sample nursing research critique paper

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Barker J, Linsley P, Kane R, 3rd edn. London: Sage; 2016

Ethical guidelines for educational research. 2018; https://tinyurl.com/c84jm5rt

Bowling A Research methods in health, 4th edn. Maidenhead: Open University Press/McGraw-Hill Education; 2014

Gliner JA, Morgan GAMahwah (NJ): Lawrence Erlbaum Associates; 2000

Critical Skills Appraisal Programme checklists. 2021; https://casp-uk.net/casp-tools-checklists

Cresswell J, 4th edn. London: Sage; 2013

Grainger A Principles of temperature monitoring. Nurs Stand. 2013; 27:(50)48-55 https://doi.org/10.7748/ns2013.08.27.50.48.e7242

Jupp VLondon: Sage; 2006

Continuing professional development (CPD). 2021; http://www.hcpc-uk.org/cpd

London: NHS England; 2017 http://www.hee.nhs.uk/our-work/advanced-clinical-practice

Kennedy M, Burnett E Hand hygiene knowledge and attitudes: comparisons between student nurses. Journal of Infection Prevention. 2011; 12:(6)246-250 https://doi.org/10.1177/1757177411411124

Lindsay-Smith G, O'Sullivan G, Eime R, Harvey J, van Ufflen JGZ A mixed methods case study exploring the impact of membership of a multi-activity, multi-centre community group on the social wellbeing of older adults. BMC Geriatrics. 2018; 18 https://bmcgeriatr.biomedcentral.com/track/pdf/10.1186/s12877-018-0913-1.pdf

Morse JM, Pooler C, Vann-Ward T Awaiting diagnosis of breast cancer: strategies of enduring for preserving self. Oncology Nursing Forum. 2014; 41:(4)350-359 https://doi.org/10.1188/14.ONF.350-359

Revalidation. 2019; http://revalidation.nmc.org.uk

Parahoo K Nursing research, principles, processes and issues, 3rd edn. Basingstoke: Palgrave Macmillan; 2014

Polit DF, Beck CT Nursing research, 10th edn. Philadelphia (PA): Wolters Kluwer; 2017

Critiquing a published healthcare research paper

Angela Grainger

Nurse Lecturer/Scholarship Lead, BPP University, and editorial board member

View articles · Email Angela

Research is defined as a ‘systematic inquiry using orderly disciplined methods to answer questions or to solve problems' ( Polit and Beck, 2017 :743). Research requires academic discipline coupled with specific research competencies so that an appropriate study is designed and conducted, leading to the drawing of relevant conclusions relating to the explicit aim/s of the study.

Relevance of research to nursing and health care

For those embarking on a higher degree such as a master's, taught doctorate, or a doctor of philosophy, the relationship between research, knowledge production and knowledge utilisation becomes clear during their research tuition and guidance from their research supervisor. But why should other busy practitioners juggling a work/home life balance find time to be interested in healthcare research? The answer lies in the relationship between the outcomes of research and its relationship to the determination of evidence-based practice (EBP).

The Health and Care Professions Council (HCPC) and the Nursing and Midwifery Council (NMC) require registered practitioners to keep their knowledge and skills up to date. This requirement incorporates being aware of the current EBP relevant to the registrant's field of practice, and to consider its application in relation to the decisions made in the delivery of patient care.

Advanced clinical practitioners (ACPs) are required to be involved in aspects of research activities ( Health Education England, 2017 ). It is for this reason that practitioners need to know how EBP is influenced by research findings and, moreover, need to be able to read and interpret a research study that relates to a particular evidence base. Reading professional peer-reviewed journals that have an impact factor (the yearly average number of citations of papers published in a previous 2-year period in a given journal is calculated by a scientometric index giving an impact factor) is evidence of continuing professional development (CPD).

CPD fulfils part of the HCPC's and the NMC's required professional revalidation process ( HCPC, 2021 ; NMC, 2019 ). For CPD in relation to revalidation, practitioners can give the publication details of a research paper, along with a critique of that paper, highlighting the relevance of the paper's findings to the registrant's field of practice.

Defining evidence-based practice

According to Barker et al (2016:4.1) EBP is the integration of research evidence and knowledge to current clinical practice and is to be used at a local level to ensure that patients receive the best quality care available. Because patients are at the receiving end of EBP it is important that the research evidence is credible. This is why a research study has to be designed and undertaken rigorously in accordance with academic and scientific discipline.

