problem solving strategies in healthcare

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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A step-by-step guide to overcoming challenges through problem solving in healthcare

By ishika rastogi.

May 13, 2024

Jump to section

• Healthcare horizons: Confronting contemporary challenges 
• Exploring the key parameters in modern healthcare industry 
• Cloudnine's Leadership Transformation through AntWalk’s "Aspire" Program

Introducing AntWalk: Your partner in problem solving

Did you know according to a recent study by the American Hospital Association (AHA) 72% of hospitals and health system leaders reported their organization is facing workforce shortages . 

Indeed, this is one of the many challenges faced by the healthcare industry today and these loopholes gets clearly visible by a report from Global Health Security Index 2023, which stated “ The average country score was only 40.2 out of 100, highlighting significant gaps in national preparedness for health emergencies .”  

Considering these statistics, it’s evident that the healthcare industry is navigating through complex challenges, from workforce shortages to global health emergencies and many more.  

As we delve deeper into these issues, it becomes increasingly crucial to unlock strategic solutions that can address the multifaceted nature of healthcare problems.  

Join us as we explore the steps of problem-solving skills in healthcare, aiming to uncover actionable strategies that can pave the way for organizations to overcome the obstacles in the healthcare industry.  

Healthcare horizons: Confronting contemporary challenges 

The healthcare sector is encountering numerous transformations that present fresh hurdles for medical institutions regardless of their size. Notably, dynamic government regulations, deficits in staffing, advancements in technology, and evolving patient demands contribute to a novel landscape where managing a medical facility entails more than simply providing patient care. 

Let’s explore the key challenges confronting the healthcare industry and strategies to maintain a competitive edge. 

• Cybersecurity: Data breaches, ransomware and other types of cyberattacks in healthcare, but as advancement in technology is rapidly increasing, like use of Artificial Intelligence in healthcare, telehealth and other initiatives, it has become extremely important to protect these initiatives from external threats. This is also shown through Healthcare Data Breach Report by Hipaa Journal which stated that “ the number of compromised records decreased by 34.3% from month to month, however July’s total was unusually high. Almost 12 million records were reported lost or stolen in August, a far cry from the average of 7.49 million records each month in 2023 .” 

• Staff shortage and burnout: Since 2020, there has been a tenfold increase in staff turnover and burnout in the healthcare industry. The healthcare sector had the second-highest number of employment opportunities in the US by September 2022, only surpassed by lodging and food services.   But now the biggest challenge in healthcare cause concern as workforce shortages and increased turnover has increased manifolds. These difficulties include increased expenses, an increase in errors, longer processing times, and income losses. 
• Ineffective Communication: Communication within institutes is one of the biggest problems in healthcare industry. Studies shows that hospitals lose $12 billion annually due to inadequate communication, which is equivalent to 2% of total income . Building strong internal communication is a necessity for healthcare institutes as it would help in patient care quality through effective internal communication. 
• Customer Success and Relation: Healthcare organizations grapple with various challenges in customer success and relations, such as the complexity of maintaining effective communication channels amidst digital healthcare trends. Adhering to stringent regulations while ensuring patient satisfaction poses an ongoing dilemma. Managing patient education to ensure understanding of treatments and care plans adds another layer of difficulty. Moreover, delivering personalized care becomes increasingly challenging as patient volumes rise and transitioning from fee-for-service to value-based care models incentivize providers to deliver high-quality, cost-effective care while navigating these complexities. 
• Effective Payment Model: Healthcare facilities previously relied on the fee-for-service payment model, emphasising the number of patients and operations. This made doctors less likely to practise collaboration and preventive care. The value-based payment paradigm, which connects payment to patient outcomes, is currently gaining popularity. Patients under this paradigm obtain better care, especially for chronic diseases, even though only 15% of physicians have made the changeover. 
• Big Data: Big data in healthcare   sector is becoming more and more dispersed across various systems and entities, which makes it more difficult to optimise patient care, even with its expanding volume. Accurate insights are hampered, for example, when patient self-reporting is relied upon during insurance or provider changes, resulting in inadequate data transfer. 

Now that we are aware that the healthcare industry faces a variety of new obstacles, let’s look at some of the parameter the sector has employed to overcome these obstacles. 

Exploring the key parameters in modern healthcare industry 

Cynefin framework .

The Cynefin Framework, conceptualized by Dave Snowden , is a revolutionary tool designed for healthcare leaders to enhance their decision-making strategies. It categorizes scenarios into four domains: simple, complicated, complex, and chaotic, helping leaders tailor their approaches to different situations.

This framework encourages a shift in perspective, urging leaders to adopt flexible, context-sensitive strategies for more effective solutions. It’s especially relevant in healthcare, where it can significantly improve how leaders address the sector’s inherent complexities and fluid situations, from routine procedures to handling unprecedented medical crises like the COVID-19 pandemic. 

Since The Cynefin decision making framework only looks at one aspect of the process— decision-making process in strategic management—it is critical to address the issues that have grown because of technological advancements in the healthcare sector. Overcoming these challenges in the healthcare tech might pose several difficulties for organizations.  

But here AntWalk can turn the tables around. Let’s see how AntWalk assisted Cloud9 to smoothly overcome their challenges. 

Cloudnine’s Leadership Transformation through AntWalk’s “Aspire” Program 

Cloudnine collaborated with AntWalk to enhance and operational efficiency & leadership in healthcare management through the “Aspire” program, focusing on proactive care, teamwork, and data-driven decision-making. The initiative featured expert-led sessions and practical training, significantly improving patient satisfaction, service ratings, and financial performance. This partnership successfully empowered leaders to streamline processes and elevate the overall patient care experience.     

AntWalk’s talent platform is the ideal choice for healthcare organizations seeking to surmount their unique challenges and enhance their workforce capabilities. Through its assess, align and mitigating tools, AntWalk offers a suite of solutions designed to address the specific needs of the healthcare sector. 

With its different learning partners, specializing in areas such as cybersecurity, power skills, digital transformation, and customer success, AntWalk ensures that healthcare professionals have access to the latest knowledge and skills required to navigate the complexities of the industry.  

Whether it’s staying ahead of cybersecurity threats, mastering digital tools for patient care, or honing interpersonal skills crucial for customer satisfaction, AntWalk’s comprehensive platform equips healthcare teams with the expertise they need to excel. 

By offering a flexible and adaptive approach to skill development, AntWalk enabled healthcare organizations like Cloudnine to foster a culture of continuous learning and innovation helps healthcare organizations to overcome their challenges and thrive in an ever-evolving landscape. 

Take the first step towards unlocking innovative solutions for your healthcare organization by connecting with AntWalk today. 

Key Takeaways

• The healthcare sector struggles with staffing, global crises, cybersecurity, burnout, communication, and customer relations 
• Addressing the growing complexity of healthcare challenges necessitates innovative solutions
• The blog emphasizes the Cynefin Framework for healthcare leaders to navigate complexity with tailored strategies
• AntWalk offers a healthcare-specific business platform emphasizing cybersecurity, digital transformation, and customer satisfaction, alongside facilitating self-paced learning for healthcare professionals

Empowering organizations through a Capability-driven Talent Supply Chain, where Capability is the cornerstone for making impactful people decisions. 

AntWalk Envisions a world where merit and capability transcend all barriers – race, gender, sexual orientation, language, degree, or years of experience. 

Mission:  

We help Organizations measure and build Capabilities in line with their Business Priorities. Begin your journey to a more capable organization at AntWalk . 

I am an avid marketer, who waltzes through the world of global trends, weaving insights into captivating words. When not in the digital spotlight, I trade marketing buzz with the dance moves, cherishing life with my puppy.

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Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008 ). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) ( Tanner, 2006 , p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

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Creative Problem Solving in Healthcare

CREATIVE PROBLEM SOLVING IN THE HEALTHCARE SETTING

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There are 5 primary strategies to use when looking for creative ways to solve problems in healthcare:

• Brainstorming
• Thinking hats
• Problem reversal
• Role-playing

We all have to deal with problems, not only at work, but also in our personal lives. Planning a wedding or a party, finding child care, paying bills, trying to arrange transportation for family members to get where they need to go…all of these are frequent problems that we have to deal with.

As a healthcare worker, your workplace is always changing. It is full of challenges and new clients. You must monitor your client’s condition and perform prescribed treatments. You must know when to inform health professionals about your client’s condition. You must help your clients to make decisions.

