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Global Qualitative Nursing Research

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

Journal Highlights

• Indexed in: Emerging Sources Citation Index (ESCI), PubMed Central (PMC) and Scopus
• Publication is subject to payment of an article processing charge (APC)
• Submit here

Global Qualitative Nursing Research (GQNR) is an open access peer reviewed journal focusing on qualitative research in fields relevant to nursing and other health professionals worldwide. Please see the Aims and Scope tab for further information. This journal is a member of the Committee on Publication Ethics (COPE). Submission information Submit your manuscript at https://mc.manuscriptcentral.com/gqn Please see the Submission Guidelines tab for more information on how to submit your article to the journal. Open access article processing charge (APC) information Publication in the journal is subject to payment of an article processing charge (APC). The APC serves to support the journal and ensures that articles are freely accessible online in perpetuity under a Creative Commons licence. Members of the International Institute for Qualitative Methodology are entitled to a 25% discount on the APC. The article processing charge (APC) for this journal is is 2000 USD. Contact Please direct any queries to [email protected] Special Sections Global Qualitative Nursing Research has the following special sections open for submission and publication:

• Methodological Development
• Advancing Theory/Metasynthesis
• Establishing Evidence
• Application to Practice

Translations Authors can publish translated versions of their article alongside the English version. Please see Submission Guidelines Section 6 for more details.

GQNR will publish research articles using qualitative methods and qualitatively-driven mixed-method designs as well as meta-syntheses and articles focused on methodological development. Special sections include Ethics, Methodological Development, Advancing Theory/Metasynthesis, Establishing Evidence, and Application to Practice.

• Clarivate Analytics: Emerging Sources Citation Index (ESCI)
• Directory of Open Access Journals (DOAJ)
• Google Scholar: h-5 index - 11, h-5 median - 13
• PubMed Central (PMC)

Global Qualitative Nursing Research (GQNR) is an international, interdisciplinary, refereed journal focusing on qualitative research in fields relevant to nursing world-wide. The journal specializes in topics related to nursing practice, responses to health, illness, and disability, health promotion, healthcare delivery, and global issues that affect nursing and healthcare. GQNR also welcomes qualitative studies pertinent to nursing that advance knowledge of diversity and systemic biases (e.g., racism), including the intersection of multiple oppressions and social identities, that shape experiences of health and illness, nursing and healthcare, and their implications for health equity. The journal provides a forum for sharing qualitative research from around the world that has international relevance for nursing.

GQNR will publish qualitative methods research, qualitatively-driven mixed-method designs, as well as meta-syntheses and articles focused on methodological developments. Each article accepted by peer review is made freely available online immediately upon publication, is published under a Creative Commons license and will be hosted online in perpetuity. Publication costs of the journal are covered by the collection of article processing charges which are paid by the funder, institution or author of each manuscript upon acceptance. There is no charge for submitting a paper to the journal.

The following author guidelines are designed assist authors with the manuscript preparation and submission process.  Please note that manuscripts not conforming to these guidelines may be returned. Only manuscripts of sufficient quality that meet the aims and scope of Global Qualitative Nursing Research will be reviewed.

Sage Publishing disseminates high-quality research and engaged scholarship globally, and we are committed to diversity and inclusion in publishing. We encourage submissions from a diverse range of authors from across all countries and backgrounds.

Manuscript Submission Guidelines: Global Qualitative Nursing Research

• Open Access
• Article processing charge (APC)
• What do we publish? 3.1 Aims & Scope 3.2 Article types 3.3 Writing your paper 3.3.1 Making your article discoverable
• Editorial policies 4.1 Peer review policy 4.2 Authorship 4.3 Acknowledgements 4.4 Writing Assistance 4.5 Funding 4.6 Declaration of conflicting interests 4.7 Research ethics and patient consent 4.8 Clinical trials 4.9 Reporting guidelines 4.10 Diversity: Naming and exploring implications of systematic biases in research 4.11 Sex and gender equity in research
• Publishing policies 5.1 Publication ethics 5.2 Contributor’s publishing agreement
• Preparing your manuscript 6.1 Article format 6.2 Word processing formats 6.3 Writing style 6.4 Artwork, figures and other graphics 6.5 Reference style 6.6 English language editing services 6.7 Publishing translated versions of articles 6.8 Supplementary material
• Submitting your manuscript 7.1 Title, keywords and abstracts 7.2 ORCID 7.3 Information required for completing your submission 7.4 Permissions
• On acceptance and publication 8.1 SAGE Production 8.2 Continuous publication 8.3 Promoting your article
• Further information

1. Open Access

Global Qualitative Nursing Research  (GQNR) is an open access, international, peer reviewed journal focusing on qualitative research in field relevant to nursing. GQNR will publish qualitative methods research, qualitatively-driven mixed-method designs, as well as meta-syntheses and articles focused on methodological developments. Each article accepted by peer review is made freely available online immediately upon publication, is published under a Creative Commons license and will be hosted online in perpetuity. Publication costs of the journal are covered by the collection of article processing charges which are paid by the funder, institution or author of each manuscript upon acceptance. There is no charge for submitting a paper to the journal.

For general information on open access at SAGE please visit the  Open Access page  or view our  Open Access FAQs . 

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2. Article processing charge (APC)

If, after peer review, your manuscript is accepted for publication, a one-time article processing charge (APC) is payable. This APC covers the cost of publication and ensures that your article will be freely available online in perpetuity under a Creative Commons license.

As of September 5 2023, the article processing charge (APC) is 2000 USD.

Students are entitled to a 75% discount off the current APC as long as they are the first and corresponding author. Validation is required after submission. 

Members of the International Institute for Qualitative Methodology are entitled to a 25% discount on the APC. 

Please note that all communication concerning the APC should be conducted with SAGE Publications rather than with GQNR. 

3. What do we publish?

Global Qualitative Nursing Research welcomes submissions focusing on qualitative research in fields relevant to nursing and are aligned with the aims and scope of the journal outlined here: https://journals.sagepub.com/aims-scope/GQN .

GQNR is a nursing focused journal and regardless of the topic, if intended for nurses, it should reflect a nursing perspective and/or the contribution that nurses bring to interprofessional ways of delivering care. In addition, we encourage authors to use the language of nursing and nurses versus healthcare professionals, providers, and clinicians when referring to nurses.

GQNR is an international journal so the relevance of manuscripts to the subject field internationally and also its transferability into other care settings, cultures or nursing specialties should be considered.

3.1 Aims & Scope

Before submitting your manuscript to Global Qualitative Nursing Research, please ensure you have read the Aims & Scope. 

3.2 Article types

Global Qualitative Nursing Research publishes the following types of articles:

• Single-method qualitative research
• Qualitatively-driven mixed-method research
• Qualitative studies that are part of multiple method projects
• Metasynthesis studies that advance theory
• Scoping reviews of qualitative research
• Qualitative methodological development 
• Qualitative study protocols

Guidelines for each article type are included below:

Single method qualitative research :  GQNR publishes high quality, methodologically rigorous qualitative research that contributes original findings to areas of international relevance for nursing, midwifery or related fields. The journal welcomes qualitative research papers that are based on various qualitative approaches and forms of data. A full description of the qualitative approach is required including the epistemological underpinnings/methodology and methods, and the analytical lens and strategies used in data analysis, and strategies to support rigor.

Qualitative driven mixed method research : GQNR invites articles about studies in which the main study was qualitative, and the supplementary data collection was either qualitative or quantitative (QUAL qant or QUAL qual designs) (for more information see Morse,  2003 ,  2010 ,  2016 ). Mixed-method studies are studies in which the data collected for a main study is supplemented with data that were collected using a data collection strategy that is not normally used in the main study. For example, a study using a grounded theory design in which laboratory results are added to qualitative data collected would be called a mixed-method study, but the addition of the same kind of quantitative data in an ethnographic study would not be called a mixed-method study, as ethnographies typically include both qualitative and quantitative data. Articles reporting studies designed using a mixed-method approach must include the data from both the main study and the supplemental component. Articles that describe supplemental data only will not be accepted, as the supplemental data cannot stand on its own; it is only interpretable in the context of the main study.  Within the description of the design, the authors must include a statement about why a mixed-method approach was used. In the data collection section of the article, the authors must include an explanation about when and how the data from the main study and the supplemental component were integrated (e.g.,  Taylor, 2020 ).

Qualitative studies within multiple method research projects : GQNR is interested in receiving articles about qualitative studies that are part of multiple method projects, provided they meet the usual criteria for qualitative studies. Multiple method (multimethod) projects are comprised of a group of complete studies that are linked by one overarching aim. These studies may be qualitative or quantitative, are complete and can each stand alone, with separate but complementary research questions that link the study to the overall aim of the project. We also invite articles reporting the results of all the studies within a multiple method project (that include at least one qualitative study) and a description of how the results of each study contribute to the overarching aim of the project (e.g.,  Porr et al., 2010 ). 

Metasynthesis studies that advance theory : Articles are invited that synthesize and interpret data across qualitative studies using relevant and rigorous approaches and make distinctive contributions to the body of evidence for practice. Articles should include inclusion/exclusion processes congruent with aims of the review; data display approaches that support analysis; evidence of critical reflection on the role played by method, theoretical framework, disciplinary orientation, and local conditions in shaping included studies; interpretations that reflect advances in the field over time; and a conceptually, well-integrated set of new findings that make a substantive contribution to the field that extends beyond individual qualitative studies. Systematic or scoping reviews of qualitative studies that simply summarize commonalities among a collection of qualitative studies will not be considered. 

Scoping reviews of qualitative research:  GQNR invites high quality, rigorous scoping reviews of qualitative research that are conducted for the purpose of identifying gaps in the current qualitative evidence, investigating how qualitative research has been conducted, and identifying areas that require further qualitative inquiry. A compelling rationale for the scoping review is required.  Scoping reviews will only be considered if they clearly make a substantive and constructive contribution to the field and nursing and/or advance our thinking about qualitative methods. Possible contributions of scoping reviews of qualitative research include: advancing our thinking about how qualitative research is conducted on a particular topic/field and contributing to method development, clarifying concepts in the literature by examining relevant qualitative research, and mapping qualitative evidence to inform future research.  Scoping reviews must be conducted using rigorous and transparent methods.  Scoping reviews that include both qualitative and quantitative research will not be considered.

Methodological development : Articles are invited that focus on qualitative methods that provide insights, advances or innovations that are likely to be of interest to qualitative researchers in fields relevant to nursing world-wide. What the paper adds to existing methodological knowledge must be clearly explained.

Qualitative study protocols : To further the development of qualitative methods, GQNR accepts nationally funded study protocols for qualitative or qualitatively-driven mixed method studies that illustrate novel methodological ideas and/or practices. Student proposals / non-funded / locally-funded studies will not be considered. We encourage the submission of protocol manuscripts at an early stage of the study and prior to completion of data collection. Manuscripts that report work already carried out will not be considered as protocols. The dates of the study must be included in the manuscript and cover letter. Articles describing study protocols should include:  background/study justification, explanation and justification of method, sampling/recruitment, data management/analysis plan, ethical considerations, and approach to supporting qualitative rigor. A dissemination plan (publications, data deposition and curation) should be included, as well as a discussion about how the methods will meet study aims. Proof of both ethics approval and funding will be required on submission as supplementary files. The inclusion of copies of interview guides and/or field work plans as supplementary files are encouraged. Reviewers will be instructed to review for clarity and sufficient detail. The intention of peer review is not to alter the study design. Reviewers will be asked to check that the study is scientifically credible (i.e., congruence between methodology and methods, strategies to establish rigor, etc.) and ethically sound in its scope and methods, and that there is sufficient detail to instill confidence that the study will be conducted successfully.

3.3 Writing your paper

The SAGE Author Gateway has some general advice and on  how to get published , plus links to further resources.

3.3.1 Making your article discoverable 

The title, keywords and abstract are key to ensuring readers find your article through search engines such as Google. For information and guidance on how to make your article more discoverable, visit our Gateway page on  How to Help Readers Find Your Article Online.

4. Editorial policies

4.1 Peer review policy

SAGE does not permit the use of author-suggested (recommended) reviewers at any stage of the submission process, be that through the web-based submission system or other communication.

Reviewers should be experts in their fields and should be able to provide an objective assessment of the manuscript. Our policy is that reviewers should not be assigned to a paper if:

• The reviewer is based at the same institution as any of the co-authors.
• The reviewer is based at the funding body of the paper.
• The author has recommended the reviewer.
• The reviewer has provided a personal (e.g. Gmail/Yahoo/Hotmail) email account and an institutional email account cannot be found after performing a basic Google search (name, department and institution).

Following a preliminary triage to eliminate submissions unsuitable for Global Qualitative Nursing Research all papers are sent out for peer review. The cover letter is important. To help the Editor in this preliminary evaluation, please indicate in your letter to the editor why you think the paper is suitable for publication and relevant to the subject field internationally.

The journal’s policy is to have manuscripts reviewed by three expert reviewers. Global Qualitative Nursing Research utilizes a double-anonymized peer review process in which the reviewer and authors’ names and information are withheld from the other. All manuscripts are reviewed as rapidly as possible, while maintaining rigor. Reviewers make comments to the author and recommendations to the Editor-in-Chief who then makes the final decision.

GQNR maintains a transparent review system: once all reviews are received, they are forwarded to the author(s) as well as to ALL reviewers.

Global Qualitative Nursing Research  is committed to delivering high quality, fast peer-review for your paper, and as such has partnered with Publons. Publons is a third-party service that seeks to track, verify and give credit for peer review. Reviewers for Global Qualitative Nursing Research can opt in to Publons in order to claim their reviews or have them automatically verified and added to their reviewer profile. Reviewers claiming credit for their review will be associated with the relevant journal, but the article name, reviewer’s decision and the content of their review is not published on the site. For more information visit the  Publons  website.

The Editor or members of the Editorial Board may occasionally submit their own manuscripts for possible publication in the journal. In these cases, the peer review process will be managed by alternative members of the Board and the submitting Editor/Board member will have no involvement in the decision-making process.

4.2 Authorship

Papers should only be submitted for consideration once consent is given by all contributing authors. Those submitting papers should carefully check that all those whose work contributed to the paper are acknowledged as contributing authors. The list of authors should include all those who can legitimately claim authorship. This is all those who:

• Made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of data,
• Drafted the article or revised it critically for important intellectual content,
• Approved the version to be published,
• Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Authors should meet the conditions of all of the points above. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

When a large, multicenter group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript. These individuals should fully meet the criteria for authorship.

Authors should determine the order of authorship among themselves and should settle any disagreements before submitting their manuscript. Changes in authorship (i.e., order, addition, and deletion of authors) should be discussed and approved by all authors. Any requests for such changes in authorship after initial manuscript submission and before publication should be explained in writing to the editor in a letter or email from all authors.

Acquisition of funding, collection of data, or general supervision of the research group alone does not constitute authorship, although all contributors who do not meet the criteria for authorship should be listed in the Acknowledgments section. Please refer to the  International Committee of Medical Journal Editors (ICMJE) authorship guidelines  for more information on authorship.

4.3 Acknowledgements

All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general support.

4.4 Writing assistance

Individuals who provided writing assistance, e.g. from a specialist communications company, do not qualify as authors and so should be included in the Acknowledgements section. Authors must disclose any writing assistance – including the individual’s name, company and level of input – and identify the entity that paid for this assistance. It is not necessary to disclose use of language polishing services.

For manuscripts translated into English from another language, the name and affiliation of the translator may also be included. Except on a separate title page, the names of authors, and/or translators should not appear in manuscripts submitted for review; they are to be added only after the article is accepted for publication. 

Please supply any personal acknowledgements separately to the main text to facilitate anonymous peer review.

4.5 Funding

To comply with the guidance for research funders, authors, and publishers issued by the Research Information Network (RIN), Global Qualitative Nursing Research requires all authors to acknowledge their funding in a consistent fashion under a heading “Funding.” Please visit the Funding Acknowledgements page on the SAGE Journal Author Gateway to confirm the format of the acknowledgment text in the event of funding, or state that: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

4.6 Declaration of conflicting interests

It is the policy of  Global Qualitative Nursing Research  to require a declaration of conflicting interests from all authors enabling a statement to be carried within the paginated pages of all published articles.

Please include your declaration at the end of your manuscript after any acknowledgments and prior to the references, under a heading “Declaration of Conflicting Interests.” If no conflict exists, please state that ‘The Author(s) declare(s) that there is no conflict of interest’. For guidance on conflict of interest statements, please see the ICMJE recommendations here .

When making a declaration the disclosure information must be specific and include any financial relationship that any author of the article has with any sponsoring organization and the for profit interests the organization represents, and with any for-profit product discussed or implied in the text of the article.

Any commercial or financial involvements that might represent an appearance of a conflict of interest need to be additionally disclosed in the covering letter accompanying your article, to assist the Editor in evaluating whether sufficient disclosure has been made within the Declaration of Conflicting Interests provided in the article.

4.7 Research ethics and patient consent

Medical research involving human subjects must be conducted according to the  World Medical Association Declaration of Helsinki .

Submitted manuscripts should conform to the  ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals .

• All papers reporting animal and/or human studies must state in the methods section that the relevant Ethics Committee or Institutional Review Board provided (or waived) approval. Please ensure that you anonymized the name and institution of the review committee until such time as your article has been accepted. The Editor will request authors to replace the name and add the approval number once the article review has been completed.
• For research articles, authors are also required to state in the methods section whether participants provided informed consent and whether the consent was written or verbal.

Global Qualitative Nursing Research is committed to protecting the identity and confidentiality of research study participants. With the exception of participatory action research (PAR), no information that could potentially allow identification of a participant—or even a specific study site—should be included in a submitted manuscript or, subsequently, in a published article. Study sites, such as hospitals, clinics, or other organizations, should not be named, but instead should be described; for example: “Study participants were recruited from the coronary care unit of a large metropolitan hospital on the eastern seaboard of the United States.”

