ( Fig. 1 ) although the distinction between these approaches is less absolute than it may appear and terminology varies.

Major approaches for determining nurse staffing requirements.

Telford's professional judgement method ( Telford, 1979 ), first formally described in the UK in the 1970s, provides a way of converting the shift-level staffing plan, decided using expert opinion, into the number of staff to employ. The method describes calculation of the number of nurses to employ (generally referred to in the UK literature as the nursing ‘establishment’) in order to reliably fill the daily staffing plan (planned roster), making allowance for holidays, study leave and sickness/absence. Conversely, this method can be used to infer the daily staffing plan from the whole time equivalent staff employed by a ward, as illustrated by Hurst (2002 ). The full ‘Telford’ method provides a framework for wider deliberation, but the judgement of required staffing does not require the use of objective measures to determine need ( Arthur and James, 1994 ), hence it is an example of a ‘ professional judgement’- based approach . In recent years, this deliberative approach without formal measurement is reflected in the United States Veteran's Administration staffing methodology ( Taylor et al., 2015 ).

‘Benchmarking approaches ’ involve using expert judgements to identify suitable comparators, with the staffing levels compared between similar units to establish requirements. For many years this approach was used by the audit commission in the UK ( Audit Commission, 2001 ) to compare nursing establishments and expenditure between units across hospitals. Although characterised by Hurst (2002) as a distinct method, like professional judgement, benchmarking does not involve any formal assessment of patient requirements for nursing care. Rather, consensus methods and expert professional judgement are often used in selecting appropriate benchmarks and so it could be characterised as a particular form of the professional judgement approach, although such characterisation requires that such a judgement is applied. Furthermore, while the process of comparison with similar wards gives the appearance of objectivity, much depends on how the initial staffing levels were arrived at, and there is ample evidence that perceptions of staffing requirements are often anchored to historical staffing levels ( Ball et al., 2019 ; Twigg and Duffield, 2009 ).

While accounts of professional judgement and benchmarking exercises often focus on determining establishments, both can also be used to determine a daily staffing plan or shift-level nurse-patient ratio or equivalent (such as nursing hours per patient). In this way they assign a target number of nursing staff or hours per patient or bed ( Hurst, 2002 ), informing staff deployment decisions. Such approaches specify unit types to which a particular staffing level applies, although categories tend to be broad (e.g. intensive care, general medical surgical and rehabilitation). Some more recent approaches to monitoring workload (see below) extend this approach to take a wider view of activity, for example adding in admissions and discharges over and above the patient census, and therefore we term these patient-nurse ratio approaches ‘volume-based’ approaches .

Approaches that appear to set minimum staffing levels per patient, an example of a volume-based approach, are sometimes explicit in stating that additional staffing may be required to meet peaks in demand. For example, the legislation that established mandatory nurse-patient ratios in California includes a stipulation that hospitals also use a system for determining individual patient care requirements to identify the need for staffing above the specified minimum ( State of California, 1999 ). Thus, approaches which seek to determine staffing requirements accounting for individual patient variation in need or other factors driving workload can be used as alternatives to, or in conjunction with, minimum staffing levels based purely on patient volumes.

Whereas volume-based approaches measure variation in workload determined by patient counts, other approaches recognise that patients in a given type of ward may have different care requirements. Edwardson and Giovannetti (1994) , offer a typology of three main approaches for determining individual patient need: prototype, task and indicator systems. Hurst also describes three main types: Patient Classification Systems, timed-task and regression-based ( Hurst et al., 2002 ).

Prototype or Patient Classification Systems group patients according to their nursing care needs and assign a required staffing level for each ( Fasoli and Haddock, 2010 ; Hurst, 2002 ). They use either pre-existing categorisations, e.g. diagnosis-related groups ( Fasoli and Haddock, 2010 ), or bespoke categorisations, e.g. classifications based on levels of acuity and/or dependency groups. The Safer Nursing Care Tool ( The Shelford Group, 2014 ), the most widely used method for determining staffing requirements in England ( Ball et al., 2019 ), is one such system. Patients are allocated to one of five acuity/dependency categories with a weighting (described as a ‘multiplier’) to indicate the required staff to employ associated with patients in each category.

In task (or timed-task ) approaches, a detailed care plan, consisting of specific ‘tasks’, is constructed for each new patient and used to determine the required staffing ( Hurst, 2002 ). Each task is assigned an amount of time. The commercial GRASP system, still widely used in the United States, is an example of such a system ( Edwardson and Giovannetti, 1994 ).

As with prototype approaches, indicator approaches ultimately assign patients to categories, in this case based upon ratings across a number of factors that are related to the time required to deliver patient care. These can include broad assessments of condition (e.g. ‘unstable’), states (e.g. ‘non ambulatory’), specific activities (e.g. complex dressings) or needs (e.g. for emotional support or education) ( Edwardson and Giovannetti, 1994 ). The Oulu Patient Classification, part of the RAFAELA system, is one such example. Patients are assigned to one of four classifications, representing different amounts of care required, based upon a weighted rating of care needs across six dimensions ( Fagerström and Rainio, 1999 ). However, the inclusion of some specific activities in Edwardson and Giovennetti's definition of indicator approaches makes it clear that the distinction from task / activity-based systems is not an absolute one. Typically, though, task-based systems take many more elements into account: over 200 in some cases ( Edwardson and Giovannetti, 1994 ).

Hurst also identified regression -based approaches, which model the relationship between patient-, ward- and hospital-related variables, and the establishment in adequately-staffed wards ( Hurst, 2002 ). To obtain the recommended establishment for a particular ward, coefficients derived from the regression models are used to estimate the required staffing. There are relatively few examples, although Hoi and colleagues provide one recent example, the Workload Intensity Measurement System ( Hoi et al., 2010 ). In some respects, regression-based models simply represent a particular approach to allocating time across a number of factors within an indicator-based system, rather than directly observing or estimating time linked to specific activities or patient groups. The RAFAELA system, widely used in the Nordic countries, although based on a relatively simple indicator system, uses a regression-based approach to determine the staffing required to deliver an acceptable intensity of nursing work for a given set of patients in a given setting ( Fagerström and Rainio, 1999 ; Fagerstrom and Rauhala, 2007 ; Rauhala and Fagerström, 2004 ).

In these more tailored approaches, the method for determining the required times for patient groups or tasks varies. The literature describes the use of both empirical observations and expert opinion to determine the average time associated with tasks or patient classifications ( De Cordova et al., 2010 ; Myny et al., 2014 ; Myny et al., 2010 ). In some cases, there is an explicit attempt to make workload/time allocations based on reaching some threshold of quality. For example, wards contributing to the database from which the multipliers for the Safer Nursing Care Tool are derived must meet a predefined standard for care quality ( Smith et al., 2009 ). Non-patient contact time, for example care planning and documentation or other activities that take place away from the bedside (which are not always easily attributable to individual patients), is dealt with in different ways. All approaches consider this, often assigning a fixed percentage time allocation over and above direct care that has been measured.

While some approaches appear to be more precise than others, using detailed patient care plans at one extreme (timed-task) and apparently assuming all patients have similar needs (volume-based) at the other, all use average time allocations, with an unstated assumption that when summed across tasks and patients, individual variation can be accommodated.

3.1.1. Staffing decisions and the use of tools

A number of different decisions can be made using staffing systems and tools, with decisions operating in different time frames ( Table 1 ). Nursing managers must decide in advance how many nursing staff to employ (often referred to as the nursing establishment ) and how many nursing staff to deploy each shift, either as a fixed daily staffing plan or in response to immediate demand. Accounts of indicator and task approaches often focus on measuring immediate need (and implicitly deploying staff to meet such need) rather than determining an establishment to fill planned rosters. These are separate but inter-related decisions, which all rely on being able to quantify nursing workload. The distinction is sometimes unclear in published accounts and the relationship between these uses tends to be implicit rather than explicit.

Uses of staffing systems and tools.

For example, the Safer Nursing Care Tool was designed to support decisions about the total nursing establishment required on a ward based on meeting the daily needs of a sample of patients ( The Shelford Group, 2014 ). More recently, its core acuity-dependency scoring system has been used to plan and review daily staffing levels, supporting deployment and real-time redeployment decisions, for example using the SafeCare system from the commercial rostering system provider Allocate ( Allocate Software, 2017 ).

There are also examples of tools specifically to balance workload within a unit, which thus focussed primarily on immediate assignments for staff members ( Brennan and Daly, 2015 ; Brennan et al., 2012 ). Finally, tools can be used retrospectively to review the success of staffing plans (how well the plan met needs) or as a measure of resource use for pricing, budgeting or billing purposes ( Kolakowski, 2016 ).

3.1.2. Overlap between approaches

While the classifications are useful to distinguish broad approaches, the differences are not absolute. For example, professional judgement-based approaches might involve benchmarking to set a fixed establishment for a ward based on an underlying staffing model that aims for a given nurse-patient ratio on each shift and so resembles a volume-based approach. The original determination of the staffing requirement might have involved a detailed appraisal of patient need on a given ward involving many factors similar to those considered in other systems, without a formal calculation of workload based on measurements.

On the other hand, prototype or indicator systems set establishments or daily staffing plans based on a measurement of a sample of individual patient needs, assuming that this can be used to generalise to the patient population as a whole. The establishment, once set, implies that care needs are then met by a fixed nurse-to-patient ratio or number of hours per day, although these ratios may differ between wards. Indeed, a prototype classification system, such as the Safer Nursing Care Tool, resembles a volume-based mandatory minimum staffing policy supplemented by assessment of variation above the base requirement, such as that implemented in California, because there is an implied absolute minimum staffing level per patient, associated with the prototype with the lowest staffing requirement.

3.1.3. Choice of tools

The reviews cited earlier made it clear that there was little basis to prefer any one approach over another based on the available evidence. Professional judgement-based approaches, despite being open to accusations of subjectivity, cannot be readily dismissed without evidence that moving from a judgement-based staffing model to one informed by a tool has improved any outcomes or made more efficient staffing allocations. Existing reviews present no such evidence ( Arthur and James, 1994 ; Aydelotte, 1973 ; DHSS Operational Research Service, 1982 ; Fasoli and Haddock, 2010 ; Griffiths et al., 2016 ; Hurst, 2002 ; Twigg and Duffield, 2009 ). Professional judgement remains central and indeed is incorporated into some tools. One of the most comprehensively researched systems determines the staffing requirement by titration against a subjective report of work intensity ( Fagerström and Rainio, 1999 ; Rauhala and Fagerström, 2004 ).

The use of subjective judgements would matter little if different approaches gave similar results, but this is not the case. While direct comparisons are relatively rare, it is clear from the available evidence that different systems can give vastly different estimates of required staffing (e.g. Jenkins-Clarke, 1992 ; O'Brien-Pallas et al., 1991 , 1992 , 1989 ). In one study, the five systems tested provided estimates that correlated highly. However, they offered a wide range of average staffing requirements for the same sample of 256 patients, from 6.65 h per patient per day to 11.18 ( O'Brien-Pallas et al., 1992 ).

3.2. Recent evidence

From our searches for primary studies we found 37 recent sources to consider. They were diverse in their methods although all were observational studies. We classified the sources according to the main purposes of the articles, although some articles did not clearly sit in a single category and were given a dual classification (see Table 2 for classifications and Table 4 in Supplemental material for fuller descriptions).

Recent studies/sources used in the review.

3.2.1. Descriptions

These descriptive studies illustrate the currency of a range of approaches including professional judgement ( Taylor et al., 2015 ), prototype ( Fenton and Casey, 2015 ; The Shelford Group, 2014 ) and indicator systems ( Fagerström et al., 2014 ; Kolakowski, 2016 ), with at least one explicitly combining approaches ( Fagerström et al., 2014 ). Studies demonstrate variation between wards and from day to day and month to month (e.g. Gabbay and Bukchin, 2009 ; Smith et al., 2009 ), arising from the number of patients, the numbers of admissions and discharges, individual patient characteristics and their specific needs (e.g. Fagerström et al., 2014 ; Hurst, 2009 ; Smith et al., 2009 ), as well as contextual factors such as the physical arrangement of the ward ( Hurst, 2008 ).