The elements of EBP

EBP comprises three elements ( Figure 1 ). The key element is research evidence, followed by the expert knowledge and professional opinion of the practitioner, which is important especially when there is no research evidence—for example, the most appropriate way to assist a patient out of bed, or perform a bed bath. Last, but in no way of least importance, is the patient's preference for a particular procedure. An example of this is the continued use of thermal screening dots for measuring a child's temperature on the forehead, or in the armpit because children find these options more acceptable than other temperature measuring devices, which, it is argued, might give a more accurate reading ( Grainger, 2013 ).

Understanding key research principles

To interpret a published research study requires an understanding of key research principles. Research authors use specific research terms in their publications to describe and to explain what they have done and why. So without an awareness of the research principles underpinning the study, how can readers know if what they are reading is credible?

Validity and reliability have long been the two pillars on which the quality of a research study has been judged ( Gliner and Morgan, 2000 ). Validity refers to how accurately a method measures what it is intended to measure. If a research study has a high validity, it means that it produces results that correspond to real properties, characteristics, and variations in the part of the physical or social world that is being studied ( Jupp, 2006 ).

Reliability is the extent to which a measuring instrument, for example, a survey using closed questions, gives the same consistent results when that survey is repeated. The measurement is considered reliable if the same result can be consistently achieved by using the same methods under the same circumstances ( Parahoo, 2014 ).

The research topic is known as the phenomenon in a singular sense, or phenomena if what is to be researched is plural. It is a key principle of research that it is the nature of the phenomenon, in association with the study's explicit research aim/s, that determines the research design. The research design refers to the overall structure or plan of the research ( Bowling, 2014 :166).

Methodology means the philosophy underpinning how the research will be conducted. It is essential for the study's research design that an appropriate methodology for the conduct and execution of the study is selected, otherwise the research will not meet the requirements of being valid and reliable. The research methods will include the design for data sampling, how recruitment into the study will be undertaken, the method/s used for the actual data collection, and the subsequent data analysis from which conclusions will be drawn (see Figure 2 ).

Quantitative, qualitative, and mixed-methods studies

A quantitative methodology is where the phenomenon lends itself to an investigation of data that can be numerically analysed using an appropriate statistical test/s. Quantitative research rests on the philosophical view that science has to be neutral and value-free, which is why precise measurement instruments are required ( Box 1 ). Quantitative research is influenced by the physical sciences such as mathematics, physics, and chemistry. The purpose of quantitative studies is to identify whether there are any causal relationships between variables present in the phenomenon. In short, a variable is an attribute that can vary and take on different values, such as the body temperature or the heart rate ( Polit and Beck, 2017 :748).

Quantitative studies can sometimes have a hypothesis. A hypothesis is a prediction of the study's outcome, and the aim of the study is to show either that the hypothesis is demonstrated as proven, or that it is not proven. Often a hypothesis is about a predicted relationship between variables. There are two types of variables, independent and dependent. An independent variable causes a change in the specific phenomenon being studied, while a dependent variable is the change in that phenomenon. The first example in Box 1 might help to clarify the difference.

An example of a hypothesis would be that older people who have a history of falls have a reduction in the incidence of falls due to exercise therapy. The causal relationship is between the independent variable— the exercise therapy—and the dependent variable—a falls reduction.

A qualitative methodology aims to explore a phenomenon with the aim of understanding the experience of the phenomenon from the perspective of those affected by it. Qualitative research is influenced by the social and not the physical sciences. Concepts and themes arise from the researcher/s interpretation of the data gained from observations and interviews. The collected data are non-numerical and this is the distinction from a quantitative study. The data collected are coded in accordance with the type of method being used in the research study, for example, discourse analysis; phenomenology; grounded theory. The researcher identifies themes from the data descriptions, and from the data analysis a theoretical understanding is seen to emerge.

A qualitative methodology rests on the philosophical view that science cannot be neutral and value-free because the researcher and the participants are part of the world that the research study aims to explore.