Do not include participant names in the manuscript. If the use of names is absolutely necessary for reader understanding (this is rarely the case), use pseudonyms. Even when using pseudonyms, it should not be possible for the reader to “track” the comments or behaviors of any participant throughout the manuscript.

Authors who include participant names and/or photos/images in which individuals are identifiable must submit written permission from the participants to do so (no exceptions).  Permission to use photographs should contain the following verbiage: “Permission is granted to use, reproduce, and distribute the likeness/photograph(s) in all media (print and electronic) throughout the world in all languages.”

Information on informed consent to report individual cases or case series should be included in the manuscript text. A statement is required regarding whether written informed consent for patient information and images to be published was provided by the patient(s) or a legally authorized representative.

Research participants have a right to privacy that should not be infringed upon without informed consent. Identifying information, including participants' names, initials, or other identifying characteristics, should not be published in written descriptions and photographs unless the information is essential for scientific purposes and the participant (or parent or guardian) gives signed and dated written informed consent for publication (submitted as a separate document when submitting the manuscript). Informed consent for this purpose requires that a participant who is identifiable be shown the manuscript to be published prior to giving consent.

Identifying details should be omitted if they are not essential. Faces in photographs should be obscured. If identifying characteristics are altered to protect anonymity, authors should provide assurance that alterations do not distort scientific meaning.

Please also refer to the  ICMJE Recommendations for the Protection of Research Participants .

4.8 Clinical trials

Global Qualitative Nursing Research conforms to the  ICMJE requirement  that clinical trials are registered in a WHO-approved public trials registry at or before the time of first patient enrolment as a condition of consideration for publication. The trial registry name and URL, and registration number must be included at the end of the abstract.

4.9 Reporting guidelines

The relevant  EQUATOR Network  reporting guidelines should be followed depending on the type of study. Metasyntheses should include the completed  PRISMA 2020 flow chart as a cited figure and the completed PRISMA checklist should be uploaded with your submission as a supplementary file. The  EQUATOR wizard can help you identify the appropriate guideline. Other resources can be found at  NLM’s Research Reporting Guidelines and Initiatives .

4.10 Diversity: Naming and exploring implications of systemic biases in research

GQNR encourages authors to acknowledge and advance understanding of diversity and systematic biases that shape experiences of health, illness, disability, nursing and healthcare, and their implications for health equity. Diversity includes all aspects of human differences such as socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, ability, age, and culture.

We invite authors to:

• consider diversity in the design, implementation, and evaluation of research 
• name and explore implications of systemic biases (e.g., racism, ageism, ableism, and gender bias) as well as the intersection of multiple oppressions and social identities that shape health 
• acknowledge the positionality of the researcher(s) in relation to the study context and its influence on the research process    
• use non-stigmatizing, respectful person-first language (e.g., person who used opioids vs. opioid user or addict) or identity-first language (e.g., autistic person, deaf person or person with intellectual disability) keeping in mind what is best for representing study participants

Authors have an opportunity to address issues related to diversity in the background section, explain how diversity was accounted for in the study design, and/or how study findings address or do not address issues of diversity or reveal systemic bias and their implications for health equity.

4.11 Sex and gender equity in research

We encourage authors to follow the ‘ Sex and Gender Equity in Research – SAGER – guidelines ’ and to include sex and gender considerations where relevant. Authors should use the terms sex (biological attribute) and gender (shaped by social and cultural circumstances) carefully in order to avoid confusing both terms. Article titles and/or abstracts should indicate clearly what sex(es) the study applies to. Authors should also describe in the background, whether sex and/or gender differences may be expected; report how sex and/or gender were accounted for in the design of the study; provide disaggregated data by sex and/or gender, where appropriate; and discuss respective results. If a sex and/or gender analysis was not conducted, the rationale should be given in the Discussion. Resources related to integrating sex and gender in health research have been developed by the Canadian Institutes of Health Research. They can be freely accessed here:   www.cihr-irsc.gc.ca/e/50833.html  

5. Publishing policies

5.1 Publication ethics

SAGE is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’  International Standards for Authors  and view the Publication Ethics page on the  SAGE Author Gateway .

5.1.1 Plagiarism

Global Qualitative Nursing Research  and SAGE take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of published articles. Equally, we seek to protect the reputation of the journal against malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarized other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.

5.1.2 Duplicate and prior publication

Global Qualitative Nursing Research  conforms to the ICMJE recommendations regarding duplicate and prior publications . If material has been previously published, it is not generally acceptable for publication in a SAGE journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the  SAGE Author Gateway  or if in doubt, contact the Editor at the address given below.

Duplicate publication is publication of a paper that overlaps substantially with one already published, without clear, visible reference to the previous publication. Prior publication may include release of information in the public domain (e.g., preprints).

When authors submit a manuscript reporting work that has already been reported in large part in a published article or is contained in or closely related to another paper that has been submitted or accepted for publication elsewhere, the letter of submission should clearly say so and the authors should provide copies of the related material to help the editor decide how to handle the submission.

Authors who choose to post their work on a preprint server should choose one that clearly identifies preprints as not peer-reviewed work and includes disclosures of authors’ relationships and activities. It is the author’s responsibility to inform a journal if the work has been previously posted on a preprint server. In addition, it is the author’s (and not journal editor’s) responsibility to ensure that preprints are amended to point readers to subsequent versions, including the final published article.

5.2 Contributor’s publishing agreement

Before publication SAGE requires the author as the rights holder to sign a Journal Contributor’s Publishing Agreement. Global Qualitative Nursing Research publishes manuscripts under  Creative Commons licenses . The standard license for the journal is Creative Commons by Attribution Non-Commercial (CC BY-NC), which allows others to re-use the work without permission as long as the work is properly referenced and the use is non-commercial. For more information, you are advised to visit  SAGE's OA licenses page .

Alternative license arrangements are available, for example, to meet particular funder mandates, made at the author’s request.

6. Preparing your manuscript

The following guidelines are designed to assist authors with the manuscript preparation and submission process. Manuscripts that do not conform to these guidelines will be returned to the authors without further review. The entire manuscript (including tables, figures, and references) must be prepared according to the Publication Manual of the American Psychological Association (APA Style Manual 7th edition).

6.1 Article format (see previously published articles in GQNR for style)

• Title page: Title should be succinct; list all authors and their affiliation; keywords. Please upload the title page separately from the main document.
• Include a short title (no more than 50 characters) as a header on all pages, including the title page, for the purposes of double-anonymized peer-review.
• Anonymized review: Do not include any author identifying information in your manuscript, including authors’ own citations. Do not include acknowledgements until the article is accepted.
• Abstract: Unstructured, 150-200 words . This should be the first page of the main manuscript, and it should be on its own page.
• Key words: Provide 4-6 keywords to highlight the main concepts and the scope of the manuscript. Please include region/country where the study was conducted as a key word if appropriate. Include key words following the abstract.
• Main manuscript text: GQNR does not have a word or page count limit. Manuscripts should be as tight as possible, preferably less than 30 pages including references . Longer manuscripts, if exceptional, will be considered.
• Ethics: Include a statement of IRB approval and participant consent. Present demographics as a group, not listed as individuals. Do not link quotations to particular individuals unless essential (as in case studies) as this threatens anonymity.
• Results: Rich and descriptive; theoretical; linked to practice if possible.
• Discussion: Link your findings with research and theory in literature, including other geographical areas and qualitative research.
• References: APA 7th Edition format. Use pertinent references only. References should be on a separate page.

6.2 Word processing formats

Accepted formats for the text, tables, and figures of submitted manuscripts are MS Word .doc and .docx files. The text must be double-spaced throughout. Set margins at 1 inch on all sides. Text should be in standard font (e.g., Times New Roman) 12-point. Do not add line numbers to the text; these are added automatically in the Manuscript Central system.

6.3 Writing style

Writing should be scholarly, and the style consistent throughout the manuscript. If there are two or more authors, do not use “I” statements. Use the past tense when writing about things that happened, were said, or were written in the past. Avoid anthropomorphic language; long, complex sentences; and unnecessary information. Voice: Both the abstract and the manuscript should be written in the first-person active voice. Avoid passive language.

6.4 Artwork, figures and other graphics

Include figures, charts, and tables created in MS Word in the main text rather than at the end of the document. However, figures, tables, and other files created outside of Word should be submitted separately. In this instance, please indicate where table and figures should be inserted within manuscript (e.g., INSERT TABLE 1 HERE). If using or adapting any copyrighted (previously published) material see APA for requirements.

6.4.1 Tables

Tables organize relevant, essential data that would be too awkward or too lengthy to include in the text, and should be used only to provide data not already included in the text. For example, grouped participant demographics take less space presented in a descriptive paragraph than they do as a table. Table titles should be concise and descriptive. Multiple tables within the same manuscript should be similar in appearance and design.

6.4.2  Figures 

Like tables, figures should be used sparingly, and only when it is necessary to clarify complex relationships or concepts. Mention figure placement in the manuscript text, but submit each figure in a separate document, with the figure number and title on the first page, followed by the figure itself on the second page. Figure titles should be concise and descriptive. Designate placement of each figure within the manuscript by entering (on a separate line between paragraphs) INSERT FIGURE 1 ABOUT HERE. Figure callouts should be placed following the paragraph in which they are first mentioned. Figures supplied in color will appear in color online.

6.4.3  Photographs

Photographs may be included but should have permission to reprint and faces should be concealed using mosaic patches – unless permission has been given by the individual to use their identity. This permission must be forwarded to QHR’s Managing Editor.

TIFF, JPED, or common picture formats accepted. The preferred format for graphs and line art is EPS.

Resolution: Rasterized based files (i.e. with .tiff or .jpeg extension) require a resolution of at least 300 dpi (dots per inch). Line art should be supplied with a minimum resolution of 800 dpi.

Dimension: Check that the artworks supplied match or exceed the dimensions of the journal. Images cannot be scaled up after origination.

6.4.4 Artwork

Participant artwork may be included provided the content is free of any material that could potentially identify the participant who created it (or any persons who might be depicted). Use artwork only with the permission of the participant. All content should be dark enough to facilitate clear visibility online. Artwork supplied in color will appear in color online.

6.5 Reference style

Global Qualitative Nursing Research  adheres to the APA 7th edition reference style. You may review this quick reference sheet to ensure your manuscript conforms to this reference style.

To anonymize the manuscript for review, citations for references authored by any author of the submitted manuscript should read only “(Author, year).” References authored by any author of the submitted manuscript should read only “Author. (year).” Do not include the reference title or any other information pertaining to the reference.

6.6 English language editing services

Authors seeking assistance with English language editing, translation, or figure and manuscript formatting to fit the journal’s specifications should consider using SAGE Language Services. Note:  Some non-native English authors of accepted articles may be required to have their final manuscript professionally edited by a native-English-speaking editor.  Visit  SAGE Language Services  on our Journal Author Gateway for further information, or contact the journal office at GQNR- [email protected] .

6.7 Publishing translated versions of articles

GQNR encourages authors to submit translated versions of your title, abstract and key words to be published alongside the English version. In addition, GQNR allows translated versions of accepted article to be published along with the English version as a supplementary file. Please follow the instructions in the submission site to ensure your translated version is published. Authors may use the proof of their accepted Article as the basis of the Translation and may use similar formatting and typesetting for the Translation as used in the original Article to create a PDF of the Translation. The Editor will arrange for light review of each Translation prior to publication. The review may be completed by a member of the Editorial Board or other trusted academic reviewer who is fluent in the language of the Translation to review the Translation to confirm there are no material errors in the Translation that result in an inconsistency with the original Article.

As part of GQNR’s commitment to supporting and disseminating qualitative nursing research internationally, selected articles may be subject to translation by GQNR following acceptance and/or publication. Authors will be notified if their article and/or the article title, abstract is selected for translation. 

For further questions, please email  [email protected]  

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This journal is able to host additional materials online (e.g. datasets, podcasts, videos, images etc.) alongside the full-text of the article. These will be subjected to peer-review alongside the article. For more information please refer to our guidelines on submitting supplementary files, which can be found within SAGE’s  Manuscript Submission Guidelines  page. 

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• Joan L. Bottorff, RN, PhD, FCAHS, FAAN is a professor at the University of British Columbia, Faculty of Health and Social Development, School of Nursing in Kelowna, British Columbia, Canada.

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The collection of ORCID iDs from corresponding authors is now part of the submission process of this journal. If you already have an ORCID iD you will be asked to associate that to your submission during the online submission process. We also strongly encourage all co-authors to link their ORCID ID to their accounts in our online peer review platforms. It takes seconds to do: click the link when prompted, sign into your ORCID account and our systems are automatically updated. Your ORCID iD will become part of your accepted publication’s metadata, making your work attributable to you and only you. Your ORCID iD is published with your article so that fellow researchers reading your work can link to your ORCID profile and from there link to your other publications.

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Your SAGE Production Editor will keep you informed as to your article’s progress throughout the production process. Proofs will be sent by PDF to the corresponding author and should be returned promptly. Authors are reminded to check their proofs carefully to confirm that all author information, including names, affiliations, sequence and contact details are correct, and that Funding and Conflict of Interest statements, if any, are accurate. Please note that if there are any changes to the author list at this stage all authors will be required to complete and sign a form authorizing the change.

8.2 Online publication

One of the many benefits of publishing your research in an open access journal is the speed to publication. Your article will be published online in a fully citable form with a DOI number as soon as it has completed the production process. At this time it will be completely free to view and download for all. 

8.3 Promoting your article

Publication is not the end of the process! You can help disseminate your paper and ensure it is as widely read and cited as possible. The SAGE Author Gateway has numerous resources to help you promote your work. Visit the  Promote Your Article  page on the Gateway for tips and advice. 

9. Further information

Any correspondence, queries or additional requests for information on the Manuscript Submission process should be sent to the Global Qualitative Nursing Research Publishing Editor as follows: Lorianne Sarsfield

Email: [email protected]

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Qualitative Research in Nursing and Health Professions Regulation

• Allison Squires, PhD, RN, FAAN Allison Squires Search for articles by this author
• Caroline Dorsen, PhD, FNP, RN Caroline Dorsen Search for articles by this author
• Credentialing
• government regulation
• professional autonomy
• qualitative research
• • Explain the importance of qualitative research for studies about regulatory issues in nursing.
• • Discuss the core concepts of qualitative research.
• • Describe common methodological challenges researchers can encounter when conducting qualitative research on professional regulatory issues.
• • Identify solutions that can enhance the quality, rigor, and trustworthiness of the findings for regulatory studies.
• Blackman T.
• Google Scholar
• Bradley E.H.
• Devers K.J.
• Scopus (2269)
• Evans-Agnew R.A.
• Boutain D.M.
• Griffith D.M.
• Shelton R.C.
• Scopus (30)
• Waterfield J.
• Holden M.A.
• Ismail K.M.
• Foster N.E.
• Saunders B.
• Kingstone T.
• Scopus (4861)
• Scopus (709)
• Vandermause R.
• Edmundson L.
• Perfetti A.R.
• Yardley S.J.
• Richardson J.C.

A Review of Core Qualitative Research Concepts

• Bochner A.P.
• Scopus (1409)
• Scopus (3251)
• Open table in a new tab
• Patton M.Q.
• Hennink M.M.
• Kaiser B.N.
• Marconi V.C.
• Scopus (1586)
• Vanstone M.

A Note on Cross-language Qualitative Research on Regulatory Issues

• Scopus (136)
• Scopus (387)
• Ziebland S.
• Chiumento A.
• Barbour R.S.
• Poon M.K.-L.
• Scopus (35)
• Lincoln Y.S.
• Gonzalez y Gonzalez E.M.
• Aroztegui Massera C.
• MacKenzie C.A.
• Santos H.P.O.
• Sandelowski M.
• Scopus (98)
• Suurmond J.
• Woudstra A.
• Essink-Bot M.-L.
• Scopus (190)
• Wong J.P.-H.
• Scopus (110)

An Overview of Qualitative Study Designs Appropriate for Regulatory Studies

• Carter S.M.
• Scopus (411)
• Scopus (265)
• Scopus (115)
• Scopus (76)
• Scopus (180)
• Trinidad S.B.
• Scopus (1325)
• van Manen M.
• Willis D.G.
• Sullivan-Bolyai S.
• Scopus (213)

Underutilized Qualitative Designs in Regulatory Research

• Anderson R.A.
• Crabtree B.F.
• Steele D.J.
• McDaniel R.R.
• Scopus (185)
• Carolan C.M.
• Cresswell K.
• Robertson A.
• Morgan S.J.
• Pullon S.R.H.
• Macdonald L.M.
• McKinlay E.M.

Introduction to qualitative nursing research

This type of research can reveal important information that quantitative research can’t.

• Qualitative research is valuable because it approaches a phenomenon, such as a clinical problem, about which little is known by trying to understand its many facets.
• Most qualitative research is emergent, holistic, detailed, and uses many strategies to collect data.
• Qualitative research generates evidence and helps nurses determine patient preferences.

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

All nurses are expected to understand and apply evidence to their professional practice. Some of the evidence should be in the form of research, which fills gaps in knowledge, developing and expanding on current understanding. Both quantitative and qualitative research methods inform nursing practice, but quantitative research tends to be more emphasized. In addition, many nurses don’t feel comfortable conducting or evaluating qualitative research. But once you understand qualitative research, you can more easily apply it to your nursing practice.

What is qualitative research?

Defining qualitative research can be challenging. In fact, some authors suggest that providing a simple definition is contrary to the method’s philosophy. Qualitative research approaches a phenomenon, such as a clinical problem, from a place of unknowing and attempts to understand its many facets. This makes qualitative research particularly useful when little is known about a phenomenon because the research helps identify key concepts and constructs. Qualitative research sets the foundation for future quantitative or qualitative research. Qualitative research also can stand alone without quantitative research.

