No (not moderated by bias).
The present study was a systematic review with meta-analysis of the published literature on the state of the confidence–performance relationship. We distinguished self-confidence from self-efficacy based on the terms used by authors in their article. Overall, results showed that self-confidence has a positive effect on performance, moderated by sport-type, measure of performance, and athlete sex. Our findings mirrored those of the two past meta-analyses [ 11 , 12 ]. Given the congruencies and the minimal bias in our data, the certainty is high that the confidence–performance relationship is small in magnitude. Even at its strongest, the relationship in our mean level data rarely crossed the moderate threshold ( r > 0.30) in meaningfulness.
An intriguing question is why is the confidence–performance relationship not as strong as theory would predict? Michie et al. [ 69 ] proposed self-confidence impacts performance via mechanisms such as increasing effort, selecting appropriate strategies, and regulating unwanted emotions. One explanation is that the central premise of higher confidence leading to better performance is overstated. To address this question, researchers would need to test the mechanisms by which the confidence–performance relationship occurs, which relies on using methods that enable the accurate detection of the influence of self-confidence on performance. It is apparent by reviewing the 41 included studies and the literature overall, that researchers have focused primarily on testing the strength of the confidence–performance relationships and have given little attention to investigating the mechanisms that underpin them. Thus, future research should investigate possible confidence–performance mechanisms.
Concerning Terry’s [ 20 ] propositions, our results showed a stronger relationship between confidence and performance in short duration sports compared to longer duration sports and individual sports compared to team sports. These results speak to the idea that self-confidence may change during performance, either increasing or decreasing. In team sports, self-confidence could be dependent upon teammates’ actions and confidence could change once performance begins. Thus, the longer the sport event, the greater the possibility that confidence changes and thus the confidence–performance relationship weakens. Likewise, in team sports, one individual’s confidence may have little to do with performance outcome if they get minimal playing time and/or the actions of teammates determine the performance outcome. It is possible that self-confidence will be influential on performance, but to detect its effect requires a more sensitive research design, such as repeated measures within the event. Emotion research has faced similar challenges, whether it be measuring emotions prior to performance [ 28 ] or using retrospective designs [ 70 ]. In our included studies, only Totterdell [ 66 ] used a repeated-measures design. A few excellent examples in the emotion research exist whereby researchers captured multiple emotion–performance relationships during competition [ 71 , 72 ]. Hence, to understand the confidence–performance relationship, we suggest repeated confidence testing within the event while recording performance.
Continuing our questioning as to why the confidence–performance relationship is small though moderated by performance characteristics (i.e., type and reference), another issue when measuring self-confidence is the extent to which participants have accurate knowledge of tasks demands. For example, if people have recently completed the task, then they have an experiential basis to rate future expectancies. Bandura [ 73 ] highlighted that when there is an abundance of feedback on a specific task, confidence estimates tend to mirror previous performance closely. Such an assertion works well when the performance task remains stable, such as with a math puzzle. In sports competition, even closed skills contain factors that change and when the level of competition rises, and differences between winners and losers are marginal, such uncontrollable factors grow in importance.
A further issue when assessing self-confidence is the extent to which people have access to relevant information on which to base self-confidence estimates. Athletes may base their confidence on belief in skill execution, physical fitness, and intended effort, but confidence estimates remain hypotheses until tested by situational factors. There is an ongoing feedback loop between behavior and perception, whereby athletes assess and re-assess their confidence estimates from continuous performance feedback. Failing to meet the standard expected tends to activate unpleasant emotions that serve as a signal to improve performance possibly by increasing effort or changing strategy. However, at the time athletes self-report their confidence, the information used comes from memories distal from the current competition. Therefore, given the importance of having accurate and available information to inform self-confidence ratings, objective (vs. subjective) and other-referenced (vs. self-referenced) performance measures are more accurate and available to the performer.
A limitation of research investigating sport confidence is that neither the information used by athletes to rate self-confidence, nor the strategies they plan to use to achieve their goals are known. Therefore, we do not know how athletes arrive at their ratings, only what ratings they provide. Research has been conducted into the antecedents of self-confidence ratings among athletes [ 74 , 75 ], which provides additional insights. However, further exploration, perhaps using qualitative techniques, of exactly how athletes arrive at their self-confidence ratings and develop their beliefs about the effectiveness of planned competition strategies would be particularly germane.
Examination of the evidence base and strategies to deliver performance expectations might be particularly useful when exploring sex differences in the confidence–performance relationship. Although male athletes tend to report higher self-confidence compared to female athletes [ 24 ], this does not in itself explain sex differences in the confidence–performance relationship. Using intra-individual analysis of performance in the shooting phase of 254 international biathlon competitions, Ahammer et al. [ 76 ] showed that a one standard deviation reduction in self-confidence increased the number of missed shots by 0.53 standard deviations for men, but there was no effect of self-confidence on missed shots for women. Further investigation of sex-based differences in cognitive, behavioral, and emotional processes that occur between the pre-competition assessment of self-confidence and the outcome of performance may provide valuable insights into the confidence–performance relationship. Last, an interesting observation relates to the age of samples used to study self-confidence. Nearly all samples were younger adults, with mean age exceeding 30 in only three studies. With aging and gathering experiences, athletes might accrue greater knowledge of task demands and therefore provide more accurate confidence estimates. We suggest that future research should investigate the confidence–performance relationship in targeted populations, such as all-female and master athletes.
Even having closely followed the PRISMA statement [ 25 ], limitations within our meta-analysis are evident. First, although we identified 41 studies meeting our inclusion criteria, it is possible we missed relevant studies because the CSAI-2 measure is more closely associated with anxiety than with confidence, and article titles, abstracts, and keywords might make no mention of confidence despite having measured it. Likewise, studies with multiple psychological measures might exclude mention of confidence in the title, abstract, and keywords. We ameliorated this potential limitation by retaining studies for full-text screening if there was even a suspicion that confidence was a measured variable despite not being mentioned in the title, abstract, nor keywords. Second, we decided, given the decades covered in our search, from the 1980s or potentially earlier to the 2020s, not to contact authors for missing data. Our reasoning was the passage of time for data storage and even deceased researchers would bias the data available. However, the minimal publication bias found eased our concerns of these two limitations. Third, with 41 studies contributing 49 samples, small sample sizes were present in some of our moderator analyses. Smaller samples limited statistical power to detect significant between-level differences and may have contributed to larger confidence intervals. Fourth, we attempted to test the individual difference moderators reported in Craft et al. [ 11 ] and Woodman and Hardy [ 12 ]. Without exact operational definitions and coding for levels such as elite, European club, and top and lower standard, we may have coded our samples differently to previous research teams. Last, we sought to include eligible studies with no language restriction. To do so, we used Google Translate ( https://translate.google.com/ , accessed on 1 March 2021). It is possible that Google Translate is not 100% accurate and we either excluded eligible studies or included ineligible studies. Although we have mentioned use of Google Translate as a limitation, including studies without a language restriction was a clear strength of our meta-analysis, instead of including only studies published in English.
Self-confidence dominates the sport media and the athletic rhetoric as vital to performance, in such statements such as “If you don’t have confidence, you will always find a way to not win” (Carl Lewis, 9-time Olympic Gold Medalist). However, based on our meta-analysis and two past meta-analyses, the confidence–performance relationship is small in magnitude with a few important moderators. It might be true, as Carl Lewis asserts, that without confidence one cannot win. However, it might be simply that without more confidence than the other team or competitor at a critical moment, one will find a way not to win.
The research team wishes to acknowledge the Department of Kinesiology and Sport Management for supporting the research by purchasing the Comprehensive Meta-Analysis software.
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph19116381/s1 , Supplement 1. Search strategy, Supplement 2. Risk of individual study bias ratings, Supplement 3. Comparison of Results, and Supplement 4. PRISMA Checklist.
This research was funded by the Texas Tech University Office of the Vice-Provost and the Texas Tech University TrUE SPARK program. MS was funded by Texas Tech University Office of the Vice-Provost. CS and SC were funded by Texas Tech University TrUE SPARK program.
Conceptualization, M.L. and P.C.T.; methodology, M.L., M.S., A.M.L. and P.C.T. software use, M.L.; formal analysis, M.L. and C.S.; data curation, M.L., M.S., C.S. and S.C.; writing—original draft preparation, M.L., P.C.T. and A.M.L.; writing—review and editing, M.L., P.C.T., A.M.L. and S.C.; supervision, M.L. and P.C.T.; project administration, M.L.; funding acquisition, M.L. All authors have read and agreed to the published version of the manuscript.
Not applicable for studies not involving humans or animals.
Not applicable for studies not involving humans.
Conflicts of interest.
The authors declare no conflict of interest. The funders for M.S., C.S., and S.C. had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
It’s a problem when women are perceived as too confident. Or not confident enough.
When women fail to achieve career goals, leaders are prone to attribute it to a lack of self-confidence. And when women demonstrate high levels of confidence through behaviors, such as being extroverted or assertive, they risk overdoing it and, ironically, being perceived as lacking confidence. No matter the outcome, women’s lack of career progression is blamed on them, an attack they share with other underrepresented groups. This leads women to beat themselves up, which can weaken self-esteem and, in a downward spiral, further erode self-perceptions of confidence.
Women are regularly exhorted to demonstrate self-confidence as a strategy to progress their careers, raise their pay, and become more successful at work. Self-help guides commend women to “lean in” to reach their goals, “stand their ground,” make strong eye contact, attune their voices, postures, and gestures to come across more assertively, and to “fake it ‘til they make it.” Women have to do all this while balancing on a knife edge the need to remain likeable/ warm by appearing unintimidating, unforceful, and undomineering.
Verywell / Madelyn Goodnight
Low self-esteem refers to a person having an overall poor sense of self-value. It essentially means having a poor opinion of yourself. Low self-esteem can encompass a range of factors, such as your sense of identity, self-confidence, feelings of competence, and feelings of belonging.
Self-esteem is about more than just generally liking yourself—it also means believing that you deserve love and valuing your own thoughts, feelings, opinions, interests, and goals. It can also play a role in how you allow others to treat you .
Having self-esteem not only impacts how you feel about and treat yourself, but it can even affect your motivation to go after the things you want in life and your ability to develop healthy, supportive relationships. It plays an important role in a variety of areas in life, which is why having low self-esteem can be such a serious problem.
Having low self-esteem means that you often think negatively about yourself, judge yourself badly, and lack confidence in your abilities.
While not a mental illness, poor self-esteem can still affect a person’s thoughts, emotions, and patterns of behavior. Sometimes its signs can be fairly apparent. Other times, low self-esteem symptoms are much more subtle.
For example, some people with low self-esteem talk negatively about themselves, while others go out of their way to make sure other people are pleased with them. In either case, a lack of personal worth and value can have a negative impact on life and wellness.
Some common signs or symptoms of low self-esteem include:
You can also find online self-esteem tests to help determine whether your self-worth may be low. For instance, the Open-Source Psychometrics Projects offers free access to a version of the Rosenberg Self Esteem Scale , which is a test used to measure self-esteem in research.
People with low self-confidence tend to have low self-esteem, and vice versa. Low self-esteem can play a role in causing a lack of confidence, but poor confidence can also contribute to or worsen poor self-esteem.
Being confident in yourself and your abilities allows you to know that you can rely on yourself to manage different situations. This self-trust means that you feel comfortable and confident navigating many different things you might encounter in life, which can play an important role in your overall well-being .
Finding ways to gain confidence in yourself and your abilities can be helpful. Acquiring and practicing new skills is one tactic you might try. This may even help reduce feelings of anxiousness as research connects a lack of confidence with higher anxiety levels, especially when under stress.
People who have low self-esteem often feel that they have little control over their lives or what happens to them. This can be due to the feeling that they have little ability to create changes in themselves or in the world. Because they have an external locus of control , they feel powerless to do anything to fix their problems.
Research has found that in situations where people have little control over what happens, having higher self-esteem can help relieve some of the negative effects of this loss of control, which ultimately benefits mental health.
If you feel like you have no control over your life or situation, finding ways to improve your self-esteem may be helpful for your well-being.
Social comparison can sometimes serve a positive function and enhance a person's sense of self. But comparing yourself to others can also damage self-esteem. People with low self-esteem may be more likely to engage in what is known as upward social comparison, or comparing themselves to people who they think are better than themselves.
Upward social comparison isn't always bad. For instance, these comparisons can be a source of information and inspiration for improvement. When people are left with feelings of inadequacy or hopelessness , however, it can inhibit self-esteem.
Social media can also play a role in such comparisons, contributing to low self-esteem. If you often compare yourself unfavorably to people on social media sites such as Facebook and Instagram, your self-esteem may take a hit.
When a person has low self-esteem, they may struggle to ask for what they need. Trouble asking for what you need can be caused by feeling embarrassed. Or you may feel that a need for assistance and support is a sign that you are incompetent.
Because their self-regard is low, someone with low self-esteem might also feel that they don't deserve help. They don't prioritize their own desires, so they struggle to assert themselves when they are in need.
Even after making a decision, people who have low self-worth often worry that they’ve made the wrong choice. They doubt their own opinions and may defer to what others think instead of sticking to their choices.
This can lead to a great deal of second-guessing and self-doubt. This makes it harder for people with low self-esteem to make decisions about their lives.
A 2017 study published in the Journal of Experimental Social Psychology found that low self-esteem is directly correlated to not being able to accept or capitalize on compliments from others.
Positive feedback is often met with suspicion and distrust. Complimentary words do not align with their beliefs about themselves, so people with self-esteem issues may feel that the other person is being flippant or even cruel.
Because they don’t have a positive opinion about themselves, people who have low self-esteem find it difficult to accept compliments from others.
Low self-esteem causes people to focus on their flaws rather than their strengths. Rather than build themselves up with positive self-talk, they always seem to have something negative to say about themselves, engaging in negative self-talk instead.
When things go wrong, people with low self-esteem often blame themselves. They find fault with some aspect of themselves, whether it is their appearance, their personality, or their abilities.
Because they lack confidence in their abilities, people with low self-esteem doubt their ability to achieve success. Because they fear failure, they tend to either avoid challenges or give up quickly without really trying.