Unlike quantitative studies, the results of which can often be generalised due to the preciseness of the measuring instruments, qualitative studies are not usually generalisable. However, knowledge comparisons can be made between studies that have some similarity of focus. For example, the uncovering of causative or aggravating factors leading to the experiences of pain management for oncology patients, and for patients who have rheumatoid arthritis, or another long-term health problem for which pain is a characteristic feature. The validity of a qualitative study relates to the accurate representation of the data collected and analysed, and which shows that data has been saturated, meaning no new data or analysed findings are forthcoming. This is demonstrated in a clear data audit trail, and the study's findings are therefore seen as credible (see the second example in Box 1 ).

Box 1.Research study examples

• An example of a quantitative research study Kennedy and Burnett (2011) conducted a survey to determine whether there were any discernible differences in knowledge and attitudes between second- and third-year pre-registration nursing students toward hand-hygiene practices. The collected data and its subsequent analysis is presented in numerical tables and graphs, but these are supported by text explaining the research findings and how these were ascertained. For full details, see 10.1177/1757177411411124
• 2. An example of a qualitative research study Morse et al (2014) undertook an exploratory study to see what coping strategies were used by women awaiting a possible diagnosis of breast cancer. Direct quotes from the study participants appeared in the writing up of the research because it is a requirement of qualitative research that there be a transparent data audit trail. The research showed two things, both essential requirements of qualitative research. First, how the collected data were saturated to ensure that no data had been left inadequately explored, or that the data coding had been prematurely closed and, second, having captured the breadth and depth of the data findings, the researchers showed how the direct quotes were thematically coded to reveal the women's coping strategies. For full details, see 10.1188/14.ONF.350-359
• 3. An example of a mixed-methods study Lindsay-Smith et al (2018) investigated and explored the impact on elderly people's social wellbeing when they were members of a community that provided multi-activities. The study combined a quantitative survey that recorded participants' sociodemographic characteristics and measured participation in activities with a focus group study to gauge participants' perceptions of the benefits of taking part in the activities. For full details, see https://bmcgeriatr.biomedcentral.com/track/pdf/10.1186/s12877-018-0913-1.pdf

Sometimes a study cannot meet its stated research aims by using solely a quantitative or a qualitative methodology, so a mixed-methods approach combining both quantitative and qualitative methods for the collection and analysis of data are used. Cresswell (2013) explains that, depending on the aim and purpose of the study, it is possible to collect either the quantitative data first and analyse these, followed by the qualitative data and their analysis. This is an explanatory/exploratory sequence. Or the qualitative data may be collected first and analysed, followed by the quantitative; an exploratory/explanatory process. Whichever approach is used, the cumulative data analyses have to be synthesised to give a clear picture of the overall findings ( Box 1 ).

The issue of bias

Bias is a negative feature of research because it relates to either an error in the conceptualisation of the study due to the researcher/s adopting a skewed or idiosyncratic perspective, or to errors in the data analysis. Bias will affect the validity and reliability of a study, so it is important that any bias is eliminated in quantitative studies, or minimised and accounted for in qualitative studies.

Scientific and ethical approval

It should be noted that, before any research study proceeds, the research proposal for that study must have been reviewed and agreed to by a scientific and ethics committee. The purpose of a scientific and ethics committee is to see that those recruited into a study are not harmed or damaged, and that the study will contribute to the advancement of knowledge. The committee pays particular attention to whether any bias might have been introduced to a study. The researchers will have detailed the reason why the study is required, the explicit aim/s and purpose of the study, the methodology of the study, and its subsequent design, including the chosen research methods for the collection of the data (sampling and study recruitment), and what method/s will be used for data analysis.

A literature review is undertaken and the established (published) international literature on the research topic is summarised to highlight what is already known on the topic and/or to show any topic gaps that have not yet been researched. The British Educational Research Association (BERA) (2018) also gives guidance for research proposals that are deemed to be educational evaluation studies, including ‘close-practice’ research studies. Any ethical issues such as how people will be recruited into the study, the gaining of informed voluntary consent, any conflict of interest between the researcher/s and the proposed research topic, and whether the research is being funded or financially supported by a particular source will also have been considered.