Although qualitative research is diverse, certain characteristics—holism, subjectivity, intersubjectivity, and situated contexts—guide its methodology. This type of research stresses the importance of studying each individual as a holistic system (holism) influenced by surroundings (situated contexts); each person develops his or her own subjective world (subjectivity) that’s influenced by interactions with others (intersubjectivity) and surroundings (situated contexts). Think of it this way: Each person experiences and interprets the world differently based on many factors, including his or her history and interactions. The truth is a composite of realities.

Qualitative research designs

Because qualitative research explores diverse topics and examines phenomena where little is known, designs and methodologies vary. Despite this variation, most qualitative research designs are emergent and holistic. In addition, they require merging data collection strategies and an intensely involved researcher. (See Research design characteristics .)

Although qualitative research designs are emergent, advanced planning and careful consideration should include identifying a phenomenon of interest, selecting a research design, indicating broad data collection strategies and opportunities to enhance study quality, and considering and/or setting aside (bracketing) personal biases, views, and assumptions.

Many qualitative research designs are used in nursing. Most originated in other disciplines, while some claim no link to a particular disciplinary tradition. Designs that aren’t linked to a discipline, such as descriptive designs, may borrow techniques from other methodologies; some authors don’t consider them to be rigorous (high-quality and trustworthy). (See Common qualitative research designs .)

Sampling approaches

Sampling approaches depend on the qualitative research design selected. However, in general, qualitative samples are small, nonrandom, emergently selected, and intensely studied. Qualitative research sampling is concerned with accurately representing and discovering meaning in experience, rather than generalizability. For this reason, researchers tend to look for participants or informants who are considered “information rich” because they maximize understanding by representing varying demographics and/or ranges of experiences. As a study progresses, researchers look for participants who confirm, challenge, modify, or enrich understanding of the phenomenon of interest. Many authors argue that the concepts and constructs discovered in qualitative research transcend a particular study, however, and find applicability to others. For example, consider a qualitative study about the lived experience of minority nursing faculty and the incivility they endure. The concepts learned in this study may transcend nursing or minority faculty members and also apply to other populations, such as foreign-born students, nurses, or faculty.

Qualitative nursing research can take many forms. The design you choose will depend on the question you’re trying to answer.

A sample size is estimated before a qualitative study begins, but the final sample size depends on the study scope, data quality, sensitivity of the research topic or phenomenon of interest, and researchers’ skills. For example, a study with a narrow scope, skilled researchers, and a nonsensitive topic likely will require a smaller sample. Data saturation frequently is a key consideration in final sample size. When no new insights or information are obtained, data saturation is attained and sampling stops, although researchers may analyze one or two more cases to be certain. (See Sampling types .)

Some controversy exists around the concept of saturation in qualitative nursing research. Thorne argues that saturation is a concept appropriate for grounded theory studies and not other study types. She suggests that “information power” is perhaps more appropriate terminology for qualitative nursing research sampling and sample size.

Data collection and analysis

Researchers are guided by their study design when choosing data collection and analysis methods. Common types of data collection include interviews (unstructured, semistructured, focus groups); observations of people, environments, or contexts; documents; records; artifacts; photographs; or journals. When collecting data, researchers must be mindful of gaining participant trust while also guarding against too much emotional involvement, ensuring comprehensive data collection and analysis, conducting appropriate data management, and engaging in reflexivity.

Data usually are recorded in detailed notes, memos, and audio or visual recordings, which frequently are transcribed verbatim and analyzed manually or using software programs, such as ATLAS.ti, HyperRESEARCH, MAXQDA, or NVivo. Analyzing qualitative data is complex work. Researchers act as reductionists, distilling enormous amounts of data into concise yet rich and valuable knowledge. They code or identify themes, translating abstract ideas into meaningful information. The good news is that qualitative research typically is easy to understand because it’s reported in stories told in everyday language.

Evaluating a qualitative study

Evaluating qualitative research studies can be challenging. Many terms—rigor, validity, integrity, and trustworthiness—can describe study quality, but in the end you want to know whether the study’s findings accurately and comprehensively represent the phenomenon of interest. Many researchers identify a quality framework when discussing quality-enhancement strategies. Example frameworks include:

• Trustworthiness criteria framework, which enhances credibility, dependability, confirmability, transferability, and authenticity
• Validity in qualitative research framework, which enhances credibility, authenticity, criticality, integrity, explicitness, vividness, creativity, thoroughness, congruence, and sensitivity.

With all frameworks, many strategies can be used to help meet identified criteria and enhance quality. (See Research quality enhancement ). And considering the study as a whole is important to evaluating its quality and rigor. For example, when looking for evidence of rigor, look for a clear and concise report title that describes the research topic and design and an abstract that summarizes key points (background, purpose, methods, results, conclusions).

Application to nursing practice

Qualitative research not only generates evidence but also can help nurses determine patient preferences. Without qualitative research, we can’t truly understand others, including their interpretations, meanings, needs, and wants. Qualitative research isn’t generalizable in the traditional sense, but it helps nurses open their minds to others’ experiences. For example, nurses can protect patient autonomy by understanding them and not reducing them to universal protocols or plans. As Munhall states, “Each person we encounter help[s] us discover what is best for [him or her]. The other person, not us, is truly the expert knower of [him- or herself].” Qualitative nursing research helps us understand the complexity and many facets of a problem and gives us insights as we encourage others’ voices and searches for meaning.

When paired with clinical judgment and other evidence, qualitative research helps us implement evidence-based practice successfully. For example, a phenomenological inquiry into the lived experience of disaster workers might help expose strengths and weaknesses of individuals, populations, and systems, providing areas of focused intervention. Or a phenomenological study of the lived experience of critical-care patients might expose factors (such dark rooms or no visible clocks) that contribute to delirium.

Successful implementation

Qualitative nursing research guides understanding in practice and sets the foundation for future quantitative and qualitative research. Knowing how to conduct and evaluate qualitative research can help nurses implement evidence-based practice successfully.

When evaluating a qualitative study, you should consider it as a whole. The following questions to consider when examining study quality and evidence of rigor are adapted from the Standards for Reporting Qualitative Research.

Jennifer Chicca is a PhD candidate at the Indiana University of Pennsylvania in Indiana, Pennsylvania, and a part-time faculty member at the University of North Carolina Wilmington.

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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Qualitative Research Findings as Evidence: Utility in Nursing Practice

Wendy r. miller.

1311 N Street, Bedford, IN 47421, ude.iupui@lbeurtrw , Indiana University School of Nursing

The use of qualitative research methods in nursing research is common. There is a need for Clinical Nurse Specialists (CNSs) to become informed regarding how such qualitative findings can serve as evidence for nursing practice changes.

To inform CNSs of the meaning and utility of qualitative research findings. Implications for qualitative research findings as evidence in nursing practice are particularly discussed.

Introduction

As the use of qualitative research methods proliferates throughout health care, and specifically nursing research studies, there is a need for Clinical Nurse Specialists (CNSs) to become informed regarding the potential utility of qualitative research findings in practice. In this column, the questions of what qualitative findings mean , how the ever-increasing amounts of qualitative research evidence can be used, and how such findings can contribute to evidence-based nursing practice, are considered. First, to provide readers with a context for the discussion, a brief overview of qualitative research and its theoretical underpinnings is included.

What is Qualitative Research?

Qualitative research refers to a method of inquiry in which the researcher, acting as data collection instrument, seeks to answer questions about how or why a particular phenomenon occurs. Questions regarding of what a phenomenon is comprised may also guide qualitative research 1 . The most fundamental assumption underlying qualitative research is that reality is something socially constructed on an individual basis 2 . Varied methods of qualitative research exist. Examples of qualitative methods employed in nursing research include grounded theory, phenomenology, ethnography, and qualitative description. Each method has its own assumptions and purposes and an appropriate method is chosen based on the research question. For example, a researcher investigating the process involved in the occurrence of a phenomenon would likely choose grounded theory, while a researcher interested in the meaning of the phenomenon would utilize phenomenology. Regardless of method, participants are purposefully enrolled based on their familiarity with the phenomenon. Data are generally collected via one or a combination of three mechanisms: interviews, observation, or document/photograph review. Data are analyzed inductively via specific, rigorous techniques and then organized in a manner which best answers the research question 3 . Importantly, the objective of qualitative research is not the accumulation of information, but the growth of understanding about phenomena of concern to nursing 4 .

The Nature of Qualitative Research Findings and their Use as Evidence

The way in which qualitative findings appear in research reports varies depending on the method utilized. Experts (Sandelowski and Kearney) in the field recommend categorizing qualitative findings in terms of the knowledge they generate, regardless of methodological origin. Sandelowski and Barroso 5 have developed a typology of qualitative research findings. In this typology, findings exist on a continuum. Categories on the far left side of the continuum (“no finding,” consisting of a report of raw data, and “topical survey,” consisting of an organization of the data in a table of contents format) are considered to be not research and not qualitative research, respectively. The remaining three categories on the right side of the continuum (“thematic survey,” consisting of patterns found in the data, “conceptual/thematic description,” in which concepts and themes are used to link and illuminate concepts in new ways, and “interpretive explanation,” the defining feature of which is a transformation of data into theories or full explanations of a phenomenon) are considered exploratory, descriptive, and explanatory, respectively. While the authors note that the goal of the typology is not to judge the quality of findings, the typology can assist readers in determining which types of findings should be omitted from evidence influencing practice (no finding and topical survey) and those which may be more sophisticated, furthest from the data, and potentially applicable to practice.

Kearney 6 , too, has put forth a categorization mechanism for qualitative findings based on their degree of complexity and discovery and asserts that their application as evidence in practice is based on the category in which they fall. Findings “bound by a priori frameworks” are produced via the application of existing sets of ideas to data without identifying new insights. These findings cannot serve as evidence. Findings comprised of “descriptive categories” are similar to those in the “topical survey” 5 and serve as a type of evidence that provides a map for previously unstudied experiences. “Shared pathway or meaning” findings portray linked themes or concepts, as well as an analyst’s ideas for practice implications. Findings that situate under the category of “depiction of experiential variation” not only describe the essence of an experience but portray how that experience varies depending on context. Finally, findings characterized as a “dense explanatory description” are considered the gold standard and explain human behavior and choice-making. 6 Findings in this category are most readily applied to clinical practice.

Now that the types of qualitative findings have been described, it is possible to discuss how such findings are used in nursing practice. A common misconception is that qualitative research findings are, by default, preliminary to quantitative studies, cannot stand alone, and lack generalizability 4 . Qualitative findings, however, can be complete by themselves. Sandelowski 4 differentiates between the generalizability of quantitative findings versus that of qualitative findings. Regarding quantitative findings, generalization is characterized by establishing universal laws for populations based on information from samples deemed to be similar to those populations, which cannot, nor is it meant to, be achieved with qualitative findings. Qualitative findings are not generalizable in the prevalent sense of the word—they do not provide laws or relationships that can be taken from a single sample and applied to entire populations. Rather, they are generalizable in a way that is particularly pertinent to nursing practice, in which there is an expectation that scientific findings, and nursing care itself, be tailored to unique individuals in their distinct contexts. That is, qualitative findings provide idiographic knowledge about human experiences to readers , who can apply qualitative findings to the care of individuals who are in situations similar to that of those in the sample from which findings came 4 . A prime example of the generalizability of qualitative findings is seen in Conrad’s 7 study, which reframed the problem of “non-compliance” to “self-regulation” whereby patients with epilepsy changed medication practices in order to exert control over their disease. The findings from this study have been generalizable in that they have, in the form of a self-regulation theory, helped in understanding the origins of seemingly self-destructive behavior associated with a wide range of “noncompliant” behavior related to childhood immunizations, safe sex practices, and self-management of asthma and diabetes 8 . As the above example demonstrates, a CNS who reads qualitative research can potentially gain insight into the behaviors, needs, and experiences of his or her patient population, informing CNS practice. For example, an obstetrics/neonatal CNS who learns about the etiologies of prenatal “non-compliance” behavior via reviewing qualitative research findings is armed with information to help him or her develop etiology-specific nursing interventions for mothers living this experience, rather than relying on more general interventions to improve treatment adherence.

Sandelowski 9 notes that qualitative findings can demonstrate instrumental, symbolic, and conceptual utility. Instrumental utilization refers to the concrete application of findings that have been made into new forms such as clinical guidelines, standards of care, appraisal tools, algorithms, and intervention protocols. Symbolic utilization is less concrete and does not result in a true practice change, but rather findings are used to legitimate a position or practice. Symbolic utilization of findings is often a precursor to instrumental utilization. Conceptual utilization is very intangible, and leads to the way in which a user thinks about providing care.

Qualitative findings have demonstrated independent instrumental utility in leading to key changes in clinical communication practices. The results of one study eventually led to the recommendation that active listening, appraisal, teaching, and social support be included in patient-family-provider communication. These findings were executed into practice directly and have led to improved outcomes 10 . A CNS could similarly directly apply qualitative findings to practice. For example, an oncology CNS who learned, via reading qualitative research, that oncology patients prefer a certain type of communication style at the end of life could work in the nursing sphere to educate nurses and develop with them a communication guide for these particular patients. The CNS could then measure pertinent outcomes associated with the intervention (patient satisfaction, for example). Qualitative findings also demonstrate instrumental utility by refining quantitative research. Qualitative findings often underlie the concepts measured in quantitative instruments. 9 Further, qualitative findings provide knowledge about how individual and contextual factors affect the impact of an intervention 11 and can explain subject variation on targeted outcomes of an intervention 12 . That is, qualitative methods can be used to investigate unexpected quantitative results or to explain why the effectiveness (success of an intervention in a research study) is not equal to its efficacy (success of an intervention in practice). For example, qualitative findings might inform a CNS of potential reasons a particular evidence-based intervention has not been effective in his or her patient population or for a specific patient. Conceptually and symbolically, qualitative findings are useful by increasing nurses’ understanding of patients’ experiences, thereby allowing for more tailored interventions in care, as well as the anticipation of problems that might be encountered by a particular patient in a particular context 9 . Qualitative findings inform a CNS’ understanding of patients’ experiences, improving his or her ability to develop specific, tailored interventions, particularly in the patient and nursing spheres, that will improve patient outcomes. For instance, a CNS who learned, via reading qualitative research, that ventilated patients’ chief concern is their inability to communicate while intubated could devise and implement nursing interventions that would allow for the use of alternative communication strategies for these patients. In effect, the experiences of patients in a certain situation (as captured via qualitative methods) have informed, and potentially improved, the care provided to other patients in that situation.

Kearney 6 has made explicit statements regarding the ways in which qualitative findings can directly impact nursing practice. First, findings can lead to clinical insight or empathy . In this simplest mode of application, nurses can learn “what it feels like” to be in a given illness situation, common factors encountered by patients in that situation, and different ways patients view an illness. Armed with this understanding, the nurse pays attention to new cues from the patient, can make sense of certain presumably aberrant behaviors, and provide support in a more informed way. Qualitative findings can also contribute to assessment of patient status or progress . Findings which portray a trajectory of illness can inform the development of clinical assessment tools for individual patients or, with further testing, a particular patient population. For example, if a nurse reads that there are five reactions from teenage mothers immediately following birth, he or she can monitor for specific cues and form questions to determine the patient’s reaction and possible needs. Qualitative findings can also be applied via anticipatory guidance . This type of application is somewhat interventionist, as nurses share qualitative findings directly with clients, offering a research-based perspective on what patients might be experiencing and how others have described that experience. Findings at the “shared pathway” level are needed for this application. Coaching is achieved when the nurse shares qualitative findings with clients and further advises regarding steps they should consider taking to reduce stress/symptoms and improve adaptation. This application requires higher-complexity findings.

Evaluating the Validity of Qualitative Research

How does one know if he or she can trust the results of a qualitative study? Unlike in quantitative research, in which there are checklists and p values available to guide such a decision, the evaluation of qualitative research is less clear-cut. While researchers have created checklists to ease the process by which the validity of qualitative findings is assessed 13 , experts in the field struggle to come to a consensus regarding the appropriate criteria for evaluating qualitative studies because, according to Sandelowski 14 and others 15 – 16 , no criteria can uniformly address quality in the many various methods used in qualitative research. That is, quality “looks different” from one qualitative method to the next. Sandelowski and Barroso 16 prefer that the quality of qualitative studies be judged based on criteria specific to the method being used. These authors offer a reading guide , to which readers of this journal are referred, which guides readers through evaluating the features of any qualitative report most relevant to its quality and use 16 .

Undeniably, qualitative methods have become a standard way in which researchers generate knowledge pertinent to nursing practice. Thus, CNSs are surrounded by much qualitative evidence with which they might lack familiarity in utilizing. Here, the discussion, though admittedly non-exhaustive, has hopefully illuminated to readers the value and potential utility of qualitative findings as evidence in nursing, including ways in which such findings can be immediately applied to practice. Further, readers have been exposed to the evaluation of qualitative studies and it is hoped that they will seek out the suggested sources in helping them to learn to read and critique qualitative studies so that data generated from such studies can be added to the CNS’s repertoire of evidence.

Acknowledgments

This column was made possible by Grant Number 2T32 NR007066 from the National Institute of Nursing Research

Wendy Miller is an Adult Health Clinical Nurse Specialist and a PhD in Nursing Science student at the Indiana University School of Nursing. She is studying the self-management of older adults with epilepsy and is supported by a T32 pre-doctoral training grant.

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• Open access
• Published: 09 April 2024

A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services

• Malin Knutsen Glette 1 , 2 ,
• Tone Kringeland 2 ,
• Lipika Samal 3 , 4 ,
• David W. Bates 3 , 4 &
• Siri Wiig 1  

BMC Health Services Research volume  24 , Article number:  442 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services.

The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included.

Three main themes emerged from the thematic analysis: “Navigating the role of a leader during the pandemic,” “The aftermath – management of COVID-19 in rural primary healthcare services”, and “The benefits and drawbacks of being small and rural during the pandemic.”