While demonstrating that measured demand for nursing care can vary considerably, none of the descriptive studies provided a measure that allowed the variation to be directly quantified in terms of variability in the staff required from day to day. Knowledge of this variability would help determine whether a fixed staffing plan is liable to meet patient need on a regular basis. This lack of direct quantification is an important limitation given that tools are used to guide fixed staffing plans.

3.2.2. Comparisons

The findings of earlier studies, showing that different methods can give very different results, are reflected in recent research. Differences between alternative approaches to counting patients for methodologies using hours per patient day appear to be of marginal practical significance ( Beswick et al., 2010 ; Simon et al., 2011 ), but other factors can make a substantial difference to estimated staffing requirements. Methods that take into account more factors appear to arrive at higher workloads. An unquantified statistically significant increase to workload from including patient turnover in a volume-based measure was noted in one study ( Beswick et al., 2010 ). An acuity- and dependency-based indicator system identified an additional six hours of care per day compared to a standard (fixed) hours per patient day method ( Rivera, 2017 ). A new multifactorial indicator system with additional care categories and revised timings resulted in an estimated nursing requirement that was double that determined by an existing simpler system ( Hoi et al., 2010 ).

3.2.3. Tool development

Many studies (thirteen) report the development of new measures or adaptation of existing measures. Most system types, including professional judgement, volume-based approaches and timed-task feature on this list, adding to the range considered in recent descriptions (above). The measures were often developed for local use only. Typically, papers identify time or some weighting associated with aspects of care or particular groups of patients ‘on average’. However, they generally fail to report or consider variability in the underlying estimates.

That variation around the average time could be important is illustrated in the work of Myny and colleagues in Belgium ( Myny et al., 2014 , 2010 ), which as well as being an exception by reporting variability, also represents one of the few examples of a sustained programme of research in recent years. Although the reports were focussed on demonstrating the precision of the mean time estimates they derived, the degree of variation associated with a particular task is well illustrated. The estimated standard time for “partial help with hygienic care in bed” had a 95% confidence interval from 7.6 to 21.2 min. The underlying sample of observations could not be easily determined but the wide confidence intervals appear to result from intrinsic variability rather than simply a small sample. “Settling a bed ridden patient” had an interquartile range from 5 to 25.75 min ( Myny et al., 2010 ).

It may be that prototype approaches, where measures are based on typical care needs of patients fitting a particular profile, are less subject to variation between individuals with the same classification because multiple care needs ‘average out’, but we found no equivalent estimates of variation for such systems. One reason that measures of variability rarely appear may be that despite the external appearance of ‘objectivity’, the times or weights assigned within systems are often wholly or partly arrived at through an expert consensus exercise, for example , Brennan et al. (2012) and Hurst et al. (2008) . In part this is likely due to the volume of observation required to obtain reliable time estimates ( Myny et al., 2010 ). It is clear that professional judgement remains an important source of information and validation for any system.

3.2.4. Evaluation

Correlations between measures of staffing requirement or workload have been used to establish validity (e.g. Brennan et al., 2012 ; Hurst et al., 2008 ; Larson et al., 2017 ; Morales-Asencio et al., 2015 ; Smith et al., 2009 ). In all but one of these examples, the criterion used to establish validity is, in effect, a professional judgement of demand for nursing care. The centrality of professional judgement as a criterion is demonstrated by the RAFAELA system, in which the Oulu Patient Classification (OPC) weighting that is associated with nurses’ judgements that staffing is ‘optimal’ is used to set target staffing ( Fagerström et al., 2014 ).

Successful implementation of any system requires significant investment to engage and train staff. Taylor and colleagues describe the substantial challenges faced in implementing a professional judgement-based system for the US Veteran's Administration ( Taylor et al., 2015 ). While concluding that their system can be successfully implemented, they highlighted nursing leadership and front line staff buy-in as essential. They also emphasised the importance of staff training and the risk of cynicism if staff invest effort in a new system but see little tangible outcome. Even in the face of broad staff support, a pre-implementation study found that there was insufficient engagement with the measures of staffing adequacy required by the RAFAELA system, and satisfactory reliability also proved hard to achieve ( van Oostveen et al., 2016 ). Nurses can make reliable assessments using a number of systems ( Brennan et al., 2012 ; Liljamo et al., 2017 ; Perroca, 2013 ), although achieving inter-rater agreement is not always straightforward and the reliability of ratings in a new setting should not be assumed, even for tools where reliability has been established previously ( van Oostveen et al., 2016 ). Reliability of assessment in “real life” may be considerably lower than that achieved under controlled conditions and there are potential adverse effects on engagement when items that end users consider to be important aspects of care are omitted because of less desirable psychometric properties ( Brennan and Daly, 2015 ).

Given the importance of nurse staffing levels for maintaining the quality of patient care and the significant proportion of hospital budgets spent on staffing wards, there has been remarkably little attention given to the impact of tools or systems. Nonetheless recent years have seen the appearance of some evidence linking a mismatch between staff deployed and a calculated staffing requirement to adverse outcomes. This evidence does not clearly point to any particular measurement system and instead tends to align with evidence showing the benefits of higher staffing levels. These studies give some further indication of the validity of some tools as workload measures, but do not, in general, support conclusions that the tools give ‘optimal’ staffing levels, in the sense of identifying a level at which adverse outcomes are minimised or there are diminishing returns from further increase.

A US study using an unspecified commercial Patient Classification System found that the hazard of death was increased by 2% on every occasion a patient was exposed to a shift with 8 or more hours below the target defined by the system ( Needleman et al., 2011a ). Mortality was also increased by exposure to shifts with unusually high patient turnover, suggesting that this might be generating additional workload unmeasured by the system.

In Finland, nursing workload above the ‘optimal’ level measured using the OPC was associated with adverse patient outcomes, including increased mortality ( Fagerstrom et al., 2018 ; Junttila et al., 2016 ). However, nursing workload below the optimal level (higher staffing) was associated with improvements in outcomes ( Fagerstrom et al., 2018 ; Junttila et al., 2016 ), challenging the notion of this staffing level as ‘optimal’. Furthermore, the OPC workload measure was not clearly superior to a simple patient per nurse measure based on analysis of decision curves ( Fagerstrom et al., 2018 ).

More recently, a UK study found that registered nurse staffing below the level planned using the Safer Nursing Care Tool was associated with a 9% increase in the hazard of death in one English hospital trust, although low assistant staffing according to this criterion was not associated with mortality increases ( Griffiths et al., 2018a ). This study also explored staffing level as a continuous variable and found that the relationship between mortality and registered nurse staffing levels appeared to be linear, with no clear threshold effect at the Safer Nursing Care Tool-recommended level.

After implementing a ‘Nursing Hours per Patient Day’ methodology in three hospitals in Australia, there were increases in staffing levels and improvements in several patient outcomes over time, including mortality ( Twigg et al., 2011 ). This volume-based methodology assigns a minimum staffing level (measured in hours per patient day) for six different ward types, based on the patient case mix and complexity. An accompanying economic analysis estimated the cost per life year gained was AUD$8907 ( Twigg et al., 2013 ).

3.2.5. Operational research

Studies emanating from the tradition of operational research are examples of a larger body of literature that focuses on nurse rostering rather than workload measurement tools ( Saville et al., 2019 ). These studies highlight that rosters based on average staffing requirement may not provide an optimal solution to meet varying patient need.

Two studies determined that optimal staffing in the face of varying patient demand was higher than a level determined by staffing to meet the mean demand ( Davis et al., 2014 ; Harper et al., 2010 ). In one case, apparent ‘overstaffing’ was associated with net cost savings in modelling, in part because of the potential value of ‘excess’ staff who were available for redeployment to understaffed units ( Davis et al., 2014 ). Other studies modelled the effects of the use of varying configurations of ‘float’ pools to meet fluctuation in demand arising from multiple sources ( Kortbeek et al., 2015 ; Maenhout and Vanhoucke, 2013 ). These two studies again demonstrate the myriad of sources of variation in demand, and the challenge of matching supply of nursing care to that demand, particularly with an establishment based on the ‘average’ demand, while providing little insight into how demand for nursing care should be measured in the first place.

4. Discussion

Writing in 1994, Edwardson and Giovanetti concluded that a number of key questions about nursing workload systems remained unanswered:

• • Do the results of workload measurement systems depart significantly from the professional judgements of practicing nurses?
• • Does the implementation of a staffing methodology or tool lead to altered staffing levels or, conversely, do historical staffing levels influence the assessment of need?
• • Do workload measurement systems improve the quality of care?
• • Do workload measurement systems result in more efficient use of nursing personnel?

While recent years have seen a continued interest and a significant number of publications, these questions remain largely unanswered. There is evidence that some systems are reliable, that workload measured by a system correlates with other (largely subjective) measures, that low staffing relative to a measured requirement is associated with worse patient outcomes and that increased staffing levels associated with use of a system is associated with improved patient outcomes. However, there is no basis on which to determine that any system gives the ‘correct’ staffing levels.

The results of several workload measurement systems correlate with the professional judgement of practicing nurses, but the correspondence is not perfect and the significance of any discrepancies in estimated staffing requirements is unclear. Despite correlations, different systems can give dramatically different results and so it is clear that there can be no single answer to the questions of whether workload measurement systems result in improvements in the utilisation of nursing personnel . The advantage of complex systems over simpler systems is unclear. There is some evidence that the more aspects of care are included in otherwise similar indicator or volume-based systems, the higher the estimated staffing requirement. However, there is little basis on which to judge which is correct other than an evidence base showing higher staffing is associated with better outcomes.

Patient outcomes have been shown to improve when staffing is increased above levels identified as ‘optimal’ using professional judgements and a widely used prototype system. Such a finding is consistent with historical staffing levels and expectations influencing perceptions of what is required. So although professional judgement remains central and no system has been shown to be superior, it too may be systematically biased. Although there are perceptions of benefits from using staffing methodologies, the effect on the costs or quality of care remains unclear and the resources involved in running the systems are unquantified, although the required investments could be considerable ( Ball et al., 2019 ).

Given the significant body of evidence that emphasises the specific association between registered nurse staffing levels or skill mix and outcomes (e.g. Aiken et al., 2017 ) it is perhaps surprising that the mix of staff is rarely addressed directly in this literature. This may be because many systems have their origins in settings where the contribution of support staff to direct patient care is lower, e.g. the USA ( Aiken et al., 2017 ). The issue of determining skill mix is compounded by the fact that the involvement of support staff in the delivery of nursing care can vary widely ( Kessler et al., 2010 ). Some tools consider only registered or licensed nurses while others, such as the Safer Nursing Care Tool ( The Shelford Group, 2014 ), plan the total nursing team size and defer the skill mix decision to professional judgement.

4.1. Sources of variation

The methods described in the literature generally match staffing levels to the average (mean) demand associated with a particular patient group, factor or aspect of care when attempting to estimate current or future staffing requirements. Yet in the face of variable demand, simplistic responses based on the average may not be the best way to use the results of measurement systems. While much of the literature is concerned with measurement and identification of sources of variation, it is poor at quantifying such variation in a way that allows its impact on decision-making to be understood.

When workload distributions are approximately normal with small standard deviations, the mean may be an appropriate basis for planning, as the workload will vary from the mean by a relatively small amount. Assuming some degree of flexibility in the work capacity of a given group of staff, most patients’ needs might be safely accommodated most of the time. While some systems such as RAFAELA are explicit about an acceptable degree of variation from the mean ( Fagerström et al., 2014 ), this is rare, and the impact on safety of small deviations has not been widely researched.

However, both substantial variability and skewed distributions seem more plausible. Reports rarely provide estimates of variation in time required for specific aspects of care, but the few that do show that variation around the mean is considerable ( Myny et al., 2014 ). Left (negatively) skewed ward occupancy distributions have been reported ( Davis et al., 2014 ). When this is the case, mean staffing requirements are lower than the median, leading to relative understaffing more than 50% of the time if the mean is used.