Problems can quickly arise and you will have to solve these problems. You need to know what to do and when to do it. Some of these problems will require creative solutions. Being able to creatively problem-solve is an important skill for today’s healthcare workers. Knowing the types of problems that can arise and planning for them in case they do happen will help you to deal with problems effectively.

ABOUT PROBLEM SOLVING

Problem-solving requires critical thinking skills and creativity. What is a problem? What does creativity mean? What is critical thinking?

A problem is a gap or difference in what the situation now is and what you would like it to be.

Creativity is basically the production of order out of chaos. Creativity is developing new, flexible, open-minded approaches or solutions to a problem.

Critical thinking is examining and reflecting on ideas and thinking. Then judgments are made and a course of action decided upon. By combining critical thinking and problem solving, the problem is identified, information is gathered, beliefs and ideas are challenged, and different options are examined creatively. Asking questions is the way to build critical thinking into problem solving.

CREATIVE PROBLEM-SOLVING STRATEGIES

Several strategies that you can use to solve problems creatively are brainstorming, thinking hats, problem reversal, S.W.O.T., and role playing.

Brainstorming Brainstorming is often used by groups, but can also be used by you alone. It is used to create as many possible solutions to a problem as possible. To be effective, the ideas must not be judged or evaluated in any way as they are being developed, no matter how bizarre they seem. Wild ideas are welcomed. Ideas can build on other ideas. New ideas can be created by changing ideas already mentioned.

The more solutions that can be created, the more likely you are to find an effective one. Also, the more variety there is in the solutions, the more likely you are to find an effective one. Once all possible ideas have been created, they are considered for possible consequences. A solution is then selected.

Consider for a moment Divide a square into 4 equal parts. How many possible ways can you think of to divide a square into 4 equal parts?

Below are 4 of the possible answers to this exercise. There are actually many different ways to divide a square into 4 equal parts. This exercise helps to develop your creative thinking skills. It also shows that there is often more than one right answer to a problem.

Thinking hats Thinking hats can also be used in groups, or by you alone. It was originally designed by Edward de Bono. It uses six colored (imaginary) hats. Each hat stands for a different way of thinking about a problem or issue. Using all of the hats will help you to consider the problem more creatively. You will be able to think about the problem from a different viewpoint than you usually take. If it is being used with a group, all members have on the same colored hat at the same time.

1. The white hat is neutral. Facts, figures, and information are examined. It helps to decide if more information is needed.

2. The red hat is for feelings, hunches, and intuition. There is no need to explain your feelings.

3. The yellow hat is for optimism and a logical, positive view of things. It looks at the benefits. It also helps during the evaluation of ideas.

4. The black hat is the logical negative. It uses caution and judgement. It does not encourage creativity. It helps during the evaluation of ideas. It is usually better to use the yellow hat before the black one, to look at the benefits first.

5. The green hat is for creative thinking and new ideas.

6. The blue hat is used to think about the problem-solving process. It ensures the process is being followed. It helps to decide what should be done next.

Problem reversal Sometimes, you will get a different view of a problem if you look at it from the opposite direction. State the problem in reverse. Change a positive statement into a negative one. For example, if there is a problem with a co-worker and you want to improve the situation, consider what would make the situation worse.

S.W.O.T. Analyzing the strengths, weaknesses, opportunities, and threats (S.W.O.T.) is another way of evaluating a problem. It can also be used when evaluating the solutions. What are the possible benefits? What strengths are present? What are the weaknesses? What new opportunities or situations can be created? How can we take advantage of these opportunities? What is the possible harm in the problem? What is the possible harm in the solution?

TIPS TO HELP WITH PROBLEM-SOLVING

1. Think before acting. Use a problem-solving process.

2. Think clearly – stay open-minded. Recognize the effects your emotions can have on your thinking. Separate facts from opinions. Look for errors in reasoning. Consider the evidence (information) – do not jump to conclusions. Don’t try to make the facts fit the solution you want to use.

3. Ask as many questions as you can. Make sure you are asking the right questions to find out what the problem really is. Find out all you can about the problem.

4. Get good ideas from everyone and from everywhere. Edward Land was taking photographs of his family on vacation. His daughter asked him, “Why do we have to wait to see the pictures?” Land thought about this and came up with the idea of instant photography and the Polaroid Camera.

5. Be selective. You cannot solve every problem. Make sure the problem is yours to solve.

6. If a problem seems to be overwhelming, break it into parts.

7. Make the best use of what you have. People often waste a lot of time and energy on “if only.” When you are solving problems, focus on what you have available and what you can change or fix. Spending time on “if only” will just waste time. Spending time and energy saying, “It wouldn’t be a problem if only we had twice as much money for equipment” does not solve the problem – especially if you know you are not going to get twice as much money. Gather the facts as they exist and develop realistic solutions.

8. Look for the opportunity in the problem. Developing creative solutions takes advantage of the opportunity in the problem. For example, a long-term institution for the elderly is looking at the possibility of having to lay-off employees. At the same time, there is a community need for daycare services for the elderly. Perhaps a creative solution would be to develop a daycare program for the elderly instead of laying the employees off.

9. Don’t wait for a problem to occur. If you can take action before a situation turns into a problem, do so.

10. Plan for problems before they occur.

11. Negotiate. Negotiation means that those involved have some of their needs met. This is usually a good strategy in problem-solving. Everybody gets something.

12. Ensure the solution fits the problem. Once the solution has been put into action, it is important to evaluate the plan to ensure the problem has actually been solved and not just hidden for a while.

13. Expect success. Believe in your ability. Work towards realistic goals rather than trying to save the world. Use your skills, time, and energy wisely.

14. Look forward, not backward. Don’t always count on strategies that worked in the past. Be curious. Have the self-confidence to try new things.

15. Although we would like to have all of our problems solved quickly, don’t expect to be able to solve every problem, especially with the first strategy used.

16. Keep your sense of humor.

17. Avoid judging during the gathering of information and development of ideas. The most important question in the creative process is “How might we…?” “We can’t because …” is a barrier to creative problem solving.

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I look upon the “Herb Interaction” book as a “quickie” for my pharmacy team, no need to get bogged down on the computer.

The book on “foot ulcers” spoke to me, I now understand the importance of foot care.

We forget sometimes the power of the patient for healing through compliance and self care habits. We should provide understandable information.

The Dr’ Guide books were a great door opener and relationship builder with the allergy medical team. Our reps loved them.

We had the highest BRC (business Reply Card) return rate of all time – it built up great customer goodwill and easier repeat calls.

The distribution of the Dr. Guide books was the most cost effective, most quickly integrated and best ROI program I have had in years – no committee development meetings, no sky high “creative” costs and so appropriate for our product / treatment messages.

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving

Affiliations.

• 1 San Francisco Veterans Affairs Health Care System, San Francisco, USA. [email protected].
• 2 Department of Medicine, University of California San Francisco, San Francisco, USA. [email protected].
• 3 San Francisco Veterans Affairs Health Care System, San Francisco, USA.
• 4 Department of Medicine, University of California San Francisco, San Francisco, USA.
• 5 Office of Rural Health, Veterans Health Administration, Washington, DC, USA.
• 6 Quality Enhancement Research Initiative, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC, USA.
• 7 Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA.
• PMID: 32918200
• PMCID: PMC7878661
• DOI: 10.1007/s11606-020-06169-3

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.

Publication types

• Research Support, U.S. Gov't, Non-P.H.S.
• Delivery of Health Care
• Health Personnel*
• Implementation Science
• Problem Solving*

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• P30 DK092926/DK/NIDDK NIH HHS/United States

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Problem-Solving Strategies and Obstacles

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Sean is a fact-checker and researcher with experience in sociology, field research, and data analytics.

JGI / Jamie Grill / Getty Images

• Application
• Improvement

From deciding what to eat for dinner to considering whether it's the right time to buy a house, problem-solving is a large part of our daily lives. Learn some of the problem-solving strategies that exist and how to use them in real life, along with ways to overcome obstacles that are making it harder to resolve the issues you face.

What Is Problem-Solving?

In cognitive psychology , the term 'problem-solving' refers to the mental process that people go through to discover, analyze, and solve problems.

A problem exists when there is a goal that we want to achieve but the process by which we will achieve it is not obvious to us. Put another way, there is something that we want to occur in our life, yet we are not immediately certain how to make it happen.