Conclusions

Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

Peer Review reports

In 2021, essential healthcare services in 90% of the world’s countries were disrupted by the COVID-19 pandemic [ 1 ]. Healthcare services were heavily stressed and had to address unexpected issues and sudden changes, whilst still providing high quality care over a prolonged period [ 2 , 3 ]. Despite the intense focus on hospitals during this period, other parts of the healthcare system such as nursing homes and homecare services also faced extreme challenges. These included issues such as having to introduce and constantly adapt new infection control routines, as well as being given increased responsibility in caring for infected and seriously ill patients in facilities that were not built for such circumstances [ 4 , 5 , 6 , 7 ]. Mortality rates in nursing homes were especially high [ 8 ].

Resilience in healthcare is about a system’s ability to adapt to challenges and changes at different levels (e.g., organization, leaders, health personnel) to maintain high quality care [ 9 , 10 ]. During the COVID-19 pandemic, leaders and the front line were forced to rapidly adjust to keep healthcare services afloat. It has been demonstrated in previous research that effective leadership is crucial in navigating crises and building resilience within health systems [ 11 , 12 , 13 ]. Furthermore, leaders play key roles in facilitating health personnel resilience, for example, through promoting a positive outlook on change and by developing health personnels’ competencies and strengths [ 12 , 14 , 15 ]. During the COVID-19 pandemic, this role became intensified [ 16 , 17 , 18 ], and leaders’ roles in promoting resilient healthcare services were central, for example safeguarding resources, providing emotional support and organizing systems to cope with extreme stresses [ 3 , 19 ].

Smaller, rural nursing homes and home care services are geographically dispersed and typically remote from specialized healthcare services or other nursing home and homecare services. They also tend to have reduced access to personnel due to low population density, frequently leading to the need to make independent decisions, often in complex situations [ 20 ]. Overall, rural healthcare services face different challenges than their urban counterparts [ 21 , 22 , 23 ]. The COVID-19 pandemic intensified some of these issues and created new ones which needed to be managed [ 21 , 24 , 25 ].

The research base on COVID-19 has expanded extensively the past years [ 26 ], covering areas such as clinical risks and outcomes for healthcare workers [ 27 ] and patients [ 28 ], hospital admissions [ 29 ] and healthcare utilization during the pandemic [ 30 ]. Moreover, areas like healthcare leaders' [ 16 , 17 , 31 ] and healthcare professionals’ [ 2 , 32 ] strategies to handle the pandemic challenges, and COVID related strategies’ effect on quality of care [ 33 , 34 ]. And lastly, but not exhaustively, the COVID-19 pandemic in different healthcare settings such as hospitals [ 35 ], primary healthcare services and [ 36 ] mental healthcare services [ 37 ]. However, research on rural healthcare settings, particularly leaders in rural nursing homes and homecare services, have received less attention [ 38 , 39 , 40 ]. Despite the anticipated importance of primary healthcare services in future healthcare and the prevalence of rural healthcare options [ 41 , 42 ]. Overall, there are still lessons to be learned from the COVID-19 pandemic, specifically identifying resilience promoting and inhibiting factors in different health care settings during crisis, how leaders deal with crisis management, and furthermore, to understand and draw lessons from challenges that were overcome during the pandemic[ 43 , 44 ].

Aim and research question

The aim of this study was to assess how healthcare leaders in rural primary healthcare services managed nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study aimed to explore how adaptations to changes and challenges induced by the pandemic were handled by these leaders.

The research question guiding the study was: How did primary healthcare leaders in rural areas experience their leadership during the COVID-19 pandemic, and how did they adapt to the rapid onset changes demanded by the COVID-19 outbreak?

The study employed a qualitative explorative design to study in-depth, how nursing home and homecare leaders in Norwegian rural primary healthcare services experienced and addressed the extreme challenges and needs for change induced by the COVID-19 pandemic [ 45 , 46 ]. Four rural municipalities of different sizes were included in the study. Nursing home and homecare leaders at different organizational levels participated in individual interviews (See Table  1 ).

Norway is divided into 356 municipalities. These municipalities have the autonomy to administer and manage their primary healthcare services, subject to certain laws and regulations (e.g., Act on municipal health and care services [ 47 ], Act on patient and user rights [ 48 ] and Regulation on quality in nursing and care services for service provision [ 49 ]). All municipalities are obligated to offer specified healthcare services independent of their size and inhabitant number (Se Fig.  1 for a brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and included municipalities).

Brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and the included municipalities

Recruitment and participants

Recruitment was anchored in the municipal management. The municipal manager of health and care in 11 municipalities across the Norwegian west coast were first contacted via email, then by telephone (se Fig.  1 ). Most managers who responded to our contact were positive, but many had to decline due to time constraints related to pandemic management. Four managers agreed to data collection in their municipality with the stipulation that the nursing home- and homecare leaders wanted to participate. All levels of leaders were eligible for inclusion due to the small size of the healthcare services. We contacted the leaders of nursing homes and home care services in the four municipalities, first by email, then by telephone. Nine leaders agreed to participate. One leader declined. All included leaders were female, registered nurses (RNs), and had long and broad experiences with working as RNs either in the healthcare service they now were leaders in, or in other healthcare settings. Some leaders stated that they had continued education or Master’s degrees, but more leader specific qualifications such as leader education, training or courses were not disclosed (Table  1 . Overview of participants and setting).

Data collection

Individual interviews were conducted from November 2021 to November 2022 by the first author (MKG). Leaders in one of the municipalities (municipality B) wished to do the interview in a group interview (three leaders), which we arranged. All but one interview was conducted at the leaders’ work premises (in their offices or in meeting rooms). One leader was interviewed via Zoom due to a temporary need for increased infection precautions. All interviews were guided by a predeveloped interview guide which was based on resilience in healthcare theory [ 50 , 51 ] and contained subject such as: Success factors and challenges with handling the COVID-19 pandemic; New solutions and how new knowledge and information was handled; and Lessons learned from the pandemic.

Data analysis

The interviews were audio recorded and transcribed. The analysis followed the steps in Braun and Clarkes thematic approach [ 52 ]. This involved reading through the transcripts multiple times to find meanings related to the overall research question. Text with meaning was inserted into a Word table which provided initial codes. After the coding process, which involved creating and continuously revising codes, there were 47 codes. The codes were then organized into categories and categories were sorted into initial main themes. Themes and categories were assessed to determine whether any of them should be merged, refined, split or eliminated [ 52 ] (see Table  2 for example of the analysis process). The author team reviewed and approved categories and themes to ensure that each theme illuminated its essence [ 52 ].

We analyzed the interviews and identified three main themes and eight categories (Table  3 ). The results are presented according to identified main themes.

Navigating the role of a leader during the pandemic

Overall, the leaders seemed to have two primary focuses when they talked about how they had experienced the COVID-19 pandemic. These were their personal coping, and how they managed the organizational challenges arising throughout the pandemic period. Particularly in the beginning, they reported feelings of fear and insecurity. Leaders dreaded the consequences which could result from mistakes, such as providing wrong, or missing essential information.

“Having such a responsibility is a burden, and even though you’re not alone, you still feel like you’re the one responsible for the safety of the employees and the patients. Ensuring the safety of everyone was the priority, which is why it was critical to make sure that the protocols we were distributing were the correct ones…” (L1 nursing home municipality C)

Additionally, several leaders stated that they were concerned about personnel who had contracted COVID-19 (some of whom had serious symptoms), and even felt responsible for their situation. Leaders of two of the municipalities reported feelings of frustration, and despair, and all leaders reported long working hours. Leaders expressed that they felt that they had been “on call” for the last two years, and described long working days, with limited consideration for evenings, nights, weekends, or vacations.

A range of organizational challenges was described (e.g., dealing with a stressed economy, experiencing task overload, working within an unprepared organization and the struggle to get a hold on enough personal protective equipment. One of the most prominent challenges in the data set, was the acquisition, interpretation, and distribution of information issued by the authorities. The leaders described that new information was issued frequently along with constantly changing routines. New routines where developed, distributed, and discarded nonstop in the attempt to “get the organization in line with the state authorities”.

“There was new information issued [from the Norwegian directorate of health] almost hourly… we had more than enough to, in a way, keep up with all these procedures that came, or all the new messages that came, and these [information and routines] had to be issued out to the employees and to the next of kin…” (L1 nursing home municipality A)

Despite the difficulties related to information flow, or lack thereof, the leaders devised a range of solutions to make information more accessible to their staff (e.g., informational e-mails, developing short information sheets, making information binders, and meeting up physically to go through new routines with their employees). The data indicated that it was hard to gauge how much information to make available to their staff, who were eager for knowledge, yet still found it hard to process everything. On occasion, the leaders desired assistance or someone to assume authority, or as one leader articulated: “someone to push the red button” (L1 homecare municipality C), due to their struggles to keep up with information, regulations, and routines in the face of rapid changes.

Not surprisingly, leaders felt a heightened need to take the lead during the COVID-19 pandemic. This was a long-running crisis, and they had to be present, approachable and a source of support for their staff, while also striving to gain the employees’ understanding. For example, in one healthcare service the employees wanted more strict rules than necessary and had strong opinions on how things should be done in “in their healthcare service”, while the leader was stringent with sticking to national regulations which were less strict. Another aspect was handling disagreement with measures among employees. Often measures were not in line with the employees’ wishes, which created friction.

The pandemic highlighted the importance of leaders taking on the task of creating a secure working environment for their employees. The leaders noted considerable anxiety among the staff, particularly in facilities that had not experienced any COVID-19 cases. Leaders came to understand the importance of tending to all wards, regardless of whether they had been affected by the infection, even though it was perceived as taxing. Overall, the leaders worked actively to make the situation in wards with infection outbreaks as best as possible. A leader from a healthcare service which had a major COVID-19 outbreak stated:

“We constantly tried to create new procedures to make it as easy as possible for them [So] that they didn’t have to think about anything. That they [didn’t have to think about] bringing food to work, that they had to [remember] this or that. That they were provided with everything they needed…” (L2 nursing home municipality C)

Another recurring topic in the dataset, was the constant challenges and changes the leaders had to overcome and adapt to during the COVID-19 pandemic. For example, there was a need to plan for all possible scenarios, particularly if they were to have a major infection outbreak among the staff (e.g., how to limit the infection outbreak, how to deal with staffing, how to arrange the wards in case of an outbreak). One healthcare service experienced such a scenario, which demanded a rapid response, when they had a major COVID-19 outbreak with over twenty infected employees almost overnight. The leaders were left with the impossible task of covering a range of shifts, and they were forced to adopt a strategy of reaching out to other healthcare services within their municipality (other wards, nursing homes, the home care services and psychiatric services) asking if they had any nurses “to spare.” Eventually, they managed to cover their staffing needs without using a temp agency.

The leaders of this nursing home also had to deal with numerous small, but important challenges such as how to deal with dirty laundry, what to do with food scraps, where to put decorations and knick-knacks, how to provide wardrobes and lunchrooms, and generally, how to handle an infection outbreak in facilities not designed for this purpose.

Leaders in all primary healthcare services implemented strategies to prevent infection or spread of infection. They introduced longer shifts, split up the personnel in teams, made cleaning routines for lunchrooms and on-call rooms, set up a temporary visiting room for next of kin, developed routines for patient visits, regularly debriefed personnel of infection routines, made temporary wardrobes, and removed unnecessary tasks from the work schedule. New digital tools were introduced, particularly for distributing instructional videos and information among employees, and to keep contact with other leaders.

Although many leaders described the situation as challenging, particularly in the beginning, many found themselves gaining increased control over the situation as time went by.

“Little by little, in some way, the routine of everyday life has become more settled… you can’t completely relax yet, but you can certainly feel a bit more organized, and more confident in your decisions, since we have been doing it for a while [ca 1 year]. (L1 nursing home municipality C)

The aftermath—management of covid-19 in rural primary healthcare services

Despite organizational as well as personal challenges, leaders’ overall impression of the COVID-19 management was positive. The leaders firmly believed that the quality of healthcare services had been preserved, and all the physical healthcare needs of the patients had been properly cared for. According to leaders, there was not a rise in adverse events (e.g., falls, wounds) and patients and next of kin were positive in their feedback. The one main concern regarding quality of care was, however, the aspect of the patients’ sociopsychological state. Patients became isolated and lonely when they could not receive visitors or had to be isolated in their rooms or their homes during COVID. Nevertheless, the leaders expressed admiration for the healthcare personnel's work in addressing psychosocial needs to the best of their capacity. Overall, the leaders were proud of how the front-line healthcare personnel had handled the pandemic, and the extraordinary effort they put in to keeping the healthcare services running.

Several leaders stated that they now felt better prepared for “a next pandemic”, but they also had multiple suggestions for organizational improvements. These suggestions included: set up a visit coordinator, develop a better pandemic plan, be better prepared nationally, develop local PPE storage sites, introduce digital supervision for isolation rooms (for example RoomMate [ 53 ]), provide more psychological help for employees who struggled in the aftermath of an infection outbreak, have designated staff on standby for emergency situations, establish clear communication channels for obtaining information and, when constructing new nursing homes and healthcare facilities, consider infection control measures.

The leaders also discussed the knowledge they had acquired during this period. Many talked about learning how to use digital tools, but mostly they talked about the experience they had gained in handling crisis:

“I believe we are equipped in a whole different way now. There’s no doubt about that. Both employees and leaders and the healthcare service in general, I think… I have no doubt about that… so… there have been lessons learned, no doubt about it….” (L1 nursing home municipality C)

Leaders also talked about what they experienced as success factors in handling the pandemic: Long shifts (11,5 h), with the same shift going 4 days in a row to avoid contacts between different shift, the use of Microsoft Teams and other communication tools to increased and ease intermunicipal cooperation, and the possibility to share experiences, making quick decisions and take action quickly, developing close cooperation with the municipality chief medical officer and the nursing home physician, the involvement of the occupational healthcare service (take the employees’ work situation seriously) and the conduct of “Risk, Vulnerability and Preparedness” analysis (a tool to identify possible threats in order to implement preventive measures and necessary emergency response). The leaders also talked about the advantages of getting input from employees (e.g., through close cooperation with the employee representatives).

The benefits and drawbacks of being small and rural during a pandemic

Aspects of being a small healthcare service within a small municipality were highlighted by several of the leaders. For example, the leader of one the smaller healthcare service included in the study, addressed the challenge of acquiring enough competent staff. To be able to fulfill their requirements for competent staff, the municipality needed to buy healthcare services from neighboring municipalities. Another drawback was that employees who had competence or healthcare education often lacked experience in infection control and infection control routines, because they had rarely or never had infectious outbreaks of any kind. This made it particularly challenging to implement infection control measures. In one of the larger municipalities in this study, they had worked targeted for years to increase the competence in their municipality by focusing on full time positions to all and educating assistants to become Licensed practical nurses (LPN). They benefited from these measures during the pandemic.

Another aspect which was emphasized as essential to survive a pandemic in a small municipality, was intermunicipal cooperation. Leaders of all four healthcare services stated that they built increased cooperation with nearby municipalities during the pandemic. Leaders from the different municipalities met often, sometimes several times a week, and helped each other, shared routines, and methods, asked each other questions, coordinated covid-19 testing and developed intermunicipal corona wards, kept each other updated on infection status locally, and relied on each other’s strengths.

“We established a very good intermunicipal cooperation within the health and care services. We helped each other. Shared both routines and procedures, and actually had Teams meetings twice a week, where I could ask questions…and… we all had different strengths in the roles we held, not all of them [group members] were healthcare personnel either, and they had a lot of questions regarding the practical [handling of the pandemic]. At the same time, they [people who were not healthcare personnel] were good at developing routines and procedures, which they shared with the rest. In other words, the cooperation between the municipalities was very good, and for a small municipality, it was worth its weight in gold”. (L1, nursing home/homecare Municipality D)

The same leader stated that they could not have managed the pandemic without support from other larger municipalities and advised closer cooperation following the pandemic as well. An advantage of being small was the ability to easily track and monitor the virus spread within the municipality. Moreover, it was easy to have close cooperation with the infectious disease physician, the municipal chief medical officer, and the nursing home physician, as one person often held several of these roles. Some leaders also had several roles themselves such as a combination of nursing home leader and homecare leader or a combination of nursing home leader and health and care manager (overseeing all health and care services in the municipality). This was perceived as both an advantage and a disadvantage. This was an advantage because they gained a full overview of the situation due to their multiple areas of responsibility, but a disadvantage because it was demanding for one person to handle everything alone, making the system vulnerable. Another challenging aspect was a lack of people to fill all the necessary roles. For example, in one municipality they did not have a public health officer (a physician in charge of the healthcare services in a municipality, and the municipal management’s medical adviser), and had to hire a private practicing physician, who was not resident in the municipality to take on this role.

The economy was also a continuous source of worry. Running a small healthcare service within a small municipality was stated as expensive because the municipalities were obligated to provide the same healthcare services as the larger municipalities, but with less income (e.g., tax payment per inhabitant). The pandemic led to new expenses such as overtime payment, and wage supplement for changed work hours. Leader had to continuously balance a sound use of resources, and responsible operation.

Table 4 provides and overview of the challenges leaders encountered, how they were handled, and leaders’ suggestions for further improvement.

We assessed how leaders in rural primary healthcare services coped with unprecedented challenges during the COVID-19 pandemic. On one hand, they had to manage personal struggles such as insecurity, guilt, and excessive workload. At the same time, they had to confront major organizational issues such as financial instability, lack of resources, and information overload. Moreover, their roles changed, and the need to lead, make more decisions and be more supportive was heightened. While adapting to these changing roles, the leaders continuously introduced new measures to handle pandemic induced challenges including development of new routines, distilled and distributed information, reorganized staffing plans and rearranged wards. Although patients’ safety and quality of care was perceived as safeguarded throughout the COVID-19 pandemic period, leaders had several suggestions for improvements in case of future crises.