Even where a mean adequately allows staff to meet variable demand, it is often unclear how much care needs to be observed to establish a reliable mean. As is clear from Myny et al. (2010) , estimating reliable means can be challenging even in a large scale study. The basis on which recommended observation periods were determined for widely used systems such as the Safer Nursing Care Tool is unclear because variation is not reported.

Variation in demand arises at multiple levels, for example patient census, need per patient and time taken to deliver care for a patient with a given set of needs. While some systems account for these factors to some extent, they rarely consider that the averages they use to determine staffing requirements, associated with a given factor, are also subject to variation. So while a task-based system may recognise that different patients require very different care, in assigning an average time it does not account for the variability in time taken to complete a task. In Table 3 , we summarise some major sources of variation. Variation around the average may be compounded as multiple aspects of care are considered, or may tend to ‘average out’, but this is simply unknown.

Sources of variation in demand for and supply of nursing care.

While task-based systems are challenged by the need to specify and time all aspects of nursing work, prototype systems cannot account for variation associated with activities that are not directly linked to the patient prototype. For example, patient turnover generates substantial nursing work ( Myny et al., 2012 ), which is highly variable between and within wards, with some predictable sources of variation (such as day of the week) ( Griffiths et al., 2018a ). Such variation is not easy to account for in a patient prototype because patients are admitted or discharged at points in time, while the prototype does not change.

Few systems formally consider non-patient factors that may influence workload. For example, while evidence that ward layout may alter staffing requirements is limited ( Hurst, 2008 ), simple factors influenced by layout such as travel distances and opportunity for patient surveillance are recognised as having the potential to generate considerable variation in workload ( Maben et al., 2016 , 2015 ). While variation arising from factors such as layout can be accommodated if times required are estimated for each unit, this does raise a final issue.

Variation is often systematic and just as demand is variable, so is the supply of staff to meet that demand (see Table 3 ). This is a particular issue when planning establishments and advance rosters to meet need. As an example, in order to ensure that there are sufficient staff available to provide cover on wards, the literature describes the need to add an “uplift” to establishments to allow for staff sickness ( Hurst, 2002 ; Telford, 1979 ). However, staff sickness does not occur uniformly. Rather it occurs in clusters, with clear seasonal patterns and variation by day of the week ( Barham and Begum, 2005 ). Allowing a small percentage of additional staff based on the average percentage of time lost does not mean that sufficient staff are available to cover days or weeks when staff are actually absent.

4.2. ‘Optimal’ staffing

Each staffing method makes an underlying assumption about what constitutes ‘adequate’, ‘safe’ or ‘quality’ staffing, although these are often implicit. The staffing to deliver the ‘right’ frequency and length of nursing tasks in the timed-task approach, and the ‘right’ amount of care per patient in the nurse-patient ratio approach must be decided upon. These parameters are generally obtained from expert judgement, from observations of care provided or from existing establishments, ideally in settings deemed to meet some quality criteria ( Hurst, 2002 ). The question of whether this staffing level is ‘optimal’, or what criteria might define an optimal staffing level is rarely, if ever, addressed.

There is evidence that staffing to the ‘optimal’ level defined by the RAFAELA tool is associated with reduced mortality when compared to lower staffing ( Junttila et al., 2016 ) but since mortality is further reduced by staffing at higher levels, it is hard to conclude that this staffing level is, truly, optimal. It is, in effect, a professional judgement about what constitutes reasonable staffing, which is, in turn, bounded by historical expectations ( Taylor et al., 2015 ; Telford, 1979 ). While this question arises in relation to the RAFAELA tool, because it explicitly identifies an optimum staffing level, the issue applies to all systems. While tools can motivate staffing increases it is also possible that they could restrict staffing at a level that is not clearly ‘optimal’.

The appropriate response to variation in the productivity of staff, related to factors such as experience or efficient deployment of a team, also makes any definition of an ‘optimal’ staffing level a challenge. While it seems important to recognise that (for example) less experienced staff may be less able to meet a given level of demand and thus require some additional support, setting a lower staffing level based on the relative efficiency of a team may appear to be punishing success. Furthermore, while most systems emphasise measurement of demand, optimal management of staffing involves achieving an appropriate balance between supply and demand. ‘Optimal’ staffing levels may be lower if peaks in demand can be reduced ( Litvak et al., 2005 ; Litvak and Laskowski-Jones, 2011 ). Nursing services do not operate in isolation and the demand for nursing care and the required level of staff may also change as inputs from other staff groups vary. Perhaps, above all, this illustrates that there is a limit to what can be achieved through measurement, both because of the fallible nature of the measures, but also because of the complex judgements that are required.

4.3. Limitations

The volume of literature considered for this review and the wide range of questions addressed means that we have not focussed on critiquing specific studies or attempting to draw conclusions about any particular approach. We may have missed some recent studies or older studies about some of the tools featuring in the more recent research. However, our approach of building on existing reviews and our extensive searches means that it is unlikely that we have missed substantial volumes of research that would lead to an overall different conclusion.

4.4. Future research

Staff costs and patient outcomes using different systems have rarely been compared. Controlled trials comparing outcomes of staffing guided by tools with other approaches may be challenging to undertake, but are by no means impossible to conceive. Cluster randomised trials may be feasible and controlled before-and-after studies of staffing systems have been reported or are underway ( Drennan et al., 2018 ). Because there are so many unanswered questions much progress can be made outside a trial framework. Natural variation around target staffing levels (for example due to staff sickness) provide further opportunity to study the association of target staffing levels with outcomes using quasi-experimental methods. Questions that remain unanswered about many tools include the extent to which they truly identify a level of staffing sufficient to meet the needs of a ward of patients, and the number of observations required to get an accurate baseline to estimate average need. The apparently simple assumption, that staffing to meet average need is the optimal response to varying demand, is also untested empirically, although research reviewed here suggests this assumption is likely to be incorrect. For systems designed to determine ward establishments, the extent to which the establishments efficiently or effectively deliver staffing levels to match varying patient need (either with or without additional flexible staffing) can be addressed in observational and simulation studies.

5. Conclusions

The volume of literature on staffing methodologies is vast and growing. However, there is no substantial evidence base on which to select any particular method or tool. There has been a repeated pattern whereby new tools are developed with little programmatic research addressed at existing tools, even when they are widely used. The extensive research reporting the development of the RAFAELA system stands out as an honourable exception in this regard, although neither costs nor effects of using the tool compared to another tool or no tool at all have been reported. Benefits associated with tools appear to be based on increased staffing levels.

Despite the lack of evidence, an appetite for formal systems and tools exists. While professional judgement remains the nearest to a gold standard, the desire to use a tool or other formal system to support and indeed justify such a judgement has remained a constant theme that can be traced back to Telford's work in the 1970s in the UK, and no doubt beyond. While limitations in tools have continually motivated the development of new approaches, limited evidence means it is hard to determine if existing approaches may be ‘good enough’ or if new approaches are any better in practice. The lack of discernible progress in building an evidence base leads us to conclude that rather than continue to develop new tools, it is time to take a much closer look at those already in use and to investigate the best way to use them and the costs and the consequences of doing so.

Conflict of interest

Other than the project funding, the authors declare no competing interests that might be perceived as influencing the results of this paper.

Acknowledgements and funding

This research was funded by the National Institute for Health Research’s Health Services & Delivery Research programme (grant number 14/194/21).

The views expressed are those of the author(s) and not necessarily those of the National Institute for Health Research, the Department of Health and Social Care, ‘arms-length’ bodies or other government departments.

The Safer Nursing Care Study Group comprises: Jane Ball (University of Southampton), Rosemary Chable (University Hospital Southampton National Health Service Foundation Trust), Andrew Dimech (Royal Marsden National Health Service Foundation Trust), Peter Griffiths (University of Southampton), Yvonne Jeffrey (Poole Hospital National Health Service Foundation Trust), Jeremy Jones (University of Southampton), Thomas Monks (University of Southampton), Natalie Pattison (University of Hertfordshire/East & North Herts NHS Trust), Alexandra Recio Saucedo (University of Southampton), Christina Saville (University of Southampton) and Nicky Sinden (Portsmouth Hospitals National Health Service Trust).

Supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.ijnurstu.2019.103487 .

Appendix. Supplementary materials

Nursing School Assignments and Tips to Ace All of Them

If you are about to start nursing school or considering enrolling in a nursing program, you would want to know what to expect. You will write many papers in nursing school and do many other assignments. This is true whether you pursue ADN, BSN, MSN, DNP, or PhD in Nursing.

Before we delve into the types of assignments and papers to expect in nursing school, let us begin by dispelling the myth that nursing school is hell; it is NOT. Instead, it is a beautiful and exciting journey into a noble profession. It entails a commitment to life-long continuous learning for you to grow.

Nursing school writing assignments are an excellent way for students to understand concepts taught in the classroom. You might wonder what kinds of assignments nursing students do. These assignments come in various forms and help students build critical thinking, creativity, research, clinical reasoning, and problem-solving skills that are critical in clinical settings.

This blog post looks at the diverse assignments you should expect or will cover in nursing school, including some tips to help you ace them and get better grades.

Common Nursing School Writing Assignments

Classwork forms the core of most nursing programs. You must have high-quality assignment submissions to attain better grades in nursing school. As soon as you decide to become a nursing student, you sign up for a marathon of writing different types of papers.

Whether you love or hate it, you will write papers before graduating from nursing school; that is the norm. Although not so many, you will encounter a few homework and assignments where you must submit a well-researched, formatted, and organized nursing paper.

The typical nursing school assignments include essays, research papers, term papers, and case studies. Others are article critiques/reviews, critical appraisal, evidence synthesis tables (synthesis matrix), PowerPoint Presentations, posters, discussion posts/ responses, and policy analysis papers. Other advanced papers include nursing care plans, SBAR template papers, evidence-based papers, capstone projects, theses, dissertations, proposals, etc.

These assignments are submitted either individually or as a group. Let us expound on this so you have a clear picture.

Essays for nursing classes come in various forms, including admission essays , scholarship essays, descriptive essays, persuasive essays, speech essays, expository essays, and narrative essays.

Notably, nursing essays focus on a single perspective, argument, or idea, which constantly forms the thesis of the paper.

Nursing essays focus on various topics relating to nursing practice and the broader healthcare field. You can write an essay examining a nursing theory or non-nursing theory or discuss a nursing issue .

Some essays, such as reflective nursing essays, use reflective models to reflect, analyze, and understand personal and professional encounters during clinical practice.

Each nursing essay should demonstrate your understanding of the topic, critical analysis, and organization skills. Besides, you should use evidence from peer-reviewed scholarly sources to support your arguments and ideas.

Discussion Board Posts

If you pursue a hybrid or exclusively online nursing program, you will be assigned to write weekly discussion forum posts and responses. Discussion board posts are short essay-like assignments posted in a threaded format so students can discuss nursing and healthcare topics.

You will write an original discussion post, between 200 and 300 words long, and post it on the forum. You are also expected to write a peer-response post in response to or to comment on an original post done by your peers.

Discussion boards help nursing students advance theoretical concepts, learn from one another, share ideas, and get feedback that can help them advance their knowledge in clinical reasoning and practice.

Research Papers

Nursing practice is evidence-driven, translating evidence into practice to ensure quality, accessible, and affordable healthcare. As such, nursing research takes precedence during studies and when practicing.

Nursing professors assign nursing students to write research papers on various evidence-based practice topics. The students must prove their worth by researching, analyzing, and organizing facts.

Related Writing Guides:

• How to write a nursing school research paper.
• Systematic Reviews vs Literature Review

Research papers help student nurses to review literature, conduct research, implement solutions, and draw evidence-based conclusions.

Research papers are critical in developing research and writing skills, maintaining good communication, and fostering creativity and clinical reasoning.

Potential nursing research paper topics can be quality improvement, healthcare/nursing informatics , healthcare policies, practice privileges, nursing ethics, ethical dilemmas , pathophysiology, and epidemiology .

Term Papers

In nursing school, a term paper is a type of assignment completed and submitted toward the end of the semester.