This fear of failure can be seen in behaviors such as acting out when things go wrong or looking for ways to hide feelings of inadequacy. People with low self-esteem might also make excuses, blame external factors, or try to downplay the importance of the task.
Low self-worth can cause people to feel that there is little chance that the future will be any better than the present. These feelings of hopelessness can make it hard for people with low self-esteem to engage in behaviors that will bring about positive changes in their lives.
Self-sabotage is a common way of coping with such feelings. By finding obstacles to prevent success, people with low self-esteem are able to find something else to blame for not achieving their goals or finding greater levels of happiness in their lives.
The ability to set boundaries is often established early in life. Children with caregivers who show them that they are respected and valued are better able to create good boundaries in adult relationships. They are also more likely to have a more positive view of themselves in general.
People with low self-esteem can have a difficult time setting boundaries with others. They may feel guilty or fear that people will stop liking them if they try to establish or maintain a boundary.
A lack of healthy boundaries can create problems when others don't respect a person's space and time. The lack of respect not only adds to the person's stress levels but may also make them feel less valued.
People-pleasing is another common symptom of low self-esteem. In order to gain external validation, people who don't feel good about themselves may go above and beyond to make sure that others are comfortable and happy.
Pleasing others often involves neglecting their own needs. The person with low self-esteem winds up saying yes to things they may not want to do and feeling guilty about saying no.
Research suggests that there are numerous effects of low self-esteem. For instance, having lower levels of self-esteem is linked to a number of mental health issues, including:
Low self-esteem may even play a role in the development of certain mental health conditions, such as depression . Research has also shown that people with low self-esteem are more likely to be at risk for suicidal thinking.
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.
For more mental health resources, see our National Helpline Database .
Another effect of low self-esteem is that you may find it more difficult to achieve your goals and form healthy, supportive relationships. It might also make you more sensitive to criticism or rejection.
Where someone with high self-esteem is likely to be able to shake off negative feedback, someone with poor self-value might take it more personally. This can also make people with self-esteem issues more likely to give up when faced with challenges or obstacles.
Research has found that people with low self-esteem often engage in behaviors that are designed to help preserve their limited self-worth. Actions such as acting sad or sulking are used to garner support from others.
Unfortunately, these behaviors tend to backfire. Instead of getting the support and encouragement they desire to help boost their self-esteem, the person often ends up generating negative reactions from other people.
What causes lower self-esteem in some individuals? Several factors could be at play, some of which include:
Some studies connect high amounts of social media use with lower self-esteem in adolescents. However, others warn that social media use, in general, doesn't always have this effect. Instead, it's more a matter of the purpose behind its use.
Specifically, social media can have negative effects if it is used as a way to measure your popularity or likeability. But if you use social media to share your interests with like-minded individuals, its impact can be more positive.
Physical health and appearance are additional factors contributing to low self-esteem. For instance, one study found that having missing teeth or untreated dental decay negatively contribute to self-esteem.
Low self-esteem often stems from many causes. Five common factors that play a role include negative self-talk, mental health disorders, poor coping skills, rumination, and low resilience to stress.
Building or fixing low self-esteem often takes time. But there are things you can do to help protect your mental well-being while taking steps to improve your self-regard.
Spend a little time each day focusing on positive, hopeful thoughts . Notice the little things that you are good at and allow yourself to feel proud of them.
Also, think about times in the past when you made it through something really difficult. Remind yourself that even though you might not feel your best right now, you have the ability and strength to get through it.
Poor self-esteem can sometimes leave you feeling like you don’t deserve care and consideration. Work on reminding yourself that you need care and look for things that you can do to show kindness to yourself, no matter how small they may be.
One way to practice self-care is to spend some time doing something that you enjoy. Go for a walk, chat with a friend, or engage in a hobby. Caring for yourself also involves regularly making time to rest and relax, giving your body and mind time to recoup and regroup.
Investing in your own care and comfort isn’t an indulgence or reward you have to earn—it’s absolutely vital to both your physical and mental health.
If you have low self-esteem, it can be helpful to share your struggles with someone who offers unconditional support. This might be a friend or family member, but it can also be a healthcare provider, therapist, teacher, or clergy member.
Having a network of caring people who value you and want you to value yourself can be beneficial as you work toward improving your self-esteem.
If you are dealing with low self-esteem, there are several things you can do to help improve how you feel about yourself.
Start paying attention to the automatic negative thoughts you have each day. When these negative thoughts take hold, work to actively identify cognitive distortions , such as all-or-nothing thinking and jumping to conclusions. Then, replace these distortions with more positive thoughts.
If you tend to ruminate over your mistakes or failures, learn how to forgive yourself and move on. Doing so can keep you focused on the things you can do better in the future instead of the negative things that have happened in the past.
Let go of the idea that you need to be perfect in order to have value. If this is how you feel, it can be helpful to work on accepting who you are today.
Self-acceptance doesn't mean that you don't have goals or things that you might want to work on changing. But it's important to recognize that you are worthy of love and esteem—from yourself and from others—exactly as you are right now.
Spend time thinking about the things you have accomplished and the things you are proud of. Allow yourself to appreciate your worth and your talents without making comparisons or focusing on areas you'd like to improve.
You don’t need to be better in order to value yourself—but learning to value yourself can help you work toward your goals.
It can be helpful to think of yourself as you would a friend. How would you treat someone you care about who was in the same situation? In many cases, you may find that you would give them understanding, patience, empathy , and kindness. Show yourself the same unconditional support instead of beating yourself up.
Here are a few additional things you can do to help boost your self-esteem:
Self-esteem plays an important role in your ability to pursue goals, develop healthy relationships , and feel good about who you are. While everyone struggles with their confidence once in a while, low self-esteem can affect your ability to feel happy. It can even make you more susceptible to mental health conditions such as anxiety and depression.
If you are experiencing symptoms of poor self-esteem, help is available. Consider talking to a healthcare provider or mental health professional to learn your treatment options. A therapist can help you change the thought patterns that contribute to low self-esteem and boost your confidence and opinion of yourself and your abilities.
Raising your self-esteem may take some time and effort. But over time, you can learn to better see and appreciate yourself for who you are.
Bayat B, Akbarisomar N, Tori NA, Salehiniya H. The relation between self-confidence and risk-taking among the students . J Educ Health Promot . 2019;8:27. doi:10.4103/jehp.jehp_174_18
Goette L, Bendahan S, Thorensen J, Hollis F, Sandi C. Stress pulls us apart: Anxiety leads to differences in competitive confidence under stress . Psychoneuroendocrinol . 2015;54:115-123. doi:10.1016/j.psyneuen.2015.01.019
Gabriel AS, Erickson RJ, Diefendorff JM, Krantz D. When does feeling in control benefit well-being? The boundary conditions of identity commitment and self-esteem . J Vocation Behav . 2020;119:103415. doi:10.1016/j.jvb.2020.103415
Vogel EA, Rose JP, Roberts LR, Eckles K. Social comparison, social media, and self-esteem . Psychol Pop Media Culture . 2014;3:206–222. doi:10.1037/ppm0000047
Wang JL, Wang HZ, Gaskin J, Hawk S. The mediating roles of upward social comparison and self-esteem and the moderating role of social comparison orientation in the association between social networking site usage and subjective well-being . Front Psychol . 2017;8:771. doi:10.3389/fpsyg.2017.00771
Kille DR, Eibach RP, Wood JV, Holmes, JG. Who can't take a compliment? The role of construal level and self-esteem in accepting positive feedback from close others . J Experiment Soc Psychol . 2017;68:40-49. doi:10.1016/j.jesp.2016.05.003
Naseri L, Mohamadi J, Sayehmiri K, Azizpoor Y. Perceived social support, self-esteem, and internet addiction among students of Al-Zahra University, Tehran, Iran . Iran J Psychiatry Behav Sci . 2015;9(3):e421. doi:10.17795/ijpbs-421
Gartland D, Riggs E, Muyeen S, et al. What factors are associated with resilient outcomes in children exposed to social adversity? A systematic review . BMJ Open . 2019;9(4):e024870. doi:10.1136/bmjopen-2018-024870
Maldonado L, Huang Y, Chen R, Kasen S, Cohen P, Chen H. Impact of early adolescent anxiety disorders on self-esteem development from adolescence to young adulthood . J Adolesc Health . 2013;53(2):287-292. doi:10.1016/j.jadohealth.2013.02.025
Nguyen DT, Wright EP, Dedding C, Pham TT, Bunders J. Low self-esteem and its association with anxiety, depression, and suicidal ideation in Vietnamese secondary school students: A cross-sectional study . Front Psychiatry . 2019;10:698. doi:10.3389/fpsyt.2019.00698
Kalvin CB, Bierman KL, Gatzke-Kopp LM. Emotional Reactivity, Behavior Problems, and Social Adjustment at School Entry in a High-risk Sample . J Abnorm Child Psychol . 2016;44(8):1527-1541. doi:10.1007/s10802-016-0139-7
Don BP, Girme YU, Hammond MD. Low self-esteem predicts indirect support seeking and its relationship consequences in intimate relationships . Pers Soc Psychol Bull . 2019;45(7):1028-1041. doi:10.1177/0146167218802837
Hagen R, Havnen A, Hjemdal O, Ryum T, Solem S. Protective and vulnerability factors in self-esteem: The role of metacognitions, brooding, and resilience . Front Psychol . 2020;11:1447. doi:10.3389/fpsyg.2020.01447
Woods HC, Scott H. #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem . J Adolescence . 2016;51:41-49. doi:10.1016/j.adolescence.2016.05.008
Pennsylvania State University. Social media and self-esteem .
Kaur P, Singh S, Mathur A, et al. Impact of dental disorders and its influence on self esteem levels among adolescents . J Clin Diagn Res . 2017;11(4):ZC05-ZC08. doi:10.7860/JCDR/2017/23362.9515
By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."
This information is designed to help teachers respond to students who may need support. It is not intended to be used as a diagnostic tool or to replace the use of formal assessments employed by mental health professionals. Additionally, it is important to consider the context of the situation, individual differences, and cultural and linguistic considerations.
Teachers are an important part of establishing and maintaining healthy environments for children to learn and grow. Teachers can help students who are not confident in themselves or who are afraid to make a mistake to build their feelings of confidence. Teachers can also play an important role in referring students experiencing low self-esteem to professionals in the building who can be of assistance.
Download this Primer
More Primers
Self-esteem is the degree to which students feel satisfied with themselves and feel valuable and worthy of respect.
Perceived competence is a belief that one has skills in a particular area (e.g., math, spelling, peer relationships). Self-esteem and perceived competence are necessary for students to take risks in their learning and to bounce back after failure or adversity. Low self-esteem or lack of confidence leaves students doubting their ability to succeed, making them hesitant to engage in learning or take appropriate academic growth risks. Self-esteem is often built and buttressed through estimable acts and achievements—even small ones.
Students may make self-disparaging comments such as, “I’m stupid,” “I can’t do this,” “I always do everything wrong,” “No one likes me,” etc.
Students with low self-esteem may take blame for things that are not their fault or are out of their control, or they may try to control other children’s behavior to alleviate a sense of helplessness.
Students may react to adversity by giving up, avoiding risks, or disengaging from tasks, or turning off their cameras during virtual learning (VL).
Students may be reluctant to try new things or be unable to tolerate typical levels of frustration. They also may pretend they don’t care, may clown around, or may be aggressive to cover up their lack of confidence, or log off from the virtual learning environment (VLE) abruptly.
Students may do very well for a period of time, then suddenly underperform.
Students may be afraid their success was a fluke or be worried that expectations from others are suddenly too high.
Do : Give specific and genuine positive feedback on effort rather than outcome, when warranted. For example, “You made a lot of progress on that project in just an hour,” or, “The topic sentence of that paragraph is really strong.”
Don’t praise excessively or vaguely or provide generic praise like, “Good job.”
Do : Point out concrete signs of progress, even if they are small.
Don’t give repeated, general pep talks that include, “You can do it!”
Do : Showcase accomplishments by displaying students’ work in class or calling parents to tell them how proud you are of the students’ efforts.
Don’t focus solely on suboptimal behaviors or performance.
Do : Engage students in a conversation about their interests, and point out students’ skills privately.
Don’t address the behavior publicly or assume a student is just like other students.
Do : Engage the students’ interests by setting them up for success: give them specific tasks at which they will excel, such as caring for the class pet or running things to the front office. In a VLE, this may look like choosing music for the virtual classroom, posting a math question on the discussion board, or reflecting on their strengths on a particular assignment with a peer in a breakout.
Don't ignore or avoid the students or the issues they’re facing or assume they aren’t up to a task.
Do : Be mindful of ensuring equity in terms of acknowledging and providing positive feedback to all students.
Don't continually affirm certain/the same students or compare achievements between students.
Do : Remember that students transitioning from the classroom to VLE, or vice versa, may experience different levels of success depending on the environment.
Don't base feedback upon historical achievements, expectations, or successes; the transition between learning environments impacts many students.
Stress , sadness , bullying
Beghetto, R. A. (2007). Factors associated with middle and secondary students' perceived science competence. Journal of Research in Science Teaching: The Official Journal of the National Association for Research in Science Teaching, 44 (6), 800-814.
Guay, F., Boggiano, A.K., & Vallerand, R.J. (2001). Autonomy support, intrinsic motivation, and perceived competence: Conceptual and empirical linkages. Personality and Social Psychology Bulletin, 27 , 643-650.
Kamins, M. & Dweck, C.S. (1999). Person vs. process praise and criticism: Implications for contingent self-worth and coping. Developmental Psychology , 35, 835-847.
Pesu, L., Viljaranta, J., & Aunola, K. (2016). The role of parents’ and teachers’ beliefs in children’s self-concept development. Journal of Applied Developmental Psychology, 44, 63-71.
Zentall, S. R., & Morris, B. J. (2010). "Good job, you're so smart": The effects of inconsistency of praise type on young children's motivation. Journal of Experimental Psychology, 107 (2), 155-163.
The Mental Health Primers are developed by the Coalition for Psychology in Schools and Education . This resource was updated in October 2021 with support from cooperative agreement NU87PS004366 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views or endorsement of the CDC or the Department of Health and Human Services.
Academia.edu no longer supports Internet Explorer.
To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to upgrade your browser .
Enter the email address you signed up with and we'll email you a reset link.