Previous research on primary healthcare services during COVID-19 support several of the findings identified here. Similar challenges requiring leaders to adapt their ways of working such as insufficient contingency plans and infection control, lack of staffing, changing guidelines and routines and challenges related to information flow were found [ 17 , 31 , 54 , 55 , 56 ]. Leader strategies to handle these challenges included reallocation of staff, providing support, provide training and distill and distribute information [ 16 , 31 , 55 , 57 ]. Some findings in this study, particularly related to the rural context, has not been found elsewhere. We found that 1) the leaders’ and healthcare services’ increased their dependency on neighboring municipalities during the pandemic and 2) we identified both the advantages and drawbacks of leaders having to function in multiple roles during the pandemic. The heightened importance of cooperation within municipalities and healthcare services in rural areas as opposed to urban areas, has however, been highlighted both before and during the pandemic [ 17 , 23 ].

The pandemic prompted organizations like the World Health Organization (WHO), International Council of Nurses (ICN), and Organization for Economic Co-operation and Development (OECD) to advocate for the advancement of more resilient healthcare services to be able to overcome current and future health system challenges [ 3 , 58 , 59 ]. To achieve the goal of resilient healthcare services, a multi-focal perspective incorporating both individual, teams and systems, is needed. This is because health system organization and leadership on all levels will impact how resilience can be built on team and individual level and thereby reinforce resilience in organizations [ 12 , 51 , 60 , 61 , 62 ].

The multiple aspects of resilient leadership

Leadership style, leaders’ facilitation for flexibility and leaders’ management of resources, competence, and equipment, will affect the resilience of health personnel and thereby the organizational resilience [ 12 , 15 , 63 ]. However, resilient leadership is affected by multiple aspects. For one, leaders inherent individual resilience will influence how and if, they lead resiliently [ 64 ]. Individual resilience is a multifaceted concept consisting of the person’s determination, persistence, adaptability and recuperative capacity, and is impacted by their personal qualities, conduct and cultural outlook [ 12 ]. Similar to previous literature [ 65 , 66 ], the current study found that leaders had to cope with personal challenges such as fear, guilt, adapting to changed roles and increased workload, while performing their everyday tasks. Literature have shown that leaders' responses to challenges can be influenced by their unique personality traits, ultimately shaping their resilience and leadership style [ 67 , 68 ]. Personal qualities needed to “lead well” have also shown to vary between rural and urban healthcare services. For example, Doshi [ 69 ] found that being social, passionate and extrovert was more important in urban areas than in rural areas. This indicate that leaders’ personality traits affect resilience in healthcare, and that resilience promoting personality traits may vary across urban and rural areas. More research is needed to study these relationships.

Although measures to increase personal resilience can be effective (e.g., mindfulness, workshops/training, therapy) [ 70 , 71 , 72 , 73 ] it is not sufficient to base resilience building on these aspects alone [ 74 ]. There is a need to consider how leaders are influenced and supported by the system they are working within to become, and act more resiliently. This includes the support leaders have in their community (e.g., peer support, leader support and proper guidance), their access to resources and their freedom to make decisions [ 60 , 75 , 76 ]. In the current study, it appeared to be a connection between leaders’ coping and the amount of support they had from colleagues. In our interpretation, leaders who talked about their cooperation with others, also talked more positively of their COVID-19 experiences (e.g., how much they had learned or what they had accomplished, rather than how pressured and anxious they were). Similar results have previously been found. For example, leaders in Marshall and colleagues’ study [ 65 ] felt isolated and struggled to make sense of the situation (COVID-19 induced challenges), while leaders in Seljemo and colleagues’ study stated that support from other managers made it easier to cope with high workloads [ 31 ]. In smaller rural healthcare settings, obtaining support can be challenging due to the limited presence of leader colleagues in close proximity [ 77 ]. Additionally, Gray & Jones [ 78 ] suggests that resilient leaders are leaders who ask for help when needed. This indicates that leaders in more isolated areas may require more effort to form connections beyond their organization, and rural healthcare systems must afford greater attention to enabling peer networking (e.g., by providing time and resources).

Through recurrent intermunicipal, online meetings, leaders in the current study attained to initiate, and preserve contact with other leaders in other healthcare settings, much more than before the COVID-19 pandemic. This was particularly important for the smallest, most rural municipalities, where one leader held many roles, and was by one leader, stated as the main reason they were able to manage the COVID-19 pandemic in their primary healthcare service. The tendency to increase intermunicipal cooperation during this period, and the overall need for smaller, rural healthcare services to cooperate with others is found in other literature [ 23 , 79 ]. However, mostly as collaboration within primary healthcare services, and not across organizations. Although recommended by leaders, it is not clear if this close contact has been maintained after the pandemic.

The governance leaders are working under will affect leaders’ possibility to lead resiliently. The governance allows for effective coordination of financing, resource generation, and service delivery activities, ensuring optimal system performance [ 80 ]. Yet, governing for resilience has proven to be a major challenge, because it requires systems to be both flexible and stable at the same time [ 76 ]. Flexibility presupposes systems’, health personnel’, and leaders’ ability to adapt to current conditions, and is essential for systems to cope with unpredictable, non-linear, and ever-changing social and environmental conditions. Conversely, stability must also be implemented to ensure that new policies are sustained and effective, and to stabilize expectations and promote coordination over time [ 76 ]. This means that leaders need flexibility to make their own decisions, as well as the stability that proper guidelines and direction provides [ 81 ]. In this study, some leaders reported experiencing chaos and loss of control when routines and guidelines lacked in the beginning of the pandemic. Similar results have been found among other healthcare leaders, as well as healthcare personnel [ 32 , 66 ]. In contrast, the leaders’ need for flexibility to be able to adapt to the everchanging work environment brought on by the pandemic (examples in Table  3 ) was demonstrated in this, and other studies [ 16 , 17 ]. It can, however, be argued that the balance between flexibility and stability is often skewed more towards flexibility in rural regions. Rural leaders must make unsupported decisions more often than urban leaders as they face higher demands and fewer available resources (such as competence, staff, and funding) [ 77 ]. This requires rural leaders to be more innovative and adaptable to current circumstances [ 23 , 69 , 77 , 79 ]. That said, the availability of resources have shown to impact a system's flexibility, often by influencing the quality of its adaptations [ 2 ].

In low-resource healthcare settings across the globe, certain adaptations made to combat pandemic challenges ended up causing damage (e.g., reuse or misuse of PPE, overexploitation of healthcare personnel and the use of unconventional treatment methods) [ 2 , 82 ]. In high resource healthcare services, as included in this study, adaptations were often described as beneficial, and potential long-lasting solutions (Table  3 ) [ 16 , 17 , 31 ]. Although not comparable to low resource healthcare services, variation in resource availability and economy between the included healthcare services was also expressed in this study. Norwegian municipalities’ income is closely tied to their tax revenue and population size [ 83 ], and regardless of income, the municipalities are required to provide specific healthcare services to their inhabitants. Thus, the financial foundation of smaller more rural municipalities is not as strong as that of larger municipalities. These inequalities were expressed as notable by both leaders and by healthcare personnel in a preceding study exploring the same primary rural healthcare services as included here [ 32 ]. Since resilience in healthcare is also highly dependent on the competence and experience of employees and leaders, the combination of resource and financial deficiencies, more often experienced in rural healthcare services than in urban healthcare services, may pose particular challenges in resilience building in rural areas [ 23 , 84 ]. This is worth exploring further, along with the rural healthcare services’ particular need to be flexible versus the potential difficulty they may have in making beneficial adaptations because of a weaker financial foundation.

Resilience and leadership style

Providing support to employees was an important leader task during the pandemic [ 55 , 66 ] and have further, been found to be particularly vital in rural areas, where employees have a smaller network of colleagues to turn to [ 84 ]. Other vital leadership tasks, recognizable from crisis leadership literature and also found in this study, were the importance of organizing, directing and implementing actions, forging cooperation, enabling work- arounds or adaptation, direct and guide and the importance of communication and dissemination of information [ 85 , 86 ]. Although charismatic leadership Footnote 1 has been found to be most valuable during crisis [ 87 ], there is an ongoing discussion of what leadership style is best suited to promote resilience in healthcare [ 11 , 14 , 66 , 88 ]. For example, both transformational and transactional leadership 1 [ 89 ] have been stated as resilience promoting leadership styles [ 15 ]. However, as found in other literature [ 66 , 88 ], the results of this study indicated that leaders oscillated between different styles during the COVID-19 pandemic period. For example, in the beginning of the pandemic when uncertainty characterized the healthcare system, leaders became stricter with rules and regulations, demonstrating an authoritative leadership style 1 . Further, stepping in, lecturing about infection control procedures and use of PPE, indicated a coaching leadership 1 style and lastly, when the leaders went against employees wishes to ensure safe maintenance of operation, it showed similarities to a transformational leadership style 1 [ 90 ]. Interestingly, leaders did not speak directly about how their leadership styles changed, and seemed unaware of their leadership style adaptation. Similarly, in Sihvola et al. [ 66 ] leaders found it surprising how novel conditions could influence their leadership style.

On one side, these results, suggest that an adaptive leadership style can be necessary during crisis. On the other side, this and other studies [ 31 , 54 ] indicate that leaders need more knowledge on crisis leadership, for example, to be made aware of the potential need to oscillate between different leadership styles during a crisis, and the possible subsequent challenges. For example, a study conducted by Boyle og Mervin [ 91 ] found that being a “nurse leader” (all leaders in this study were nurses), showed challenging because the leaders were judged as a peer rather than a leader. This can cause challenges, particularly when stepping into an authoritative leadership style. Such conflicts were not reported in this study, however, these are all aspects which should be given more attention when investigating resilience in healthcare and leadership styles [ 88 ]. Furthermore, it is crucial to acquire further understanding on the distinctions between leading in rural and urban areas, and how various leadership approaches may be impacted by managing tight-knit employee teams, which is often the case in small rural nursing home and homecare services. And finally, there is a need to provide a deeper understanding of the factors that promote or impede resilience in rural primary healthcare services, and the influence of the contextual aspects on resilience in healthcare.

Limitations

This study has limitations which need to be addressed. A larger number of included primary healthcare leaders over a wider geographical area and across boarders would have provided a broader view of leader experiences during the COVID-19 pandemic. However, it was very difficult to get leaders to take time to reflect during this crisis. This study does provide insight into a variety of different municipalities of different sizes, organization and locations in the Norwegian context, providing a variety of rural primary healthcare leaders experiences during the pandemic. Interviews were conducted in different ways (focus group, digital and individually) this could have influenced leaders description of their experiences. Furthermore, interviews were held at different points throughout the pandemic phases, leading to a mix of leaders with both current and reflective experiences of navigating the pandemic. This should be taken into consideration when reading the results.

By exploring nursing home and home care leaders’ experiences with the COVID-19 pandemic in rural areas, we found that the leaders met a range of rapid onset challenges of different nature, many of which demanded fast decisions and solutions. Leaders handled these challenges and changes in a variety of ways in their different contexts. In addition to health system challenges, leaders also had to cope with rapidly changing roles, while managing their own and employees’ insecurities. This study’s results demonstrate the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements. In addition, there may be differences between how resilience in healthcare is built and progresses in rural healthcare services versus urban contexts. Further research to understand the interplay between these aspects is needed, and it is critical to consider context.

Availability of data and materials

Data are available from the corresponding author upon reasonable request.

Charismatic leadership : influence and persuasion of others to help the fulfill their mandate, also in face of adversity; Transformational leadership: pushing to work and think in new ways; Authoritative leadership : the leader in control, low autonomy; Coaching leadership : the leader support employee’s skill advancement; Transactional leadership : exchange of rewards for fulfilling expectations.

Abbreviations

International Council of Nurses

Licensed practical nurse

Organization for Economic Co-operation and Development

Personal protective equipment

Registered Nurse

The World Health Organization

WHO. COVID-19 continues to disrupt essential health services in 90% of countries WHO2021 [Available from: https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries .

Malin Knutsen G, Kristiana L, Siri W, et al. Resilience perspective on healthcare professionals’ adaptations to changes and challenges resulting from the COVID-19 pandemic: a meta-synthesis. BMJ Open. 2023;13(9):e071828.

Article   Google Scholar  

OECD. Ready for the Next Crisis? Investing in Health System Resilience. 2023.

Book   Google Scholar  

Franzosa E, Gorbenko K, Brody AA, et al. “At home, with care”: lessons from New York City home-based primary care practices managing COVID-19. J Am Geriatr Soc. 2021;69(2):300–6.

Article   PubMed   Google Scholar  

Franchini L, Varani S, Ostan R, et al. Home palliative care professionals perception of challenges during the Covid-19 outbreak: a qualitative study. Palliat Med. 2021;35(5):862–74.

Damian AJ, Gonzalez M, Oo M, Anderson D. A national study of community health centers’ readiness to address COVID-19. J Am Board Fam Med. 2021;34(Suppl):S85-s94.

Zhao S, Yin P, Xiao LD, et al. Nursing home staff perceptions of challenges and coping strategies during COVID-19 pandemic in China. Geriatric Nursin. 2021;42(4):887–93.

Aalto UL, Pitkälä KH, Andersen-Ranberg K, et al. COVID-19 pandemic and mortality in nursing homes across USA and Europe up to October 2021. Eur Geriatr Med. 2022;13(3):705–9.

Article   PubMed   PubMed Central   Google Scholar  

Wiig S, Aase K, Billett S, et al. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res. 2020;20(1):330.

Wiig S, Fahlbruch B. Exploring Resilience - An Introduction. In: Wiig S, Fahlbruch B, editors. Exploring Resilience : a scientific journey from practice to theory. Springer briefs in applied sciences and technology : safety management. Springer Open: Cham; 2019. p. 1–3.

Google Scholar  

Barasa E, Mbau R, Gilson L. What is resilience and how can it be nurtured? A systematic review of empirical literature on organizational resilience. Int J Health Policy Manag. 2018;7(6):491–503.

Bowman A. Leadership and resilience: where the literature stands. J Leadersh Stud. 2022;16(2):33–41.

Akerjordet K, Furunes T, Haver A. Health-promoting leadership: an integrative review and future research agenda. J Adv Nurs. 2018;74(7):1505–16.

Eliot JL. Resilient leadership: the impact of a servant leader on the resilience of their followers. Adv Dev Hum Resour. 2020;22(4):404–18.

Ree E, Ellis LA, Wiig S. Managers’ role in supporting resilience in healthcare: a proposed model of how managers contribute to a healthcare system’s overall resilience. Int J Health Governance. 2021;26(3):266–80.

Lyng HB, Ree E, Wibe T, Wiig S. Healthcare leaders’ use of innovative solutions to ensure resilience in healthcare during the Covid-19 pandemic: a qualitative study in Norwegian nursing homes and home care services. BMC Health Serv Res. 2021;21(1):878.

Ree E, Wiig S, Seljemo C, et al. Managers’ strategies in handling the COVID-19 pandemic in Norwegian nursing homes and homecare services. Leadership in Health Services. (ahead-of-print). 2022;200–18.

Saleem J, Ishaq M, Zakar R, et al. Experiences of frontline Pakistani emigrant physicians combating COVID-19 in the United Kingdom: a qualitative phenomenological analysis. BMC Health Serv Res. 2021;21(1):291.

Glette MK, Bates DW, Dykes PC, et al. A resilience perspective on Healthcare Personnels’ Experiences of Managing the COVID-19 Pandemic: A qualitative study in Norwegian nursing homes and come care services. BMC Health Services Research. 2023 (in review).

Smedt SED, Mehus G. Sykepleieforskning i rurale områder i Norge; en scoping review (English title: Nursing research in rural areas in Norway; a scoping review). Norsk tidsskrift for helseforskning. 2017;13;2:1–27.

W P, L R. Rural, remote and at risk: Why rural health services face a steep climb to recovery from Covid-19. Nuffield Trust; 2020.

van Pijkeren N, Msc P, Wallenburg I, et al. Caring peripheries: How care practitioners respond to processes of peripheralisation. Sociologia Ruralis. 2023;64:64–81.

van de Bovenkamp H, van Pijkeren N, Ree E, et al. Creativity at the margins: a cross-country case study on how Dutch and Norwegian peripheries address challenges to quality work in care for older persons. Health Policy. 2023;127:66–73.

Melvin SC, Wiggins C, Burse N, et al. The role of public health in COVID-19 emergency response efforts from a Rural health perspective. Prev Chronic Dis. 2020;17:E70.

Segel JE, Ross HI, Edwards JL, et al. The unique challenges facing rural providers in the COVID-19 pandemic. Popul Health Manag. 2020;24(3):304–6.

Teixeira da Silva JA, Tsigaris P, Erfanmanesh M. Publishing volumes in major databases related to Covid-19. Scientometrics. 2021;126(1):831–42.

Article   CAS   PubMed   Google Scholar  

Gholami M, Fawad I, Shadan S, et al. COVID-19 and healthcare workers: a systematic review and meta-analysis. Int J Infect Dis. 2021;104:335–46.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Ferguson J, Rosser JI, Quintero O, et al. Characteristics and outcomes of coronavirus disease patients under nonsurge conditions, Northern California, USA, March-April 2020. Emerg Infect Dis. 2020;26(8):1679–85.

Helgeland J, Telle KE, Grøsland M, et al. Admissions to Norwegian hospitals during the COVID-19 pandemic. Scandinavian J Pub Health. 2021;49(7):681–8.

Moynihan R, Sanders S, Michaleff ZA, et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open. 2021;11(3):e045343.

Seljemo C, Wiig S, Røise O, Ree E. The role of local context for managers’ strategies when adapting to the COVID-19 pandemic in Norwegian homecare services: a multiple case study. BMC Health Serv Res. 2023;23(1):492.