Maybe you want a better relationship with your spouse or another family member but you're not sure how to improve it. Or you want to start a business but are unsure what steps to take. Problem-solving helps you figure out how to achieve these desires.

The problem-solving process involves:

• Discovery of the problem
• Deciding to tackle the issue
• Seeking to understand the problem more fully
• Researching available options or solutions
• Taking action to resolve the issue

Before problem-solving can occur, it is important to first understand the exact nature of the problem itself. If your understanding of the issue is faulty, your attempts to resolve it will also be incorrect or flawed.

Problem-Solving Mental Processes

Several mental processes are at work during problem-solving. Among them are:

• Perceptually recognizing the problem
• Representing the problem in memory
• Considering relevant information that applies to the problem
• Identifying different aspects of the problem
• Labeling and describing the problem

Problem-Solving Strategies

There are many ways to go about solving a problem. Some of these strategies might be used on their own, or you may decide to employ multiple approaches when working to figure out and fix a problem.

An algorithm is a step-by-step procedure that, by following certain "rules" produces a solution. Algorithms are commonly used in mathematics to solve division or multiplication problems. But they can be used in other fields as well.

In psychology, algorithms can be used to help identify individuals with a greater risk of mental health issues. For instance, research suggests that certain algorithms might help us recognize children with an elevated risk of suicide or self-harm.

One benefit of algorithms is that they guarantee an accurate answer. However, they aren't always the best approach to problem-solving, in part because detecting patterns can be incredibly time-consuming.

There are also concerns when machine learning is involved—also known as artificial intelligence (AI)—such as whether they can accurately predict human behaviors.

Heuristics are shortcut strategies that people can use to solve a problem at hand. These "rule of thumb" approaches allow you to simplify complex problems, reducing the total number of possible solutions to a more manageable set.

If you find yourself sitting in a traffic jam, for example, you may quickly consider other routes, taking one to get moving once again. When shopping for a new car, you might think back to a prior experience when negotiating got you a lower price, then employ the same tactics.

While heuristics may be helpful when facing smaller issues, major decisions shouldn't necessarily be made using a shortcut approach. Heuristics also don't guarantee an effective solution, such as when trying to drive around a traffic jam only to find yourself on an equally crowded route.

Trial and Error

A trial-and-error approach to problem-solving involves trying a number of potential solutions to a particular issue, then ruling out those that do not work. If you're not sure whether to buy a shirt in blue or green, for instance, you may try on each before deciding which one to purchase.

This can be a good strategy to use if you have a limited number of solutions available. But if there are many different choices available, narrowing down the possible options using another problem-solving technique can be helpful before attempting trial and error.

In some cases, the solution to a problem can appear as a sudden insight. You are facing an issue in a relationship or your career when, out of nowhere, the solution appears in your mind and you know exactly what to do.

Insight can occur when the problem in front of you is similar to an issue that you've dealt with in the past. Although, you may not recognize what is occurring since the underlying mental processes that lead to insight often happen outside of conscious awareness .

Research indicates that insight is most likely to occur during times when you are alone—such as when going on a walk by yourself, when you're in the shower, or when lying in bed after waking up.

How to Apply Problem-Solving Strategies in Real Life

If you're facing a problem, you can implement one or more of these strategies to find a potential solution. Here's how to use them in real life:

• Create a flow chart . If you have time, you can take advantage of the algorithm approach to problem-solving by sitting down and making a flow chart of each potential solution, its consequences, and what happens next.
• Recall your past experiences . When a problem needs to be solved fairly quickly, heuristics may be a better approach. Think back to when you faced a similar issue, then use your knowledge and experience to choose the best option possible.
• Start trying potential solutions . If your options are limited, start trying them one by one to see which solution is best for achieving your desired goal. If a particular solution doesn't work, move on to the next.
• Take some time alone . Since insight is often achieved when you're alone, carve out time to be by yourself for a while. The answer to your problem may come to you, seemingly out of the blue, if you spend some time away from others.

Obstacles to Problem-Solving

Problem-solving is not a flawless process as there are a number of obstacles that can interfere with our ability to solve a problem quickly and efficiently. These obstacles include:

• Assumptions: When dealing with a problem, people can make assumptions about the constraints and obstacles that prevent certain solutions. Thus, they may not even try some potential options.
• Functional fixedness : This term refers to the tendency to view problems only in their customary manner. Functional fixedness prevents people from fully seeing all of the different options that might be available to find a solution.
• Irrelevant or misleading information: When trying to solve a problem, it's important to distinguish between information that is relevant to the issue and irrelevant data that can lead to faulty solutions. The more complex the problem, the easier it is to focus on misleading or irrelevant information.
• Mental set: A mental set is a tendency to only use solutions that have worked in the past rather than looking for alternative ideas. A mental set can work as a heuristic, making it a useful problem-solving tool. However, mental sets can also lead to inflexibility, making it more difficult to find effective solutions.

How to Improve Your Problem-Solving Skills

In the end, if your goal is to become a better problem-solver, it's helpful to remember that this is a process. Thus, if you want to improve your problem-solving skills, following these steps can help lead you to your solution:

• Recognize that a problem exists . If you are facing a problem, there are generally signs. For instance, if you have a mental illness , you may experience excessive fear or sadness, mood changes, and changes in sleeping or eating habits. Recognizing these signs can help you realize that an issue exists.
• Decide to solve the problem . Make a conscious decision to solve the issue at hand. Commit to yourself that you will go through the steps necessary to find a solution.
• Seek to fully understand the issue . Analyze the problem you face, looking at it from all sides. If your problem is relationship-related, for instance, ask yourself how the other person may be interpreting the issue. You might also consider how your actions might be contributing to the situation.
• Research potential options . Using the problem-solving strategies mentioned, research potential solutions. Make a list of options, then consider each one individually. What are some pros and cons of taking the available routes? What would you need to do to make them happen?
• Take action . Select the best solution possible and take action. Action is one of the steps required for change . So, go through the motions needed to resolve the issue.
• Try another option, if needed . If the solution you chose didn't work, don't give up. Either go through the problem-solving process again or simply try another option.

You can find a way to solve your problems as long as you keep working toward this goal—even if the best solution is simply to let go because no other good solution exists.

Sarathy V. Real world problem-solving .  Front Hum Neurosci . 2018;12:261. doi:10.3389/fnhum.2018.00261

Dunbar K. Problem solving . A Companion to Cognitive Science . 2017. doi:10.1002/9781405164535.ch20

Stewart SL, Celebre A, Hirdes JP, Poss JW. Risk of suicide and self-harm in kids: The development of an algorithm to identify high-risk individuals within the children's mental health system . Child Psychiat Human Develop . 2020;51:913-924. doi:10.1007/s10578-020-00968-9

Rosenbusch H, Soldner F, Evans AM, Zeelenberg M. Supervised machine learning methods in psychology: A practical introduction with annotated R code . Soc Personal Psychol Compass . 2021;15(2):e12579. doi:10.1111/spc3.12579

Mishra S. Decision-making under risk: Integrating perspectives from biology, economics, and psychology . Personal Soc Psychol Rev . 2014;18(3):280-307. doi:10.1177/1088868314530517

Csikszentmihalyi M, Sawyer K. Creative insight: The social dimension of a solitary moment . In: The Systems Model of Creativity . 2015:73-98. doi:10.1007/978-94-017-9085-7_7

Chrysikou EG, Motyka K, Nigro C, Yang SI, Thompson-Schill SL. Functional fixedness in creative thinking tasks depends on stimulus modality .  Psychol Aesthet Creat Arts . 2016;10(4):425‐435. doi:10.1037/aca0000050

Huang F, Tang S, Hu Z. Unconditional perseveration of the short-term mental set in chunk decomposition .  Front Psychol . 2018;9:2568. doi:10.3389/fpsyg.2018.02568

National Alliance on Mental Illness. Warning signs and symptoms .

Mayer RE. Thinking, problem solving, cognition, 2nd ed .

Schooler JW, Ohlsson S, Brooks K. Thoughts beyond words: When language overshadows insight. J Experiment Psychol: General . 1993;122:166-183. doi:10.1037/0096-3445.2.166

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Innovations in Teamwork for Health Care

Don’t leave teaming up to chance. Create better teamwork through science.

In this course, experts from Harvard Business School and the T.H. Chan School of Public Health teach learners to implement a strategy for organizational teamwork in health care.