Usually, a professor can assign you a specific term paper topic, or they can let you choose a topic and consult with them for approval.

Term papers can be done individually or as a group project. A term paper has an impact on your final grade.

You should use credible scholarly sources published within the last five years for recent information.

Besides, also ensure that you plan your time well, do everything as per the instructions, and submit the nursing term paper before the deadline.

A term paper can also be a nursing process change report that is expected to address an area that needs change.

Case Studies

Nursing school case study assignments are an essential learning tool.

Most professors assign hypothetical clinical case studies or case scenarios (snippets) to test your clinical reasoning skills.

As a nursing educational tool, nursing case studies help you to develop practical, theoretical knowledge by simulating real-world experiences.

When analyzing a case study, you must use concepts and knowledge from class and class text to assess a patient, plan and implement care, and evaluate the outcomes.

Sometimes, you encounter simulated or digital clinical experience case studies such as iHuman and Shadow Health .

You should be very keen when analyzing a case study and when writing the analysis report.

Case studies help you get beyond books and use your creativity, clinical reasoning, problem-solving, and analytical skills to apply theoretical knowledge to real-world problems.

Your professor can give you a case study of a patient presenting with a given condition and expect you to take them through the care planning process, including admission and discharge, as you would in a real healthcare setting.

Other times, you can be asked to develop a hypothetical case study of a patient presenting with a chronic disease or a disorder and then use the case study guidelines, including head-to-toe assessment , diagnosis , nursing care planning , and discharge planning.

Related Guides:

• How to write a great nursing case study.
• How to complete a case conceptualization report (for psychiatric nursing students)

Nursing Care Plans and SOAP Notes

A nursing care plan can be part of a case study or a stand-alone assignment. Nursing care plans are essential in nursing education as they help students develop effective nursing care planning. Formulating a nursing care plan for a patient scenario or case helps treat them as you define the guidelines and roles of nurses in caring for the patient.

You also develop solid action plans for focused and patient-centred care by documenting the patient's needs. When they are part of an assignment, you can tabulate the nursing care plan using columns so that you explore every aspect independently.

Remember to use evidence from peer-reviewed scholarly sources when giving rationale.

The SOAP notes are a clinical tool healthcare professionals use to organize patient information to minimize confusion and assess, diagnose, and treat patients. Check our comprehensive guide on developing good SOAP Notes in nursing school .

Concept Maps

Another common nursing school assignment is concept maps. Concept mapping helps you visually organize, compartmentalize, and categorize information about nursing care planning, medical diagnosis, pathophysiology, SBAR, nursing responsibilities, etc.

A nursing concept map assignment equips you with strong critical thinking, analytical, and problem-solving skills. You also hone your clinical reasoning skills in the process.

Whether it is part of an assignment or a stand-alone, learn how to write great concept maps to score the best grades.

Concept Analysis Papers

If you are taking BSN, MSN, or DNP, you will likely be assigned to write a concept analysis paper. Make sure to distinguish this from a concept paper that is a proposal. A concept analysis paper examines the structure and function of a nursing concept.

The process entails a review of the literature and creativity in coming up with borderline, related, contrast, inverted, and illegitimate cases.

You also explore the antecedents and consequences of the concept before finalizing with empirical referents.

If you need to learn about the structure of a good concept analysis paper, check out our nursing concept analysis guide . We have listed concepts you can analyze depending on your speciality, instructions, and passion.

Capstone Projects

At an advanced stage in nursing school, students are expected to submit longer research papers; capstone project papers. A nursing capstone project is a final project that allows students to demonstrate the skills, knowledge, and concepts gained throughout the nursing program.

In nursing education, the capstone project typically covers an evidence-based practice issue or problem. You can write a nursing change paper, look into a clinical process, problem, or issue, and then develop recommendations based on a study.

Most of the MSN and DNP capstone projects focus on clinical change or quality improvement. You will be expected to develop a PICOT question and formulate a research study to examine the issue, implement a change process using evidence-based models, and make recommendations.

Nursing capstone projects are individual research projects based on nursing topics either of your professional or personal interest. You have to demonstrate competency and commitment to improve health outcomes.

Apart from capstone projects, you will also write a nursing thesis and dissertation papers, which depend on the program requirements and your professor's preferences.

Check out these specific writing guides for advanced papers:

• How to write a nursing dissertation or thesis
• Tips for choosing the best nursing dissertation topic
• How to write an excellent capstone project paper
• List of capstone project topics for nursing school
• How to formulate a PICOT question
• PICOT question examples to inspire nursing students

Group Assignments

In nursing school and practice, collaboration and teamwork are highly recommended. You will encounter collaborative group assignments such as presentations (PowerPoint slides, Prezi, or other platforms), simulation assignments, writing nursing reports, and group research projects.

Group projects allow you to research, learn, and organize ideas together so that you can understand concepts better. It is essential to avoid social loafing in a group to gain more. Besides, plan your time well and avoid excuses.

You can also be assigned to work on simulation exercises as a group of nursing students. The aim of such exercises is to build a collaborative, teamwork, and decision-making spirit among the team.

When in such groups, expect to work with your peers to assess the hypothetical patient, communicate with your peers, formulate a care plan, and manage any arising issues as you would in clinical settings. Do not take such activities for granted; they contribute significantly to your grade.

Presentations

Your professor can assign you to design a PowerPoint Slide accompanied by speaker notes and send it for grading or present it online or in class. Under presentations, you will also be requested to design flyers, posters, and other visual documents to disseminate information.

It could be about a disease, health promotion, or nursing research. You must also make PowerPoint slides when presenting a thesis, dissertation, or capstone for assessments. Remember, this is the chance to bring out your creativity.

Expect other assignments such as dosage calculations, HESI test exams, skills checkoffs, electronic medical record documentation, nursing student portfolio, online quizzes, drug write-ups, process recordings, group drug presentations, etc.

In most cases, you will be given a template to use wisely and make it as appealing as possible.

Tips to Help You Ace Nursing Assignments

A lot goes into getting the best grades in nursing school. One of the main determinants of your nursing school grades is the assignments, which you are required to do and complete within set deadlines.

Even though many nursing students perform better on clinical, that needs to reflect in written assignments. Most students fear research and writing or do not take writing assignments seriously. Regardless of the assignment, here are some practical and effective tips to help you ace your nursing school writing assignments and surprise everyone, including yourself.

1. Plan your Time

The number one challenge for nursing students that inhibits them from completing assignments is the need for more time management.

Most students are juggling studies and work to make ends meet. It worsens when you have a massive workload from more than one class and a family to look after.

The simple trick to beat this is to manage your time well. You can schedule your assignments for periods when you are free and when you can concentrate and cover more. Assignments have deadlines ranging from hours to days or a few weeks.

To succeed, keep track of your assignments and other academic activities, such as mid-term and final examinations, so that you can plan your study periods. You can use online time management tools and apps to allocate your nursing school homework time.

With proper planning, you should be reassured about the last-minute rush to complete your assignment, which is responsible for the colossal failure we are experiencing in nursing schools.

2. Follow the Course Guidelines to the T

Guidelines, prompts, and reading materials accompany each writing assignment and homework. Sometimes a professor can be generous enough also to give you access to the Rubric, which breaks down how they will assess assignments. Ensure you read everything and note what is required before working on any paper.

Pay attention to these, read, and familiarize yourself with the course guidelines. Understand the formatting requirements preferred by your school, such as Vancouver, APA, or Harvard. Most nursing schools will specify this in the course documents. Also, check the databases and journal articles you can use when writing your nursing assignments.

Preparing in advance by reading the course materials to identify the recommended study materials. You will have a deeper understanding, knowledge, and skills to handle every nursing assignment correctly.

3. Have an Active Study Buddy

A nursing study buddy can be one of your classmates whom you study with. Study buddies offer mutual support, which comes in handy when completing assignments.

Select a bright and committed person with something to offer so you are not only giving. Set the study hours and have accountability follow-ups to ensure you cover much of the syllabus and concepts in time.

A study buddy can help you understand nursing concepts, theories, models, and frameworks. They can also help you review your written papers and give valuable feedback when editing and proofreading your nursing papers.

A knowledgeable, accountable, committed study partner can help you revamp your grades by submitting high-quality assignments.

4. Join a Study Group

A study group is a tried and tested means of completing nursing assignments. Apart from building your teamwork and collaborative skills, you can brainstorm ideas, critique one another, and learn more about the class assignments. With diversity in thoughts, you can get valuable insights and inputs for personal-level work.

Besides, you are also guaranteed to ace the nursing group assignments with ease. When doing group work, try to rotate into new groups so that you can appreciate the diversity of thoughts and reasoning. You can also identify individuals from your groups, those that are active, as your study buddies.

When you have accountability partners within the group, you commit to given tasks and make necessary follow-ups. If you are a part-time student, consider having students whose free time is similar to yours to benefit everyone.

5. Get Writing Assignment Help

As with other subjects in college and university, nursing students face challenges such as time management, complexity of assignments, too many assignments, and writer's block. When you feel overwhelmed with completing your nursing class assignments, you can always pay someone to handle the class for you or at least do your coursework or assignments.

One sure way to get assistance without drawing too much attention is by trusting assignment help websites like NurseMyGrade.com with your papers. Many students do not have time to complete assignments or find them challenging. Consequently, many hire nursing assignment helpers from nursing paper writing platforms.

If you feel like hiring the right professionals, use NurseMyGrade. We offer customized writing solutions to nursing students at different academic levels. Our nursing experts can complete short and lengthy assignments. You will have a well-researched and formatted paper written in Vancouver, APA, MLA, ASA, AMA, Harvard, or any citation style you choose.

You can use the tips and insights above to master nursing school assignments. We wish you all the best as you strive towards excellence. Don't worry about the many assignments. Instead, be grateful that they will equip you with knowledge, skills, and experience to make you the best nurse.

How Many Papers to Write in Nursing School

We have so far covered the general aspects of the types of assignments to expect in nursing school. Under the assignments, you may ask yourself if you must write many papers in nursing school.

While the answer depends on your professor, institutional curriculum requirements, and nursing level, you will undoubtedly write a couple of academic papers before graduating from nursing school. You will write research papers, essays, proposals, white papers, policy analysis papers, capstone project papers, case studies, scholarship essays, personal statements, quality improvement reports, etc.

Suppose you are pursuing a Licensed Practical Nurse (LPN) program. In that case, you will likely write between 13 and 15 papers during the LPN program, including short and long essays, reflective journals, essays, patient-based case studies, and others as your professor pleases.

If you are in a 2-year ADN program, expect to complete about 20 to 30 papers, including care plans, SBAR reports, essays, case studies analyses, research papers, reports, and other assignments.

For a 4-year Bachelor of Science in Nursing (BSN) program, you will write between 35 and 50 papers. If you are taking the online class program options, like the WGU BSN program, you might write more papers because they form the basis for your assessment.

BSN-level papers are demanding because you must strictly adhere to the formatting styles and be critical and organized in your presentation.

If you are taking a Master of Science in Nursing (MSN) program, an advanced-level study for registered nurses (RNs), you will do about 20-50 papers, given that it offers the foundation for nursing research. Again, at an advanced level, the MSN writing assignments are complex.

You need to plan well, research widely, and analyze facts thoroughly before drawing conclusions. During this level, expect to write papers such as MSN essays, discussion posts and responses, specialized case studies, research papers, clinical reports, advanced SOAP notes, nursing care plans, policy papers, position papers (white papers), dissertations, theses, capstone papers, project papers, and change project papers.

You are expected to show exquisite research skills for the Doctor of Nursing Practice (DNP) program, considered the highest level or terminal degree in nursing practice. At this level, you have specialized, advanced your knowledge, and have adequate experience.

Mostly, DNP papers are a little longer. You will write between 20-30 papers; depending on your nursing school curriculum and supervisor's preference, it could be less or more.

If you opt for the research route, you will write many research papers, technical papers, policy analysis papers, white papers, reflection papers, nursing dissertations, PICOT-based change project papers (DNP change project papers), and other assignments.