Glette MK, Bates DW, Dykes PC, et al. A resilience perspective on healthcare personnels’ experiences of managing the COVID-19 pandemic: a qualitative study in Norwegian nursing homes and come care services. BMC Health Serv Res. 2023;23(1):1177.

Iness AN, Abaricia JO, Sawadogo W, et al. The effect of hospital visitor policies on patients, their visitors, and health care providers during the COVID-19 pandemic: a systematic review. Am J Med. 2022;135(10):1158-67.e3.

Füszl A, Bouvier-Azula L, Van den Nest M, et al. Provision of safe patient care during the COVID-19 pandemic despite shared patient rooms in a tertiary hospital. Antimicrob Resist Infect Control. 2022;11(1):61.

Mohammadinia L, Saadatmand V, Khaledi Sardashti H, et al. Hospital response challenges and strategies during COVID-19 pandemic: a qualitative study. Front Public Health. 2023;11:1167411.

Samdal GB, Alpers LM, Sekse RJT, et al. Barriers and facilitators for leading nursing homes through the COVID-19 pandemic: a focus group study in Norway. Nurs Open. 2023;10(11):7154–67.

Abbas MJ, Kronenberg G, McBride M, et al. The early impact of the COVID-19 pandemic on acute care mental health services. Psychiatr Serv. 2021;72(3):242–6.

Nessler K, Van Poel E, Willems S, et al. The response of primary care practices in rural and urban settings in Poland to the challenges of the COVID-19 pandemic. Ann Agric Environ Med. 2022;29(4):575–81.

Anaraki NR, Mukhopadhyay M, Karaivanov Y, et al. Living and working in rural healthcare during the COVID-19 pandemic: a qualitative study of rural family physicians’ lived experiences. BMC Prim Care. 2022;23(1):335.

Pavloff M, Labrecque ME, Bally J, et al. Rural home care nursing during COVID-19. Can J Nurs Res. 2023;55(4):486–93.

OECD. Realising the Potential of Primary Health Care. OECD; 2020.

The World Bank. Rural population (% of total population) 2018. Available from: https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS . Cited 2023 18.12.

Ellis LA, Churruca K, Clay-Williams R, et al. Patterns of resilience: a scoping review and bibliometric analysis of resilient health care. Saf Sci. 2019;118:241–57.

Scott A, Braithwaite J, Melbourne Uo. Is COVID-19 opening the fault lines in our healthcare system? : Institute of Applied Economic and Social Research.; 2020 [Available from: http://nla.gov.au/nla.obj-2931172550 .

Creswell JW. Research design : qualitative, quantitative, and mixed methods approaches. 5th ed. ed. Los Angeles, Calif: SAGE; 2018.

Holloway I, Galvin K. Qualitative research in nursing and healthcare: Wiley Blackwell; 2017.

Lov om kommunal helse-og omsorgstjeneste (english title: Act on municipal health and care services), LOV-2011–06–24–30 (2011).

Lov om pasient- og brukerrettigheter (English title: Act on patient and user rights), LOV-1999-07-02-63.

Forskrift om kvalitet i pleie- og omsorgstjenestene (English title: Regulation on quality in nursing and care services for service provision), FOR-2003–06–27–792 (2003).

Hollnagel E, . Making Healthcare resilient: From safety-I to Safety-II. In: Hollnagel E, Braithwaite J, Wears RL, editors. Resilient health care. Ashgate studies in resilience engineering. 1. Farnham, Surrey, England: Ashgate; 2013.

Wiig S, Fahlbruch B. Exploring Resilience – An Introduction. In: Wiig S, Fahlbruch B, editors. Exploring Resilience: A Scientific Journey from Practice to Theory. Cham: Springer International Publishing; 2019. p. 1–5.

Chapter   Google Scholar  

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

Sensio. RoomMate. Available from: https://www.sensio.io/no/produkter/roommate?utm_term=roommate&utm_campaign=S%C3%B8k+%7C+Produkter&utm_source=adwords&utm_medium=ppc&hsa_acc=5538158809&hsa_cam=20506326432&hsa_grp=159856433744&hsa_ad=672316590141&hsa_src=g&hsa_tgt=kwd-28346982&hsa_kw=roommate&hsa_mt=p&hsa_net=adwords&hsa_ver=3&gclid=EAIaIQobChMI3rHE6qPpgwMVOVKRBR124QjJEAAYASAAEgKR5vD_BwE .  Cited 2024 19.01.

Alakeely M, Almutari A, Masud N, Altulaihi B. Preparedness of primary health care leaders during COVID-19 outbreak, Riyadh, Saudi Arabia: a qualitative study. Risk Manag Healthc Policy. 2021;14:4339–51.

Skagerström J, Fernemark H, Nilsen P, et al. Challenges of primary health care leadership during the COVID-19 pandemic in Sweden: a qualitative study of managers’ experiences. Leadersh Health Serv. 2023;36(3):389–401.

Dale JN, Morken T, Eliassen KE, et al. Preparedness and management during the first phase of the COVID-19 outbreak - a survey among emergency primary care services in Norway. BMC Health Serv Res. 2022;22(1):896.

Karreinen S, Paananen H, Kihlström L, et al. Living through uncertainty: a qualitative study on leadership and resilience in primary healthcare during COVID-19. BMC Health Serv Res. 2023;23(1):233.

ICN. ICN President calls for resilient health systems at UN High Level Meeting on Pandemic Prevention, Preparedness and Response: ICN; 2023 [updated 21.09.23. Available from: https://www.icn.ch/news/icn-president-calls-resilient-health-systems-un-high-level-meeting-pandemic-prevention .

World Health Organization. Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: a brief on the WHO position. Geneva: WHO; 2021. Available from: https://www.who.int/publications/i/item/WHO-UHL-PHC-SP-2021.02 .

Sagan A, Webb E, Rajan D, et al. Health system resilience during the pandemic: it’s mostly about governance. Eurohealth. 2021;27(1):10–5.

Wiig S, Lyng HB, Greenfield D, Braithwaite J. Care in the future—reconciling health system and individual resilience. Int J Qual Health Care. 2023;35(4):mzad082.

Tsandila-Kalakou F, Wiig S, Aase K. Factors contributing to healthcare professionals’ adaptive capacity with hospital standardization: a scoping review. BMC Health Serv Res. 2023;23(1):799.

Fagerdal B, Lyng HB, Guise V, et al. Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study. BMC Health Serv Res. 2022;22(1):908.

Gröschke D, Hofmann E, Müller ND, Wolf J. Individual and organizational resilience—Insights from healthcare providers in Germany during the COVID-19 pandemic. Front Psychol. 2022;13:965380.

Marshall F, Gordon A, Gladman JRF, Bishop S. Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatr. 2021;21(1):102.

Sihvola S, Kvist T, Nurmeksela A. Nurse leaders’ resilience and their role in supporting nurses’ resilience during the COVID-19 pandemic: a scoping review. J Nurs Manag. 2022;30(6):1869–80.

Haver A, Akerjordet K, Furunes T. Wise emotion regulation and the power of resilience in experienced hospitality leaders. Scand J Hosp Tour. 2014;14(2):152–69.

Kumari K, Ali SB, Batool M, et al. The interplay between leaders’ personality traits and mentoring quality and their impact on mentees’ job satisfaction and job performance. Front Psychol. 2022;13:937470.

Doshi D. Improving leadership of health services in rural areas: exploring traits and characteristics. Int J Healthcare Manag. 2020;13(sup1):183–91.

McKinley N, Karayiannis PN, Convie L, et al. Resilience in medical doctors: a systematic review. Postgrad Med J. 2019;95(1121):140–7.

Cleary M, Kornhaber R, Thapa DK, et al. The effectiveness of interventions to improve resilience among health professionals: a systematic review. Nurse Educ Today. 2018;71:247–63.

Huey CWT, Palaganas JC. What are the factors affecting resilience in health professionals? A synthesis of systematic reviews. Med Teach. 2020;42(5):550–60.

Joyce S, Shand F, Tighe J, et al. Road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open. 2018;8(6):e017858.

Khalili H, Lising D, Kolcu G, et al. Advancing health care resilience through a systems-based collaborative approach: Lessons learned from COVID-19. J Interprof Care. 2021;35(6):809–12.

Kaul V, Shah VH, El-Serag H. Leadership during crisis: lessons and applications from the COVID-19 pandemic. Gastroenterology. 2020;159(3):809–12.

Beunen R, Patterson J, Van Assche K. Governing for resilience: the role of institutional work. Curr Opinion Environ Sustainability. 2017;28:10–6.

van de Bovenkamp H, van Pijkeren N, Ree E, et al. Creativity at the margins: a cross-country case study on how Dutch and Norwegian peripheries address challenges to quality work in care for older persons. Health Policy. 2022;127:66–73.

Gray D, Jones K. The resilience and wellbeing of public sector leaders. Int J Pub Leadership. 2018;14(3):138–54.

Bish M, Kenny A, Nay R. A scoping review identifying contemporary issues in rural nursing leadership. J Nurs Scholarsh. 2012;44(4):411–7.

Sagan A, Webb E, Azzopardi-Muscat N, et al. Health systems resilience during COVID-19. Lessons for building back better. Health policy series. 2021; 56:[1–136 pp.]. Available from: https://eurohealthobservatory.who.int/publications/i/health-systems-resilience-during-covid-19-lessons-for-building-back-better .

Grote G. Leadership in Resilient Organizations. In: Wiig S, Fahlbruch B, editors. Exploring Resilience : a scientific journey from practice to theory. 1. Springer Open: Cham; 2019. p. 59–67.

Poon YSR, Lin YP, Griffiths P, et al. A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions. Human Resources Health. 2022;20(1):70.

NOU: 2022: no 10. Inntektssystemet for kommunene (English title: The revenue system for the municipalities). Oslo: Ministry of Local Government and Rural Affairs

Matheson C, Robertson HD, Elliott AM, et al. Resilience of primary healthcare professionals working in challenging environments: a focus group study. Br J Gen Pract. 2016;66(648):e507–15.

Boin A, Kuipers S, Overdijk W. Leadership in times of crisis: a framework for assessment. Int Rev Pub Administration. 2013;18(1):79–91.

Baker EL, Irwin R, Matthews G. Thoughts on adaptive leadership in a challenging time. J Public Health Manag Pract. 2020;26(4):378–9.

Ali BJ, Anwar G. Administrative crisis: the role of effective leadership styles in crisis management international journal of advanced engineering. Manag Sci. 2021;7(6):31–41.

Tvedt IM, Tommelein ID, Klakegg OJ, Wong J-M. Organizational values in support of leadership styles fostering organizational resilience: a process perspective. Int J Manag Proj Bus. 2023;16(2):258–78.

Grote G. Leadership in Resilient Organizations. In: Wiig S, Fahlbruch B, editors. Exploring Resilience: A Scientific Journey from Practice to Theory. Cham: Springer International Publishing; 2019. p. 59–69.

Jasper L. Building an adaptive leadership style. Strategic Finance. 2018;99(9):54–61.

Boyle TJ, Mervyn K. The making and sustaining of leaders in health care. J Health Organ Manag. 2019;33(2):241–62.

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Acknowledgements

The authors would like to thank participating leaders for their contribution to the study. We would also like to acknowledge Ole-Jørn Borum for graphical design on fig. 1 .

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MKG, SW, TK, and DWB was involved in discussions regarding the project’s development. MKG conducted interviews and led the analysis of the transcribed data. The manuscript was a collaborative effort between MKG, SW, TK, DWB and LS, where all authors provided feedback. The author team approved the manuscript before submission.

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) in 2022 and provides the ethical approval, information security and privacy services as a part of the HK-dir (Norwegian Directorate for Higher Education and Skills). An informed consent form was signed by all leaders prior to the interviews, and information about the aim of the study and their right to redraw was repeated immediately before the interviews started.

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Dr. Bates reports grants and personal fees from EarlySense, personal fees from CDI Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, personal fees and equity from Feelbet-ter, equity from Guided Clinical Solutions, and grants from IBM Watson Health, outside the submitted work. Dr. Bates has a patent pending (PHC-028564 US PCT), on intraoperative clinical decision support. The other authors report no competing interests.

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Glette, M.K., Kringeland, T., Samal, L. et al. A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services. BMC Health Serv Res 24 , 442 (2024). https://doi.org/10.1186/s12913-024-10935-y

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• Antonio Gomera   ORCID: orcid.org/0000-0003-0603-3017 2 &
• Manuel Vaquero-Abellán   ORCID: orcid.org/0000-0002-0602-317X 2 , 3 , 4  

BMC Nursing volume  23 , Article number:  229 ( 2024 ) Cite this article

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People worldwide are concerned with the possibility of climate change, microplastics, air pollution, and extreme weather affecting human health. Countries are implementing measures to reduce environmental impacts. Nurses play a vital role, primarily through Green Teams, in the process of promoting sustainable practices and minimizing the environmental footprint of health care facilities. Despite existing knowledge on this topic, assessing nurses’ environmental awareness and behavior, including the barriers they face, is crucial with regard to improving sustainable health care practices.

To analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to the creation of a sustainable environment.

A sequential mixed-method study was conducted to investigate Spanish nurses. The study utilized an online survey and interviews, including participant observation. An online survey was administered to collect quantitative data regarding environmental awareness and behavior. Qualitative interviews were conducted with environmental nurses in specific regions, with a focus on Andalusia, Spain.

Most of the surveyed nurses ( N  = 314) exhibited moderate environmental awareness (70.4%), but their environmental behavior and activities in the workplace were limited (52.23% of participants rarely performed relevant actions, and 35.03% indicated that doing so was difficult). Nurses who exhibited higher levels of environmental awareness were more likely to engage in sustainable behaviors such as waste reduction, energy conservation, and environmentally conscious purchasing decisions ( p  < 0.05). Additionally, the adjusted model indicated that nurses’ environmental behavior and activities in the workplace depend on the frequency of their environmental behaviors outside work as well as their sustainable knowledge ( p  < 0.01). The results of the qualitative study ( N  = 10) highlighted certain limitations in their daily practices related to environmental sustainability, including a lack of time, a lack of bins and the pandemic. Additionally, sustainable environmental behavior on the part of nursing leadership and the Green Team must be improved.

Conclusions

This study revealed that most nurses have adequate knowledge, attitudes, and behaviors related to environmental sustainability both inside and outside the workplace. Limitations were associated with their knowledge and behaviors outside of work. This study also highlighted the barriers and difficulties that nurses face in their attempts to engage in adequate environmental behaviors in the workplace. Based on these findings, interventions led by nurses and the Green Team should be developed to promote sustainable behaviors among nurses and address the barriers and limitations identified in this research.

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Introduction

The impact of climate change on human society is a global concern, especially with regard to microplastics, resource shortages, air pollution, droughts, and extreme weather. Such consequences affect human health both directly and indirectly, resulting in an increase in pathologies and a deterioration in medical attention [ 1 , 2 ]. In this context, diverse measures aimed at reducing the environmental impact of daily activities and minimizing the ecological footprint thereof [ 3 ] have been implemented by multiple countries [ 4 , 5 , 6 , 7 ]; these activities have been framed as environmental regulations in line with the Sustainable Development Goals (SDGs) [ 8 ].

The SDGs are being integrated into governments and a variety of other contexts, including the health care system. Spain is dedicated to such a goal, i.e., that of promoting a greener and more democratic health care transition. To achieve this goal, strategic plans have been developed to mitigate the effects of climate change [ 9 , 10 ]. One specific such program is the Strategic Health and Environment Plan (PESMA) [ 11 ], whose aim is to enhance the synergy between health and the environment innovatively by assessing the impact of the population in terms of 14 environmental indicators [ 12 ].

One such indicator focuses on the resources and support needed for sustainable practices, especially for nurses, due to the impact of the environment on their work [ 13 , 14 ]. The PESMA highlights the fact that health care providers should be included in strategies to reduce carbon footprints, build resilience to address the challenges associated with climate change and embrace a leadership role in the task of promoting sustainable health care practices [ 13 , 14 , 15 , 16 ]. Another critical aspect of PESMA focuses on education, training, and incentives that can promote sustainable behavior among health care workers, especially nurses [ 17 , 18 ]. As frontline health care workers, nurses have a unique opportunity to advocate for sustainable practices and reduce the environmental impact of the health care system. Nurses’ knowledge and behavior are limited despite the fact that nurses have positive attitudes toward environmental sustainability [ 19 ].

This situation stands in contrast to the role of nurses in the creation of more sustainable hospitals via the “Green Team” [ 20 ]. The Green Team, which originated in the United States of America a decade ago, is a committee that is responsible for finding and implementing sustainability projects to decrease the environmental impacts of daily operations. Members of various departments collaborate with sustainability staff to detect opportunities, spread awareness, and promote staff involvement in line with the Committee’s mission [ 21 ]. The team, which typically consists of and is led by nurses, aims to increase awareness of the health care industry’s effect on the environment and to develop tactics to mitigate the adverse environmental effects of hospitals.

In Spain, Green Teams, which span multiple disciplines and usually led by nursing professionals, are committed to sustainable change in health care [ 22 ]. Environmental nursing leaders on Green Teams control environmental sustainability in health care settings and provide education, resources, and support to other professionals with regard to the implementation of sustainable practices [ 23 ]. Accordingly, all nurses can contribute to the tasks of mitigating the impact of climate change on public health outcomes and promoting sustainable health for all [ 24 ]. These actions improve nurses’ knowledge, attitudes, and behavior in terms of sustainability and promote sustainable practices in health care settings, thus leading to a better understanding of the barriers faced by nurses in this context [ 24 , 25 , 26 ].