2018, Sabratha University
Abstract The study was designed to examine the impact of lack of self-confidence when EFL junior students perform their oral assignments during their academic career. The participants of this study are eight students at the third year in the English Department of Sabratha College of Arts, Libya. A semi-structured interview is used as an instrument to collect the data in this study. The research is aimed to investigate the impact of lack of self-confidence for EFL junior students while they are delivering their oral assignments. After interviewing participants and analyzing the acquired data, researchers found out that lack of self-confidence has a negative impact on EFL junior students at and that due to psychological and linguistic barriers which prevented them from accomplishing good oral assignments. Keywords: Self-confidence, Oral assignment, self-confidence deficiency
JEELS (Journal of English Education and Linguistics Studies)
JEELS (Journal of English Education and Linguistics Studies) , Agus Salim
In speaking course, the teachers usually ask the students to present their projects in front of the class through an activity called Oral Presentation. However, many of students are afraid of public speaking due to the effect of self-confidence. This study is aimed to (1) describe general self-confidence among Indonesian EFL learners, (2) describe their academic achievement in oral presentation, and (3) find out the relationship between self-confidence and their academic achievement in oral presentation. Correlational design is used to investigate the existence or non existence of the relationship between the variables. The subjects of this study are 68 students at the second semester in English Department of one private university in Lamongan, Indonesia. Documentation and questionnaire are used as instruments to collect the data in this study. The findings reveal that (1) the students' general self-confidence is quite strong, (2) the students' academic achievement in the oral presentation is good, and (3) the two variables show high correlation. Therefore, the teachers are suggested to enforce activities that could increase students' self-confidence which in turn could decrease their anxiety in public speaking.
Amalia Hasanah
The aims of this study were to investigate whether there is a correlation between Self-Confidence with EFL students’ speaking achievement. The participants of this study were the Undergraduate EFL Students of UIN Raden Fatah Palembang. purpose. The participants that were chosen can meet certain criteria from this study. In this study, the student’s self-confidence and their speaking achievement are correlated. Therefore, in order to know the students’ speaking achievement, a group of students who had already taken the informal speaking courses from the population were considered as the sample. Nonetheless, most of the third semester students have already finished the informal speaking class on last semester and they are on the next level of speaking class on this semester. Quantitative method was used in this study. The data gained from self-confidence questionnaire and the list of students’ speaking achievement was analyzed by using SPSS. The result of the study showed that there i...
dinda mucus
The study was particularly aim an investigating the correlation between self confidence and academic achievement in speaking skill. The participants were 20 pairs freshmen undergraduate students from Kanjuruhan University of Malang. SPSS was used to analyze the data from self Confidence questionnaires and compared to the final score of speaking skill. The result of the computation revealed a negative, significant correlation between self confidence and academic achievement in speaking skill. Finally, it presented that the evidences found in the field of study fail to reject the Null Hypothesis. INTRODUCTION In learning second language, some people make faster progress than some others do. Some students try hard and get many difficulties. They seem stuck on something that make them really hard to reach the learning goal. They make struggle along the learning and get only very slow progress. It is clearly when someone learn a new language, they will have factors that contribute to the success of language learning. Learning is a process that involve in it, not only cognitive factors but also affective factors. The researcher realizes that cognitive factors are easy to show while affective factors are difficult to describe scientifically. But it does not mean that the affective factors give less contribution than the cognitive do. Cognitive factors defined as the something immaterial as the circumstance or influence that contributes to producing a result. Cognitive factors refer to characteristics of the person that affect performance and learning. In this way, cognition has to do with how the world will be understood by a person and act in it. Messick's (1993: 199) says that cognitive styles are characteristic modes of perceiving, remembering, thinking, problem solving, decision making that are reflective of information processing regularities that develop in congenial ways. Affective factors defined as emotional factors which influence learning. They can have a negative or positive effect. Because affective factors also produce negative effects, the lecturers or the instructors in the classroom should build the learning atmosphere to decrease the negative effects. These factors involve cognitive functions like attention, memory, and reasoning (Danili & Reid, 2006). Thus, from those affective factors we know, learning foreign language is not a simple thing to do. It is a complex process when a learner speaks language which is not spoken in his mother tongue. Learner will get some obstacles and difficulty to do. As Bialystok, E. (1991) suggests that Language learning is a complex process. That affective factors play important role, it should contribute to the progress of learning. Some of those affective factors clearly mentioned by Brown (2000) He says that the affective domain is the emotional side of human behavior and it involve a variety of
Nutin Nasih
Abstract: Speaking is a productive skill which leads the ones have an effective communication. Then, Self-confidence is a psychological factor which plays a supportive role in speaking performance. The current study was aimed to know whether there is a significant correlation between self-confidence and speaking performance. The researcher used quantitative approach in which correlation research design was used. The total number of participants was of 30 students from the fourth semester of English Department. To obtain the data, the researcher used Confidence in Speaking English as a Foreign Language (CSEFL) questionnaire in order to know the students’ level of self-confidence and speaking performance score was used to measure the level of the students speaking performance. The finding of the present study showed that the r observed of the students’ self-confidence and speaking performance was .261 with level of significance was .163 which is greater than .05. It means that the co...
Omidullah Akbari
The purpose of this study was to measure students' self-confidence and finds its impacts on their learning process at Kandahar University. The study is descriptive in nature where quantitative questionnaire is used to collect data through stratified sampling from 1375 male and female students. The findings revealed only some of the students were low self-confident and most students were highly self-confident. In addition, students' self-confidence effected their learning in areas of students' participation, in seeking goal, developing interest in lessons, in decreasing students' anxiety, they are being comfortable with their instructors and classmates and also in sharing their opinions related to lessons in class.
Journal of General Education and Humanities
Journal of General Education and Humanities (GEHU)
Self-confidence plays a crucial part in speaking English, and many students are still less confident when speaking, which causes them to not engage more in speaking activities. This research aimed to know how self-confidence works in students speaking to ninth-grade students, specifically at SMP Negeri 9 Palu, and the factors that contributed to their lack of confidence. For the topic, 30 students were selected as the sample and given twelve questions from the questionnaire and five interview questions. The research method was a descriptive qualitative method. The results that the researcher has done are self - confidence indeed works on students’ speaking. Students’ lack of confidence is caused by some factors, which are afraid of making mistakes when they speak, they still have lack of vocabulary, lack of grammar, feel of under pressure every time the teacher asks them to speak, shyness, nervous, feel of uncomfortable, not enjoying when they attempt to speak, insecurities of their friends who have the good ability more than them. This study is expected to contribute to developing students’ speaking ability and solve students’ problems by knowing their speaking and what factors contribute to their unconfident. Moreover, this study also may help teachers treat students so they can participate actively in class without being constrained with self–confidence.
Dawood A Mahdi
This article is concerned with strategies and techniques for fostering EFL students " confidence and reducing their oral communication apprehension. This paper aims to explore strategies and techniques that could be implemented in the EFL classroom to encourage students " oral communication and foster their confidence. The first part starts with a brief introduction to present the research topic. It states the aims, purpose, research questions, and significance of the study. The second part features the relevant literature review, focusing on the current body of knowledge. The literature review provides a detailed description of the substantive findings as well as methodological and theoretical contributions to this topic. The study furnishes a wide range of reflections on English as a foreign language, and the special needs of students learning the language. It can be described as the impact of confidence on EFL students " oral communication apprehension in EFL students. In the third part, the paper discusses the methodology used in this study, followed by a discussion of an analysis of the findings in the fourth part. These two areas, i.e. discussion and findings answer the research questions and justify the research hypothesis. The last part of this work provides a conclusion to the study, accompanied by some recommendations.
Ismail Gurler
Abstract Self-confidence has a key characteristics to start any action especially for speaking in L2. Among all other language skills, speaking is of an exclusive place to have effective communication, and self-confidence is one of the facilitators to start conversation. In this regard, this study aims to find out whether there is a relationship between self-confidence and speaking skill achievement in speaking courses of the preparatory students attending both English Language Teaching (ELT) Department and English Language and Literature (ELL) Department and it also aims to determine if there is a difference between the departments and gender. Participants were 77 male and female preparatory students from both departments and all the students got English speaking courses throughout the fall semester in 2014-2015 academic year. Within a correlational research model, self-confidence questionnaire (SCQ) was applied to the participants. The collected quantitative data were analyzed by Statistical Package for the Social Sciences (SPSS) 20.0 program. The Pearson product-moment correlation coefficient and independent sample t-test were used to analyze the data. Results indicate that there is significant correlation between self-confidence and speaking skill within the level of .01. Moreover, speaking achievements reveal significant differences according to department but not gender. Self-confidence levels have significant differences regarding to the gender but not department.
Acuity: Journal of English Language Pedagogy, Literature and Culture
Marlin Marpaung
English Education Journal
Asti Wahyuni B
This research intended to analyze factors of students’ lack of self confidence in speaking English. It was also aimed to present possible strategies used to overcome students’ lack of self confidence in speaking English. The type of this research was qualitative. This research was conducted in SMA Negeri 4 BauBau. This research focused on obtaining data from the English teacher and students at eleventh grade of SMA Negeri 4 BauBau in the academic year 2018/2019 as the subjects of the research. In collecting data, the researchers used observation, interview. The technique used in analyzing data were three steps, those were data reduction, data display, and conclusion drawing. The result of this research showed that the factors which cause students’ lack of self confidence were anxiety, shyness, fear of making mistakes, and lack of vocabulary. Meanwhile, the possible strtaegies to overcome students’ lack of self confidence in speaking English were lowering students’ anxiety in classro...
Loading Preview
Sorry, preview is currently unavailable. You can download the paper by clicking the button above.
AL-ISHLAH: Jurnal Pendidikan
balqis husain
Frida Alifah
Rusdiana Junaid
Morteza Bakhtiarvand , Farshad Mahnegar
Kimberly K V Vipinosa
Norma Murga
Efi Kurniati
Fahimeeh Aleabbass
Psychology and Education: A Multidisciplinary Journal
Psychology and Education , Nicole gawan , Crisalyn R. Montoyo , Quirr Millendez
Tono SUWARTONO
Australian International Academic Centre PTY. LTD. (AIAC PTY.LTD.)
Listyani Listyani
MANI SAMIDURAI
Badran A Hassan
Hengki hengki
Ariyanti Ariyanti
ASIAN TEFL , Ariyanti Ariyanti
JES Journal 14. 84-99
Adrian Leis
Self-Esteem, Self-Expectancy and Oral Achievement in the Tunisian EFL Context: Multiple Perspectives
Marwa Mekni Toujani
COMSERVA Indonesian Jurnal of Community Services and Development
fitri alfarisy
Şakire Erbay Çetinkaya
Elaheh Tavakoli
Research Article
Asst. Prof. Dr. Budi Waluyo, FHEA
International Journal for Innovative research in Multidiciplinary Field
Abdullah Rahimi
International Journal of Research and Innovation in Social Science
Journal of Occupational Medicine and Toxicology volume 19 , Article number: 36 ( 2024 ) Cite this article
Metrics details
Depression poses a significant challenge globally, including in safety-critical industries such as aviation. In Saudi Arabia, where the aviation sector is rapidly expanding, pilots encounter unique stressors inherent to their profession. However, research on pilot mental health, particularly within the Saudi context, remains limited despite its critical role in flight safety.
This cross-sectional survey was designed to estimate the self-reported prevalence of depression in a convenience sample of airline pilots in Saudi Arabia. Participants were recruited from various commercial airlines in Saudi Arabia. Recruitment efforts utilized targeted outreach on social media platforms, focusing on pilot forums and groups. The survey was administered online for accessibility and convenience. The structured questionnaire, developed through a literature review and expert consultation, comprises sections on demographic and professional characteristics, occupational information, health habits, and depression assessment via the Patient Health Questionnaire-9 (PHQ-9).
This study enrolled 310 participants, with the largest cohort (34.8%, n = 108) falling within the 30–39 years age group, closely followed by individuals under 30 years (30.0%, n = 93). Males dominated the sex distribution (99.0%, n = 307). The mean PHQ-9 score was 8.2 ± 5.4. Notably, 40.6% ( n = 126) of the participants had a score of 10 or higher, indicating the potential for moderate, moderate-severe, or severe depression. Multivariable binary logistic regression analysis revealed that pilots with 11–15 years of experience had greater odds of experiencing depression than did those with 0–10 years of experience did (odds ratio [OR]: 3.0, 95% confidence interval [CI]: [1.1–8.4], p = 0.04). Pilots with rest times exceeding 24 h had lower odds of depression than did those with rest times less than 1 h (OR: 0.3, 95% CI: [0.1–0.8], p = 0.02). Engaging in regular exercise was associated with reduced odds of depression (OR: 0.3, 95% CI: [0.2–0.5], p < 0.01), as was longer sleep duration (> 8 h) (OR: 0.2, 95% CI: [0.1–1.0], p = 0.04).
Our study estimates the prevalence and severity of self-reported depressive symptoms among airline pilots in Saudi Arabia, surpassing global estimates. The identified factors, including lack of regular exercise, short sleep duration, and insufficient rest between flights, underscore the complex mental health challenges faced by pilots in this region. Addressing these issues is crucial not only for pilot well-being but also for flight safety.
Depression is a pervasive mental health disorder with profound implications for individuals, communities, and societies worldwide, representing a leading cause of disability and contributing significantly to the global burden of disease [ 1 ]. Its impact spans diverse populations and professions, drawing particular attention to its ramifications within safety-critical industries [ 2 ].
The aviation sector serves as a cornerstone of modern transportation systems, facilitating global connectivity and economic growth. In Saudi Arabia, a country experiencing rapid growth in its aviation sector, pilots play a crucial role in ensuring the safety of air travel. However, operating within the aviation industry entails a complex and demanding environment characterized by irregular working hours, long flights, time zone changes, and extended periods away from home [ 3 , 4 , 5 ]. These factors can disrupt circadian rhythms, exacerbate sleep disturbances, and contribute to chronic fatigue, which are recognized risk factors for depression [ 6 , 7 ].