Finally, for the Doctor of Philosophy (PhD) in nursing programs, you should expect to write between 10 and 15 papers covering research-oriented topics.

Attaining this degree makes you the epitome of success in the field. You can advance into a nursing researcher, educator, leader, or manager.

We have writers that can help you handle all these types of papers regardless of the academic level. Our Online Nursing Writing pros are available for hire anytime and any day.

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Before you go …

There are many assignments and papers to complete in nursing school, including written assignments, quizzes, exams (oral and written), reflective journals, journal entries, e-Portfolio, integrative reviews, teaching plans, presentations, etc. Whether taking an LPN program or advancing your career by pursuing a Ph.D. in Nursing, you will do many nursing school assignments.

Do not take assignments as a punishment. Instead, consider them as tools to equip and shape you into a desirable nurse practitioner.

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• Published: 16 May 2024

Competency gap among graduating nursing students: what they have achieved and what is expected of them

• Majid Purabdollah 1 , 2 ,
• Vahid Zamanzadeh 2 , 3 ,
• Akram Ghahramanian 2 , 4 ,
• Leila Valizadeh 2 , 5 ,
• Saeid Mousavi 2 , 6 &
• Mostafa Ghasempour 2 , 4  

BMC Medical Education volume  24 , Article number:  546 ( 2024 ) Cite this article

116 Accesses

Metrics details

Nurses’ professional competencies play a significant role in providing safe care to patients. Identifying the acquired and expected competencies in nursing education and the gaps between them can be a good guide for nursing education institutions to improve their educational practices.

In a descriptive-comparative study, students’ perception of acquired competencies and expected competencies from the perspective of the Iranian nursing faculties were collected with two equivalent questionnaires consisting of 85 items covering 17 competencies across 5 domains. A cluster sampling technique was employed on 721 final-year nursing students and 365 Iranian nursing faculties. The data were analyzed using descriptive statistics and independent t-tests.

The results of the study showed that the highest scores for students’ acquired competencies and nursing faculties’ expected competencies were work readiness and professional development, with mean of 3.54 (SD = 0.39) and 4.30 (SD = 0.45), respectively. Also, the lowest score for both groups was evidence-based nursing care with mean of 2.74 (SD = 0.55) and 3.74 (SD = 0.57), respectively. The comparison of competencies, as viewed by both groups of the students and the faculties, showed that the difference between the two groups’ mean scores was significant in all 5 core-competencies and 17 sub-core competencies ( P  < .001). Evidence-based nursing care was the highest mean difference (mean diff = 1) and the professional nursing process with the lowest mean difference (mean diff = 0.70).

The results of the study highlight concerns about the gap between expected and achieved competencies in Iran. Further research is recommended to identify the reasons for the gap between the two and to plan how to reduce it. This will require greater collaboration between healthcare institutions and nursing schools.

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Introduction| Background

Nursing competence refers to a set of knowledge, skills, and behaviors that are necessary to successfully perform roles or responsibilities [ 1 ]. It is crucial for ensuring the safe and high-quality care of patients [ 2 , 3 , 4 , 5 ]. However, evaluating nursing competence is challenging due to the complex, dynamic, and multi factorial nature of the clinical environment [ 3 ]. The introduction of nursing competencies and their assessment as a standard measure of clinical performance at the professional level has been highlighted by the Association of American Colleges of Nursing [ 6 , 7 ]. As a result, AACN (2020) introduces competence assessment as an emerging concept in nursing education [ 7 ].

On the other hand, the main responsibility of nursing education is to prepare graduates who have the necessary competencies to provide safe and quality care [ 3 ]. Although it is believed that it is impossible to teach everything to students, acquiring some competencies requires entering a real clinical setting and gaining work experience [ 8 ]. However, nursing students are expected to be competent to ensure patient safety and quality of care after graduation [ 9 ]. To the extent that the World Health Organization (WHO), while expressing concern about the low quality of nursing education worldwide, has recommended investing in nursing education and considers that the future to require nurses who are theoretically and clinically competent [ 5 ]. Despite efforts, the inadequate preparation of newly graduated nursing students and doubts about the competencies acquired in line with expectations to provide safe care for entering the nursing setting have become a global concern [ 10 , 11 , 12 , 13 ]. The results of studies in this field are different. The results of Amsalu et al. showed that the competence of newly graduated nursing students to provide quality and safe care was not satisfactory [ 14 ]. Some studies have also highlighted shortcomings in students’ “soft” skills, such as technical competency, critical thinking, communication, teamwork, helping roles, and professionalism [ 15 ]. Additionally, prior research has indicated that several nursing students have an unrealistic perception of their acquired competencies before entering the clinical setting and they report a high level of competence [ 2 ]. In other study, Hickerson et al. showed that the lack of preparation of nursing students is associated with an increase in patient errors and poor patient outcomes [ 16 ]. Some studies also discussed nursing competencies separately; Such as patient safety [ 17 ], clinical reasoning [ 18 ], interpersonal communication [ 19 ], and evidence-based care competence [ 20 ].

On the other hand, the growing need for safe nursing care and the advent of new educational technologies, the emergence of infectious diseases has increased the necessity of nursing competence. As a result, the nursing profession must be educated to excellence more than ever before [ 5 , 21 , 22 ]. Therefore, the self-assessment of students’ competence levels as well as the evaluation of nursing managers about the competencies expected from them is an essential criterion for all healthcare stakeholders, educators, and nursing policymakers to ensure the delivery of safe, and effective nursing care [ 9 , 23 , 24 ].

However, studies of nurse managers’ perceptions of the competence of newly graduated nursing students are limited and mostly conducted at the national level. Hence, further investigation is needed in this field [ 25 , 26 ]. Some other studies have been carried out according to the context and the needs of societies [ 3 , 26 , 27 , 28 ]. The results of some other studies in the field of students’ self-assessment of perceived competencies and managers’ and academic staff’s assessment of expected competency levels are different and sometimes contradictory, and there is the “academic-clinical gap” between expected and achieved competencies [ 25 , 29 , 30 ]. A review of the literature showed that this gap has existed for four decades, and the current literature shows that it has not changed much over time. The academe and practice settings have also been criticized for training nurses who are not sufficiently prepared to fully engage in patient care [ 1 ]. Hence, nursing managers must understand the expected competencies of newly graduated students, because they have a more complete insight into the healthcare system and the challenges facing the nursing profession. Exploration of these gaps can reveal necessities regarding the work readiness of nursing graduates and help them develop their competencies to enter the clinical setting [ 1 , 25 ].

Although research has been carried out on this topic in other countries, the educational system in those countries varies from that of Iran’s nursing education [ 31 , 32 ]. Iran’s nursing curriculum has tried to prepare nurses who have the necessary competencies to meet the care needs of society. Despite the importance of proficiency in nursing education, many nursing graduates often report feeling unprepared to fulfill expected competencies and they have deficiencies in applying their knowledge and experience in practice [ 33 ]. Firstly, the failure to define and identify the expected competencies in the nursing curriculum of Iran led to the absence of precise and efficient educational objectives. Therefore, it is acknowledged that the traditional nursing curriculum of Iran focuses more on lessons organization than competencies [ 34 ]. Secondly, insufficient attention has been given to the scheduling, location, and level of competencies in the nursing curriculum across different semesters [ 35 ]. Thirdly, the large volume of content instead of focusing on expected competencies caused nursing graduates challenged to manage complex situations [ 36 ]. Therefore, we should not expect competencies such as critical thinking, clinical judgment, problem-solving, decision-making, management, and leadership from nursing students and graduates in Iran [ 37 ]. Limited research has been conducted in this field in Iran. Studies have explored the cultural competence of nursing students [ 38 ] and psychiatric nurses [ 39 ]. Additionally, the competence priorities of nurses in acute care have been investigated [ 40 ], as well as the competency dimensions of nurses [ 41 ].

In Iran, after receiving the diploma, the students participate in a national exam called Konkur. Based on the results of this exam, they enter the field of nursing without conducting an aptitude test interview and evaluating individual and social characteristics. The 4-year nursing curriculum in Iran has 130 units including 22 general, 54 specific, 15 basic sciences, and 39 internship units. In each semester, several workshops are held according to the syllabus [ 42 ]. Instead of the expected competencies, a list of general competencies is specified as learning outcomes in the program. Accepted students based on their rank in the exam and their choice in public and Islamic Azad Universities (non-profit), are trained with a common curriculum. Islamic Azad Universities are not supported by government funding and are managed autonomously, this problem limits the access to specialized human resources and sufficient educational fields, and the lower salaries of faculty members in Azad Universities compared to the government system, students face serious challenges. Islamic Azad Universities must pay exorbitant fees to medical universities for training students in clinical departments and medical training centers, doubling these Universities’ financial problems. In some smaller cities, these financial constraints cause students to train in more limited fields of clinical training and not experience much of what they have learned in the classroom in practice and the real world of nursing. The evaluation of learners in the courses according to the curriculum is based on formative and summative evaluation with teacher-made tests, checklists, clinical assignments, conferences, and logbooks. The accreditation process of nursing schools includes two stages internal evaluation, which is done by surveying students, professors and managers of educational groups, and external accreditation is done by the nursing board. After completing all their courses, to graduate, students must participate in an exam called “Final”, which is held by each faculty without the supervision of an accreditation institution, the country’s assessment organization or the Ministry of Health, and obtain at least a score of 10 out of 20 to graduate.

Therefore, we conducted this comprehensive study as the first study in Iran to investigate the difference between the expected and perceived competence levels of final year nursing students. The study’s theoretical framework is based on Patricia Benner’s “From Novice to Expert” model [ 43 ].

Materials and methods

The present study had the following three objectives:

Determining self-perceived competency levels from the perspective of final year nursing students in Iran.

Determining expected levels of competency from the perspective of nursing faculties in Iran.

To determine the difference between the expected competencies from the perspective of nursing faculties and the achieved competencies from the perspective of final-year nursing students.

This study is a descriptive-comparative study.

First, we obtained a list of all nursing schools in the provinces of Iran from the Ministry of Health ( n  = 31). From 208 Universities, 72 nursing schools were randomly selected using two-stage cluster sampling. Among the selected faculties, we chose 721 final-year nursing students and 365 nursing faculties who met the eligibility criteria for the study. Final-year nursing students who consented to participate in the study were selected. Full-time faculty members with at least 2 years of clinical experience and nurse managers with at least 5 years of clinical education experience were also included. In this study, nursing managers, in addition to their educational roles in colleges, also have managerial roles in the field of nursing. Some of these roles include nursing faculty management, nursing board member, curriculum development and review, planning and supervision of nursing education, evaluation, and continuous improvement of nursing education. The selection criteria were based on the significant role that managers play in nursing education and curriculum development [ 44 ]. Non-full-time faculty members and managers without clinical education experience were excluded from the study.

The instrument used in this study is a questionnaire developed and psychometrically tested in a doctoral nursing dissertation [ 45 ]. To design the tool, the competencies expected of undergraduate nursing students in Iran and worldwide were first identified through a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI) and supported by the PAGER framework. Summative content analysis by Hsieh and Shannon (2005) was used for analysis, which included: counting and comparing keywords and content, followed by interpretation of textual meaning. In the second step, the results of the first step were used to create tool statements. Then the validity of the instrument was checked by face validity, content validity (determination of the ratio and index of content validity), and validity of known groups. Its reliability was also checked by internal consistency using Cronbach’s alpha method and stability using the test-retest method. The competency questionnaire comprises 85 items covering 17 competencies across 5 domains: “individualized care” (4 competencies with 21 items), “evidence-based nursing care” (2 competencies with 10 items), “professional nursing process” (3 competencies with 13 items), “nursing management” (2 competencies with 16 items), and “work readiness and professional development” (6 competencies with 25 items) [ 45 ]. “The Bondy Rating Scale was utilized to assess the competency items, with ratings ranging from 1 (Dependent) to 5 (Independent) on a 5-point Likert scale [ 46 ]. The first group (nursing students) was asked to indicate the extent to which they had acquired each competency. The second group (nursing faculties) was asked to specify the level to which they expected nursing students to achieve each competency.