What You'll Learn

Health care is a team effort. From the front desk administrators to the nurses, doctors, insurers, and even the patients and their families, there are many people involved in an individual’s care. To deliver quality care in today’s fast-paced environment, practitioners and caregivers must go beyond medical problem-solving and rely on effective collaboration and communication skills.

While other businesses may organize around a functional area or project, allowing team members to learn each other's working styles and strengths over time, health care workers often find themselves in ad hoc scenarios, coordinating with near-strangers on life and death situations. As a leader, how do you encourage trust and meet shared goals when teams are formed quickly? How do you strengthen flexibility and collaboration even as team membership and structures fluctuate across departments? 

In Innovations in Teamwork for Health Care, leaders in the field of organizational behavior and teamwork, Amy Edmondson, Professor at Harvard Business School, and Michaela Kerrissey, Assistant Professor at the Harvard T.H. Chan School of Public Health, share their latest research and present their concept of "teaming" as it relates to the health care and life science industries.

In this course, you will explore the complexities of collaboration in dynamic cross-functional teams and its impact on quality of care. You will examine the theory of teaming – where individuals join together to lend their expertise – to appreciate what enables effective teamwork and why teamwork fails; articulate the importance of psychological safety and a joint problem-solving orientation; understand the particular needs of time-limited teams; and rethink the role of hierarchy and leadership in the context of teaming.

You’ll hear firsthand from experts with experience inside and outside the health care industry, from CEO and President of the Cleveland Clinic, Tomislav Mihaljevic, to Andres Sougarret, the engineer who led the miraculous rescue of 33 Chilean miners in 2011. 

Ultimately, this course provides you with the tools needed to implement effective teaming strategies for patient-centered care and provides your organization with a framework to empower robust communication, improve efficiency, and elevate patient safety.

The course will be delivered via  HBS Online’s course platform  and immerse learners in real-world examples from experts at industry-leading organizations. By the end of the course, participants will be able to:

• Explore the science of teamwork, focusing on the psychological and sociological aspects of teaming, collaboration, and defining effective outcomes.
• Understand the complexity of building trust in ad hoc teams, including how to define purpose, build trust, and navigate interpersonal risks to reach common goals.
• Apply communication strategies that encourage psychological safety and create a safe space for all to contribute.
• Understand the value in adopting a model of joint problem-solving for patient care.
• Identify the distinct needs of time-limited project teams and how to incorporate effective and transparent feedback loops.
• Ensure accountability and identify leaders, breaking down hierarchy and encouraging the right person to step up at the right time.
• Implement a PDSA (Plan, Do, Study, and Act) framework for your organization.

Continuing Education Credits

In support of improving patient care, Harvard Medical School is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education.

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• Study the Mining Accident Rescue and Cleveland Clinic cases.
• Understand the concept of teaming and how it can be applied to the health care industry.
• Brainstorm how to organize with a team to rescue 33 trapped miners.
• Analyze the problems solved and new challenges created by organizational structures that were implemented to facilitate teamwork at the Cleveland Clinic.
• Outline and analyze an individualized teaming breakdown for your organization. 
• Study the NASA and Google cases on psychological safety.
• Collaborate with team members and leadership to create a space of psychological safety. 
• Identify the indicators of psychological safety in a group. Analyze data from Project Aristotle’s study of teams at Google.
• Consider how past experiences can affect current feelings of psychological safety.
• Study the Cleveland Clinic ,  Boehringer Ingelheim , and  Cincinnati Children’s Hospital Medical Center cases.
• Implement a joint problem-solving orientation in which team members view problems as shared and solutions as requiring collaboration.
• Match different types of diversity in the workplace with the interpersonal boundaries that they imply.
• Articulate what you bring to a team and what you might need from others.
• Walk down the ladder of inference to get to the root of a problem.
• Study the  Virginia Mason Medical Center and  Institute for Healthcare Improvement cases.
• Cultivate an organization where team learning is valued and mobilized for improved performance.  
• Identify different kinds of work on the process knowledge spectrum.
• Brainstorm how a nursing team could learn from an accidental morphine overdose.
• Study the cases of Julio Castro's Presidential Campaign and Wellframe . 
• Practice leadership skills that include coaching, enabling, and ensuring that the right voices are present or represented within the team structure. 
• Build a leadership workshop for your team using the concepts addressed in this course.
• Practice asking meaningful questions as a way to encourage input and express authentic humility.
• Learn the difference between confirmatory and exploratory responses.

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Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

Almarwani AM. The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: a quasi-experimental study. Saudi J Health Sci. 2022;11:184–9.

Article   Google Scholar  

Horntvedt MT, Nordsteien A, Fermann T, Severinsson E. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Med Educ. 2018;18:172.

Article   PubMed   PubMed Central   Google Scholar  

Larsson M, Sundler AJ, Blomberg K, Bisholt B. The clinical learning environment during clinical practice in postgraduate district nursing students’ education: a cross-sectional study. Nurs Open. 2023;10:879–88.

Article   PubMed   Google Scholar  

Sellberg M, Palmgren PJ, Möller R. A cross-sectional study of clinical learning environments across four undergraduate programs using the undergraduate clinical education environment measure. BMC Med Educ. 2021;21:258.

Saifan A, Devadas B, Mekkawi M, Amoor H, Matizha P, James J, et al. Managing the theory-practice gap in nursing education and practice: hearing the voices of nursing students in the United Arab Emirates. J Nurs Manag. 2021;29:1869–79.

Flott EA, Linden L. The clinical learning environment in nursing education: a concept analysis. J Adv Nurs. 2016;72:501–13.

Kalyani MN, Jamshidi N, Molazem Z, Torabizadeh C, Sharif F. How do nursing students experience the clinical learning environment and respond to their experiences? A qualitative study. BMJ Open. 2019;9:e028052.

Mahasneh D, Shoqirat N, Alsaraireh A, Singh C, Thorpe L. From learning on mannequins to practicing on patients: nursing students’ first-time experience of clinical placement in Jordan. SAGE Open Nurs. 2021;7:23779608211004298.

PubMed   PubMed Central   Google Scholar  

Stubin C. Clinical stress among undergraduate nursing students: perceptions of clinical nursing faculty. Int J Nurs Educ Scholarsh. 2020;17:20190111.

Ahmed WAM. Anxiety and related symptoms among critical care nurses in Albaha, Kingdom of Saudi Arabia. AIMS Med Sci. 2015;2:303–9.

Alhassan. Duke Phillips. 2024.

Ekstedt M, Lindblad M, Löfmark A. Nursing students’ perception of the clinical learning environment and supervision in relation to two different supervision models - a comparative cross-sectional study. BMC Nurs. 2019;18:49.

Bradshaw C, Murphy Tighe S, Doody O. Midwifery students’ experiences of their clinical internship: a qualitative descriptive study. Nurse Educ Today. 2018;68:213–7.

McCarthy B, Trace A, O’Donovan M, O’Regan P, Brady-Nevin C, O’Shea M, et al. Coping with stressful events: a pre-post-test of a psycho-educational intervention for undergraduate nursing and midwifery students. Nurse Educ Today. 2018;61:273–80.

Chaabane S, Chaabna K, Bhagat S, Abraham A, Doraiswamy S, Mamtani R, et al. Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews. Syst Rev. 2021;10:136.

Pines EW, Rauschhuber ML, Norgan GH, Cook JD, Canchola L, Richardson C, et al. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J Adv Nurs. 2012;68:1482–93.

Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med. 1993;55:234–47.

Article   CAS   PubMed   Google Scholar  

Boyd MA. Essentials of psychiatric nursing. Philadelphia, PA: Wolters Kluwer; 2017.

Google Scholar  

Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26:471–80.

Ni C, Lo D, Liu X, Ma J, Xu S, Li L. Chinese female nursing students’ coping strategies, self-esteem and related factors in different years of school. J Nurs Educ Pract. 2012;2:33–41.

Jan LK, Popescu L. Israel’s nursing students’ stress sources and coping strategies during their first clinical experience in hospital wards-a qualitative research. Soc Work Rev / Rev Asistenta Soc. 2014;13:163–88.

Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: a systematic review and meta-analysis. Nurse Educ Today. 2018;63:119–29.

Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12.

Bryman A. Integrating quantitative and qualitative research: how is it done? Qual Res. 2006;6:97–113.