However, measuring and identifying nurses’ environmental awareness is essential for the promotion of sustainable hospitals [ 27 , 28 ]. Multidimensional indicators have been proposed for this purpose [ 16 ], the responsibility for which lies with nurse leaders on Green Teams. Nurses are responsible for promoting sustainability in health care organizations, as discussed by Kallio et al. (2018) [ 29 ], as well as for promoting nursing competencies related to environmental sustainability [ 30 ]. Several studies, including Harris et al. (2009) and Phiri et al. (2022), have examined nurses’ roles in environmental health and the effects of their leadership on the promotion of sustainability, especially during the COVID-19 pandemic, thereby emphasizing the importance of leadership [ 31 , 32 ].

As Ojemeni et al. (2019) discussed, leadership effectiveness in Green Teams, nursing teams and health care organizations must prioritize quality control and health care improvement to ensure sustainable development [ 33 ].

The topic of environmental management in health care organizations has been studied extensively, and an environmental or ecological model of care for promoting sustainability has been proposed [ 34 ]. As environmental creators and leaders on Green Teams, nurses are vital for minimizing hazardous waste in health care settings and improving awareness [ 35 ].

Although nurses have some degree of existing knowledge and awareness of sustainability, it is crucial to assess their proficiency in environmental matters and to gauge their environmental awareness. Such an evaluation can help identify areas for improvement within clinical management units [ 20 , 33 , 36 ]. Education and training programs can effectively promote sustainable behavior among nurses, but interventions should also address the barriers they face in their attempts to implement sustainable practices [ 37 ]. Therefore, it is imperative to examine the factors that foster sustainable behavior among nurses and to identify effective interventions that can promote sustainable health care practices and minimize the environmental footprint of health care facilities. Accordingly, this study aimed to analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to creating a sustainable environment.

Study design

A sequential mixed-method study was conducted based on an online survey and interviews with a representative sample of Spanish nurses, including participant observation.

The study was divided into two phases. In the first phase, a cross-sectional, descriptive exploratory analysis was performed; this analysis relied on the results revealed using the Nurse’s Environmental Awareness Tool in Spanish (NEAT-es) [ 38 ], which was divided into three subscales: nursing awareness scale (NAS), environmental behaviors outside the workplace (PEB) and sustainable behaviors in the workplace (NPEB). In the second phase, qualitative interviews with environmental nurses (see Supplementary file 1 ) were conducted in regions featuring specific environmental units that were available in person (Andalusia).

Participants

The participants were recruited from public and private institutions associated with the National Health System, particularly from the nursing staff. The scope of the study focused on Spain, and the sample included all the nursing staff who completed the questionnaire and met the inclusion criteria.

The sampling process focused on the population of nurses in Spain in 2020, which was estimated to consist of 388,153 nurses. Therefore, a random sample of 314 participating individuals was sufficient to estimate the population with 95% confidence and an accuracy of +/- 2% units, which was expected to account for approximately 90% of the overall population. The inclusion and exclusion criteria used for the sample focused on nursing staff, nursing care auxiliary technicians, and students with relevant degrees, as this members of this group have the most significant presence in the health system and engage in direct and daily contact with environmental management in health centers (hospitals, primary care centers, sociosanitary centers and others). The remaining health and nonhealth personnel were excluded.

Additionally, the person from each unit who served as the environmental coordinator and other nurses from the ward who were members of the Green Team were asked to participate in the interviews and observations. The environmental coordinators, most of who were nursing supervisors, were determined based on the number of members of the Green Team and the sampling calculation used for the observational study. The interviews took place after various sessions, talks, or courses pertaining to environmental sustainability at the clinical management units.

Data collection

An intentional sampling process was implemented, and the data collection period spanned from November 2019 to March 2021. The observational data were collected in Spain via messages and posts on social media with the goal of quantifying nurses’ environmental awareness.

The initial sample of qualitative study included five environmental nursing leaders (NLs), 14 registered nurses (RNs), and ten nursing undergraduates. The final sample was reduced when the interviews reached data saturation ( N  = 10, five NLs, and five RNs). Before the interviews, a focal group composed of one nurse, one physician, two engineers and a psychologist was tested using the questions included in this research as part of a pilot study ( Supplementary file 1 ). These interviews were conducted at the beginning of the participant’s shift, usually in the morning, and they featured a median time of 30 min, a minimum of 20 min and a maximum of one hour per participant.

One researcher (O.A.L.) also observed nurses during their daily work after the interview from a position within the ward as an added team member or staff member. Nevertheless, the observer did not highlight mistakes or sustainability issues during the observation process. No other researcher was involved in this step of the ethnographic analysis to avoid bias with regard to observing a variety of tasks ranging from preparing medication to implementing treatments.

The data collected through the interviews were recorded on a Samsung Galaxy 31 A, and observations were collected in a field notebook based on the Google Keep and Evernote mobile applications from November 2019 to mid-March 2021. This study was conducted at a regional level 1 hospital in southern Spain, particularly in various clinical management units (neurosurgery, internal medicine, cardiology, traumatology, and COVID-19 units, among others), and it focused on nursing supervisors, who are the leaders who bear responsibility for environmental awareness (NLs), and registered nurses (RNs) who were members of the Green Team.

Data analysis

The quantitative data were analyzed by reference to descriptive statistics, including the mean, standard deviation (SD), and 95% confidence interval (CI); the relative frequencies of the variables were also analyzed. Normalization tests, Kolmogorov‒Smirnov tests with Lilliefors correction, and Q‒Q tests were used to compare the goodness-of-fit to an average data distribution with regard to continuous or discrete quantitative variables. The comparison of two or three independent means was performed using Student’s t test and analyses of variance for each variable. The Χ 2 test with Yates’ correction was used to compare percentages and Pearson’s correlation (r) coefficients across the quantitative variables. Finally, associations among the NPEB and the other variables were studied through multiple linear regression. Participant observation was used to support the qualitative study of the reflective ethnographic type [ 39 , 40 ], and this process ended when the data reached saturation. Two researchers developed transcripts for the interviews based on the recorded interviews and added descriptions based on the notes from the field notebook. The identification of themes and patrons was based on a process of triangulation among the researchers and by cross-checking the results. The interviews with nurses were analyzed to summarize the content analysis and identify keywords and concurrency among the terms. The themes thus identified included Green Teams, sustainable environmental behaviors, environment awareness, leadership barriers and limitations and areas for improvement.

EPIDAT (version 4.2) and SPSS (version 25) software were used to support the quantitative analysis. The computer program ATLAS.ti (version 22) and the Office Package with Microsoft Word Excel (version 2019) were used for the interviews and the visualization of the keywords based on the themes identified based on the records, observations and field notebooks.

Nurses’ awareness, knowledge, attitudes and skills.

The ages of the Spanish staff, mainly nurses, included in this study ( N  = 314) ranged from 19 to 68, with a mean age of 37.02 ± 12.7, CI = 95%, 35.6–38.4 years); in addition, 76.4% of these participants were women with more than 20 years of working experience (35.1%), and the majority were registered nurses (70.4%). Moreover, 113 (36%) participants worked at a local or regional hospital (30%) and were employees of a public institution (85.3%). Half of the nurses (157) worked only a morning shift (Table  1 ) in Andalusia, Madrid, or Catalonia (62.4%). The diverse autonomous regions on which this research focused were homogenously distributed and structured in line with the population. The analysis of these areas was also based on the specific inclusion of environmental units led by nurses (Andalusia, Madrid, and Catalonia), in contrast with regions featuring undetermined units or leaders related to this topic (such as Valencia) (37.5%).

Regarding nursing awareness, nurses scored higher on the PEB (31.83 ± 8.02 CI 95% 30.94–32.72 with regard to frequency vs. 32.36 ± 7.15 CI 95% 31.57–33.15 with respect to difficulty) than on the NAS (26.13 ± 9.91 CI 95% 25.03–27.23 with regard to knowledge vs. 47.39 ± 5.97 CI 95% 46.73–48.05 with respect to impact) and the NPEB (23.82 ± 6.45 CI 95% 23.10-24.53 with regard to frequency vs. 25.71 ± 6.31 CI 95% 25.01–26.41 with respect to difficulty). These results indicated that environmental knowledge among the Spanish population was limited (55.7%), although the nurses included in this research were aware of their potential impact on the environment (70.4%). The PEB subscale focused mostly on following environmental guidelines in their homes (57.3%) because these sustainable domestic tasks are easier for them (63.1%) than tasks in the professional field. The second subscale, NPEB, indicated that sustainable activities such as recycling were easy for the participants (57.6%), but sometimes they engaged in such activities less frequently than they would like (52.2%) (Fig.  1 and Fig.  2 ).

Representation of the frequency of nursing environmental behavior

Difficulty of engaging in adequate environmental behaviors

The sociodemographic variables indicated differences among the NEAT subscales (Table  2 ). Gender, working experience (with a median value of 10 years), and the position held in the institution and region were relevant with regard to environmental knowledge ( p  < 0.01), environmental behavior outside the workplace ( p  < 0.01), and environmental behavior in the workplace ( p  < 0.01).

The NPEB was associated with the worst scores, thereby reflecting the nurses’ environmental behavior and activities in the workplace (52.23% rarely performed relevant activities, and 35.03% indicated that doing so was difficult) (Fig.  1 and Fig.  2 ). The NPEB values pertaining to environmental behavior were positively linked to age ( r  = 0.412; p  < 0.001), NAS knowledge ( r  = 0.526; p  < 0.001), PEB frequency ( r  = 0. 57; p  < 0.001), PEB difficulty ( r  = 0.329; p  < 0.001), and finally, difficulty performing adequate environmental behaviors ( r  = 0.499; p  < 0.001). Additionally, the value of the NPEB with regard to the difficulty of performing adequate environmental behaviors was positively associated with age ( r  = 0.149; p  = 0.008), NAS knowledge ( r  = 0.249; p  < 0.001), PEB frequency ( r  = 0. 244; p  < 0.001) and PEB difficulty ( r  = 0.442; p  < 0.001).

Based on the relevance of certain sociodemographic variables, the nurses’ environmental awareness (NAS) and their behavior outside the workplace (PEB), linear multiple regression was performed to investigate nursing behavior in the workplace (NPEB). The initial model (square sum = 488.655; p  < 0.0001) indicated that age, the impact of nursing awareness (NAS), and the frequency of sustainable behaviors outside the workplace (PEB) were not relevant to nursing behavior in the workplace (NPEB) in terms of the frequency of performing adequate behavior or the difficulties experienced ( p  > 0.05). Based on these results, the adjusted model was calculated (Table  3 ), indicating that NPEB depends on PEB frequency and NAS knowledge ( p  < 0.01).

Nursing environmental behavior in the context of Green Teams: Barriers and areas for improvement.

The participants in the qualitative study ( N  = 10) included nine women and one man; their median age was 49 years; they exhibited an interval quartile range of 35–60; they had levels of working experience ranging between 20 and 30 years, and they worked only in the mornings (7/10). Furthermore, the group including nurses and nursing supervisors (5/10) exhibited higher levels of education (see Supplementary file 2 ). The themes identified via repetition and associations during the interviews and observations indicated links among nurses’ responsibilities on the Green Team since they conformed to the nature of such teams (i). This team and nursing leaders identified sustainable environmental behavior (ii) that could improve environmental awareness (iii), knowledge, aptitude, and skills. The nurses who are responsible for sustainable changes should be the leaders (iv), and the relevant barriers and limitations (v) and areas for improvement (vi) in diverse areas should be identified simultaneously.

Green teams were linked to nursing responsibilities in the context of environmental sustainability.

In the interviews, the Green Teams, led by environmental leader nurses and comprising various staff members, were identified as crucial committees dedicated to enhancing environmental awareness and knowledge among hospital staff. Participants indicated that these teams facilitated regular meetings to discuss sustainable practices and played a pivotal role in testing behaviors and knowledge related to environmental sustainability. The Green Teams were highlighted as platforms for fostering collaboration and discussion surrounding sustainable practices. Participants noted that these teams facilitated the main purpose of the team and its members to improve the hospital staff’s knowledge and attitudes via meetings (RN 2,3 and NL 1,3). Subsequently, the NL also indicated a key role of the team in the testing of behaviors and knowledge. The behavior of registered nurses should be tested using questions according to the NLs. Also, the NLs are included in disponibility of of proper disposal methods for medical waste:

“So, where is the rubbish bin for medicines, that white one that you showed in the session that is used for the remains of medicines that we do not give to patients?” [(NL5)]

By such comments, it can be inferred that the Green Team not only disseminates information, manages the training and measures knowledge but also ensures that staff members understand and adhere to best practices in waste management. These tasks of the NLs and other RNs in the Green Team contribute to the overall efficiency and effectiveness of environmental sustainability efforts within the hospital.

Sustainable environmental behaviors were emerged by Green Teams.

The results of the analysis indicated some degree of resistance among the nurses working at the clinical management units with regard to their lack of competencies, especially those pertaining to knowledge, skills and attitudes. The comments from the interviews highlighted potential factors contributing to this resistance, including age-related differences, varying levels of awareness, and challenges in applying the principles of reduce, reuse, and recycle (the three Rs). For instance, one repetitive comment expressed a sentiment of uncertainty, stating “It is what is, but we don’t know it or what to do with it” (RN 3,4,5, and NL 2,3).

“We know what the light packing is, and they (maintenance people) installed it to reduce the lights and reduce the expense and cost, but we don’t know what to do with the rubbish bins” [(NL 4)]

This comment highlights a disconnect between awareness of specific sustainable initiatives and the practical knowledge to implement them effectively. All comments reflect the importance of addressing knowledge gaps and providing practical guidance to support nurses in adopting sustainable environmental behaviours. By acknowledging and addressing these challenges, healthcare facilities can enhance their environmental stewardship efforts and promote a culture of sustainability among staff members.

Environmental awareness were drawn from the nursing responsibilities that led to the creation of the Green Team.

The comments indicated that environmental awareness among nurses was influenced by training sessions and courses on environmental sustainability. After receiving training featuring lectures and courses on environmental sustainability, the leaders also reflected on the ways in which nurses put the recommendations made during the environmental sustainability courses into practice. Moreover, the leaders indicated that education should be beyond formal training sessions. The environmental leaders were interested in supplementing these courses with environmental education practices for the general population, as noted, for example, in reports of discharge from patient care or cycling on the ward. These activities indicated the ideal of including a holistic approach to sustainability within the healthcare setting.

Relevant statements included, “We have to separate residues according to the material… light plastic goes to… it is important for the unit and all of us” (NL 2,5). One key point that the referees and registered nurses highlighted pertained to the climate, particularly the lack of water (NL 1–5 and RN 1,2).

“The drought is getting worse; I don’t know how we are going to keep up… we hope it rains soon” [(RN1)]

Overall, the interviews shed light on the efforts to foster environmental awareness among nurses through formal training and practical integration into everyday practices. These observations emphasize the importance of ongoing education and action in addressing environmental concerns within healthcare settings.

Leadership, which was linked by comments to the Green Teams.

The interviews revealed that leadership, particularly within the context of Green Teams, is crucial in promoting environmental awareness and fostering a culture of sustainability among nursing staff. All the participants ( n  = 10) indicated that the presence of adequate knowledge, meetings and awareness among nursing staff were the most important factors. These factors were identified as key drivers in promoting sustainable practices within the healthcare environment. NLs indicated the importance of creating a supportive working environment where nurses feel comfortable asking questions and seeking clarification without fear of negative feedback. Relevant statements included, “It is key to receive feedback from the nurses and provide a good working environment so that they can ask questions and reflect without negative comments” (NL 1,2,4, and RN 1,2). This working environment allowed the registered nurses to ask for help regarding the three Rs:

“Could you remind me (referring to the environmental coordinator) how the sustainable guidelines were included in the discharge report for the continuity of care; I remember some things from the course you gave us, but I want to convey it completely to my patient” [(RN2)]

Barriers and limitations, were drawn from nurses’ responsibilities.

Several nurses indicated that the difficulties they encountered with regard to performing environmental behaviors pertained to the lack of time, adequate bins, and space as well as the limited number of nurses per patient in the wards. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. One factor that increased the barriers to environmental adequacy was the pandemic, which increased waste and rubbish. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. Relevant statements included “There are not enough green rubbish bins for COVID waste” (EL 1,4,5 and RN1,2) and “How are we going to recycle if we don’t even have time to care for patients?” (RN 1,2 and NL 3).

All these comments indicated the barriers the nurses faced, but they also suggested possibilities for improvement. The pandemic, despite overloading nurses, also improved their awareness.

Areas subject to improvement emerged from nursing responsibilities, limitations and leadership.

Nurses indicated that despite their general levels of environmental awareness and the courses they had received, participants performed better regarding their recycling behaviors at home than at the hospital. Participants acknowledged performing better in recycling practices within their personal spaces, suggesting a potential gap in translating theoretical knowledge into practical action within the healthcare environment. Relevant statements included “It’s just that I recycle almost everything in my house, especially glass…, but here, there is no time…” (RN 1,4,5).

Moreover, time constraints emerged as a significant barrier impeding nurses’ ability to engage fully in environmental sustainability efforts. Participants cited the demanding nature of their work, particularly in the context of patient care responsibilities, as limiting their capacity to prioritize sustainability initiatives. This highlights the need for strategies to streamline environmental practices and integrate them seamlessly into nurses’ daily routines without adding undue burden.

Some statements also highlighted nurses’ willingness to improve paperwork and records. Nurses recognized the importance of incorporating environmental considerations into patient discharge reports and other documentation processes but sought further guidance on how to effectively implement these practices. Relevant statements included “Can you tell me how the patient’s continuity care report upon discharge was included in the recommendations for environmental sustainability… I want to do the report well with what you gave us in the clinical session the other day…” [(NL4)]

These comments indicated the opportunities for improvement in fostering a culture of environmental sustainability within the hospital setting. By addressing the identified challenges and providing targeted support and guidance, especially the lack of time, nurses can contribute to environmental stewardship efforts more effectively.