Data collection

First, the researcher contacted the deans and managers of the selected nursing schools by email to obtain permission. After explaining the aims of the study and the sampling method, we obtained the telephone number of the representative of the group of final year nursing students and also the email of the faculty members. The representative of the student group was then asked to forward the link to the questionnaire to 10 students who were willing to participate in the research. Informed consent for students to participate in the online research was provided through the questionnaires, while nursing faculty members who met the eligibility criteria for the study received an informed consent form attached to the email questionnaire. The informed consent process clarified the study objectives and ensured anonymity of respondent participation in the research, voluntary agreement to participate and the right to revoke consent at any time. An electronic questionnaire was then sent to 900 final year nursing students and 664 nursing faculties (from 4 March 2023 to 11 July 2023). Reminder emails were sent to nursing faculty members three times at two-week intervals. The attrition rate in the student group was reported to be 0 (no incomplete questionnaires). However, four questionnaires from nursing faculty members were discarded because of incomplete responses. Of the 900 questionnaires sent to students and 664 sent to nursing faculties, 721 students and 365 nursing faculty members completed the questionnaire. The response rates were 79% and 66% respectively.

Data were analyzed using SPSS version 22. Frequencies and percentages were used to report categorical variables and mean and standard deviations were used for quantitative variables. The normality of the quantitative data was confirmed using the Shapiro-Wilk and Skewness tests. An independent t-test was used for differences between the two groups.

Data analysis revealed that out of 721 students, 441 (61.20%) was female. The mean and deviation of the students’ age was 22.50 (SD = 1.21). Most of the students 577 (80%) were in their final semester. Also, of the total 365 faculties, the majority were female 253 (69.31%) with a mean of age 44.06 (SD = 7.46) and an age range of 22–65. The academic rank of most nursing faculty members 156 (21.60%) was assistant professor (Table  1 ).

The results of the study showed that in both groups the highest scores achieved by the students and expected by the nursing faculty members were work readiness and professional development with a mean and standard deviation of 3.54 (0.39) and 4.30 (0.45) respectively. The lowest score for both groups was also evidence-based nursing care with a mean and standard deviation of 2.74 (0.55) for students and 3.74 (0.57) for nursing faculty members (Table  2 ).

Also, the result of the study showed that the highest expected competency score from the nursing faculty members’ point of view was the safety subscale. In other words, faculty members expected nursing students to acquire safety competencies at the highest level and to be able to provide safe care independently according to the rating scale (Mean = 4.51, SD = 0.45). The mean score of the competencies achieved by the students was not above 3.77 in any of the subscales and the highest level of competency achievement according to self-report of students was related to safety competencies (mean = 3.77, SD = 0.51), preventive health services (mean = 3.69, SD = 0.79), values and ethical codes (mean = 3.67, SD = 0.77), and procedural/clinical skills (mean = 3.67, SD = 0.71). The other competency subscales from the perspective of the two groups are presented in Table  3 , from highest to lowest score.

The analysis of core competencies achieved and expected from both students’ and nursing faculty members’ perspectives revealed that, firstly, there was a significant difference between the mean scores of the two groups in all five core competencies ( P  < .001) and that the highest mean difference was related to evidence-based care with mean diff = 1 and the lowest mean difference was related to professional care process with mean diff = 0.70 (Table  4 ).

Table  5 indicates that there was a significant difference between the mean scores achieved by students and nursing faculty members in all 5 core competencies and 17 sub-core Competencies ( p  < .001).

The study aimed to determine the difference between nursing students’ self-perceived level of competence and the level of competence expected of them by their nursing faculty members. The study results indicate that students scored highest in work readiness and professional development. However, they were not independent in this competency and required support. The National League for Nursing (NLN) recognizes nursing professional development as the goal of nursing education programs [ 47 ] However, Aguayo-Gonzalez [ 48 ] believes that the appropriate time for professional development is after entering a clinical setting. This theme includes personal characteristics, legality, clinical/ procedural skills, patient safety, preventive health services, and mentoring competence. Personality traits of nursing students are strong predictors of coping with nursing stress, as suggested by Imus [ 49 ]. These outcomes reflect changes in students’ individual characteristics during their nursing education. Personality changes, such as the need for patience and persistence in nursing care and understanding the nurse identity prepare students for the nursing profession, which is consistent with the studies of Neishabouri et al. [ 50 ]. Although the students demonstrated a higher level of competence in this theme, an examination of the items indicates that they can still not adapt to the challenges of bedside nursing and to use coping techniques. This presents a concerning issue that requires attention and resolution. Previous studies have shown that nursing education can be a very stressful experience [ 51 , 52 , 53 ].

Of course, there is no consensus on the definition of professionalism and the results of studies in this field are different. For example, Akhtar et al. (2013) identified common viewpoints about professionalism held by nursing faculty and students, and four viewpoints emerged humanists, portrayers, facilitators, and regulators [ 54 ]. The findings of another study showed that nursing students perceived vulnerability, symbolic representation, role modeling, discontent, and professional development are elements that show their professionalism [ 55 ]. The differences indicate that there may be numerous contextual variables that affect individuals’ perceptions of professionalism.

The legal aspects of nursing were the next item in this theme that students needed help with. The findings of studies regarding the legal competence of newly graduated nursing students are contradictory reported that only one-third of nurse managers were satisfied with the legal competence of newly graduated nursing students [ 56 , 57 ]. Whereas the other studies showed that legality was the highest acquired competence for newly graduated nursing students [ 58 , 59 ]. However, the results of this study indicated that legality may be a challenge for newly graduated nursing students. Benner [ 43 ] highlighted the significant change for new graduates in that they now have full legal and professional responsibility for the patient. Tong and Epeneter [ 60 ] also reported that facing an ethical dilemma is one of the most stressful factors for new graduates. Therefore, the inexperience of new graduates cannot reduce the standard of care that patients expect from them [ 60 ]. Legal disputes regarding the duties and responsibilities of nurses have increased with the expansion of their roles. This is also the case in Iran. Nurses are now held accountable by law for their actions and must be aware of their legal obligations. To provide safe healthcare services, it is essential to know of professional, ethical, and criminal laws related to nursing practice. The nursing profession is accountable for the quality of services delivered to patients from both professional and legal perspectives. Therefore, it is a valuable finding that nurse managers should support new graduates to better deal with ethical dilemmas. Strengthening ethical education in nursing schools necessitates integrating real cases and ethical dilemmas into the curriculum. Especially, Nursing laws are missing from Iran’s undergraduate nursing curriculum. By incorporating authentic case studies drawn from clinical practice, nursing schools provide students with opportunities to engage in critical reflection, ethical analysis, and moral deliberation. These real cases challenge students to apply ethical principles to complex and ambiguous situations, fostering the development of ethical competence and moral sensitivity. Furthermore, ethical reflection and debriefing sessions during clinical experiences enable students to discuss and process ethical challenges encountered in practice, promoting self-awareness, empathy, and professional growth. Overall, by combining theoretical instruction with practical application and the use of real cases, nursing schools can effectively prepare future nurses to navigate ethical dilemmas with integrity and compassion.

However, the theme of evidence-based nursing care was the lowest scoring, indicating that students need help with this theme. The findings from studies conducted in this field are varied. A limited number of studies reported that nursing students were competent to implement evidence-based care [ 61 ], while other researchers reported that nursing students’ attitudes toward evidence-based care to guide clinical decisions were largely negative [ 20 , 62 ]. The principal barriers to implementing evidence-based care are lack of authority to change patient care policy, slow dissemination of evidence and lack of time at the bedside to implement evidence [ 10 ], and lack of knowledge and awareness of the process of searching databases and evaluating research [ 63 ]. While the European Higher Education Area (EHEA) framework and the International Council of Nurses Code of Ethics introduce the ability to identify, critically appraise, and apply scientific information as expected learning outcomes for nursing students [ 64 , 65 ], the variation in findings highlights the complexity of the concept of competence and its assessment [ 23 ]. Evidence-Based Nursing (EBN) education for nursing students is most beneficial when it incorporates a multifaceted approach. Interactive workshops play a crucial role, providing students with opportunities to critically appraise research articles, identify evidence-based practices, and apply them to clinical scenarios. Simulation-based learning further enhances students’ skills by offering realistic clinical experiences in a safe environment. Additionally, clinical rotations offer invaluable opportunities for students to observe and participate in evidence-based practices under the guidance of experienced preceptors. Journal clubs foster a culture of critical thinking and ongoing learning, where students regularly review and discuss current research articles. Access to online resources such as databases and evidence-based practice guidelines allows students to stay updated on the latest evidence and best practices. To bridge the gap between clinical practice and academic theory, collaboration between nursing schools and healthcare institutions is essential. This collaboration can involve partnerships to create clinical learning environments that prioritize evidence-based practice, inter professional education activities to promote collaboration across disciplines, training and support for clinical preceptors, and continuing education opportunities for practicing nurses to strengthen their understanding and application of EBN [ 66 ]. By implementing these strategies, nursing education programs can effectively prepare students to become competent practitioners who integrate evidence-based principles into their clinical practice, ultimately improving patient outcomes.

The study’s findings regarding the second objective showed that nursing faculty members expected students to achieve the highest level of competence in work readiness and professional development, and the lowest in evidence-based nursing care competence. The results of the studies in this area revealed that there is a lack of clarity about the level of competence of newly graduated nursing students and that confusion about the competencies expected of them has become a major challenge [ 13 , 67 ]. Evidence of nurse managers’ perceptions of newly graduated nursing student’s competence is limited and rather fragmented. There is a clear need for rigorous empirical studies with comprehensive views of managers, highlighting the key role of managers in the evaluation of nurse competence [ 1 , 9 ]. Some findings also reported that nursing students lacked competence in primary and specialized care after entering a real clinical setting [ 68 ] and that nursing managers were dissatisfied with the competence of students [ 30 ].

The results of the present study on the third objective confirmed the gap between expected and achieved competence requirements. The highest average difference was related to evidence-based nursing care, and the lowest mean difference was related to the professional nursing process. The findings from studies in this field vary. For instance, Brown and Crookes [ 13 ] reported that newly graduated nursing students were not independent in at least 26 out of 30 competency domains. Similar studies have also indicated that nursing students need a structured program after graduation to be ready to enter clinical work [ 30 ]. It can be stated that the nursing profession does not have clear expectations of the competencies of newly graduated nursing students, and preparing them for entry into clinical practice is a major challenge for administrators [ 13 ]. These findings can be explained by the Duchscher transition shock [ 69 ]. It is necessary to support newly graduated nursing students to develop their competence and increase their self-confidence.

The interesting but worrying finding was the low expectations of faculty members and the low scores of students in the theme of evidence-based care. However, nursing students need to keep their competencies up to date to provide safe and high-quality care. The WHO also considers the core competencies of nurse educators to be the preparation of effective, efficient, and skilled nurses who can teach the evidence-based learning process and help students apply it clinically [ 44 ]. The teaching of evidence-based nursing care appears to vary across universities, and some clinical Faculties do not have sufficient knowledge to support students. In general, it can be stated that the results of the present study are in line with the context of Iran. Some of the problems identified include a lack of attention to students’ academic talent, a lack of a competency-based curriculum, a gap between theory and clinical practice, and challenges in teaching and evaluating the achieved competencies [ 42 ].

Strengths and limitations

The study was conducted on a national level with a sizable sample. It is one of the first studies in Iran to address the gap between students’ self-perceived competence levels and nursing faculty members’ expected competency levels. Nevertheless, one of the limitations of the study is the self-report nature of the questionnaire, which may lead to social desirability bias. In addition, the COVID-19 pandemic coinciding with the student’s first and second years could potentially impact their educational quality and competencies. The limitations established during the outbreak negatively affected the nursing education of students worldwide.