Holloway I, Wheeler S. Qualitative research in nursing and healthcare. New York, NY: Wiley; 2013.

Richards L, Morse J. A user’s guide to qualitative methods. London, UK: Sage; 2007.

Lincoln Y, Guba EG. The SAGE handbook of qualitative research. Newbury Park, CA: SAGE Publications Inc; 2017.

Park S, Park KS. Family stigma: a concept analysis. Asian Nurs Res. 2014;8:165–71.

Onieva-Zafra MD, Fernández-Muñoz JJ, Fernández-Martínez E, García-Sánchez FJ, Abreu-Sánchez A, Parra-Fernández ML. Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study. BMC Med Educ. 2020;20:370.

Albloushi M, Ferguson L, Stamler L, Bassendowski S, Hellsten L, Kent-Wilkinson A. Saudi female nursing students experiences of sense of belonging in the clinical settings: a qualitative study. Nurse Educ Pract. 2019;35:69–74.

Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127–32.

Bhurtun HD, Azimirad M, Saaranen T, Turunen H. Stress and coping among nursing students during clinical training: an integrative review. J Nurs Educ. 2019;58:266–72.

Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Kalyani MN. The challenges of nursing students in the clinical learning environment: a qualitative study. ScientificWorldJournal. 2016;2016:1846178.

Porter SL. First year nursing students’ perceptions of stress and resilience during their initial clinical placement and the introduction of a stress management app: a mixed methods approach. A thesis submitted in partial fulfilment of the requirements of Edinburgh Napier University, for the award of Doctor of Philosophy. 2019. https://www.napier.ac.uk/~/media/worktribe/output-2086663/first-year-nursing-students-perceptions-of-stress-and-resilience-during-their-initial.pdf

Panda S, Dash M, John J, Rath K, Debata A, Swain D, et al. Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis. Nurse Educ Today. 2021;101:104875.

Ahmadi G, Shahriari M, Keyvanara M, Kohan S. Midwifery students’ experiences of learning clinical skills in Iran: a qualitative study. Int J Med Educ. 2018;9:64–71.

Harrison-White K, Owens J. Nurse link lecturers’ perceptions of the challenges facing student nurses in clinical learning environments: a qualitative study. Nurse Educ Pract. 2018;32:78–83.

Grobecker PA. A sense of belonging and perceived stress among baccalaureate nursing students in clinical placements. Nurse Educ Today. 2016;36:178–83.

Msiska G, Kamanga M, Chilemba E, Msosa A, Munkhondya TE. Sources of stress among undergraduate nursing students during clinical practice: a Malawian perspective. Open J Nurs. 2019;9:1.

Joolaee S, Amiri SRJ, Farahani MA, Varaei S. Iranian nursing students’ preparedness for clinical training: a qualitative study. Nurse Educ Today. 2015;35:e13–7.

Günay U, Kılınç G. The transfer of theoretical knowledge to clinical practice by nursing students and the difficulties they experience: a qualitative study. Nurse Educ Today. 2018;65:81–6.

Farzi S, Shahriari M, Farzi S. Exploring the challenges of clinical education in nursing and strategies to improve it: a qualitative study. J Educ Health Promot. 2018;7:115.

Hamaideh SH, Al-Omari H, Al-Modallal H. Nursing students’ perceived stress and coping behaviors in clinical training in Saudi Arabia. J Ment Health. 2017;26:197–203.

Yaghoobi A, Mohagheghi H, Zade MY, Ganji K, Olfatii N. The effect of time management training on test anxiety and academic achievement motivation among high school students. J Sch Psychol. 2014;3:131–44.

Kebriaei A, Bidgoli MS, Saeedi A. Relationship between use of time management skills and satisfaction with spending time among students of Zahedan University of Medical Sciences. J Med Educ Dev. 2014;6:79–88.

Chen YW, Hung CH. Predictors of Taiwanese baccalaureate nursing students’ physio-psycho-social responses during clinical practicum. Nurse Educ Today. 2014;34:73–7.

Ab Latif R, Mat Nor MZ. Stressors and coping strategies during clinical practice among diploma nursing students. Malays J Med Sci. 2019;26:88–98.

Al-Yateem N, Almarzouqi A, Dias JM, Saifan A, Timmins F. Nursing in the United Arab Emirates: current challenges and opportunities. J Nurs Manag. 2021;29:109–12.

Baraz-Pordanjani S, Memarian R, Vanaki Z. Damaged professional identity as a barrier to Iranian nursing students’ clinical learning: a qualitative study. J Clin Nurs Midwifery. 2014;3:1–15.

Labrague LJ, McEnroe-Petitte DM, Papathanasiou IV, Edet OB, Tsaras K, Leocadio MC, et al. Stress and coping strategies among nursing students: an international study. J Ment Health. 2018;27:402–8.

Madian AAEM, Abdelaziz MM, Ahmed HAE. Level of stress and coping strategies among nursing students at Damanhour University, Egypt. Am J Nurs Res. 2019;7:684–96.

Wu CS, Rong JR, Huang MZ. Factors associated with perceived stress of clinical practice among associate degree nursing students in Taiwan. BMC Nurs. 2021;20:89.

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21:401–9.

Bektaş H, Terkes N, Özer Z. Stress and ways of coping among first year nursing students: a Turkish perspective. J Hum Sci. 2018;15:319–30.

John B, Al-Sawad M. Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. J Indian Acad Appl Psychol. 2015;41:76–85.

Mapfumo JS, Chitsiko N, Chireshe R. Teaching practice generated stressors and coping mechanisms among student teachers in Zimbabwe. S Afr J Educ. 2012;32:155–66.

Timmins F, Corroon AM, Byrne G, Mooney B. The challenge of contemporary nurse education programmes. Perceived stressors of nursing students: mental health and related lifestyle issues. J Psychiatr Ment Health Nurs. 2011;18:758–66.

Hegberg NJ, Tone EB. Physical activity and stress resilience: considering those at-risk for developing mental health problems. Ment Health Phys Act. 2015;8:1–7.

Shudifat RM, Al-Husban RY. Perceived sources of stress among first-year nursing students in Jordan. J Psychosoc Nurs Ment Health Serv. 2015;53:37–43.

El Ansari W, Adetunji H, Oskrochi R. Food and mental health: relationship between food and perceived stress and depressive symptoms among university students in the United Kingdom. Cent Eur J Public Health. 2014;22:90–7.

Dias JM, Aderibigbe SA, Abraham MS. Undergraduate nursing students’ mentoring experiences in the clinical practicum: the United Arab Emirates (UAE) perspective. J Nurs Manag. 2022;30:4304–13.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Leadership Effectiveness in Healthcare Settings: A Systematic Review and Meta-Analysis of Cross-Sectional and Before–After Studies

Vincenzo restivo.

1 Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy

Giuseppa Minutolo

Alberto battaglini.

2 Vaccines and Clinical Trials Unit, Department of Health Sciences, University of Genova, Via Antonio Pastore 1, 16132 Genova, Italy

Alberto Carli

3 Santa Chiara Hospital, Largo Medaglie d’oro 9, 38122 Trento, Italy

Michele Capraro

4 School of Public Health, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy

Maddalena Gaeta

5 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini 2, 27100 Pavia, Italy

Cecilia Trucchi

6 Planning, Epidemiology and Prevention Unit, Liguria Health Authority (A.Li.Sa.), IRCCS San Martino Hospital, Largo R. Benzi 10, 16132 Genoa, Italy

Carlo Favaretti

7 Centre on Leadership in Medicine, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy

Francesco Vitale

Alessandra casuccio, associated data.

Data will be available after writing correspondence to the author.

To work efficiently in healthcare organizations and optimize resources, team members should agree with their leader’s decisions critically. However, nowadays, little evidence is available in the literature. This systematic review and meta-analysis has assessed the effectiveness of leadership interventions in improving healthcare outcomes such as performance and guidelines adherence. Overall, the search strategies retrieved 3,155 records, and 21 of them were included in the meta-analysis. Two databases were used for manuscript research: PubMed and Scopus. On 16th December 2019 the researchers searched for articles published in the English language from 2015 to 2019. Considering the study designs, the pooled leadership effectiveness was 14.0% (95%CI 10.0–18.0%) in before–after studies, whereas the correlation coefficient between leadership interventions and healthcare outcomes was 0.22 (95%CI 0.15–0.28) in the cross-sectional studies. The multi-regression analysis in the cross-sectional studies showed a higher leadership effectiveness in South America (β = 0.56; 95%CI 0.13, 0.99), in private hospitals (β = 0.60; 95%CI 0.14, 1.06), and in medical specialty (β = 0.28; 95%CI 0.02, 0.54). These results encourage the improvement of leadership culture to increase performance and guideline adherence in healthcare settings. To reach this purpose, it would be useful to introduce a leadership curriculum following undergraduate medical courses.