Pilots are exposed to various physical stressors, including cosmic radiation and electromagnetic fields, which may increase their cancer risk. Chemical stressors, such as pollutants from jet fuels and aircraft materials, can impact air quality. Additionally, the associated biological risks include exposure to foodborne pathogens and airborne microorganisms, further complicating health management. Environmental factors such as acceleration forces, hypoxia, and noise also pose significant health risks [ 8 , 9 ].
Research on pilot mental health has garnered increasing attention in recent years because of its profound implications for flight safety. The mental well-being of pilots is crucial because it directly affects their cognitive function, decision-making ability, situational awareness, and overall performance during flight operations, thereby compromising flight safety [ 10 ].
Limited research has been conducted on mental health disorders among commercial pilots globally. A systematic review by Terouz et al. [ 11 ] in 2018 included 20 studies, shedding light on the prevalence and types of mental health challenges faced by commercial airline pilots. The review revealed a wide range of depression prevalence rates, ranging from 1.9 to 12.6%. The study also identified various contributing factors to pilots’ mental health challenges, including substance abuse, exposure to verbal or sexual abuse, disrupted sleep patterns, and chronic fatigue. However, none of the studies included in the review were conducted in Saudi Arabia or the broader Middle East region, indicating a significant research gap within this specific geographical context.
Understanding the unique challenges shaping pilot mental health in Saudi Arabia is crucial not only for ensuring the well-being of these individuals but also for safeguarding the safety of air travel passengers and crews. This study aimed to address this knowledge gap by requesting self-reported data on depressive symptom prevalence and severity in a convenience sample of pilots in Saudi Arabia.
This cross-sectional survey was designed to estimate the self-reported prevalence of depression in a convenience sample of airline pilots in Saudi Arabia and identify associated demographic, occupational, and health behavior factors.
In Saudi Arabia, the General Authority of Civil Aviation (GACA) is responsible for establishing and overseeing health surveillance protocols for pilots. Saudi aviation medical examiners conduct thorough evaluations during mandatory occupational health visits. These examinations are typically performed at least annually for medical certification [ 12 ].
Participants were recruited from various commercial airlines in Saudi Arabia. The inclusion criterion included active pilots. Pilots were recruited through targeted outreach on social media platforms, with a focus on pilot forums and groups to ensure diverse representations. Referrals within professional networks were encouraged, and no incentives were provided for referrals to maintain voluntary participation. Approximately 500 pilots were estimated to be targeted for recruitment.
To ensure accessibility and convenience, the questionnaire was administered online. A survey link was disseminated through social media platforms, including LinkedIn, Twitter, and Facebook, allowing diverse types of participation. This mode accommodates pilots’ busy schedules, with an estimated completion time of 7 min. The data were collected over 6 weeks, from August 1, 2023, to September 12, 2023.
A structured questionnaire was developed through a literature review and expert consultation. The questionnaire comprises sections on demographic and professional characteristics, occupational information, health habits, and the Patient Health Questionnaire-9 (PHQ-9) questionnaire for depression assessment [ 13 ]. Prior to the main study, the questionnaire underwent preliminary testing through a pilot study involving 20 participants to ensure its clarity, relevance, and comprehensiveness.
Exposure variables.
The questionnaire covered various demographic variables, such as age group (< 30 years, 30–39 years, 40–49 years, ≥ 50 years), sex (male or female), marital status (single, married, divorced), self-reported weight (kg), height (cm), and the presence of chronic disease. Occupational information included position (captain or senior officer), years of experience, total flying hours (< 3,000, 3,000–5,000, 5,000–10,000, > 10,000), flying hours in the past year (< 500, 500–700, > 700), rest time between flights (< 1 h, 1–4 h, 4–24 h, > 24 h), and flight route duration (< 6 h, 6–12 h, > 12 h). The health behavior habit questions included whether the participant engaged in regular exercise, defined as exercising at least 3 times per week, exercise intensity (low, moderate, or high), smoking status (nonsmoker or smoker), and sleep duration (< 5 h, 5–8 h, or > 8 h). The survey questionnaire also included a section about musculoskeletal complaints, which were reported separately.
Depression severity was assessed via the PHQ-9 questionnaire, which categorizes scores into different severity levels. The PHQ-9 scores were categorized into five distinct severity levels: minimal depression (scores ranging from 0 to 4), mild depression (scores between 5 and 9), moderate depression (scores ranging from 10 to 14), moderately severe depression (scores ranging from 15 to 19), and severe depression (scores falling within the range of 20–27). The cutoff point for significant depression on the PHQ-9 questionnaire was defined as a score of 10 or higher, indicating the presence of moderate to severe depressive symptoms requiring clinical attention [ 13 ]. The primary outcome was the prevalence of depression among pilots. The secondary outcomes included associations between depression and demographic, occupational, and health behavior factors.
The data were analyzed via IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). The chi-square test was used for comparisons between variables. Multivariable logistic regression analysis was conducted to identify independent factors associated with depression, with odds ratios (ORs) and 95% confidence intervals (CIs) estimated. All p values were calculated via two-tailed tests with an alpha level of 0.05.
To assess the potential confounding effects of age on the relationships between flying hours, years of experience, and depression, a sensitivity analysis was performed. This analysis included interaction terms between age groups and years of experience to explore whether age influenced these relationships. The results of the sensitivity analysis revealed no significant interactions, indicating that age did not substantially confound the associations between flying hours, years of experience, and depression.
Ethical approval was obtained from the Ethics Committee of King Abdulaziz University. Informed consent was obtained, ensuring voluntary participation and confidentiality. Stringent data privacy and security measures were implemented to uphold ethical standards. The participants were informed that the survey was not a diagnostic tool and encouraged them to consult their healthcare provider if they were concerned about their mental health.
The study included 310 participants. The largest cohort comprised 34.8% (108 participants) of the 30–39 age group, closely followed by individuals under 30 years, constituting 30.0% (93 participants) of the sample. Males heavily dominated the sex distribution, representing 99.0% (307 participants) of the cohort. Marital status analysis revealed that 59.7% (185 individuals) were married. Regarding body mass index categories, the majority of participants were classified as normal (42.6%, 132 participants), followed by overweight (39.7%, 123 participants) and obese (17.1%, 53 participants) (Table 1 ).
Occupationally, the distribution between captains and senior officers was fairly balanced, with senior officers slightly outnumbering captains at 54.5% (169 participants) and 45.5% (141 participants), respectively. The number of years of experience varied, with the majority (57.7%, 179 participants) having between 0 and 10 years of experience. Flying hours were diverse, with nearly half of the participants (47.7%, 148 participants) accumulating fewer than 3,000 flying hours. Approximately one-third of the participants (31.0%, 96 participants) logged less than 500 h in the past year. The remaining time between flights varied as well, with 49.0% of participants (152 individuals) having less than 1 h of rest, 21.9% (68 individuals) having 1–4 h, 18.7% (58 individuals) having 4–24 h, and 10.3% (32 individuals) having more than 24 h. The flight route duration data revealed that the majority of flights (65.5%, 203 participants) lasted less than 6 h, followed by 23.9% (74 participants) lasting more than 12 h and 10.6% (33 participants) lasting between 6 and 12 h (Table 1 ).
Regarding the health habits of the participants, 194 participants (62.6%) identified as smokers. With respect to exercise, 158 participants (51.0%) engaged in physical activity regularly 3–5 times per week. The majority, 176 individuals (56.8%), reported exercising at a low intensity, whereas 86 participants (27.7%) exercised at a medium intensity. Additionally, 48 participants (15.5%) engaged in high-intensity exercise. The sleep duration among the participants varied, with 259 participants (83.5%) reporting a sleep duration of 5–8 h, 32 participants (10.3%) reporting more than 8 h, and 19 participants (6.1%) reporting less than 5 h (Fig. 1 ).
Health habits of the participants ( N = 310)
The mean PHQ-9 score among the study participants was 8.2 ± 5.4. Notably, 126 participants (40.6%) had a score of 10 or higher, indicating significant depression. Analysis of the PHQ-9 score distribution revealed that 88 participants (28.4%) exhibited minimal depression, 96 (31.0%) reported mild depression, 87 (28.1%) indicated moderate depression, 30 (9.7%) had moderately severe depression, and 9 (2.9%) had severe depression (Fig. 2 ).
Categorization of depression severity on the basis of PHQ-9 scores ( N = 310)
Table 2 presents the bivariate associations of depression with demographic, occupational, and health behavior factors. A total of 59.0% of the pilots aged 40–49 years presented with depression, whereas 34.4% of those aged < 30 years presented with depression ( p = 0.01). In terms of occupational factors, pilots with 0–10 years of experience had a lower prevalence of depression than did those with 11–15 years of experience (35.8% vs. 58.1%, p = 0.03). Similarly, pilots with 3,000–5,000 and 5,000–10,000 flying hours presented greater proportions of depression than did those with fewer flying hours (< 3,000) (49.0% and 51.6% vs. 37.2%, respectively; p = 0.04). Additionally, pilots with shorter rest times between flights (< 1 h) had a greater prevalence of depression than did those with longer rest times of 24 h (48.0% vs. 21.9%, p = 0.03).
In examining the associations between health habits and the prevalence of moderate to severe depression among the study participants, several noteworthy patterns emerged. With respect to smoking status, no significant difference was observed between nonsmokers (37.9%, 44 individuals) and smokers (42.3%, 82 individuals) in terms of experiencing depression ( p = 0.45). However, a statistically significant association was found between regular exercise and depression status ( p < 0.01). The participants who engaged in regular exercise presented a lower prevalence of depression (27.8%, 44 individuals) than did those who did not (53.9%, 82 individuals). Those engaging in low-intensity exercise had a greater prevalence of depression (51.1%, 90 individuals), followed by individuals engaging in moderate-intensity exercise (26.7%, 23 individuals) and those engaging in high-intensity exercise (27.1%, 13 individuals). Additionally, sleep duration was significantly associated with depression ( p = 0.01). Individuals reporting less than 5 h of sleep had a greater prevalence of moderate to severe depression (42.1%, 8 individuals), whereas those reporting 5–8 h of sleep presented a slightly greater prevalence (43.3%, 113 individuals), and individuals reporting more than 8 h of sleep had a lower prevalence (15.6%, 5 individuals).
Table 3 presents the findings from the multivariable analysis examining the relationships between various factors and depression among airline pilots. Notably, pilots with 11–15 years of experience had markedly greater odds of experiencing depression than did those with 0–10 years of experience (OR: 3.0, 95% CI: [1.1–8.4], p = 0.04). Additionally, pilots who had rest times between flights exceeding 24 h had significantly lower odds of depression than did those who had rest times less than 1 h (OR: 0.3, 95% CI: [0.1–0.8], p = 0.02). Furthermore, engaging in regular exercise was significantly associated with reduced odds of depression (OR: 0.3, 95% CI: [0.2–0.5], p < 0.01). Similarly, individuals with longer sleep durations (> 8 h) had a significantly lower likelihood of depression than did those with shorter sleep durations did (OR: 0.2, 95% CI: [0.1–1.0], p = 0.04).
The present study revealed an alarmingly high prevalence of depression among airline pilots, with 40.6% of the sample screening positive for depression via the PHQ-9. This figure is notably higher than the rates reported in previous studies, which range from 1.9 to 12.6% [ 11 , 14 ]. This substantial discrepancy raises important questions regarding the factors contributing to such elevated rates.
A key consideration is the screening tool used. Our study employed the PHQ-9, whereas other studies in the field have utilized different measures, including the Beck Depression Inventory-II (BDI-II) [ 10 ], Symptoms of Stress Questionnaire [ 15 ], Symptom Checklist 90 (SCL 90) [ 16 ], New Zealand Health Survey [ 17 ], and Self-Reporting Questionnaire-20 items (SRQ-20) [ 18 ]. The variation in tools across studies may partly account for differences in reported prevalence rates.
While it might be tempting to attribute this difference to the screening tool used—in our case, the PHQ-9—a deeper examination reveals that this explanation may not be sufficient. For example, Wu et al. [ 19 ] conducted a cross-sectional study focusing on mental health among airline pilots and utilized the PHQ-9. Their findings indicated that 12.6% of pilots met the depression threshold according to the PHQ-9 and that 4.1% reported suicidal thoughts within the past two weeks. A recent study by Minoretti et al. [ 14 ] investigated the impact of mild depressive symptoms on executive functions in airline pilots and revealed that 12% of the study population experienced mild depression according to the BDI-II. In fact, a previous study comparing the PHQ-9 and the BDI-II often categorized a greater proportion of participants with severe depression than did the PHQ-9.
Given this, the elevated depression rate observed in our study likely results from other factors. These could include unique characteristics of our sample, such as higher exposure to occupational stressors, fatigue, or other environmental and psychological factors specific to the airline pilot population in our country. In particular, occupational factors have emerged as significant contributors to the mental health outcomes of airline pilots in Saudi Arabia. Rest time between flights, in particular, has emerged as a critical determinant of mental health among pilots. Pilots with shorter intervals between flights demonstrated a greater prevalence of moderate to severe depression than did those with longer rest times exceeding 24 h. Sleep duration has emerged as another critical determinant of mental health among airline pilots. Sleep plays a pivotal role in regulating mood, cognitive function, and emotional stability [ 20 ]. Prolonged sleep deprivation can disrupt neurobiological processes, exacerbate stress responses, and increase vulnerability to mental health disorders [ 21 ]. Pilots who reported participating in regular physical activity presented lower prevalence rates of moderate to severe depression than did those who did not engage in regular exercise. It is unclear from our results whether those who exercised more frequently had fewer/milder depressive symptoms or whether those with more depressive symptoms felt less motivated to exercise.
Our findings reveal a concerning prevalence of depression among Saudi airline pilots. According to the GACA standards for Class 1 medical certification, pilots are disqualified if they have a history or clinical diagnosis of mood disorders, including clinical depression. The GACA guidelines explicitly state that mood disorders are grounds for disqualification [ 12 ]. The high prevalence of depression observed in our study raises questions about the fitness-to-fly licensing of pilots in Saudi Arabia. Given that pilots with severe depression may be at risk of disqualification under these standards, it is crucial to investigate whether affected pilots are being appropriately evaluated and treated. The reluctance to pursue treatment due to concerns about medical certification may result in pilots remaining untreated, potentially compromising their safety and performance. This issue underscores the need for a supportive framework that encourages pilots to seek help without fear of negative repercussions for their careers.