Acquiring nursing competencies is the final product of nursing education. The current study’s findings suggest the existence of an academic-practice gap, highlighting the need for educators, faculty members, and nursing managers to collaborate in bridging the potential gap between theory and practice. While nursing students were able to meet some expectations, such as value and ethical codes, there is still a distance between expectations and reality. Especially, evidence-based care was identified as one of the weaknesses of nursing students. It is recommended that future research investigates the best teaching strategies and more objective assessments of competencies. The findings of this study can be used as a guide for the revision of undergraduate nursing education curricula, as well as a guide for curriculum development based on the development of competencies expected of nursing students. Nursing managers can identify existing gaps and plan to fill them and use them for the professionalization of students. This requires the design of educational content and objective assessment tools to address these competencies at different levels throughout the academic semester. This significant issue necessitates enhanced cooperation between healthcare institutions and nursing schools. Enhancing nursing education requires the implementation of concrete pedagogical strategies to bridge the gap between theoretical knowledge and practical skills. Simulation-based learning emerges as a pivotal approach, offering students immersive experiences in realistic clinical scenarios using high-fidelity simulators [ 70 ]. Interprofessional education (IPE) is also instrumental, in fostering collaboration among healthcare professionals and promoting holistic patient care. Strengthening clinical preceptorship programs is essential, with a focus on providing preceptors with formal training and ongoing support to facilitate students’ clinical experiences and transition to professional practice [ 71 ]. Integrating evidence-based practice (EBP) principles throughout the curriculum cultivates critical thinking and inquiry skills among students, while technology-enhanced learning platforms offer innovative ways to engage students and support self-directed learning [ 72 ]. Diverse and comprehensive clinical experiences across various healthcare settings ensure students are prepared for the complexities of modern healthcare delivery. By implementing these practical suggestions, nursing education programs can effectively prepare students to become competent and compassionate healthcare professionals.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Huston C, et al. The academic-practice gap: strategies for an enduring problem . In nursing forum . Wiley Online Library; 2018.

Meretoja R, Isoaho H, Leino-Kilpi H. Nurse competence scale: development and psychometric testing. J Adv Nurs. 2004;47(2):124–33.

Article   Google Scholar  

Järvinen T, et al. Nurse educators’ perceptions of factors related to the competence of graduating nursing students. Nurse Educ Today. 2021;101:104884.

Satu KU, et al. Competence areas of nursing students in Europe. Nurse Educ Today. 2013;33(6):625–32.

World Health Organization. State of the world’s nursing 2020: investing in education, jobs and leadership. 2020 [cited 12 June 2023; https://www.who.int/publications-detail-redirect/9789240003279 .

Lee W-H, Kim S, An J. Development and evaluation of korean nurses’ core competency scale (KNCCS) 2017.

American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education… 2020 [cited 2023; https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf .

Gardulf A, et al. The Nurse Professional competence (NPC) scale: self-reported competence among nursing students on the point of graduation. Nurse Educ Today. 2016;36:165–71.

Kajander-Unkuri S, et al. The level of competence of graduating nursing students in 10 European countries-comparison between countries. Nurs Open. 2021;8(3):1048–62.

Labrague LJ et al. A Multicountry Study on Nursing Students’ Self-Perceived Competence and Barriers to Evidence‐Based Practice 2019. 16(3): pp. 236–246.

Visiers-Jiménez L, et al. Clinical learning environment and graduating nursing students’ competence: a multi-country cross-sectional study. Nurs Health Sci. 2021;23(2):398–410.

Herron EK. New graduate nurses’ preparation for recognition and prevention of failure to rescue: a qualitative study. J Clin Nurs. 2018;27(1–2):e390–401.

Google Scholar  

Brown RA, Crookes PA. What are the ‘necessary’ skills for a newly graduating RN? Results of an Australian survey. BMC Nurs. 2016;15:23.

Amsalu B, et al. Clinical practice competence of Mettu University nursing students: a cross-sectional study. Adv Med Educ Pract. 2020;11:791–8.

Song Y, McCreary LL. New graduate nurses’ self-assessed competencies: an integrative review. Nurse Educ Pract. 2020;45:102801.

Hickerson KA, Taylor LA, Terhaar MF. The Preparation-Practice gap: an Integrative Literature Review. J Contin Educ Nurs. 2016;47(1):17–23.

Huang FF, et al. Self-reported confidence in patient safety competencies among Chinese nursing students: a multi-site cross-sectional survey. BMC Med Educ. 2020;20(1):32.

Hong S et al. A Cross-Sectional Study: What Contributes to Nursing Students’ Clinical Reasoning Competence? Int J Environ Res Public Health, 2021. 18(13).

Mcquitty DJPE, Counseling. Teaching interpersonal communication concepts to increase awareness and reduce health disparities: Presenter (s): DaKysha Moore, NCAT, United States 2023. 109: pp. 25–26.

Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs. 2020;17(6):418–26.

Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond). 2020;20(2):124–7.

Shustack L. Integrating Google Earth in Community Health nursing courses: preparing globally aware nurses. Nurse Educ. 2020;45(2):E11–2.

Zeleníková R, et al. Self-assessed competence of final-year nursing students. Nurs Open. 2023;10(7):4607–18.

Hyun A, Tower M, Turner C. Exploration of the expected and achieved competency levels of new graduate nurses. J Nurs Manag. 2020;28(6):1418–31.

Kukkonen P, et al. Nurse managers’ perceptions of the competence of newly graduated nurses: a scoping review. J Nurs Manag. 2020;28(1):4–16.

Nilsson J et al. Nurse professional competence (NPC) assessed among newly graduated nurses in higher educational institutions in Europe. 2019. 39(3): p. 159–67.

Kajander-Unkuri S et al. Students’ Self-assessed Competence Levels during Nursing Education Continuum - A Cross-sectional Survey. Int J Nurs Educ Scholarsh, 2020. 17(1).

Salminen L, et al. The competence of nurse educators and graduating nurse students. Nurse Educ Today. 2021;98:104769.

Numminen O, et al. Newly graduated nurses’ competence and individual and organizational factors: a multivariate analysis. J Nurs Scholarsh. 2015;47(5):446–57.

Södersved Källestedt ML, et al. Perceptions of managers regarding prerequisites for the development of professional competence of newly graduated nurses: a qualitative study. J Clin Nurs. 2020;29(23–24):4784–94.

Ezzati E, et al. Exploring the social accountability challenges of nursing education system in Iran. BMC Nurs. 2023;22(1):7.

Farsi Z, et al. Comparison of Iran’s nursing education with developed and developing countries: a review on descriptive-comparative studies. BMC Nurs. 2022;21(1):105.

Salem OA et al. Competency based nursing curriculum: establishing the standards for nursing competencies in higher education. 2018. 5(11): p. 1–8.

Noohi E, Ghorbani-Gharani L. and A.J.S.i.D.o.M.E. Abbaszadeh, A comparative study of the curriculum of undergraduate nursing education in Iran and selected renowned universities in the world 2015. 12(3): pp. 450–471.

Rassouli M, Zagheri Tafreshi M. J.J.o.c.e. Esmaeil. Challenges Clin Nurs Educ Iran Strategies. 2014;2(1):11–22.

Riazi S, et al. Understanding gaps and needs in the undergratue nursing curriculum in Iran: a prelude to design a competency-based curriculum model %J payesh (Health Monitor). Journal. 2020;19(2):145–58.

ADIB HM, Mazhariazad F. Nursing Bachelor’s Education program in Iran and UCLA: A comparative study 2019.

Farokhzadian J, et al. Using a model to design, implement, and evaluate a training program for improving cultural competence among undergraduate nursing students: a mixed methods study. BMC Nurs. 2022;21(1):85.

Sargazi O, et al. Improving the professional competency of psychiatric nurses: results of a stress inoculation training program. Psychiatry Res. 2018;270:682–7.

Faraji A, et al. Evaluation of clinical competence and its related factors among ICU nurses in Kermanshah-Iran: a cross-sectional study. Int J Nurs Sci. 2019;6(4):421–5.

Atashzadeh-Shoorideh F, et al. Essential dimensions of professional competency examination in Iran from academic and clinical nurses’ perspective: a mixed-method study. J Educ Health Promot. 2021;10:414.

Purabdollah M, et al. Comparison of the Iranian and scandinavian bachelor of nursing curriculum (Sweden): a scoping review. J Educ Health Promotion. 2023;12(1):389.

Benner P. J.B.o.s., technology and society, using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education . 2004. 24(3): p. 188–99.

World Health Organization. Nurse educator core competencies. Geneva, Switzerland: World Health Organization. 2016 [cited 23 June 2023; https://www.who.int/hrh/nursing_midwifery/nurse_educator050416.pdf .

Purabdollah M, et al. Competencies expected of undergraduate nursing students: a scoping review. Nurs Open. 2023;10(12):7487–508.

Bondy KN. Clinical evaluation of student performance: the effects of criteria on accuracy and reliability. Res Nurs Health. 1984;7(1):25–33.

NLf N. Outcomes for graduates of practical/vocational, diploma, associate degree, baccalaureate, master’s, practice doctorate, and research doctorate programs in nursing . New York 2010; 201]. https:api.semanticscholar.org/corpus ID: 68620057.

Aguayo-González M, Castelló-Badía M, Monereo-Font C. Critical incidents in nursing academics: discovering a new identity. Rev Bras Enferm. 2015;68(2):195–202. 219 – 27.

Scott Imus FJJNEP. Nurse anesthesia student’s personality characteristics and academic performance: A big five personality model perspective 2019. 9: pp. 47–55.

Neishabouri M, Ahmadi F, Kazemnejad A. Iranian nursing students’ perspectives on transition to professional identity: a qualitative study. Int Nurs Rev. 2017;64(3):428–36.

Zheng S, et al. New nurses’ experience during a two year transition period to clinical practice: a phenomenological study. Nurse Educ Today. 2023;121:105682.

Aryuwat P, et al. An integrative review of resilience among nursing students in the context of nursing education. Nurs Open. 2023;10(5):2793–818.

Ayaz-Alkaya S, Simones J. Nursing education stress and coping behaviors in Turkish and the United States nursing students: a descriptive study. Nurse Educ Pract. 2022;59:103292.

Akhtar-Danesh N, et al. Perceptions of professionalism among nursing faculty and nursing students. West J Nurs Res. 2013;35(2):248–71.

Keeling J, Templeman J. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ Pract. 2013;13(1):18–22.

Nilsson J, et al. Development and validation of a new tool measuring nurses self-reported professional competence–the nurse professional competence (NPC) scale. Nurse Educ Today. 2014;34(4):574–80.

Berkow S, et al. Assessing new graduate nurse performance. J Nurs Adm. 2008;38(11):468–74.

Lofmark A, Smide B, Wikblad K. Competence of newly-graduated nurses–a comparison of the perceptions of qualified nurses and students. J Adv Nurs. 2006;53(6):721–8.

Park E, Choi J. Attributes associated with person-centered care competence among undergraduate nursing students. Res Nurs Health. 2020;43(5):511–9.

Tong V, Epeneter BJ. A comparative study of newly licensed registered nurses’ stressors: 2003 and 2015. J Contin Educ Nurs. 2018;49(3):132–40.

Florin J, et al. Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students. J Adv Nurs. 2012;68(4):888–97.

Reid J, et al. Enhancing utility and understanding of evidence based practice through undergraduate nurse education. BMC Nurs. 2017;16:58.

Phillips JM, Cullen D. Improving the adoption of evidence-based practice through RN-to-BSN education. J Contin Educ Nurs. 2014;45(10):467–72.

Stievano A, Tschudin V. The ICN code of ethics for nurses: a time for revision. Int Nurs Rev. 2019;66(2):154–6.

Ministry of Education and Research. Norwegian qualifications framework: levels and learning outcome descriptors… 2011 [cited 23 June 2023; https://www.regjeringen.no/contentassets/e579f913fa1d45c2bf2219afc726670b/nkr.pdf .

Chen Q, et al. Differences in evidence-based nursing practice competencies of clinical and academic nurses in China and opportunities for complementary collaborations: a cross‐sectional study. J Clin Nurs. 2023;32(13–14):3695–706.

Missen K, McKenna L, Beauchamp A. Registered nurses’ perceptions of new nursing graduates’ clinical competence: a systematic integrative review. Nurs Health Sci. 2016;18(2):143–53.