1. Introduction

Over the last years, patients’ outcomes, population wellness and organizational standards have become the main purposes of any healthcare structure [ 1 ]. These standards can be achieved following evidence-based practice (EBP) for diseases prevention and care [ 2 , 3 ] and optimizing available economical and human resources [ 3 , 4 ], especially in low-industrialized geographical areas [ 5 ]. This objective could be reached with effective healthcare leadership [ 3 , 4 ], which could be considered a network whose team members followed leadership critically and motivated a leader’s decisions based on the organization’s requests and targets [ 6 ]. Healthcare workers raised their compliance towards daily activities in an effective leadership context, where the leader succeeded in improving membership and performance awareness among team members [ 7 ]. Furthermore, patients could improve their health conditions in a high-level leadership framework. [ 8 ] Despite the leadership benefits for healthcare systems’ performance and patients’ outcomes [ 1 , 7 ], professionals’ confidence would decline in a damaging leadership context for workers’ health conditions and performance [ 4 , 9 , 10 ]. On the other hand, the prevention of any detrimental factor which might worsen both team performance and healthcare systems’ outcomes could demand effective leadership [ 4 , 7 , 10 ]. However, shifting from the old and assumptive leadership into a more effective and dynamic one is still a challenge [ 4 ]. Nowadays, the available evidence on the impact and effectiveness of leadership interventions is sparse and not systematically reported in the literature [ 11 , 12 ].

Recently, the spreading of the Informal Opinion Leadership style into hospital environments is changing the traditional concept of leadership. This leadership style provides a leader without any official assignment, known as an “opinion leader”, whose educational and behavioral background is suitable for the working context. Its target is to apply the best practices in healthcare creating a more familiar and collaborative team [ 2 ]. However, Flodgren et al. reported that informal leadership interventions increased healthcare outcomes [ 2 ].

Nowadays, various leadership styles are recognized with different classifications but none of them are considered the gold standard for healthcare systems because of heterogenous leadership meanings in the literature [ 4 , 5 , 6 , 12 , 13 ]. Leadership style classification by Goleman considered leaders’ behavior [ 5 , 13 ], while Chen DS-S proposed a traditional leadership style classification (charismatic, servant, transactional and transformational) [ 6 ].

Even if leadership style improvement depends on the characteristics and mission of a workplace [ 6 , 13 , 14 ], a leader should have both a high education in healthcare leadership and the behavioral qualities necessary for establishing strong human relationships and achieving a healthcare system’s goals [ 7 , 15 ]. Theoretically, any practitioner could adapt their emotive capacities and educational/working experiences to healthcare contexts, political lines, economical and human resources [ 7 ]. Nowadays, no organization adopts a policy for leader selection in a specific healthcare setting [ 15 ]. Despite the availability of a self-assessment leadership skills questionnaire for aspirant leaders and a pattern for the selection of leaders by Dubinsky et al. [ 15 ], a standardized and universally accepted method to choose leaders for healthcare organizations is still argued over [ 5 , 15 ].

Leadership failure might be caused by the arduous application of leadership skills and adaptive characteristics among team members [ 5 , 6 ]. One of the reasons for this negative event could be the lack of a standardized leadership program for medical students [ 16 , 17 ]. Consequently, working experience in healthcare settings is the only way to apply a leadership style for many medical professionals [ 12 , 16 , 17 ].

Furthermore, the literature data on leadership effectiveness in healthcare organizations were slightly significant or discordant in results. Nevertheless, the knowledge of pooled leadership effectiveness should motivate healthcare workers to apply leadership strategies in healthcare systems [ 12 ]. This systematic review and meta-analysis assesses the pooled effectiveness of leadership interventions in improving healthcare workers’ and patients’ outcomes.

2. Materials and Methods

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement guidelines [ 18 ]. The protocol was registered on the PROSPERO database with code CRD42020198679 on 15 August 2020. Following these methodological standards, leadership interventions were evaluated as the pooled effectiveness and influential characteristic of healthcare settings, such as leadership style, workplace, settings and the study period.

2.1. Data Sources and Search Strategy

PubMed and Scopus were the two databases used for the research into the literature. On 16th December 2019, manuscripts in the English language published between 2015 and 2019 were searched by specific MeSH terms for each dataset. Those for PubMed were “leadership” OR “leadership” AND “clinical” AND “outcome” AND “public health” OR “public” AND “health” OR “public health” AND “humans”. Those for Scopus were “leadership” AND “clinical” AND “outcome” AND “public” AND “health”.

2.2. Study Selection and Data Extraction

In accordance with the PRISMA Statement, the following PICOS method was used for including articles [ 18 ]: the target population was all healthcare workers in any hospital or clinical setting (Population); the interventions were any leader’s recommendation to fulfil quality standards or performance indexes of a healthcare system (Intervention) [ 19 ]; to be included, the study should have a control group or reference at baseline as comparison (Control); and any effectiveness measure in terms of change in adherence to healthcare guidelines or performances (Outcome). In detail, any outcome implicated into healthcare workers’ capacity and characteristics in reaching a healthcare systems purposes following the highest standards was considered as performance [ 19 ]. Moreover, whatever clinical practices resulted after having respected the recommendations, procedures or statements settled previously was considered as guideline adherence [ 20 ]. The selected study design was an observational or experimental/quasi-experimental study design (trial, case control, cohort, cross-sectional, before-after study), excluding any systematic reviews, metanalyses, study protocol and guidelines (Studies).

The leaders’ interventions followed Chen’s leadership styles classification [ 6 ]. According to this, the charismatic leadership style can be defined also as an emotive leadership because of members’ strong feelings which guide the relationship with their leader. Its purpose is the improvement of workers’ motivation to reach predetermined organizational targets following a leader’s planning strategies and foresights. Servant leadership style is a sharing leadership style in whose members can increase their skills and competences through steady leader support, and they have a role in an organization’s goals. The transformational leadership style focuses on practical aspects such as new approaches for problem solving, new interventions to reach purposes, future planning and viewpoints sharing. Originality in a transformational leadership style has a key role of improving previous workers’ and healthcare system conditions in the achievement of objectives. The transactional leadership style requires a working context where technical skills are fundamental, and whose leader realizes a double-sense sharing process of knowledge and tasks with members. Furthermore, workers’ performances are improved through a rewarding system [ 6 ].

In this study, the supervisor trained the research team for practical manuscript selection and data extraction. The aim was to ensure data homogeneity and to check the authors’ procedures for selection and data collection. The screening phase was performed by four researchers reading each manuscript’s title and abstract independently and choosing to exclude any article that did not fulfill the inclusion criteria. Afterwards, the included manuscripts were searched for in the full text. They were retrieved freely, by institutional access or requesting them from the authors.

The assessment phase consisted of full-text reading to select articles following the inclusion criteria. The supervisor solved any contrasting view about article selection and variable selection.

The final database was built up by collecting the information from all included full-text articles: author, title, study year, year of publication, country/geographic location, study design, viability and type of evaluation scales for leadership competence, study period, type of intervention to improve leadership awareness, setting of leader intervention, selection modality of leaders, leadership style adopted, outcomes assessed such as guideline adherence or healthcare workers’ performance, benefits for patients’ health or patients’ outcomes improvement, public or private hospitals or healthcare units, ward specialty, intervention in single specialty or multi-professional settings, number of beds, number of healthcare workers involved in leadership interventions and sample size.

Each included article in this systematic review and meta-analysis received a standardized quality score for the specific study design, according to Newcastle–Ottawa, for the assessment of the quality of the cross-sectional study, and the Study Quality Assessment Tools by the National Heart, Lung, and Blood Institute were used for all other study designs [ 21 , 22 ].