SPH Writing Support Services

• Appointment System
• ESL Conversation Group
• Mini-Courses
• Thesis/Dissertation Writing Group
• Career Writing
• Citing Sources
• Critiquing Research Articles
• Project Planning for the Beginner This link opens in a new window
• Grant Writing
• Publishing in the Sciences
• Systematic Review Overview
• Systematic Review Resources This link opens in a new window
• Writing Across Borders / Writing Across the Curriculum
• Conducting an article critique for a quantitative research study: Perspectives for doctoral students and other novice readers (Vance et al.)
• Critique Process (Boswell & Cannon)
• The experience of critiquing published research: Learning from the student and researcher perspective (Knowles & Gray)
• A guide to critiquing a research paper. Methodological appraisal of a paper on nurses in abortion care (Lipp & Fothergill)
• Step-by-step guide to critiquing research. Part 1: Quantitative research (Coughlan et al.)
• Step-by-step guide to critiquing research. Part 2: Qualitative research (Coughlan et al.)

Guidelines:

• Critiquing Research Articles (Flinders University)
• Framework for How to Read and Critique a Research Study (American Nurses Association)
• How to Critique a Journal Article (UIS)
• How to Critique a Research Paper (University of Michigan)
• How to Write an Article Critique
• Research Article Critique Form
• Writing a Critique or Review of a Research Article (University of Calgary)

Presentations:

• The Critique Process: Reviewing and Critiquing Research
• Writing a Critique
• << Previous: Citing Sources
• Next: Project Planning for the Beginner >>
• Last Updated: Apr 30, 2024 12:52 PM
• URL: https://libguides.sph.uth.tmc.edu/writing_support_services

Reading and critiquing a research article

Nurses use research to answer questions about their practice, solve problems, improve the quality of patient care, generate new research questions, and shape health policy. Nurses who confront questions about practice and policy need strong, high-quality, evidence-based research. Research articles in peer-reviewed journals typically undergo a rigorous review process to ensure scholarly standards are met. Nonetheless, standards vary among reviewers and journals. This article presents a framework nurses can use to read and critique a research article.

When deciding to read an article, determine if it’s about a question you have an interest in or if it can be of use in your practice. You may want to have a research article available to read and critique as you consider the following questions.

Does the title accurately describe the article?

A good title will pique your interest but typically you will not know until you are done reading the article if the title is an accurate description. An informative title conveys the article’s key concepts, methods, and variables.

Is the abstract representative of the article?

The abstract provides a brief overview of the purpose of the study, research questions, methods, results, and conclusions. This helps you decide if it’s an article you want to read. Some people use the abstract to discuss a study and never read further. This is unwise because the abstract is just a preview of the article and may be misleading.

Does the introduction make the purpose of the article clear?

A good introduction provides the basis for the article. It includes a statement of the problem, a rationale for the study, and the research questions. When a hypothesis is being tested, it should be clearly stated and include the expected results.

Is a theoretical framework described?

When a theoretical framework is used, it should inform the study and provide a rationale. The concepts of the theoretical framework should relate to the topic and serve as a basis for interpreting the results. Some research doesn’t use a theoretical framework, such as health services research, which examines issues such as access to care, healthcare costs, and healthcare delivery. Clinical research such as comparing the effectiveness of two drugs won’t include a theoretical framework.

Is the literature review relevant to the study and comprehensive? Does it include recent research?

The literature review provides a context for the study. It establishes what is, and is not known about the research problem. Publication dates are important but there are caveats. Most literature reviews include articles published within the last 3 to 5 years. It can take more than a year for an article to be reviewed, revised, accepted, and published, causing some references to seem outdated.

Literature reviews may include older studies to demonstrate important changes in knowledge over time. In an area of study where little or no research has been conducted, there may be only a few relevant articles that are a decade or more old. In an emerging area of study there may be no published research, in which case related research should be referenced. If you are familiar with the area of research, review the references to determine if well-known and highly regarded studies are included.

Does the methods section explain how a research question was addressed?

The methods section provides enough information to allow the study to be replicated. Components of this section indicate if the design is appropriate to answer the research question(s).

• Did the researcher select the correct sample to answer the research questions and was the size sufficient to obtain valid results?
• If a data collection instrument was used, how was it created and validated?
• If any materials were used, such as written guides or equipment, were they described?
• How were data collected?
• Was reliability and validity accounted for?
• Were the procedures listed in a step-by-step manner?