While our study provides valuable insights into the prevalence and correlates of depression among airline pilots in Saudi Arabia, several limitations should be acknowledged to contextualize the findings and guide future research endeavors. First, the cross-sectional nature of the survey design restricts our ability to establish causal relationships between variables. Although we can identify associations between certain factors and depression incidence, we cannot infer causation or temporal sequencing. Second, self-reporting biases may have influenced the accuracy and reliability of the data collected in our study. The participants may have underreported or overreported their symptoms of depression due to social desirability bias or recall errors. Third, the sampling strategy employed in our study may limit the generalizability of the results to the broader population of airline pilots in Saudi Arabia. Convenience sampling via online recruitment methods may have introduced selection bias, favoring participation among certain demographic groups or individuals with specific characteristics. Fourth, self-reported measures of depression relied upon the use of the PHQ-9. While the PHQ-9 is a validated screening tool for depression, it does not substitute for a comprehensive clinical evaluation conducted by trained mental health professionals. Finally, the questionnaire did not undergo formal validation, which should be considered a limitation of the study.
In conclusion, this study recruited pilots to self-report their depressive symptoms, and a greater percentage of the pilots experienced more severe symptoms than the authors expected on the basis of their background research. The identification of associated factors such as lack of regular exercise, short sleep duration, and inadequate rest between flights underscores the multifaceted nature of the mental health challenges faced by pilots in this region. Addressing these issues is paramount not only for safeguarding the well-being of pilots but also for ensuring flight safety. In the future, targeted interventions and policy initiatives should be implemented to promote mental health awareness, facilitate access to support services, and mitigate occupational stressors within the aviation industry. By prioritizing the mental well-being of pilots, stakeholders can contribute to a safer and healthier aviation environment for all.
No datasets were generated or analysed during the current study.
Collaborators GBDMD. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of Disease Study 2019. Lancet Psychiatry. 2022;9(2):137–50.
Article Google Scholar
Laditka JN, Laditka SB, Arif AA, Adeyemi OJ. Psychological distress is more common in some occupations and increases with job tenure: a thirty-seven year panel study in the United States. BMC Psychol. 2023;11(1):95.
Article PubMed PubMed Central Google Scholar
Aljurf TM, Olaish AH, BaHammam AS. Assessment of sleepiness, fatigue, and depression among Gulf Cooperation Council commercial airline pilots. Sleep Breath. 2018;22(2):411–9.
Article PubMed Google Scholar
O’Hagan AD, Issartel J, Nevill A, Warrington G. Flying Into Depression. Workplace Health Saf. 2017;65(3):109–17.
Venus M, Holtforth MG. Short and long Haul pilots rosters, stress, sleep problems, fatigue, Mental Health, and well-being. Aerosp Med Hum Perform. 2021;92(10):786–97.
Fang H, Tu S, Sheng J, Shao A. Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019;23(4):2324–32.
Mendoza J. Circadian insights into the biology of depression: symptoms, treatments and animal models. Behav Brain Res. 2019;376:112186.
Kim JN, Lee BM. Risk factors, health risks, and risk management for aircraft personnel and frequent flyers. J Toxicol Environ Health B Crit Rev. 2007;10(3):223–34.
Article CAS PubMed Google Scholar
Minoretti P, Emanuele E. Health in the skies: a narrative review of the issues faced by Commercial Airline pilots. Cureus. 2023;15(4):e38000.
PubMed PubMed Central Google Scholar
Minoretti P, Santiago Sáez AS, García Martín ÁF, Liaño Riera M, Gómez Serrano M, Emanuele E. Mild depressive symptoms in Airline pilots Associated with impaired executive functions. Cureus. 2023;15(7):e41616.
Pasha T, Stokes PRA. Reflecting on the Germanwings Disaster: a systematic review of depression and suicide in Commercial Airline pilots. Front Psychiatry. 2018;9:86.
Aviation GAC. GACA Regulation: Sect. 1, Personnel Licensing. Edition 4.0. In. Kingdom of Saudi Arabia; 2014.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.
Article CAS PubMed PubMed Central Google Scholar
Minoretti P, Liaño Riera M, Gómez Serrano M, Santiago Sáez A. García Martín Á: brushing away the blues: self-reported oral Hygiene practices are Associated with mild depressive symptoms in Airline pilots. Cureus. 2024;16(5):e60695.
Little LF, Gaffney IC, Rosen KH, Bender MM. Corporate instability is related to airline pilots’ stress symptoms. Aviat Space Environ Med. 1990;61(11):977–82.
CAS PubMed Google Scholar
Widyahening IS. High level of work stressors increase the risk of mental-emotional disturbances among airline pilots. Med J Indonesia. 2007;16(2):117–21.
Sykes AJ, Larsen PD, Griffiths RF, Aldington S. A study of airline pilot morbidity. Aviat Space Environ Med. 2012;83(10):1001–5.
Feijó D, Luiz RR, Camara VM. Common mental disorders among civil aviation pilots. Aviat Space Environ Med. 2012;83(5):509–13.
Wu AC, Donnelly McLay D, Weisskopf MG, McNeely E, Betancourt TS, Allen JG. Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey. Environ Health. 2016;15(1):121.
Vandekerckhove M, Wang YL. Emotion, emotion regulation and sleep: an intimate relationship. AIMS Neurosci. 2018;5(1):1–17.
Medic G, Wille M, Hemels ME. Short- and long-term health consequences of sleep disruption. Nat Sci Sleep. 2017;9:151–61.
Download references
We would like to thank AJE’s Curie platform for their assistance in preparing and reviewing this manuscript. Their support was invaluable in enhancing the clarity and quality of our work.
This research received no specific funding from any external source. All the authors contributed their time and resources voluntarily.
Authors and affiliations.
Family Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Sarah AlMuammar, Rahaf Alkhaldi, Roaa Alsharif, Daniah Allbdi, Mashael Alasmari, Bashair Alasmari, Afaf Alkhaldi, Refaal Aldealij & Nabeela Ismail
You can also search for this author in PubMed Google Scholar
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Correspondence to Sarah AlMuammar .
Ethics approval and informed consent.
The study was conducted in strict adherence to the principles outlined in the Declaration of Helsinki, with ethical clearance obtained from the Institutional Review Board at King Abdulaziz University. The informed consent process included a comprehensive explanation of the voluntary nature of participation, with a particular emphasis on measures taken to ensure the confidentiality of participant information.
Not applicable.
The authors declare no competing interests.
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, 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 you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. 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-nc-nd/4.0/ .
Reprints and permissions
Cite this article.
AlMuammar, S., Alkhaldi, R., Alsharif, R. et al. Navigating the skies: a cross-sectional study of depression among Saudi Arabian airline pilots. J Occup Med Toxicol 19 , 36 (2024). https://doi.org/10.1186/s12995-024-00435-4
Download citation
Received : 04 May 2024
Accepted : 28 August 2024
Published : 03 September 2024
DOI : https://doi.org/10.1186/s12995-024-00435-4
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
ISSN: 1745-6673
BMC Nursing volume 23 , Article number: 612 ( 2024 ) Cite this article
Metrics details
Providing positive and supportive environments for nurses and midwives working in ever-changing and complex healthcare services is paramount. Clinical supervision is one approach that nurtures and supports professional guidance, ethical practice, and personal development, which impacts positively on staff morale and standards of care delivery. In the context of this study, peer group clinical supervision provides allocated time to reflect and discuss care provided and facilitated by clinical supervisors who are at the same grade/level as the supervisees.
To explore the clinical supervisor’s experiences of peer group clinical supervision a mixed methods study design was utilised within Irish health services (midwifery, intellectual disability, general, mental health). The Manchester Clinical Supervision Scale was used to survey clinical supervisors ( n = 36) and semi-structured interviews ( n = 10) with clinical supervisors were conducted. Survey data were analysed through SPSS and interview data were analysed utilising content analysis. The qualitative and quantitative data’s reporting rigour was guided by the CROSS and SRQR guidelines.
Participants generally had a positive encounter when providing clinical supervision. They highly appreciated the value of clinical supervision and expressed a considerable degree of contentment with the supervision they provided to supervisees. The advantages of peer group clinical supervision encompass aspects related to self (such as confidence, leadership, personal development, and resilience), service and organisation (including a positive working environment, employee retention, and safety), and patient care (involving critical thinking and evaluation, patient safety, adherence to quality standards, and elevated levels of care).
There are many benefits of peer group clinical supervision at an individual, service, organisation, and patient level. Nevertheless, there is a need to address a lack of awareness and misconceptions surrounding clinical supervision to create an environment and culture conducive to realising its full potential. It is crucial that clinical supervision be accessible to nurses and midwives of all grades across all healthcare services, with national planning to address capacity and sustainability.
Peer Review reports
Within a dynamic healthcare system, nurses and midwives face growing demands, underscoring the necessity for ongoing personal and professional development. This is essential to improve the effectiveness and efficiency of care delivery for patients, families, and societies. Despite the increased emphasis on increasing the quality and safety of healthcare services and delivery, there is evidence highlighting declining standards of nursing and midwifery care [ 1 ]. The recent focus on re-affirming and re-committing to core values guiding nursing and midwifery practice is encouraging such as compassion, care and commitment [ 2 ], competence, communication, and courage [ 3 ]. However, imposing value statements in isolation is unlikely to change behaviours and greater consideration needs to be given to ways in which compassion, care, and commitment are nurtured and ultimately applied in daily practice. Furthermore, concerns have been raised about global staff shortages [ 4 ], the evidence suggesting several contributing factors such as poor workforce planning [ 5 ], job dissatisfaction [ 6 ], and healthcare migration [ 7 ]. Without adequate resources and staffing, compromising standards of care and threats to patient safety will be imminent therefore the importance of developing effective strategies for retaining competent registered nurses and midwives is paramount in today’s climate of increased staff shortages [ 4 ]. Clinical supervision serves as a means to facilitate these advancements and has been linked to heightened job satisfaction, enhanced staff retention, improved staff effectiveness, and effective clinical governance, by aiding in quality improvements, risk management, and heightened accountability [ 8 ].
Clinical supervision is a key component of professional practice and while the aim is largely known, there is no universally accepted definition of clinical supervision [ 8 ]. Clinical supervision is a structured process where clinicians are allowed protected time to reflect on their practice within a supportive environment and with the purpose of developing high-quality clinical care [ 9 ]. Recent literature published on clinical supervision [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ] highlights the advantages and merits of clinical supervision. However, there are challenges also identified such as a lack of consensus regarding the meaning and goal, implementation issues, variations in approaches in its operationalisation, and an absence of research evidence on its effectiveness. Duration and experience in clinical supervision link to positive benefits [ 8 ], but there is little evidence of how clinical supervision altered individual behaviours and practices. This is reinforced by Kuhne et al., [ 15 ] who emphasise that satisfaction rather than effectiveness is more commonly examined. It is crucial to emphasise that reviews have pinpointed that clinical supervision lowers the risks of adverse patient outcomes [ 9 ] and demonstrates enhancements in the execution of certain care processes. Peer group clinical supervision is a form of clinical supervision whereby two or more practitioners engage in a supervision or consultation process to improve their professional practice [ 17 ]. There is limited evidence regarding peer group clinical supervision and research on the experiences of peer clinical supervision and stakeholders is needed [ 13 ]. In Ireland, peer group clinical supervision has been recommended and guidelines have been developed [ 18 ]. In the Irish context, peer clinical supervision is where both clinical supervisees and clinical supervisors are peers at the same level/grade. However, greater evidence is required to inform future decisions on the implementation of peer group clinical supervision and the purpose of this study is to explore clinical supervisors’ experiences of peer group clinical supervision. As the focus is on peer group supervisors and utilising mixed methods the experiences of the other stakeholders were investigated and reported separately.
A mixed methods approach was used (survey and semi-structured interviews) to capture clinical supervisor’s experiences of clinical supervision. The study adhered to the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] (Supplementary File S1 ) and Standards for Reporting Qualitative Research guidelines [ 20 ] (Supplementary File S2 ).
This study was conducted with participants who successfully completed a professionally credited award: clinical supervision module run by a university in Ireland (74 clinical supervisors across 5 programmes over 3 years). The specific selection criteria for participants were that they were registered nurses/midwives delivering peer group clinical supervision within the West region of Ireland. The specific exclusion criteria were as follows: (1) nurses and midwives who haven’t finished the clinical supervision module at the University, (2) newly appointed peer group clinical supervisors who have yet to establish their groups and initiate the delivery of peer group clinical supervision.
The Manchester Clinical Supervision Scale-26 was used to survey participants in February/March 2022 and measure the peer group clinical supervisors’ overall experiences of facilitating peer group clinical supervision. The Manchester Clinical Supervision Scale-26 is a validated 26-item self-report questionnaire with a Likert-type (1–5) scale ranging from strongly disagree (1) to strongly agree (5) [ 21 ]. The Manchester Clinical Supervision Scale-26 measures the efficiency of and satisfaction with supervision, to investigate the skills acquisition aspect of clinical supervision and its effect on the quality of clinical care [ 21 ]. The instrument consists of two main sections to measure three (normative, restorative, and formative) dimensions of clinical supervision utilising six sub-scales: (1) trust and rapport, (2) supervisor advice/support, (3) improved care/skills, (4) importance/value of clinical supervision, (5) finding time, (6) personal issues/reflections and a total score for the Manchester Clinical Supervision Scale-26 is also calculated. Section two consisted of the demographic section of the questionnaire and was tailored to include eight demographic questions concerning the supervisor’s demographics, supervisee characteristics, and characteristics of clinical supervision sessions. There were also two open field questions on the Manchester Clinical Supervision Scale-26 (model of clinical supervision used and any other comments about experience of peer group clinical supervision). The main question about participants’ experiences with peer clinical supervision was “What was your experience of peer clinical supervision?” This was gathered through individual semi-structured interviews lasting between 20 and 45 min, in March/April 2022 (Supplementary file 3 ).
Health service institutional review boards of two University hospitals approved this study (Ref: 091/19 and Ref: C.A. 2199). Participants were recruited after receiving a full explanation of the study’s purpose and procedure and all relevant information. Participants were aware of potential risks and benefits and could withdraw from the study, or the survey could be stopped at any time. Informed consent was recorded, and participant identities were protected by using a pseudonym to protect anonymity.