2.3. Statistical Data Analysis

The manuscripts metadata were extracted in a Microsoft Excel spreadsheet to remove duplicate articles and collect data. The included article variables for the quantitative meta-analysis were: first author, publication year, continent of study, outcome, public or private organization, hospital or local healthcare unit, surgical or non-surgical ward, multi- or single-professionals, ward specialty, sample size, quality score of each manuscript, leadership style, year of study and study design.

The measurement of the outcomes of interest (either performance or guidelines adherence) depended on the study design of the included manuscripts in the meta-analysis:

• for cross-sectional studies, the outcome of interest was the correlation between leadership improvement and guideline adherence or healthcare performance;
• the outcome derived from before–after studies or the trial was the percentage of leadership improvement intervention in guideline adherence or healthcare performance;
• the incidence occurrence of improved results among exposed and not exposed healthcare workers of leadership interventions and the relative risks (RR) were the outcomes in cohort studies;
• the odds ratio (OR) between the case of healthcare workers who had received a leadership intervention and the control group for case-control studies.

Pooled estimates were calculated using both the fixed effects and DerSimonian and Laird random effects models, weighting individual study results by the inverse of their variances [ 23 ]. Forest plots assessed the pooled estimates and the corresponding 95%CI across the studies. The heterogeneity test was performed by a chi-square test at a significance level of p < 0.05, reporting the I 2 statistic together with a 25%, 50% or 75% cut-off, indicating low, moderate, and high heterogeneity, respectively [ 24 , 25 ].

Subgroup analysis and meta-regression analyses explored the sources of significant heterogeneity. Subgroup analysis considered the leadership style (charismatic, servant, transactional and transformational), continent of study (North America, Europe, Oceania), median cut-off year of study conduction (studies conducted between 2005 and 2011 and studies conducted between 2012 and 2019), type of hospital organization (public or private hospital), type of specialty (surgical or medical specialty) and type of team (multi-professional or single-professional team).

Meta-regression analysis considered the following variables: year of starting study, continent of study conduction, public or private hospital, surgical or non-surgical specialty ward, type of healthcare service (hospital or local health unit), type of healthcare workers involved (multi- or single-professional), leadership style, and study quality score. All variables included in the model were relevant in the coefficient analysis.

To assess a potential publication bias, a graphical funnel plot reported the logarithm effect estimate and related the standard error from each study, and the Egger test was performed [ 26 , 27 ].

All data were analyzed using the statistical package STATA/SE 16.1 (StataCorp LP, College 482 Station, TX, USA), with the “metan” command used for meta-analysis, and “metafunnel”, “metabias” and “confunnel” for publication bias assessment [ 28 ].

3.1. Studies Characteristics

Overall, the search strategies retrieved 3,155 relevant records. After removing 570 (18.1%) duplicates, 2,585 (81.9%) articles were suitable for the screening phase, of which only 284 (11.0%) articles were selected for the assessment phase. During the assessment phase, 263 (92.6%) articles were excluded. The most frequent reasons of exclusion were the absence of relevant outcomes ( n = 134, 51.0%) and other study designs ( n = 61, 23.2%). Very few articles were rejected due to them being written in another language ( n = 1, 0.4%), due to the publication year being out of 2015–2019 ( n = 1, 0.4%) or having an unavailable full text ( n = 3, 1.1%).

A total of 21 (7.4%) articles were included in the qualitative and quantitative analysis, of which nine (42.9%) were cross-sectional studies and twelve (57.1%) were before and after studies ( Figure 1 ).

Flow-chart of selection manuscript phases for systematic review and meta-analysis on leadership effectiveness in healthcare workers.

The number of healthcare workers enrolled was 25,099 (median = 308, IQR = 89–1190), including at least 2,275 nurses (9.1%, median = 324, IQR = 199–458). Most of the studies involved a public hospital ( n = 16, 76.2%). Among the studies from private healthcare settings, three (60.0%) were conducted in North America. Articles which analyzed servant and charismatic leadership styles were nine (42.9%) and eight (38.1%), respectively. Interventions with a transactional leadership style were examined in six (28.6%) studies, while those with a transformational leadership style were examined in five studies (23.8%). Overall, 82 healthcare outcomes were assessed and 71 (86.6%) of them were classified as performance. Adherence-to-guidelines outcomes were 11 (13.4%), which were related mainly to hospital stay ( n = 7, 64.0%) and drug administration ( n = 3, 27.0%). Clements et al. and Lornudd et al. showed the highest number of outcomes, which were 19 (23.2%) and 12 (14.6%), respectively [ 29 , 30 ].

3.2. Leadership Effectiveness in before–after Studies

Before–after studies ( Supplementary Table S1 ) involved 22,241 (88.6%, median = 735, IQR = 68–1273) healthcare workers for a total of twelve articles, of which six (50.0%) consisted of performance and five (41.7%) of guidelines adherence and one (8.3%) of both outcomes. Among healthcare workers, there were 1,294 nurses (5.8%, median = 647, IQR = 40–1,254). Only the article by Savage et al. reported no number of involved healthcare workers [ 31 ].

The number of studies conducted after 2011 or between 2012–2019 was seven (58.3%), while only one (8.3%) article reported a study beginning both before and after 2011. Most of studies were conducted in Northern America ( n = 5, 41.7%). The servant leadership style and charismatic leadership style were the most frequently implemented, as reported in five (41.7%) and four (33.3%) articles, respectively. Only one (8.3%) study adopted a transformational leadership style.

The pooled effectiveness of leadership was 14.0% (95%CI 10.0–18.0%), with a high level of heterogeneity (I 2 = 99.9%, p < 0.0001) among the before–after studies ( Figure 2 ).

Effectiveness of leadership in before after studies. Dashed line represents the pooled effectiveness value [ 29 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ].

The highest level of effectiveness was reported by Weech-Maldonado R et al. with an effectiveness of 199% (95%CI 183–215%) based on the Cultural Competency Assessment Tool for Hospitals (CCATH) [ 39 ]. The effectiveness of leadership changed in accordance with the leadership style ( Supplementary Figure S1 ) and publication bias ( Supplementary Figure S2 ).

Multi-regression analysis indicated a negative association between leadership effectiveness and studies from Oceania, but this result was not statistically significant (β = −0.33; 95% IC −1.25, 0.59). On the other hand, a charismatic leadership style affected healthcare outcomes positively even if it was not statistically relevant (β = 0.24; 95% IC −0.69, 1.17) ( Table 1 ).

Correlation coefficients and multi-regression analysis of leadership effectiveness in before–after studies.

3.3. Leadership Effectiveness in Cross Sectional Studies

A total of 2858 (median = 199, IQR = 110–322) healthcare workers were involved in the cross-sectional studies ( Supplementary Table S2 ), of which 981 (34.3%) were nurses. Most of the studies were conducted in Asia ( n = 4, 44.4%) and North America ( n = 3, 33.3%). All of the cross-sectional studies regarded only the healthcare professionals’ performance. Multi-professional teams were involved in seven (77.8%) studies, and they were more frequently conducted in both medical and surgical wards ( n = 6, 66.7%). The leadership styles were equally distributed in the articles and two (22.2%) of them examined more than two leadership styles at the same time.

The pooled effectiveness of the leadership interventions in the cross-sectional studies had a correlation coefficient of 0.22 (95%CI 0.15–0.28), whose heterogeneity was remarkably high (I 2 = 96.7%, p < 0.0001) ( Figure 3 ).

Effectiveness of leadership in cross-sectional studies. Dashed line represents the pooled effectiveness value [ 30 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

The effectiveness of leadership in the cross-sectional studies changed in accordance with the leadership style ( Supplementary Figure S3 ) and publication bias ( Supplementary Figure S4 ).

Multi-regression analysis showed a higher leadership effectiveness in studies conducted in South America (β = 0.56 95%CI 0.13–0.99) in private hospitals (β = 0.60; 95%CI 0.14–1.06) and in the medical vs. surgical specialty (β = −0.22; 95%CI −0.54, −0.02) ( Table 2 ).

Multi-regression analysis of leadership effectiveness in cross-sectional studies.

* 0.05 ≤ p < 0.01.