The current research highlights the relevance of nurses as promoters of environmentally sustainable behaviors in their roles as members of Green Teams and important leaders. The findings suggest that nurses exhibit acceptable knowledge, attitudes, and behaviors with regard to environmental sustainability both inside and outside the workplace. These results are complemented by a qualitative analysis indicating that such behaviors originate from nursing responsibility, Green Teams, leadership identification of barriers and areas of improvement. Both analyses highlight the fact that environmental nursing behavior in the workplace depends on sustainable behaviors outside the workplace. The qualitative analysis also identifies diverse barriers to the task of promoting sustainable behavior within the workplace, such as the COVID-19 pandemic and the need for more time to be allocated to this process. One key point identified by both analyses is that nurses have acceptable levels of knowledge; however, their attitudes, although as yet imperfect, are improving.

Several studies of nurses’ awareness of environmental sustainability have revealed that nurses exhibit moderate levels of awareness and a considerable degree of concern regarding the health impacts of climate change [ 37 , 42 , 43 ], as reflected in the NEAT-es results.

Interestingly, the participants exhibited a tendency to perform environmentally sustainable behaviors more consistently in their personal lives than in professional settings. These results are consistent with previous research on registered nurse and nursing students [ 36 , 41 , 42 ]. According to Swedish research, nurses generally recognize environmental issues but may lack awareness of the environmental impact of health care [ 43 ]. Polivka Barbara J. et al. (2012) highlighted the gap between nurses’ knowledge of sustainability and workplace behaviors, thereby emphasizing the need for education and training programs to promote sustainable practices [ 44 ]. These issues were also observed in a study conducted in Taiwan, which revealed that while nursing students exhibit positive attitudes toward sustainability, their knowledge and behaviors are inadequate [ 45 ].

By conducting qualitative analysis, this research also identified multiple barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions caused by the COVID-19 pandemic, a lack of bins, and a lack of health care personnel. These findings are in line with those reported in other research, but certain barriers (in terms of resources, time, and support) to the implementation of sustainable practices in the workplace remain [ 29 ]. This study suggests that interventions should be designed to address these barriers and promote sustainable behavior among nurses, a suggestion which is consistent with the current research. These findings highlight the importance of comprehending nurses’ perspectives on environmental sustainability in health care contexts as well as the necessity for targeted interventions and support mechanisms [ 46 ]. The tasks assigned to nursing leaders and the Green Team involved addressing these barriers and promoting sustainable practices among nurses in the context of their professional roles. Environmental nursing leaders seem to be crucial with regard to establishing a more environmentally conscious health care environment, which is in line with recommendations to create a greener health care system [ 21 , 31 ]. Despite the results of the interviews, some global qualitative studies of nurses’ views on environmental issues have exhibited variations across countries [ 47 , 48 ]. In Sweden, nurses already exhibit pro-sustainability attitudes before the introduction of the 2030 SDGs [ 16 ]. However, the integration of environmental sustainability education into nursing programs can prepare future nurses more effectively to address the challenges associated with climate change and promote sustainable health outcomes [ 49 ].

Limitations

Although this investigation provides valuable insights, it is important to acknowledge its limitations. First, the study was conducted during the COVID-19 pandemic in Spain, which may have influenced the results due to the unique circumstances and stressors faced by health care workers during this period. Additionally, the assessment of nurses’ environmental awareness was performed on a larger scale, i.e., across multiple regions, and therefore may not accurately reflect individual attitudes and behaviors since the qualitative investigations focused on a specific region. However, this approach was adopted to minimize the risk of the ecological fallacy. Future studies could explore individual perspectives and experiences by reference to more diverse and representative samples.

Despite these limitations, this research is highly relevant because it sheds light on the role of nurses in the task of promoting environmental sustainability in health care settings. The research also emphasized the role of nursing leadership in the tasks of promoting environmental sustainability and providing nurses with the necessary resources and support to implement sustainable practices.

In conclusion, while nurses generally exhibit acceptable levels of knowledge, attitudes, and behaviors regarding environmental sustainability, a notable gap persists in terms of the frequency of sustainable actions within the professional settings in which they operate. This finding highlights the importance of closely aligning nurses’ personal and professional sustainability practices.

The qualitative analysis conducted as part of this study identified several barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions resulting from the COVID-19 pandemic, issues with waste disposal, and challenges related to health care personnel. Despite the fact that these findings are in line with those reported in previous research, persistent barriers such as limited resources, time, and support hinder the implementation of sustainable practices in the workplace. Therefore, interventions aimed at addressing these barriers and promoting sustainable behavior among nurses are essential, as highlighted by both current research and the corresponding qualitative insights. Therefore, nursing leaders and Green Teams are pivotal with regard to overcoming these barriers and fostering sustainable practices within health care environments. Environmental nursing leaders in particular are instrumental to the cultivation of a more environmentally conscious health care system, thereby aligning with recommendations for greener health care practices.

Data availability

The datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request.

Romanello M, Di Napoli C, Drummond P, Green C, Kennard H, Lampard P, et al. The 2022 report of the Lancet countdown on health and climate change: health at the mercy of fossil fuels. Lancet. 2022;400(10363):1619–54. https://doi.org/10.1016/S0140-6736(22)01540-9

Article   PubMed   Google Scholar  

Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581–630. https://doi.org/10.1016/S0140-6736(17)32464-9

Fadhullah W, Imran NIN, Ismail SNS, Jaafar MH, Abdullah H. Household solid waste management practices and perceptions among residents in the East Coast of Malaysia. BMC Public Health. 2022;22(1):1. https://doi.org/10.1186/s12889-021-12274-7

Article   PubMed   PubMed Central   Google Scholar  

Castañeda-Hidalgo H, Visovsky C, Hernández DE, González-Quirarte NH, Compeán-Ortiz L, Campiño SM. Nursing’s contributions to Sustainable Development Goals in Latin America through education, leadership, and partnerships. Int J Nurs Studi. 2021;121:104004. https://doi.org/10.1016/j.ijnurstu.2021.104004

Article   Google Scholar  

Dossey BM, Rosa WE, Beck DM. Nursing and the Sustainable Development Goals: from Nightingale to now. Am J Nurs. 2019;119(5):44–9. https://doi.org/10.1097/01.NAJ.0000557912.35398.8f

Rosa WE, Dossey BM, Koithan M, Kreitzer MJ, Manjrekar P, Meleis AI, et al. Nursing theory in the Quest for the Sustainable Development Goals. Nurs Sci Q. 2020;33(2):178–82. https://doi.org/10.1177/0894318420903495

United Nations Department of Economic and Social Affairs. Sustainable Development Knowledge Platform. In: Open Working Group proposal for Sustainable Development Goals. 2023. https://sustainabledevelopment.un.org/content/documents/1579SDGs Proposal.pdf.Accessed 17 Apr 2023.

Sanahuja JA. El Pacto Verde, NextGenerationEU y la nueva Europa geopolítica. In: Fundación Carolina.2022. https://www.fundacioncarolina.es/dt_fc_63/ . Accessed 17 Apr 2023.

Boto-Álvarez A, García-Fernández R. Implementation of the 2030 Agenda Sustainable Development Goals in Spain. Sustainability. 2020;12(6):2546. https://doi.org/10.3390/su12062546

Gomera Martínez A,Villamandos, de la Torre F, Vaquero Abellán. M,. Measurement and categorization of environmental awareness in university students: the contribution of the University to strengthen it. Ambientalización curricular y sostenibilidad. Nuevos retos de profesionalización docente. 2012;16(2):215– 28.

Ministerio de Sanidad. Plan Estratégico de Salud y Medioambiente 2022–2026. In: Ministerio para la Transición Ecológica y el Reto Demográfico.2021. https://www.sanidad.gob.es/ciudadanos/pesma/docs/241121_PESMA.pdf . Accessed 25 Apr 2023.

Ministerio de Sanidad. Plan Estratégico de Salud y Medioambiente. In: 1 a Programa de Actuación. Ministerio para la Transición Ecológica y el Reto Demográfico;2022. https://www.sanidad.gob.es/ciudadanos/pesma/docs/1er_PA_PESMA.pdf . Accessed 25 Apr 2023.

Hart J. Health Care without Harm: taking Environmental Action to improve lives and the planet. Integr Complement Ther. 2022;28(5):251–4. https://doi.org/10.1089/ict.2022.29036.pro

Health Care Without Harm. Hospitales que curan el planeta. In: Informe sobre el trabajo de los miembros de la Red Global de Hospitales Verdes y Saludables en América Latina. Red Global de Hospitales Verdes y Saludables en America Latina. 2022. https://saludsindanio.org/sites/default/files/documents-files/7287/Hospitales que curan el planeta 2022-FINAL_web_0 %281%29_0.pdf . Accessed 25 Apr 2023.

McDermott-Levy R. The nurse’s role on green teams: an environmental health opportunity. Pa Nurse. 2011;66(1):17–21.

PubMed   Google Scholar  

Schenk E, Johnson S. Nurse-sensitive environmental indicators: a qualitative study. J Nurs Manag. 2022;30(8):4378–86. https://doi.org/10.1111/jonm.13861 . Epub 2022 Oct 20.

Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epidemiological analysis. PLoS Med. 2018;15(7):e1002623. https://doi.org/10.1371/journal.pmed.1002623

Article   CAS   PubMed   PubMed Central   Google Scholar  

Mateen A, Nisar QA, Nasir N. Fostering pro-environmental behaviors in the healthcare organizations: an empirical analysis of psychological and strategic factors. Asia Pac Manage Rev. 2023;28(1):13–23. https://doi.org/10.1016/j.apmrv.2022.01.004

Michie S, West R. Sustained behavior change is key to preventing and tackling future pandemics. Nat Med. 2021;27(5):749–52. https://doi.org/10.1038/s41591-021-01345-2

Article   CAS   PubMed   Google Scholar  

Mejia EA, Sattler B. Starting a Health Care System Green Team. AORN J. 2009;90(1):33–40. https://doi.org/10.1016/j.aorn.2009.03.001

Practice Green Health. Comparison chart of hospital green teams and their structure. 2019. https://practicegreenhealth.org/sites/default/files/2019-02/Comparison chart of hospitals green team structure_2017.pdf . Accessed 1st Frebuary 2024.

Dickman E, Backler C, Berg CD, Komandt M, Schiller J. Climate change and oncology nursing: a call to action. Clin J Oncol Nurs. 2022;26(1):109–13. https://doi.org/10.1188/22.CJON.109-113

de la Gámez J, Padilla Fortes A. Análisis De La producción científica visible en internet de Los técnicos de salud ambiental del Servicio Andaluz De Salud. Rev GeI Inf Doc. 2010;20:409–25.

Google Scholar  

Filho W. Non-conventional learning on sustainable development: achieving the SDGs. Environ Sci Eur. 2021. https://doi.org/10.1186/s12302-021-00525-8 . 33;97.

Filho W, Tripathi S, Andrade Guerra JB, Gine R, Orlovic Lovren V, Willats J. Using the sustainable development goals towards a better understanding of sustainability challenges. Int J Sustainable Dev World Ecol. 2018;26:1–12. https://doi.org/10.1080/13504509.2018.1505674

Portela Dos Santos O, Melly P, Joost S, Verloo H. Climate Change, Environmental Health, and challenges for nursing Discipline. Int J Environ Res Public Health. 2023;20(9):5682. https://doi.org/10.3390/ijerph20095682

Sattler B, Randall KS, Choiniere D. Reducing Hazardous Chemical exposures in the neonatal intensive care unit: a New Role for nurses. Crit Care Nurs Q. 2012;35(1):102–11. https://doi.org/10.1097/CNQ.0b013e31823b2084

Trent L, Law J, Grimaldi D. Create intensive care green teams, there is no time to waste. Intensive Care Med. 2023;49(4):440–3. https://doi.org/10.1007/s00134-023-07015-w

Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Environmental responsibility in hospital care: findings from a qualitative study. J Hosp Adm. 2018;7(5):56. https://doi.org/10.5430/jha.v7n5p56

Rosa WE, Catton H, Davidson PM, Hannaway CJ, Iro E, Klopper HC, et al. Nurses and midwives as Global Partners to achieve the Sustainable Development Goals in the Anthropocene. J Nurs Scholarsh. 2021;53(5):552–60. https://doi.org/10.1111/jnu.12672

Harris N, Pisa L, Talioaga S, Vezeau T. Hospitals going green: a holistic view of the issue and the critical role of the nurse leader. Holist Nurs Pract. 2009;23(2):101–11. https://doi.org/10.1097/HNP.0b013e3181a110fe

Phiri MM, MacPherson EE, Panulo M, Chidziwisano K, Kalua K, Chawanangwa M, Chirambo, et al. Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study. BMJ Open. 2022;12(6):e051125. https://doi.org/10.1136/bmjopen-2021-051125

Ojemeni MT, Karanja V, Cadet G, Charles A, Dushimimana E, McMahon C, et al. Fostering nursing leadership: an important key to achieving sustainable development goals and universal health care. Int J Nurs Stud. 2019;100:103421. https://doi.org/10.1016/j.ijnurstu.2019.103421

German E. The environmental or ecological model of care. Nriagu JO. Encyclopedia of Environmental Health. Netherlands:Elsevier Science; 2019. pp. 447–50.

Vasset F, Fagerstrøm L, Frilund M. Sustainable Nursing Leadership in Nordic Health Care Organizations. Scand J Caring Sci. 2021;14(2):2–1527.

Kallio H, Pietilä AM, Kangasniemi M. Environmental responsibility in nursing in hospitals: a modified Delphi study of nurses’ views. J Clin Nurs. 2020;29(21–22):4045–56. https://doi.org/10.1111/jocn.15429

Richardson J, Grose J, Bradbury M, Kelsey J. Developing awareness of sustainability in nursing and midwifery using a scenario-based approach: evidence from a pre and post educational intervention study. Nurse Educ Today. 2017;54:51–5. https://doi.org/10.1016/j.nedt.2017.04.022

Luque-Alcaraz OM, Gomera A, Ruíz Á, Aparicio-Martinez P, Vaquero-Abellan M. Validation of the Spanish Version of the questionnaire on environmental awareness in nursing (NEAT). Healthcare. 2022;10(8):1420. https://doi.org/10.3390/healthcare10081420

Amezcua M. El Trabajo De Campo Etnográfico En Salud. Index Enferm (Gran). 2000;30:30–5.

Jamali HR. Does research using qualitative methods (grounded theory, ethnography, and phenomenology) have more impact? Libr Inform Sci Res. 2018;40(3):201–7. https://doi.org/10.1016/j.lisr.2018.09.002

Cowie J, Nicoll A, Dimova ED, Campbell P, Duncan EA. The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review. BMC Health Serv Res. 2020;20(1):588. https://doi.org/10.1186/s12913-020-05434-9

Kircher M, Doheny BM, Raab K, Onello E, Gingerich S, Potter T. Understanding the knowledge, attitudes, and practices of Healthcare professionals toward Climate Change and Health in Minnesota. Challenges. 2022;13(2):57. https://doi.org/10.3390/challe13020057

Boström M, Andersson E, Berg M, Gustafsson K, Gustavsson E, Hysing E, et al. Conditions for transformative learning for Sustainable Development: A Theoretical Review and Approach. Sustainability. 2018;10(12):4479. https://doi.org/10.3390/su10124479

Polivka BJ, Chaudry RV, Crawford JM. Public Health nurses’ knowledge and attitudes regarding Climate Change. Environ Health Perspecti. 2012;120(3):321–5. https://doi.org/10.1289/ehp.1104025

Hsieh PL, Chen SH, Chang LC. School nurses’ perceptions, knowledge, and related factors Associated with evidence-based practice in Taiwan. Int J Environ Res Public Health. 2018;15(9):1845. https://doi.org/10.3390/ijerph15091845

Rojas-Perez HL, Díaz-Vásquez MA, Díaz-Manchay RJ, Zeña-Ñañez S, Failoc-Rojas VE, Smith D. Nurses’ environmental practices in Northern Peruvian hospitals. Workplace Health Saf. 2024;72(2):68–74. https://doi.org/10.1177/21650799231163130

Anåker A, Nilsson M, Holmner Å, Elf M. Nurses’ perceptions of climate and environmental issues: a qualitative study. J Adv Nurs. 2015;71(8):1883–91. https://doi.org/10.1111/jan.12655

Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954–65. https://doi.org/10.1111/jan.13031

International Council of Nurses. International Nurses Day 2023 report. Value, protect, respect and invest in our nurses for a sustainable future for nursing and health care.2023. https://www.icn.ch/news/icn-marks-international-nurses-day-launch-its-our-nurses-our-future-campaign . Accessed 25 Apr 2023.

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Acknowledgements

The authors would like to thank the Excellent Official Nursing School and all the professionals who participated in this research for their support.

This research received no external funding; however, the project did receive an award from the Excellent Official Nursing School in Cordoba, Spain, in 2020.

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A.G. and M. V-A. conceived and designed the study, and O.M. L. and P.A-M. acquired the data, analyzed and interpreted the data, and drafted the article. The publication and supervision of the article were the responsibility of A.G. and M. V-A. All authors contributed equally to the writing and preparation of the final manuscript.

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Ethical approval was obtained from the Ethics Committee of Reina Sofia Hospital of Cordoba, which is part of the Andalusian Health Care System in Spain (Act No. 267, ref.3605). This research was in line with the Organic Law 3/2018 of December 5 on the Protection of Personal Data and Guarantee of Digital Rights as well as the Nursing Ethics Code and the 1964 Declaration of Helsinki. The participants were informed of the study’s purpose before participation; their informed consent was obtained, and they were informed that they were able to withdraw from the study at any stage. All the data were obtained after informed consent was collected; in addition, the data were anonymized and saved securely in a database, thereby maintaining all stipulations of the Personal Data Law.

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Luque-Alcaraz, O.M., Aparicio-Martínez, P., Gomera, A. et al. The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis. BMC Nurs 23 , 229 (2024). https://doi.org/10.1186/s12912-024-01895-z

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DOI : https://doi.org/10.1186/s12912-024-01895-z

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