Survey data was analysed using the data analysis software package Statistical Package for the Social Sciences, version 26 (SPSS Inc., Chicago, Il, USA). Descriptive analysis was undertaken to summarise responses to all items and categorical variables (nominal and ordinal) were analysed using frequencies to detail the number and percentage of responses to each question. Scores on the Manchester Clinical Supervision Scale-26 were reverse scored for 9 items (Q1-Q6, Q8, Q20,21) and total scores for each of the six sub-scales were calculated by adding the scores for each item. Raw scores for the individual sub-scales varied in range from 0 to 20 and these raw scores were then converted to percentages which were used in addition to the raw scores for each sub-scale to describe and summarise the results of the Manchester Clinical Supervision Scale-26. Cronbach’s alpha coefficient was undertaken with the 26 questions included within the Manchester Clinical Supervision Scale-26 and more importantly with each of the dimensions in the Manchester Clinical Supervision Scale-26. The open-ended questions on the Manchester Clinical Supervision Scale-26 and interviews were analysed using content analysis guided by Colorafi and Evans [ 22 ] and categories were generated using their eight steps, (1) creating a coding framework, (2) adding codes and memos, (3) applying the first level of coding, (4) categorising codes and applying the second level of coding, (5) revising and redefining the codes, (6) adding memos, (7) visualising data and (8) representing the data.
To ensure the validity and rigour of this study the researchers utilised the Manchester Clinical Supervision Scale-26 a recognised clinical supervision tool with good reliability and wide usage. Interviews were recorded, transcribed, and verified by four participants, data were collected until no new components appeared, data collection methods and analysis procedures were described, and the authors’ biases were minimised throughout the research process. The Manchester Clinical Supervision Scale-26 instrument internal consistency reliability was assessed which was overall good (α = 0.878) with individual subscale also good e.g., normative domain 0.765, restorative domain 0.864, and formative domain 0.900. Reporting rigour was demonstrated using the Consensus-Based Checklist for Reporting of Survey Studies guidelines [ 19 ] and Standards for Reporting Qualitative Research guidelines [ 20 ].
Participant and clinical supervision characteristics.
Thirty-six of the fifty-two (69.2%) peer group clinical supervisors working across a particular region of Ireland responded to the Manchester Clinical Supervision Scale-26 survey online via Qualtrics. Table 1 identifies the demographics of the sample who were predominantly female (94.4%) with a mean age of 44.7 years (SD. 7.63).
Peer group clinical supervision session characteristics (Table 2 ) highlight over half of peer group clinical supervisors ( n = 20, 55.6%) had been delivering peer group clinical supervision for less than one year and were mainly delivered to female supervisees ( n = 28, 77.8%). Most peer group clinical supervision sessions took place monthly ( n = 32, 88.9%) for 31–60 min ( n = 27, 75%).
Participants generally viewed peer group clinical supervision as effective (Table 3 ), the total mean Manchester Clinical Supervision Scale-26 score among all peer group clinical supervisors was 76.47 (SD. 12.801) out of 104, Surpassing the clinical supervision threshold score of 73, which was established by the developers of the Manchester Clinical Supervision Scale-26 as the benchmark indicating proficient clinical supervision provision [ 21 ]. Of the three domains; normative, formative, and restorative, the restorative domain scored the highest (mean 28.56, SD. 6.67). The mean scores compare favourably to that of the Manchester Clinical Supervision Scale-26 benchmark data and suggest that the peer group clinical supervisors were satisfied with both the level of support, encouragement, and guidance they provided and the level of trust/rapport they had developed during the peer group clinical supervision sessions. 83.3% ( n = 30) of peer group clinical supervisors reported being either very satisfied ( n = 12, 33.3%) or moderately satisfied ( n = 18, 50%) with the peer group clinical supervision they currently delivered. Within the peer group clinical supervisor’s supervisee related issues ( n = 17, 47.2%), work environment-related issues ( n = 16, 44.4%), staff-related issues ( n = 15, 41.7%) were reported as the most frequent issues, with patient/client related issues being less frequent ( n = 8, 22.2%). The most identified model used to facilitate peer group clinical supervision was the Proctors model ( n = 8, 22.22%), which was followed by group ( n = 2, 5.55%), peer ( n = 2, 5.55%), and a combination of the seven-eyed model of clinical supervision and Proctors model ( n = 1, 2.77%) with some not sure what model they used ( n = 2, 5.553%) and 58.33% ( n = 21) did not report what model they used.
‘Please enter any additional comments , which are related to your current experience of delivering Peer Group Clinical Supervision.’ There were 22 response comments to this question, which represented 61.1% of the 36 survey respondents, which were analysed using content analysis guided by Colorafi & Evans [ 22 ]. Three categories were generated. These included: personal value/benefit of peer group clinical supervision, challenges with facilitating peer group clinical supervision, and new to peer group clinical supervision.
The first category ‘personal value/benefit of peer group clinical supervision’ highlighted positive experiences of both receiving and providing peer group clinical supervision. Peer group clinical supervisors reported that they enjoyed the sessions and found them both worthwhile and beneficial for both the group and them as peer group clinical supervisors in terms of creating a trusted supportive group environment and motivation to develop. Peer group clinical supervision was highlighted as very important for the peer group clinical supervisors working lives and they hoped that there would be more uptake from all staff. One peer group clinical supervisor expressed that external clinical supervision was a ‘lifeline’ to shaping their supervisory journey to date.
The second category ‘challenges with facilitating peer group clinical supervision’, identified time constraints, lack of buy-in/support from management, staff shortages, lack of commitment by supervisees, and COVID-19 pandemic restrictions and related sick leave, as potential barriers to facilitating peer group clinical supervision. COVID-19 was perceived to have a negative impact on peer group clinical supervision sessions due to staff shortages, which resulted in difficulties for supervisees attending the sessions during work time. Peer group clinical supervisors felt that peer group clinical supervision was not supported by management and there was limited ‘buy-in’ at times. There was also a feeling expressed that peer group clinical supervision was in its infancy, as COVID-19 and its related restrictions impacted on this by either slowing down the process of commencing peer group clinical supervision in certain areas or having to move online. However, more recently improvements in managerial support and supervisee engagement with the peer group clinical supervision process are noted.
The final category ‘new to peer group clinical supervision’ highlighted that some peer group clinical supervisors were new to the process of providing peer group clinical supervision and some felt that this survey was not a true reflection of their experience of delivering peer group clinical supervision, as they were not fully established yet as clinical supervisors due to the impact of COVID-19. Peer group clinical supervisors identified that while they were new to providing peer group clinical supervision, they were enjoying it and that it was a learning curve for them.
The qualitative phase explored peer group clinical supervisors’ ( n = 10) own experiences of preparation received and experiences of being a peer group clinical supervisor. Three themes were identified through data analysis, building the foundations, enacting engagement and actions, and realities (Table 4 ).
This theme highlights the importance of prior knowledge, awareness, and training but also the recruitment process and education in preparing peer group clinical supervisors.
Participant’s prior knowledge and awareness of peer group clinical supervision was mixed with some reporting having little or no knowledge of clinical supervision.
I’m 20 years plus trained as a nurse , and I had no awareness of clinical supervision beforehand , I really hadn’t got a clue what all of this was about , so it was a very new concept to me (Bernie) .
Others were excited about peer group clinical supervision and while they could see the need they were aware that there may be limited awareness of the value and process of clinical supervision among peers.
I find that there’s great enthusiasm and passion for clinical supervision as it’s a great support mechanism for staff in practice , however , there’s a lack of awareness of clinical supervision (Jane) .
Some participants highlighted that the recruitment process to become a peer group clinical supervisor was vague in some organisations with an unclear and non-transparent process evident where people were chosen by the organisation’s management rather than self-selecting interested parties.
It was just the way the training was put to the people , they were kind of nominated and told they were going and there was a lot of upset over that , so they ended up in some not going at all (Ailbhe) .
In addition, the recruitment process was seen as top loaded where senior grades of staff were chosen, and this limited staff nurse grade opportunities where there was a clear need for peer group clinical supervisors and support.
We haven’t got down to the ground level like you know we’ve done the directors , we’ve done the CNM3s the CNM2s we are at the CNM1s , so we need to get down to the staff nurse level so the nurses at the direct frontline are left out and aren’t receiving supervision because we don’t have them trained (Bernie) .
Participants valued the training and education provided but there was a clear sense of ‘imposter syndrome’ for some peer group clinical supervisors starting out. Participants questioned their qualifications, training duration, and confidence to undertake the role of peer group clinical supervisor.
Because it is group supervision and I know that you know they say that we are qualified to do supervision and you know we’re now qualified clinical supervisors but I’m not sure that a three-month module qualifies you to be at the top of your game (Maria) .
Participants when engaged in the peer group clinical supervisor educational programme did find it beneficial and the true benefit was the actual re-engagement in education and published evidence along with the mix of nursing and midwifery practice areas.
I found it very beneficial , I mean I hadn’t been engaged in education here in a while , so it was great to be back in that field and you know with the literature that’s big (Claire) .
This theme highlights the importance of forming the groups, getting a clear message out, setting the scene, and grounding the group.
Recruitment for the group was of key importance to the peer group clinical supervisor and they all sent out a general invitation to form their group. Some supervisors used invitation letters or posters in addition to a general email and this was effective in recruiting supervisees.
You’re reaching out to people , I linked in with the ADoN and I put together a poster and circulated that I wasn’t ‘cherry picking , and I set up a meeting through Webex so people could get a sense of what it was if they were on the fence about it or unsure if it was for them (Karen) .
In forming the peer clinical supervision groups consideration needs to be given to the actual number of supervisees and participants reported four to six supervisees as ideal but that number can alter due to attendance.
The ideal is having five or six consistent people and that they all come on board and that you get the dynamics of the group and everything working (Claire) .
Within the recruitment process, it was evident that there was a limited and often misguided understanding or perception of peer group clinical supervision.
Greater awareness of what actually clinical supervision is , people misjudge it as a supervision where someone is appraising you , when in fact it is more of a support mechanism , I think peer support is the key element that needs to be brought out (Jane) .
Given the lack of clarity and understanding regarding peer group clinical supervision, the participants felt strongly that further clarity is needed and that the focus needs to be on the support it offers to self, practice, and the profession.
Clinical supervision to me is clinical leadership (Jane) .
In the initial phase of the group coming together the aspect of setting the scene and grounding the group was seen as important. A key aspect of this process was establishing the ground rules which not only set the boundaries and gave structure but also ensured the adoption of principles of trust, confidentiality, and safety.
We start with the ground rules , they give us structure it’s our contract setting out the commitment the expectation for us all , and the confidentiality as that’s so important to the trust and safety and building the relationships (Brid) .
Awareness of group dynamics is important in this process along with awareness of the group members (supervisees) as to their role and expectations.
I reiterate the role of each person in relation to confidentiality and the relationship that they would have with each other within the group and the group is very much aware that it is based on respect for each person’s point of view people may have a fear of contributing to the group and setting the ground rules is important (Jane) .
To ground the group, peer group clinical supervisors saw the importance of being present and allowing oneself to be in the room. This was evident in the time allocated at the start of each session to allow ‘grounding’ to occur in the form of techniques such as a short meditation, relaxation, or deep breathing.
At the start , I do a bit of relaxation and deep breathing , and I saw that with our own external supervisor how she settled us into place so very much about connecting with your body and you’ve arrived , then always come in with the contract in my first sentence , remember today you know we’re in a confidential space , of course , you can take away information , but the only information you will take from today is your own information and then the respect aspect (Mary Rose) .
This settling in and grounding was seen as necessary for people to feel comfortable and engage in the peer group clinical supervision process where they could focus, be open, converse, and be aware of their role and the role of peer group clinical supervision.
People have to be open, open about their practice and be willing to learn and this can only occur by sharing, clinical supervision gives us the space to do it in a space where we know we will be respected, and we can trust (Claire) .
This theme highlights the importance of the peer group clinical supervisors’ past experiences, delivering peer group clinical supervision sessions, responding to COVID-19, personal and professional development, and future opportunities.
Past experiences of peer group clinical supervisors were not always positive and for one participant this related to the lack of ground rules or focus of the sessions and the fact it was facilitated by a non-nurse.
In the past , I suppose I would have found it very frustrating as a participant because I just found that it was going round in circles , people moaning and you know it wasn’t very solution focused so I came from my situation where I was very frustrated with clinical supervision , it was facilitated by somebody that was non-nursing then it wasn’t very , there wasn’t the ground rules , it was very loose (Caroline) .
However, many did not have prior experience of peer group clinical supervision. Nonetheless, through the education and preparation received, there was a sense of commitment to embrace the concept, practice, and philosophy.
I did not really have any exposure or really much information on clinical supervision , but it has opened my eyes , and as one might say I am now a believer (Brid) .
In delivering peer group clinical supervision, participants felt supervisees were wary, as they did not know what peer group clinical supervision was, and they had focused more on the word supervision which was misleading to them. Nonetheless, the process was challenging, and buy-in was questioned at an individual and managerial level.
Buy-in wasn’t great I think now of course people will blame the pandemic , but this all happened before the pandemic , there didn’t seem to be you know , the same support from management that I would have expected so I kind of understood it in a way because then there wasn’t the same real respect from the practitioners either (Mary Rose) .
From the peer group clinical supervisor’s perspective, they were all novices in delivering/facilitating peer group clinical supervision sessions, and the support of the external clinical supervisors, and their own peer group clinical supervision sessions were invaluable along with a clinical supervision model.
Having supervision myself was key and something that is vital and needed , we all need to look at our practice and how we work it’s no good just facilitating others without being part of the process yourself but for me I would say the three principles of clinical supervision , you know the normative , formative and restorative , I keep hammering that home and bring that in regularly and revisit the contract and I have to do that often you know (Claire) .
All peer group clinical supervisors commented on the preparation for their peer group clinical supervision sessions and the importance of them having the right frame of mind and that often they needed to read over their course work and published evidence.
I want everybody to have a shared voice and you know that if one person , there is something that somebody feels very strongly and wants to talk about it that they e-mail in advance like we don’t have a set agenda but that’s agreed from the participant at the start (Caroline) .