4. Discussion

Leadership effectiveness in healthcare settings is a topic that is already treated in a quantitative matter, but only this systematic review and meta-analysis showed the pooled effectiveness of leadership intervention improving some healthcare outcomes such as performance and adherence to guidelines. However, the assessment of leadership effectiveness could be complicated because it depends on the study methodology and selected outcomes [ 12 ]. Health outcomes might benefit from leadership interventions, as Flodgren et al. was concerned about opinion leadership [ 2 ], whose adhesion to guidelines increased by 10.8% (95% CI: 3.5–14.6%). On the other hand, other outcomes did not improve after opinion leadership interventions [ 2 ]. Another review by Ford et al. about emergency wards reported a summary from the literature data which acknowledged an improvement in trauma care management through healthcare workers’ performance and adhesion to guidelines after effective leadership interventions [ 14 ]. Nevertheless, some variables such as collaboration among different healthcare professionals and patients’ healthcare needs might affect leadership intervention effectiveness [ 14 ]. Therefore, a defined leadership style might fail in a healthcare setting rather than in other settings [ 5 , 13 , 14 ].

The leadership effectiveness assessed through cross-sectional studies was higher in South America than in other continents. A possible explanation of this result could be the more frequent use of a transactional leadership style in this area, where the transactional leadership interventions were effective at optimizing economic resources and improving healthcare workers’ performance through cash rewards [ 48 ]. Financing methods for healthcare organizations might be different from one country to another, so the effectiveness of a leadership style can change. Reaching both economic targets and patients’ wellness could be considered a challenge for any leadership intervention [ 48 ], especially in poorer countries [ 5 ].

This meta-analysis showed a negative association between leadership effectiveness and studies by surgical wards. Other research has supported these results, which reported surgical ward performance worsened in any leadership context (charismatic, servant, transactional, transformational) [ 47 ]. In those workplaces, adopting a leadership style to improve surgical performance might be challenging because of nervous tension and little available time during surgical procedures [ 47 ]. On the other hand, a cross-sectional study declared that a surgical team’s performance in private surgical settings benefitted from charismatic leadership-style interventions [ 42 ]. This style of leadership intervention might be successful among a few healthcare workers [ 42 ], where creating relationships is easier [ 6 ]. Even a nursing team’s performance in trauma care increased after charismatic leadership-style interventions because of better communicative and supportive abilities than certain other professional categories [ 29 , 47 ]. However, nowadays there is no standardized leadership in healthcare basic courses [ 5 , 6 , 12 ]. Consequently, promoting leadership culture after undergraduate medical courses could achieve a proper increase in both leadership agreement and working wellness as well as a higher quality of care. [ 17 ]. Furthermore, for healthcare workers who have already worked in a healthcare setting, leadership improvement could consist of implementing basic knowledge on that topic. Consequently, they could reach a higher quality of care practice through working wellness [ 17 ] and overcoming the lack of previous leadership training [ 17 ].

Although very few studies have included in a meta-analysis examined in private healthcare settings [ 35 , 38 , 40 , 41 , 42 ], leadership interventions had more effectiveness in private hospitals than in public hospitals. This result could be related to the continent of origin, and indeed 60.0% of these studies were derived from North America [ 38 , 41 , 42 ], where patients’ outcomes and healthcare workers’ performance could influence available hospital budgets [ 38 , 40 , 41 , 42 ], especially in peripheral healthcare units [ 38 , 41 ]. Private hospitals paid more attention to the cost-effectiveness of any healthcare action and a positive balance of capital for healthcare settings might depend on the effectiveness of leadership interventions [ 40 , 41 , 42 ]. Furthermore, private healthcare assistance focused on nursing performance because of its impact on both a patients’ and an organizations’ outcomes. Therefore, healthcare systems’ quality could improve with effective leadership actions for a nursing team [ 40 ].

Other factors reported in the literature could affect leadership effectiveness, although they were not examined in this meta-analysis. For instance, professionals’ specialty and gender could have an effect on these results and shape leadership style choice and effectiveness [ 1 ]. Moreover, racial differences among members might influence healthcare system performance. Weech-Maldonado et al. found a higher compliance and self-improvement by black-race professionals than white ones after transactional leadership interventions [ 39 ].

Healthcare workers’ and patients’ outcomes depended on style of leadership interventions [ 1 ]. According to the results of this meta-analysis, interventions conducted by a transactional leadership style increased healthcare outcomes, though nevertheless their effectiveness was higher in the cross-sectional studies than in the before–after studies. Conversely, the improvement by a transformational leadership style was higher in before–after studies than in the cross-sectional studies. Both a charismatic and servant leadership style increased effectiveness more in the cross-sectional studies than in the before–after studies. This data shows that any setting required a specific leadership style for improving performance and guideline adherence by each team member who could understand the importance of their role and their tasks [ 1 ]. Some outcomes had a better improvement than others. Focusing on Savage et al.’s outcomes, a transformational leadership style improved checklist adherence [ 31 ]. The time of patients’ transport by Murphy et al. was reduced after conducting interventions based on a charismatic leadership style [ 37 ]. Jodar et al. showed that performances were elevated in units whose healthcare workers were subjected to transactional and transformational leadership-style interventions [ 1 ].

These meta-analysis results were slightly relevant because of the high heterogeneity among the studies, as confirmed by both funnel plots. This publication bias might be caused by unpublished articles due to either lacking data on leadership effectiveness, failing appropriate leadership strategies in the wrong settings or non-cooperating teams [ 12 ]. The association between leadership interventions and healthcare outcomes was slightly explored or gave no statistically significant results [ 12 ], although professionals’ performance and patients’ outcomes were closely related to the adopted leadership style, as reported by the latest literature sources [ 7 ]. Other aspects than effectiveness should be investigated for leadership. For example, the evaluation of the psychological effect of leadership should be explored using other databases.

The study design choice could affect the results about leadership effectiveness, making their detection and their statistical relevance tough [ 12 ]. Despite the strongest evidence of this study design [ 50 ], nowadays, trials about leadership effectiveness on healthcare outcomes are lacking and have to be improved [ 12 ]. Notwithstanding, this analysis gave the first results of leadership effectiveness from the available study designs.

Performance and adherence to guidelines were the main two outcomes examined in this meta-analysis because of their highest impact on patients, healthcare workers and hospital organizations. They included several other types of outcomes which were independent each other and gave different effectiveness results [ 12 ]. The lack of neither an official classification nor standardized guidelines explained the heterogeneity of these outcomes. To reach consistent results, they were classified into performance and guideline adherence by the description of each outcome in the related manuscripts [ 5 , 6 , 12 ].

Another important aspect is outcome assessment after leadership interventions, which might be fulfilled by several standardized indexes and other evaluation methods [ 40 , 41 ]. Therefore, leadership interventions should be investigated in further studies [ 5 ], converging on a univocal and official leadership definition and classification to obtain comparable results among countries [ 5 , 6 , 12 ].

5. Conclusions

This meta-analysis gave the first pooled data estimating leadership effectiveness in healthcare settings. However, some of them, e.g., surgery, required a dedicated approach to select the most worthwhile leadership style for refining healthcare worker performances and guideline adhesion. This can be implemented using a standardized leadership program for surgical settings.

Only cross-sectional studies gave significant results in leadership effectiveness. For this reason, leadership effectiveness needs to be supported and strengthened by other study designs, especially those with the highest evidence levels, such as trials. Finally, further research should be carried out to define guidelines on leadership style choice and establish shared healthcare policies worldwide.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph191710995/s1 , Figure S1. Leadership effectiveness by leadership style in before after studies; Figure S2. Funnel plot of before after studies; Figure S3. Leadership effectiveness in cross sectional studies by four leadership style; Figure S4. Funnel plot of cross-sectional studies; Table S1. Before after studies included in this systematic review and meta-analysis; Table S2. Cross-sectional studies included in this systematic review and meta-analysis. All outcomes were performance.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, V.R., A.C. (Alessandra Casuccio), F.V. and C.F.; methodology, V.R., M.G., A.O. and C.T.; software, V.R.; validation, G.M., A.B., A.C. (Alberto Carli) and M.C.; formal analysis, V.R.; investigation, G.M., A.B., A.C. (Alberto Carli) and M.C.; resources, A.C. (Alessandra Casuccio); data curation, G.M. and V.R.; writing—original draft preparation, G.M.; writing—review and editing, A.C. (Alessandra Casuccio), F.V., C.F., M.G., A.O., C.T., A.B., A.C. (Alberto Carli) and M.C.; visualization, G.M.; supervision, V.R.; project administration, C.F.; funding acquisition, A.C. (Alessandra Casuccio), F.V. and C.F. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to secondary data analysis for the systematic review and meta-anlysis.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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