Leonardsen AL, et al. Nurses’ perspectives on technical skill requirements in primary and tertiary healthcare services. Nurs Open. 2020;7(5):1424–30.

Duchscher JE. B.J.J.o.a.n. Transition Shock: Initial Stage role Adaptation New Graduated Registered Nurses. 2009;65(5):1103–13.

Ajemba MN, Ikwe C, Iroanya JC. Effectiveness of simulation-based training in medical education: assessing the impact of simulation-based training on clinical skills acquisition and retention: a systematic review. World J Adv Res Reviews. 2024;21(1):1833–43.

Krystallidou D et al. Interprofessional education for healthcare professionals. A BEME realist review of what works, why, for whom and in what circumstances in undergraduate health sciences education: BEME Guide No. 83 Medical Teacher, 2024: pp. 1–18.

Sun Y, et al. Critical thinking abilities among newly graduated nurses: a cross-sectional survey study in China. Nurs Open. 2023;10(3):1383–92.

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Acknowledgements

The authors extend their gratitude to all the nursing students and faculties who took part in this study.

This article is part of research approved with the financial support of the deputy of research and technology of Tabriz University of Medical Sciences.

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M P: conceptualized the study, data collection, analysis and interpretation, drafting of manuscript; V Z: conceptualized the study, analysis and interpretation, drafting of manuscript; LV: conceptualized the study, data collection and analysis, manuscript revision; A Gh: conceptualized the study, data collection, analysis, and drafting of manuscript; S M: conceptualized the study, analysis, and drafting of manuscript; M Gh: data collection, analysis, and interpretation, drafting of manuscript; All authors read and approved the final manuscript.

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Purabdollah, M., Zamanzadeh, V., Ghahramanian, A. et al. Competency gap among graduating nursing students: what they have achieved and what is expected of them. BMC Med Educ 24 , 546 (2024). https://doi.org/10.1186/s12909-024-05532-w

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National Nurses Week 2024: RN reflects on the state of the profession, calls for change

Monday, May 6 kicks off National Nurses Week , and it gives folks an opportunity to show their love and appreciation for the people who take care of the sick, injured and dying.

From neonatal nurses who help welcome newborns into the world to hospice nurses that provide peace and comfort to their dying patients, nurses play a crucial role in the medical industry.

According to the American Association of Colleges of Nurses, nurses make up the largest part of the healthcare workforce, are the primary health providers for patients in hospitals and give the most long-term care in the nation.

Restaurants and chains, like Chipotle and Dunkin' , are offering discounts and coupons to the medical professionals to show their appreciation for what they do. But experts are saying that it isn't enough and what nurses need right now goes beyond discounts.

New nursing home staffing regulations Nursing homes must meet minimum federal staffing levels under Biden rule

Catherine Kennedy, a registered nurse and the Vice President of National Nurses United , told USA TODAY that there needs to be systemic change on the federal level to give nurses the best chance to care for their patients.

A study published by the National Library of Medicine states that in 2021, nurses would work an average of "8.2 hours of paid overtime and 5.8 hours of unpaid overtime per week that year — making up the equivalent of more than 9000 full-time jobs."

According to a different study that analyzed a poll sent in from 29,472 registered nurses and 24,061 licensed practical nurses or licensed vocational nurses across 45 different states found that that 62% of nurses said they saw an increase in their work load during the COVID-19 pandemic.

According to those polled they felt the following at least “a few times a week” or “every day:”

• 50.8% felt "emotionally drained"
• 56.4% felt "used up"
• 49.7% felt "fatigued"
• 45.1% felt "burned out "
• 29.4% felt "at the end of their rope"

Despite being labeled as heroes during COVID-19, Kennedy said nurses were not given the support they needed to do their jobs properly.

"Nurses were in tears because they could not provide the proper care," said Kennedy. "So a lot of nurses left nursing and other states because of that."

Difference between 2020 and now

According to Kennedy, nurses have always struggled to fight for better working conditions. But, when cases of COVID surged and the world shut down in 2020 , "it got worse."

She said nurses had to fight to make sure they had the proper equipment they needed to protect themselves, and adds that that hasn't changed four years later.

Hospitals and medical institutes are using the same techniques they did at the height of the pandemic to cut costs and it comes at the expense of nurses' safety, said Kennedy.

"It is still a constant battle to make sure that nurses are protected [and] have what they need as it relates to proper [personal protective equipment.]"

She adds that it's been an "ongoing battle" just to make sure the working conditions are safe for patients and nurses.

Safe working conditions

Safe working conditions for nurses doesn't just include having enough masks to protect oneself. It means having enough nurses and aides on staff to provide the care patients need without overworking an understaffed team.

"Every day that we walk through the doors of a hospital, we wanna be able to do the things that we've been trained to do and that's to take care of our patients," said Kennedy.

But, she adds that having to fight to be properly staffed, errors in patients' admission and racial discrimination play a factor in how well nurses can do their job.

Kennedy said that it's important to allow nurses to "do what we do best and that's taking care of patients, and we can't do that if we don't have safe working conditions."

According to National Nurses United , when nurses "are forced" to focus on too many patients, patients are at a higher risk of the following:

• Preventable medical errors
• Avoidable complications
• Pressure sores
• Longer hospital stays
• Higher numbers of hospital readmissions

Nurses push for change by backing proposed staffing standards act

To avoid complications related to overwork, exhaustion and burnout, the union supports the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023, S. 1113 and H.R. 2530.

Although the act was introduced a year ago in March 2023 it is still awaiting approval.

If passed, the act will require hospitals to enforce a nurse-to-patient ratio and limit the number of patients a nurse can be assigned.

Hospitals will also have to post notices of what the nurse-to-patient ratio is in each unit, record ratios in every shift and follow a procedure that determines how the ratio is determined for each unit. It will ban other staff from performing tasks that should be done by a nurse unless they are "specifically authorized within a state's scope of practice rules."

The act also states that a nurse can refuse assignments if "it would violate minimum ratios or if they are not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing their nurse's license."

Kennedy said that a nurse-to-patient ratio will improve work conditions and bring nurses back to their jobs.

California already has a ratio in place and Kennedy said it improves working conditions.

When Kennedy worked as a nurse before the ratio was put in place, she saw anywhere from 12 to 24 patients a day. Now, she only sees five.

According to the union, the ratio law reduced costs for hospitals, improved nurse safety and job satisfaction and reduced the following:

• Spending on temporary RNs,
• Overtime costs
• Staff turnover

"California is not an island," said Kennedy. "And so federally, we need to push the ratio law because the patients are no different in California than they are in Mississippi or Montana."

Just a number: At 88 years old, Volusia-Flagler softball umpire Mart Hannah is not slowing down

DAYTONA BEACH — Mart Hannah opens the driver's door of her white Ford Mustang and reaches in for something she’s saved for almost three decades. She wants to show it.

It’s a 1996 clipping from the Daytona Beach News-Journal. The bold headline at the top of the page reads, “The lady is an ump.” Underneath it, “Hannah named Fla. arbiter of the year.”

“I want to be out there doing this until I can’t do it well anymore,” Hannah was quoted as saying in the story by Randy Rorrer.

That point has not arrived yet.

“I do it because I love the game and like the people,” Hannah continued. “If you’re in it for the money, you’re in it for the wrong reason.”

Yep. Still the case.

In October, Mart Hannah will turn 89 years old. She entered sports officiating 50 years ago as a Little League baseball umpire. This is her 38th year as a Florida High School Athletic Association softball umpire. She completed her 34th season as a prep volleyball referee last fall.

She has no immediate plans of stepping away, either.

“I just enjoy the game,” Hannah said. “As long as I can move as well as everyone else does, I'm fine.”

How Mart Hannah got started

Hannah has always been a good athlete.

She used to belong to a local track club and in 1976, decided to try out for the amateur Olympics in St. Petersburg.

She walked out with seven all-around gold medals.

But softball was always Hannah’s favorite sport.

She grew up playing as a coal miner’s daughter in Harlan, Kentucky. Even before she moved to Daytona Beach in 1959, she was a member of adult leagues. She suited up for high-level tournament clubs until she was 55. Her team captured a state title in the late 1980s.

She got into umpiring simply through playing.

“It was hard back then to get officials, and there was no females calling at all,” Hannah said. “It was all men. And I thought, ‘Well, you know, I'd be interested in doing that.’”

If memory serves correctly, she made roughly $40 a game in the beginning. Earlier this month, she pocketed $89 for a district final at Father Lopez Catholic High School.

She started off part-time. Her full-time job was as a nurse at Halifax Medical Center.

But in 1990, at age 55, Hannah retired from nursing and dove deeper into officiating. 

Mart Hannah has umpired games far and wide

At her peak, Hannah worked 15 games a week. She’d head to a local field three or four nights Tuesday-Friday. Then, on Saturday and Sunday, she’d drive to tournaments and do five or six games each day.

Her husband, Robert, traveled with her. They were married 61 years until his passing 10 years ago. They had three kids — Alan, Kim and Leisa.

Hannah’s only break came on Mondays. She has competed in a bowling league on that night for decades. Her team recently won a championship.

“And we're the oldest team!” Hannah said.

The games didn’t stop in the summer. When the school year concluded, Hannah pivoted to adult men’s and women’s leagues. She’s done national world series for both.

She also served as the president of A-1 Officials Association, the only woman that’s ever held the position.

“The men respected me,” she said. “They know I'm a strong personality, so they never questioned anything. It was fun.”

Hannah quit going to tournaments about a decade ago. For the last seven years, she has not donned a helmet and chest protector and called balls and strikes behind home plate.

Eight years ago this month, she officiated a regional playoff game in Vero Beach with no problems. But the following day, after she had returned home, Hannah felt like someone had squeezed her.

She consulted her doctor, who told her she needed to go to the hospital. Hannah ended up undergoing quadruple bypass heart surgery.

It never affected her work schedule, though. Three months later, in August, Hannah was back to bowling on Monday nights and refereeing volleyball when the season kicked off.

In softball, she has lined up exclusively as a base umpire since her procedure.

Her region involves three counties: Volusia, Flagler and the occasional trip to Putnam. She usually draws three assignments per week. She also is a supervisor for area softball officials.

Mart Hannah’s routine

Hannah keeps busy, and that might be the secret to her longevity. On the field, she looks and moves like someone decades younger.

Every other day, Hannah runs 6-10 miles. She mows her own lawn, trims the bushes and maintains the rest of her yard. She does plenty of squatting.

Because she stays in shape, Hannah said umpiring has not gotten more difficult as she’s aged. She’s never battled soreness following a game.

She attempts to be the first umpire at the field on days she’s working. For a 6 p.m. game at Father Lopez on May 2, Hannah arrived at 5:15, beating her two colleagues.

“I want to be there to make sure everything is set up, everything is ready to go,” she said.

OK, being prepared, what else makes a good umpire?

“I think to not hear anything around you, stay in your game, do your job and forget about everything else,” Hannah said.

Mart Hannah’s umpiring future

According to the FHSAA, the oldest softball umpire in the state just turned 94.

Hannah’s target?

“Really, I want to be able to run, compete,” she said. “My goal was 90. That's another year. So we'll see what happens, you know?”

She has endured thousands of games. She’s seen no-hitters, survived a 27-inning contest and worked double-digit state softball finals, plus another five in volleyball.

Her adrenaline still pumps for big games.

“It's an honor, especially with my age because not everybody knows my age,” Hannah said. “Hopefully, they can't tell when I'm on the field.”

During the District 4-2A championship on May 2, Hannah alternated between positions near the third-base line and the second-base bag depending on where the runners were. She made calls on a couple of close plays. Between each inning, she jogged to the circle and brushed the dirt off the rubber.

No. 3 Father Lopez looked to upset top-seeded Countryside Christian. After falling behind 5-3 in the first two innings, the Green Wave exploded for six runs in the top of the third. The Minutemen tied it in the bottom of the six and eventually walked it off 11-10 in the seventh.

Hannah left the field with a smile on her face.

“That was a great game, wasn’t it?” she said.