To assist this, the peer group clinical supervisors noted the importance of their own peer group clinical supervision, the support of their peers, and external clinical supervisors. This preparation in an unpredictable situation can be difficult but drawing on one’s experience and the experience within the group can assist in navigating beyond unexpected situations.
I utilise the models of clinical supervision and this helps guide me , I am more of a facilitator of the group we are experts in our own area and our own role but you can only be an expert if you take the time to examine your practice and how you operate in your role (Brid) .
All clinical supervisors noted that the early sessions can be superficial, and the focus can be on other practice or management issues, but as time moves on and people become more engaged and involved it becomes easier as their understanding of supervision becomes clearer. In addition, there may be hesitancy and people may have difficulty opening up with certain people in the group and this is a reality that can put people off.
Initially there was so much managerial bashing and I think through supervision , I began to kind of think , I need the pillars of supervision , the governance , bringing more knowledge and it shifted everything in the room , trying to marry it with all the tensions that people have (Mary Rose) .
For some clinical supervisors, there were expected and unexpected challenges for them as clinical supervisors in terms of the discussions veering off course and expectations of their own ability.
The other big challenge is when they go off , how do you bring him back , you know when they veer off and you’re expected to be a peer , but you have to try and recoil that you have to get the balance with that right (Mary Rose) .
While peer group clinical supervision is accepted and seen as a valuable process by the peer group clinical supervisors, facilitating peer group supervision with people known to you can be difficult and may affect the process.
I’d love to supervise a group where I actually don’t know the people , I don’t know the dynamics within the group , and I’d love to see what it would be like in a group (Bernie) .
Of concern to clinical supervisors was the aspect of non-attendance and while there may be valid reasons such as COVID-19 the absence of a supervisee for several sessions can affect the group dynamics, especially if the supervisee has only engaged with early group sessions.
One of the ones that couldn’t attend because of COVID and whatever , but she’s coming to the next one and I just feel there’s a lot of issues in her area and I suppose I’m mindful that I don’t want that sort of thing to seep in , so I suppose it’s just for me just to keep reiterating the ground rules and the boundaries , that’s something I just have to manage as a facilitator , but what if they don’t attend how far will the group have progressed before she attends (Caroline) .
The advent of COVID-19 forced peer group clinical supervisors to find alternative means of providing peer group clinical supervision sessions which saw the move from face-to-face to online sessions. The online transition was seen as seamless for many established groups while others struggled to deliver sessions.
With COVID we did online for us it was fine because we were already formed (Corina) .
While the transition may have been positive many clinical supervisors came across issues because they were using an online format that would not be present in the face-to-face session.
We did have a session where somebody was in the main office and they have a really loud booming voice and they were saying stuff that was not appropriate to say outside of clinical supervision and I was like are you in the office can you lower it down a bit can you put your headphones on (Maria) .
However, two peer group clinical supervisors ceased or hasted the progress of rolling out peer group clinical supervision sessions mainly due to redeployment and staff availability.
With COVID it just had to be canceled here , it’s just the whole thing was canceled so it was very , very difficult for people (Mary Rose) .
It was clear from clinical supervisors that online sessions were appropriate but that they felt they were only appropriate for existing established groups that have had the opportunity to build relationships, develop trust, embed the ground rules, and create the space for open communication and once established a combined approach would be appropriate.
Since we weren’t as established as a group , not everybody knew each other it would be difficult to establish that so we would hold off/reschedule , obviously COVID is a major one but also I suppose if you have an established group now , and again , you could go to a remote one , but I felt like since we weren’t established as a group it would be difficult to develop it in that way (Karen) .
Within practice COVID-19 took priority and other aspects such as peer group clinical supervision moved lower down on the priority list for managers but not for the clinical supervisors even where redeployment occurred.
With COVID all the practical side , if one of the managers is dealing with an outbreak , they won’t be attending clinical supervision , because that has to be prioritised , whereas we’ve prioritised clinical supervision (Maria) .
The valuing of peer group clinical supervision was seen as important by clinical supervisors, and they saw it as particularly needed during COVID-19 as staff were dealing with many personal and professional issues.
During the height of COVID , we had to take a bit of a break for four months as things were so demanding at work for people but then I realised that clinical supervision was needed and started back up and they all wanted to come back (Brid) .
Having peer group clinical supervision during COVID-19 supported staff and enabled the group to form supportive relationships.
COVID has impacted over the last two years in every shape and they needed the supervision and the opportunity to have a safe supportive space and it gelled the group I think as we all were there for each other (Claire) .
While COVID-19 posed many challenges it also afforded clinical supervisors and supervisees the opportunity for change and to consider alternative means of running peer group clinical supervision sessions. This change resulted in online delivery and in reflecting on both forms of delivery (face-to-face and online) clinical supervisors saw the benefit in both. Face-to-face was seen as being needed to form the group and then the group could move online once the group was established with an occasional periodic face-to-face session to maintain motivation commitment and reinforce relationships and support.
Online formats can be effective if the group is already established or the group has gone through the storming and forming phase and the ground rules have been set and trust built , then I don’t see any problem with a blended online version of clinical supervision , and I think it will be effective (Jane) .
Growth and development were evident from peer group clinical supervisors’ experiences and this growth and development occurred at a personal, professional, and patient/client level. This development also produced an awakening and valuing of one’s passion for self and their profession.
I suppose clinical supervision is about development I can see a lot of development for me and my supervisees , you know personally and professionally , it’s the support really , clinical supervision can reinvigorate it’s very exciting and a great opportunity for nursing to support each other and in care provision (Claire) .
A key to the peer group clinical supervisor’s development was the aspect of transferable skills and the confidence they gained in fulfilling their role.
All of these skills that you learn are transferable and I am a better manager because of clinical supervision (Maria) .
The confidence and skills gained translated into the clinical supervisor’s own practice as a clinical practitioner and clinical supervisor but they were also realistic in predicting the impact on others.
I have empowered my staff , I empower them to use their voice and I give my supervisees a voice and hope they take that with them (Corina) .
Fundamental to the development process was the impact on care itself and while this cannot always be measured or identified, the clinical supervisors could see that care and support of the individual practitioner (supervisee) translated into better care for the patient/client.
Care is only as good as the person delivering it and what they know , how they function and what energy and passion they have , and clinical supervision gives the person support to begin to understand their practice and how and why they do things in a certain way and when they do that they can begin to question and even change their way of doing something (Brid) .
Based on the clinical supervisor’s experiences there was a clear need identified regarding valuing and embedded peer group clinical supervision within nursing/midwifery practice.
There has to be an emphasis placed on supervision it needs to be part of the fabric of a service and valued by all in that service , we should be asking why is it not available if it’s not there but there is some work first on promoting it and people knowing what it actually is and address the misconceptions (Claire) .
While such valuing and buy-in are important, it is not to say that all staff need to have peer group clinical supervision so as to allow for personal choice. In addition, to value peer group clinical supervision it needs to be evident across all staffing grades and one could question where the best starting point is.
While we should not mandate that all staff do clinical supervision it should become embedded within practice more and I suppose really to become part of our custom and practice and be across all levels of staff (Brid) .
When peer group clinical supervision is embedded within practice then it should be custom and practice, where it is included in all staff orientations and is nationally driven.
I suppose we need to be driving it forward at the coal face at induction , at orientation and any development for the future will have to be driven by the NMPDUs or nationally (Ailbhe) .
A formalised process needs to address the release of peer group clinical supervisors but also the necessity to consider the number of peer group clinical supervisors at a particular grade.
The issue is release and the timeframe as they have a group but they also have their external supervision so you have to really work out how much time you’re talking about (Maria) .
Vital within the process of peer group clinical supervision is receiving peer group clinical supervision and peer support and this needs to underpin good peer group clinical supervision practice.
Receiving peer group supervision helps me , there are times where I would doubt myself , it’s good to have the other group that I can go to and put it out there to my own group and say , look at this , this is what we did , or this is what came up and this is how (Bernie) .
For future roll out to staff nurse/midwife grade resourcing needs to be considered as peer group clinical supervisors who were managers could see the impact of having several peer group clinical supervisors in their practice area may have on care delivery.
Facilitating groups is an issue and needs to be looked at in terms of the bigger picture because while I might be able to do a second group the question is how I would be supported and released to do so (Maria) .
While there was ambiguity regarding peer group clinical supervision there was an awareness of other disciplines availing of peer group clinical supervision, raising questions about the equality of supports available for all disciplines.
I always heard other disciplines like social workers would always have been very good saying I can’t meet you I have supervision that day and I used to think my God what’s this fabulous hour that these disciplines are getting and as a nursing staff it just wasn’t there and available (Bernie) .
To address this equity issue and the aspect of low numbers of certain grades an interdisciplinary approach within nursing and midwifery could be used or a broader interdisciplinary approach across all healthcare professionals. An interdisciplinary or across-services approach was seen as potentially fruitful.
I think the value of interprofessional or interdisciplinary learning is key it addresses problem-solving from different perspectives that mix within the group is important for cross-fertilisation and embedding the learning and developing the experience for each participant within the group (Jane) .
As we move beyond COVID-19 and into the future there is a need to actively promote peer group clinical supervision and this would clarify what peer group clinical supervision actually is, its uptake and stimulate interest.
I’d say it’s like promoting vaccinations if you could do a roadshow with people , I think that would be very beneficial , and to launch it , like you have a launch an official launch behind it (Mary Rose) .
The advantages of peer group clinical supervision highlighted in this study pertain to self-enhancement (confidence, leadership, personal development, resilience), organisational and service-related aspects (positive work environment, staff retention, safety), and professional patient care (critical thinking and evaluation, patient safety, adherence to quality standards, elevated care standards). These findings align with broader literature that acknowledges various areas, including self-confidence and facilitation [ 23 ], leadership [ 24 ], personal development [ 25 ], resilience [ 26 ], positive/supportive working environment [ 27 ], staff retention [ 28 ], sense of safety [ 29 ], critical thinking and evaluation [ 30 ], patient safety [ 31 ], quality standards [ 32 ] and increased standards of care [ 33 ].
In this study, peer group clinical supervision appeared to contribute to the alleviation of stress and anxiety. Participants recognised the significance of these sessions, where they could openly discuss and reflect on professional situations both emotionally and rationally. Central to these discussions was the creation of a safe, trustworthy, and collegial environment, aligning with evidence in the literature [ 34 ]. Clinical supervision provided a platform to share resources (information, knowledge, and skills) and address issues while offering mutual support [ 35 ]. The emergence of COVID-19 has stressed the significance of peer group clinical supervision and support for the nursing/midwifery workforce [ 36 ], highlighting the need to help nurses/midwifes preserve their well-being and participate in collaborative problem-solving. COVID-19 impacted and disrupted clinical supervision frequency, duration and access [ 37 ]. What was evident during COVID-19 was the stress and need for support for staff and given the restorative or supportive functions of clinical supervision it is a mechanism of support. However, clinical supervisors need support themselves to be able to better meet the supervisee’s needs [ 38 ].
The value of peer group clinical supervision in nurturing a conducive working environment cannot be overstated, as it indorses the understanding and adherence to workplace policies by empowering supervisees to understand the importance and rationale behind these policies [ 39 ]. This becomes vital in a continuously changing healthcare landscape, where guidelines and policies may be subject to change, especially in response to situations such as COVID-19. In an era characterised by international workforce mobility and a shortage of healthcare professionals, a supportive and positive working environment through the provision of peer group clinical supervision can positively influence staff retention [ 40 ], enhance job satisfaction [ 41 ], and mitigate burnout [ 42 ]. A critical aspect of the peer group clinical supervision process concerns providing staff the opportunity to reflect, step back, problem-solve and generate solutions. This, in turn, ensures critical thinking and evaluation within clinical supervision, focusing on understanding the issues and context, and problem-solving to draw constructive lessons for the future [ 30 ]. Research has determined a link between clinical supervision and improvements in the quality and standards of care [ 31 ]. Therefore, peer group clinical supervision plays a critical role in enhancing patient safety by nurturing improved communication among staff, facilitating reflection, promoting greater self-awareness, promoting the exchange of ideas, problem-solving, and facilitating collective learning from shared experiences.
Starting a group arose as a foundational aspect emphasised in this study. The creation of the environment through establishing ground rules, building relationships, fostering trust, displaying respect, and upholding confidentiality was evident. Vital to this process is the recruitment of clinical supervisees and deciding the suitable group size, with a specific emphasis on addressing individuals’ inclination to engage, their knowledge and understanding of peer group clinical supervision, and dissipating any lack of awareness or misconceptions regarding peer group supervision. Furthermore, the educational training of peer group clinical supervisors and the support from external clinical supervisors played a vital role in the rollout and formation of peer group clinical supervision. The evidence stresses the significance of an open and safe environment, wherein supervisees feel secure and trust their supervisor. In such an environment, they can effectively reflect on practice and related issues [ 41 ]. This study emphasises that the effectiveness of peer group supervision is more influenced by the process than the content. Clinical supervisors utilised the process to structure their sessions, fostering energy and interest to support their peers and cultivate new insights. For peer group clinical supervision to be effective, regularity is essential. Meetings should be scheduled in advance, allocate protected time, and take place in a private space [ 35 ]. While it is widely acknowledged that clinical supervisors need to be experts in their professional field to be credible, this study highlights that the crucial aspects of supervision lie in the quality of the relationship with the supervisor. The clinical supervisor should be supportive, caring, open, collaborative, sensitive, flexible, helpful, non-judgmental, and focused on tacit knowledge, experiential learning, and providing real-time feedback.
Critical to the success of peer group clinical supervision is the endorsement and support from management, considering the organisational culture and attitudes towards the practice of clinical supervision as an essential factor [ 43 ]. This support and buy-in are necessary at both the management and individual levels [ 28 ]. The primary obstacles to effective supervision often revolve around a lack of time and heavy workloads [ 44 ]. Clinical supervisors frequently struggle to find time amidst busy environments, impacting the flexibility and quality of the sessions [ 45 ]. Time constraints also limit the opportunity for reflection within clinical supervision sessions, leaving supervisees feeling compelled to resolve issues on their own without adequate support [ 45 ]. Nevertheless, time-related challenges are not unexpected, prompting a crucial question about the value placed on clinical supervision and its integration into the culture and fabric of the organisation or profession to make it a customary practice. Learning from experiences like those during the COVID-19 pandemic has introduced alternative ways of working, and the use of technology (such as Zoom, Microsoft Teams, Skype) may serve as a means to address time, resource, and travel issues associated with clinical supervision.