Independent and dependent variables should be described and terms defined. For example, if patient falls in the hospital are considered the dependent variable, or outcome, what are the independent variables, or factors, being investigated that may influence the rate at which patient falls occur? In this example, independent variables might include nurse staffing, registered nurse composition (such as education and certification), and hospital Magnet &#174 status.

Is the analytical approach consistent with the study questions and research design?

The analytical approach relates to the study questions and research design. A quantitative study may use descriptive statistics to summarize the data and other tests, such as chi squares, t-tests, or regression analysis, to compare or evaluate the data. A qualitative study may use such approaches as coding, content analysis, or grounded theory analysis. A reader who is unfamiliar with the analytical approach may choose to rely on the expertise of the journal’s peer reviewers who assessed whether the analytical approach was correct.

Are the results presented clearly in the text and in tables and figures?

Results should be clearly summarized in the text, tables, and figures. Tables and figures are only a partial representation of the results and critical information may be only in the text. In a quantitative study, the significance of the statistical tests is important. The presentation of qualitative results should avoid interpretation, which is reserved for the discussion.

Are the limitations presented and their implications discussed?

It is essential that the limitations of the study be presented. These are the factors that explain why the results may need to be carefully interpreted, may only be generalized to certain situations, or may provide less robust results than anticipated. Examples of limitations include a low response rate to a survey, not being able to establish causality when a cross-sectional study design was used, and having key stakeholders refuse to be interviewed.

Does the discussion explain the results in relation to the theoretical framework, research questions, and significance of the study?

The discussion serves as an opportunity to explain the results in respect to the research questions and the theoretical framework. Authors use the discussion to interpret the results and explain the meaning and significance of the study. It’s also important to distinguish the study from others that preceded it and provide recommendations for future research.

Depending on the research, it may be equally important for the investigators to present the clinical and/or practical significance of the results. Relevant policy recommendations are also important. Evaluate if the recommendations are supported by the data or seem to be more of an opinion. A succinct conclusion typically completes the article.

Once you’re done reading the article, how do you decide if the research is something you want to use?

Determine the scientific merit of the study by evaluating the level and quality of the evidence. There are many scales to use, several of which can be found in the Research Toolkit on the American Nurses Association’s website http://www.nursingworld.org/research-toolkit.aspx . Consider what you learned and decide if the study is relevant to your practice or answered your question as well as whether you can implement the findings.

A new skill

A systematic approach to reading and critiquing a research article serves as a foundation for translating evidence into practice and policy. Every nurse can acquire this skill.

Louise Kaplan is director of the nursing program at Saint Martin’s University in Lacey, Washington. At the end of this article is a checklist for evaluating an article.

Selected references

Hudson-Barr D. How to read a research article. J Spec Pediatr Nurs . 2004;9(2):70-2.

King’s College D. Leonard Corgan Library. Reading a research article. http://www.lib.jmu.edu/ilworkshop08/materials/studyguide3.pdf . Accessed September 5, 2012.

Oliver D, Mahon SM. Reading a research article part I: Types of variables. Clin J Oncol Nurs . 2005;9(1):110-12.

Oliver D, Mahon SM. Reading a research article part II: Parametric and nonparametric statistics. Clin J Oncol Nurs . 2005;9(2):238-240.

Oliver D, Mahon SM. Reading a research article part III: The data collection instrument. Clin J Oncol Nurs . 2006;10(3):423-26.

Rumrill P, Fitzgerald S, Ware, M. Guidelines for evaluating research articles. Work . 2000;14(3):257-63.

15 Comments .

very helpful resource to critique any research article

I like it helped me a lot in my critical appraisal. thank you very much.

This article will help me with my understanding of how to read and critique a research article. This article was helpful in breaking down this information very basic to get a clear, concise understanding. Now I can take this information and go to the next level in my discussions

Great information and I will use this article for future reference.

This checklist and explanation for a literature review and/or reading and critiquing a research article was very helpful. As I only have 2 more classes to get my degree, I wish I knew this info 2 semesters ago! I will also pass this along to coworkers that will be going back to school in the near future.

Great article, I enjoyed the information. Thank You for this resource. Carolyn Martinez

Fantastic guide to the interpretation of clinical trials. Found this so helpful!

Great information and article. Thank you for the information.

well explained. its sometimes hard for P.G students to understand the concept but these guidelines are helpful to learn for novice.

This is great,am looking for guilgline on how to do research critique and this is just the solution.Thnks weldone

Unsure how to appropriately critique an article, thank you for your infomation

I am currently taking a Health Service Research course and was not sure how to sturcture my assignment. Thanks for posting this article!

very informative…very helpful to students doing research work.

Great timing; have just been asked to review and article and you provide the guide! Will share with colleagues.

I will be passing this article on to a friend who is taking a nursing research class. This article is a great reference for nursing students.

Comments are closed.

NurseLine Newsletter

• First Name *
• Last Name *
• Hidden Referrer

*By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. The details, including your email address/mobile number, may be used to keep you informed about future products and services.

Test Your Knowledge

Recent posts.

Effective clinical learning for nursing students

Nursing professional development at night

Engaging nurses in scholarly work

Mentorship matters

2023 nursing trends and salary survey results

NCLEX vs Next Generation

Patient care assistant training

Re-imagining nursing’s social contract with the public

Is there a nurse in the House? Or the Senate?

Prevent compassion fatigue through self-compassion

Implementing trauma-informed care 

Addressing transgender myths

Motivate Gen Z nursing students

Postural orthostatic tachycardia syndrome

Pulmonary hypertension: Consider the “zebra”

Making sense of research: A guide for critiquing a paper

Affiliation.

• 1 School of Nursing, Griffith University, Meadowbrook, Queensland.
• PMID: 16114192
• DOI: 10.5172/conu.14.1.38

Learning how to critique research articles is one of the fundamental skills of scholarship in any discipline. The range, quantity and quality of publications available today via print, electronic and Internet databases means it has become essential to equip students and practitioners with the prerequisites to judge the integrity and usefulness of published research. Finding, understanding and critiquing quality articles can be a difficult process. This article sets out some helpful indicators to assist the novice to make sense of research.

Publication types

• Data Interpretation, Statistical
• Research Design
• Review Literature as Topic

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Write for Us
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 22, Issue 1
• How to appraise qualitative research
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

• View inline

Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

• Download figure
• Open in new tab
• Download powerpoint

Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

Read the full text or download the PDF:

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

Nicol J, Tiedemann M. Legislative Summary: Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). Available from: https://lop.parl.ca/staticfiles/PublicWebsite/Home/ResearchPublications/LegislativeSummaries/PDF/42-1/c14-e.pdf .

Downie J, Scallion K. Foreseeably unclear. The meaning of the “reasonably foreseeable” criterion for access to medical assistance in dying in Canada. Dalhousie Law J. 2018;41(1):23–57.

Nicol J, Tiedeman M. Legislative summary of Bill C-7: an act to amend the criminal code (medical assistance in dying). Ottawa: Government of Canada; 2021.

Google Scholar  

Council of Canadian Academies. The state of knowledge on medical assistance in dying where a mental disorder is the sole underlying medical condition. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf .

Council of Canadian Academies. The state of knowledge on advance requests for medical assistance in dying. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2019/02/The-State-of-Knowledge-on-Advance-Requests-for-Medical-Assistance-in-Dying.pdf .

Council of Canadian Academies. The state of knowledge on medical assistance in dying for mature minors. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-for-Mature-Minors.pdf .

Health Canada. Third annual report on medical assistance in dying in Canada 2021. Ottawa; 2022. [cited 2023 Oct 23]. Available from: https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2021.html .

Banner D, Schiller CJ, Freeman S. Medical assistance in dying: a political issue for nurses and nursing in Canada. Nurs Philos. 2019;20(4): e12281.

Article   PubMed   Google Scholar  

Pesut B, Thorne S, Stager ML, Schiller CJ, Penney C, Hoffman C, et al. Medical assistance in dying: a review of Canadian nursing regulatory documents. Policy Polit Nurs Pract. 2019;20(3):113–30.

Article   PubMed   PubMed Central   Google Scholar  

College of Registered Nurses of British Columbia. Scope of practice for registered nurses [Internet]. Vancouver; 2018. Available from: https://www.bccnm.ca/Documents/standards_practice/rn/RN_ScopeofPractice.pdf .

Pesut B, Thorne S, Schiller C, Greig M, Roussel J, Tishelman C. Constructing good nursing practice for medical assistance in dying in Canada: an interpretive descriptive study. Global Qual Nurs Res. 2020;7:2333393620938686. https://doi.org/10.1177/2333393620938686 .

Article   Google Scholar  

Pesut B, Thorne S, Schiller CJ, Greig M, Roussel J. The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death. BMC Nurs. 2020;19:12. https://doi.org/10.1186/s12912-020-0404-5 .

Pesut B, Greig M, Thorne S, Burgess M, Storch JL, Tishelman C, et al. Nursing and euthanasia: a narrative review of the nursing ethics literature. Nurs Ethics. 2020;27(1):152–67.

Pesut B, Thorne S, Storch J, Chambaere K, Greig M, Burgess M. Riding an elephant: a qualitative study of nurses’ moral journeys in the context of Medical Assistance in Dying (MAiD). Journal Clin Nurs. 2020;29(19–20):3870–81.

Lamb C, Babenko-Mould Y, Evans M, Wong CA, Kirkwood KW. Conscientious objection and nurses: results of an interpretive phenomenological study. Nurs Ethics. 2018;26(5):1337–49.

Wright DK, Chan LS, Fishman JR, Macdonald ME. “Reflection and soul searching:” Negotiating nursing identity at the fault lines of palliative care and medical assistance in dying. Social Sci & Med. 2021;289: 114366.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;54(4):511–20.

Bruce A, Beuthin R. Medically assisted dying in Canada: "Beautiful Death" is transforming nurses' experiences of suffering. The Canadian J Nurs Res | Revue Canadienne de Recherche en Sci Infirmieres. 2020;52(4):268–77. https://doi.org/10.1177/0844562119856234 .

Canadian Nurses Association. Code of ethics for registered nurses. Ottawa; 2017. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics .

Canadian Nurses Association. National nursing framework on Medical Assistance in Dying in Canada. Ottawa: 2017. Available from: https://www.virtualhospice.ca/Assets/cna-national-nursing-framework-on-maidEng_20170216155827.pdf .

Pesut B, Thorne S, Greig M. Shades of gray: conscientious objection in medical assistance in dying. Nursing Inq. 2020;27(1): e12308.

Durojaiye A, Ryan R, Doody O. Student nurse education and preparation for palliative care: a scoping review. PLoS ONE. 2023. https://doi.org/10.1371/journal.pone.0286678 .

McMechan C, Bruce A, Beuthin R. Canadian nursing students’ experiences with medical assistance in dying | Les expériences d’étudiantes en sciences infirmières au regard de l’aide médicale à mourir. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2019;5(1). https://doi.org/10.17483/2368-6669.1179 .

Adler M, Ziglio E. Gazing into the oracle. The Delphi method and its application to social policy and public health. London: Jessica Kingsley Publishers; 1996

Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205–12.

Keeney S, Hasson F, McKenna H. The Delphi technique in nursing and health research. 1st ed. City: Wiley; 2011.

Willis GB. Cognitive interviewing: a tool for improving questionnaire design. 1st ed. Thousand Oaks, Calif: Sage; 2005. ISBN: 9780761928041

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood EW. Conscience, conscientious objection, and nursing: a concept analysis. Nurs Ethics. 2017;26(1):37–49.

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood K. Nurses’ use of conscientious objection and the implications of conscience. J Adv Nurs. 2018;75(3):594–602.

de Vaus D. Surveys in social research. 6th ed. Abingdon, Oxon: Routledge; 2014.

Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best practices for developing and validating scales for health, social, and behavioral research: A primer. Front Public Health. 2018;6:149. https://doi.org/10.3389/fpubh.2018.00149 .

Puchta C, Potter J. Focus group practice. 1st ed. London: Sage; 2004.

Book   Google Scholar  

Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. 5th ed. Oxford: Oxford University Press; 2015.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Adesina O, DeBellis A, Zannettino L. Third-year Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care. Int J of Palliative Nurs. 2014;20(8):395–401.

Bator EX, Philpott B, Costa AP. This moral coil: a cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying. BMC Med Ethics. 2017;18(1):58.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;53(4):511–20.

Brown J, Goodridge D, Thorpe L, Crizzle A. What is right for me, is not necessarily right for you: the endogenous factors influencing nonparticipation in medical assistance in dying. Qual Health Res. 2021;31(10):1786–1800.

Falconer J, Couture F, Demir KK, Lang M, Shefman Z, Woo M. Perceptions and intentions toward medical assistance in dying among Canadian medical students. BMC Med Ethics. 2019;20(1):22.

Green G, Reicher S, Herman M, Raspaolo A, Spero T, Blau A. Attitudes toward euthanasia—dual view: Nursing students and nurses. Death Stud. 2022;46(1):124–31.

Hosseinzadeh K, Rafiei H. Nursing student attitudes toward euthanasia: a cross-sectional study. Nurs Ethics. 2019;26(2):496–503.

Ozcelik H, Tekir O, Samancioglu S, Fadiloglu C, Ozkara E. Nursing students’ approaches toward euthanasia. Omega (Westport). 2014;69(1):93–103.

Canning SE, Drew C. Canadian nursing students’ understanding, and comfort levels related to medical assistance in dying. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2022;8(2). https://doi.org/10.17483/2368-6669.1326 .

Edo-Gual M, Tomás-Sábado J, Bardallo-Porras D, Monforte-Royo C. The impact of death and dying on nursing students: an explanatory model. J Clin Nurs. 2014;23(23–24):3501–12.

Freeman LA, Pfaff KA, Kopchek L, Liebman J. Investigating palliative care nurse attitudes towards medical assistance in dying: an exploratory cross-sectional study. J Adv Nurs. 2020;76(2):535–45.

Brown J, Goodridge D, Thorpe L, Crizzle A. “I am okay with it, but I am not going to do it:” the exogenous factors influencing non-participation in medical assistance in dying. Qual Health Res. 2021;31(12):2274–89.

Dimoula M, Kotronoulas G, Katsaragakis S, Christou M, Sgourou S, Patiraki E. Undergraduate nursing students’ knowledge about palliative care and attitudes towards end-of-life care: A three-cohort, cross-sectional survey. Nurs Educ Today. 2019;74:7–14.

Matchim Y, Raetong P. Thai nursing students’ experiences of caring for patients at the end of life: a phenomenological study. Int J Palliative Nurs. 2018;24(5):220–9.

Canadian Institute for Health Research. Sex and gender in health research [Internet]. Ottawa: CIHR; 2021 [cited 2023 Oct 23]. Available from: https://cihr-irsc.gc.ca/e/50833.html .

Canadian Nurses’ Association. Nursing statistics. Ottawa: CNA; 2023 [cited 2023 Oct 23]. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-statistics .

Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025–47. https://doi.org/10.1007/s11135-011-9640-9 .

Ferri P, Di Lorenzo R, Stifani S, Morotti E, Vagnini M, Jiménez Herrera MF, et al. Nursing student attitudes toward dying patient care: a European multicenter cross-sectional study. Acta Bio Medica Atenei Parmensis. 2021;92(S2): e2021018.

PubMed   PubMed Central   Google Scholar  

Beuthin R, Bruce A. Medical assistance in dying (MAiD): Ten things leaders need to know. Nurs Leadership. 2018;31(4):74–81.

Thiele T, Dunsford J. Nurse leaders’ role in medical assistance in dying: a relational ethics approach. Nurs Ethics. 2019;26(4):993–9.

Download references

Acknowledgements

We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

Author information

Authors and affiliations.

School of Health and Human Services, Selkirk College, Castlegar, BC, Canada

Jocelyn Schroeder & Barbara Pesut

School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada

Barbara Pesut, Lise Olsen, Nelly D. Oelke & Helen Sharp

You can also search for this author in PubMed   Google Scholar

Contributions

JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Authors’ information

JS conducted this study as part of their graduate requirements in the School of Nursing, University of British Columbia Okanagan.

Corresponding author

Correspondence to Barbara Pesut .

Ethics declarations

Ethics approval and consent to participate.

The research was approved by the Selkirk College Research Ethics Board (REB) ID # 2021–011 and the University of British Columbia Behavioral Research Ethics Board ID # H21-01181.

All participants provided written and informed consent through approved consent processes. Research was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., supplementary material 2., supplementary material 3., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

Download citation

Received : 24 October 2023

Accepted : 28 April 2024

Published : 14 May 2024

DOI : https://doi.org/10.1186/s12912-024-01984-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medical assistance in dying (MAiD)
• End of life care
• Student nurses
• Nursing education

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]