Despite clinical supervision having a long international history, persistent misconceptions require attention. Some of these include not considering clinical supervision a priority [ 46 ], perceiving it as a luxury [ 41 ], deeming it self-indulgent [ 47 ], or viewing it as mere casual conversation during work hours [ 48 ]. A significant challenge lies in the lack of a shared understanding regarding the role and purpose of clinical supervision, with past perceptions associating it with surveillance and being monitored [ 48 ]. These negative connotations often result in a lack of engagement [ 41 ]. Without encouragement and recognition of the importance of clinical supervision from management or the organisation, it is unlikely to become embedded in the organisational culture, impeding its normalisation [ 39 ].
In this study, some peer group clinical supervisors expressed feelings of being impostors and believed they lacked the knowledge, skills, and training to effectively fulfil their roles. While a deficiency in skills and competence are possible obstacles to providing effective clinical supervision [ 49 ], the peer group clinical supervisors in this study did not report such issues. Instead, their concerns were more about questioning their ability to function in the role of a peer group clinical supervisor, especially after a brief training program. The literature acknowledges a lack of training where clinical supervisors may feel unprepared and ill-equipped for their role [ 41 ]. To address these challenges, clinical supervisors need to be well-versed in professional guidelines and ethical standards, have clear roles, and understand the scope of practice and responsibilities associated with being a clinical supervisor [ 41 ].
The support provided by external clinical supervisors and the peer group clinical supervision sessions played a pivotal role in helping peer group clinical supervisors ease into their roles, gain experiential learning, and enhance their facilitation skills within a supportive structure. Educating clinical supervisors is an investment, but it should not be a one-time occurrence. Ongoing external clinical supervision for clinical supervisors [ 50 ] and continuous professional development [ 51 ] are crucial, as they contribute to the likelihood of clinical supervisors remaining in their roles. However, it is important to interpret the results of this study with caution due to the small sample size in the survey. Generalising the study results should be approached with care, particularly as the study was limited to two regions in Ireland. However, the addition of qualitative data in this mixed-methods study may have helped offset this limitation.
This study highlights the numerous advantages of peer group clinical supervision at individual, service, organisational, and patient/client levels. Success hinges on addressing the initial lack of awareness and misconceptions about peer group clinical supervision by creating the right environment and establishing ground rules. To unlock the full potential of peer group clinical supervision, it is imperative to secure management and organisational support for staff release. More crucially, there is a need for valuing and integrating peer group clinical supervision into nursing and midwifery education and practice. Making peer group clinical supervision accessible to all grades of nurses and midwives across various healthcare services is essential, necessitating strategic planning to tackle capacity and sustainability challenges.
Data are available from the corresponding author upon request owing to privacy or ethical restrictions.
Zelenikova R, Gurkova E, Friganovic A, Uchmanowicz I, Jarosova D, Ziakova K, Plevova I, Papastavrou E. Unfinished nursing care in four central European countries. J Nurs Manage. 2020;28(8):1888–900. https://doi.org/10.1111/jonm.12896 .
Article Google Scholar
Department of Health, Office of the Chief Nursing Officer. Position paper 1: values for nurses and midwives in Ireland. Dublin: The Stationery Office; 2016.
Google Scholar
Cummings J, Bennett V. Developing the culture of compassionate care: creating a new vision for nurses, midwives and care-givers. London: Department of Health; 2012.
Both-Nwabuwe JM, Dijkstra MT, Klink A, Beersma B. Maldistribution or scarcity of nurses: the devil is in the detail. J Nurs Manage. 2018;26(2):86–93. https://doi.org/10.1111/jonm.12531 .
Squires A, Jylha V, Jun J, Ensio A, Kinnunen J. A scoping review of nursing workforce planning and forecasting research. J Nurs Manage. 2017;25:587–96. https://doi.org/10.1111/jonm.12510 .
Sasso L, Bagnasco A, Catania G, Zanini M, Aleo G, Watson R. Push and pull factors of nurses’ intention to leave. J Nurs Manage. 2019;27:946–54. https://doi.org/10.1111/jonm.12745 .
Gea-Caballero V, Castro-Sánchez E, Díaz‐Herrera MA, Sarabia‐Cobo C, Juárez‐Vela R, Zabaleta‐Del Olmo E. Motivations, beliefs, and expectations of Spanish nurses planning migration for economic reasons: a cross‐sectional, web‐based survey. J Nurs Scholarsh. 2019;51(2):178–86. https://doi.org/10.1111/jnu.12455 .
Article PubMed Google Scholar
Cutcliffe J, Sloan G, Bashaw M. A systematic review of clinical supervision evaluation studies in nursing. Int J Ment Health Nurs. 2018;27:1344–63. https://doi.org/10.1111/inm.12443 .
Snowdon DA, Hau R, Leggat SG, Taylor NF. Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. Int J Qual Health C. 2016;28(4):447–55. https://doi.org/10.1093/intqhc/mzw059 .
Turner J, Hill A. Implementing clinical supervision (part 1): a review of the literature. Ment Health Nurs. 2011;31(3):8–12.
Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Finding a way forward: a literature review on the current debates around clinical supervision. Contemp Nurse. 2013;45(1):22–32. https://doi.org/10.5172/conu.2013.45.1.22 .
Buss N, Gonge H. Empirical studies of clinical supervision in psychiatric nursing: a systematic literature review and methodological critique. Int J Ment Health Nurs. 2009;18(4):250–64. https://doi.org/10.1111/j.1447-0349.2009.00612.x .
Pollock A, Campbell P, Deery R, Fleming M, Rankin J, Sloan G, Cheyne H. A systematic review of evidence relating to clinical supervision for nurses, midwives and allied health professionals. J Adv Nurs. 2017;73(8):1825–37. https://doi.org/10.1111/jan.13253 .
Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience: a systematic review. BMC Health Serv Res. 2017;17(1):1–11. https://doi.org/10.1186/s12913-017-2739-5 .
Kühne F, Maas J, Wiesenthal S, Weck F. Empirical research in clinical supervision: a systematic review and suggestions for future studies. BMC Psychol. 2019;7(1):1–11. https://doi.org/10.1186/s40359-019-0327-7 .
Snowdon DA, Sargent M, Williams CM, Maloney S, Caspers K, Taylor NF. Effective clinical supervision of allied health professionals: a mixed methods study. BMC Health Serv Res. 2020;20(1):1–11. https://doi.org/10.1186/s12913-019-4873-8 .
Borders LD. Dyadic, triadic, and group models of peer supervision/consultation: what are their components, and is there evidence of their effectiveness? Clin Psychol. 2012;16(2):59–71.
Health Service Executive. Guidance document on peer group clinical supervision. Mayo: Nursing and Midwifery Planning and Development Unit Health Service Executive West Mid West; 2023.
Sharma A, Minh Duc NT, Lam Thang L, Nam T, Ng NH, Abbas SJ, Huy KS, Marušić NT, Paul A, Kwok CL. Karamouzian, M. A consensus-based checklist for reporting of survey studies (CROSS). J Gen Intern Med. 2021;36(10):3179–87. https://doi.org/10.1007/s11606-021-06737-1 .
Article PubMed PubMed Central Google Scholar
O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;899:1245–51. https://doi.org/10.1097/ACM.0000000000000388 .
Winstanley J, White E. The MCSS-26©: revision of the Manchester Clinical Supervision Scale© using the Rasch Measurement Model. J Nurs Meas. 2011;193(2011):160–78. https://doi.org/10.1891/1061-3749.19.3.160 .
Colorafi KJ, Evans B. Qualitative descriptive methods in health science research. HERD-Health Env Res. 2016;9:16–25. https://doi.org/10.1177/1937586715614171 .
Agnew T, Vaught CC, Getz HG, Fortune J. Peer group clinical supervision program fosters confidence and professionalism. Prof Sch Couns. 2000;4(1):6–12.
Mc Carthy V, Goodwin J, Saab MM, Kilty C, Meehan E, Connaire S, O’Donovan A. Nurses and midwives’ experiences with peer-group clinical supervision intervention: a pilot study. J Nurs Manage. 2021;29:2523–33. https://doi.org/10.1111/jonm.13404 .
Rothwell C, Kehoe A, Farook SF, Illing J. Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review. BMJ Open. 2021;119:e052929. https://doi.org/10.1136/bmjopen-2021-052929 .
Francis A, Bulman C. In what ways might group clinical supervision affect the development of resilience in hospice nurses. Int J Palliat Nurs. 2019;25:387–96. https://doi.org/10.12968/ijpn.2019.25.8.387 .
Chircop Coleiro A, Creaner M, Timulak L. The good, the bad, and the less than ideal in clinical supervision: a qualitative meta-analysis of supervisee experiences. Couns Psychol Quart. 2023;36(2):189–210. https://doi.org/10.1080/09515070.2021.2023098 .
Stacey G, Cook G, Aubeeluck A, Stranks B, Long L, Krepa M, Lucre K. The implementation of resilience based clinical supervision to support transition to practice in newly qualified healthcare professionals. Nurs Educ Today. 2020;94:104564. https://doi.org/10.1016/j.nedt.2020.104564 .
Feerick A, Doyle L, Keogh B. Forensic mental health nurses’ perceptions of clinical supervision: a qualitative descriptive study. Issues Ment Health Nurs. 2021;42:682–9. https://doi.org/10.1080/01612840.2020.1843095 .
Corey G, Haynes RH, Moulton P, Muratori M. Clinical supervision in the helping professions: a practical guide. Alexandria, VA: American Counseling Association; 2021.
Sturman N, Parker M, Jorm C. Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning. Adv Health Sci Educ. 2021;26:297–311. https://doi.org/10.1007/s10459-020-09986-7 .
Alfonsson S, Parling T, Spännargård Å, Andersson G, Lundgren T. The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review. Cogn Behav Therapy. 2018;47(3):206–28. https://doi.org/10.1080/16506073.2017.1369559 .
Coelho M, Esteves I, Mota M, Pestana-Santos M, Santos MR, Pires R. Clinical supervision of the nurse in the community to promote quality of care provided by the caregiver: scoping review protocol. Millenium J Educ Technol Health. 2022;2:83–9. https://doi.org/10.29352/mill0218.26656 .
Toros K, Falch-Eriksen A. Structured peer group supervision: systematic case reflection for constructing new perspectives and solutions. Int Soc Work. 2022;65:1160–5. https://doi.org/10.1177/0020872820969774 .
Bifarin O, Stonehouse D. Clinical supervision: an important part of every nurse’s practice. Brit J Nurs. 2017;26(6):331–5. https://doi.org/10.12968/bjon.2017.26.6.331 .
Turner J, Simbani N, Doody O, Wagstaff C, McCarthy-Grunwald S. Clinical supervision in difficult times and at all times. Ment Health Nurs. 2022;42(1):10–3.
Martin P, Tian E, Kumar S, Lizarondo L. A rapid review of the impact of COVID-19 on clinical supervision practices of healthcare workers and students in healthcare settings. J Adv Nurs. 2022;78:3531–9. https://doi.org/10.1111/jan.15360 .
van Dam M, van Hamersvelt H, Schoonhoven L, Hoff RG, Cate OT, Marije P. Hennus. Clinical supervision under pressure: a qualitative study amongst health care professionals working on the ICU during COVID-19. Med Edu Online. 2023;28:1. https://doi.org/10.1080/10872981.2023.2231614 .
Martin P, Lizarondo L, Kumar S, Snowdon D. Impact of clinical supervision on healthcare organisational outcomes: a mixed methods systematic review. PLoS ONE. 2021;1611:e0260156. https://doi.org/10.1371/journal.pone.0260156 .
Article CAS Google Scholar
Hussein R, Salamonson Y, Hu W, Everett B. Clinical supervision and ward orientation predict new graduate nurses’ intention to work in critical care: findings from a prospective observational study. Aust Crit Care. 2019;325:397–402. https://doi.org/10.1016/j.aucc.2018.09.003 .
Love B, Sidebotham M, Fenwick J, Harvey S, Fairbrother G. Unscrambling what’s in your head: a mixed method evaluation of clinical supervision for midwives. Women Birth. 2017;30:271–81. https://doi.org/10.1016/j.wombi.2016.11.002 .
Berry S, Robertson N. Burnout within forensic psychiatric nursing: its relationship with ward environment and effective clinical supervision? J Psychiatr Ment Health Nurs. 2019;26:7–8. https://doi.org/10.1111/jpm.12538 .
Markey K, Murphy L, O’Donnell C, Turner J, Doody O. Clinical supervision: a panacea for missed care. J Nurs Manage. 2020;28:2113–7. https://doi.org/10.1111/jonm.13001 .
Brody AA, Edelman L, Siegel EO, Foster V, Bailey DE Jr., Bryant AL, Bond SM. Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences. Nurs Outlook. 2016;64(4):332–8. https://doi.org/10.1016/j.outlook.2016.03.004 .
Bulman C, Forde-Johnson C, Griffiths A, Hallworth S, Kerry A, Khan S, Mills K, Sharp P. The development of peer reflective supervision amongst nurse educator colleagues: an action research project. Nurs Educ Today. 2016;45:148–55. https://doi.org/10.1016/j.nedt.2016.07.010 .
Pack M. Unsticking the stuckness’: a qualitative study of the clinical supervisory needs of early-career health social workers. Brit J Soc Work. 2015;45:1821–36. https://doi.org/10.1093/bjsw/bcu069 .
Bayliss J. Clinical supervision for palliative care. London: Quay Books; 2006.
Kenny A, Allenby A. Implementing clinical supervision for Australian rural nurses. Nurs Educ Pract. 2013;13(3):165–9. https://doi.org/10.1016/j.nepr.2012.08.009 .
MacLaren J, Stenhouse R, Ritchie D. Mental health nurses’ experiences of managing work-related emotions through supervision. J Adv Nurs. 2016;72:2423–34. https://doi.org/10.1111/jan.12995 .
Wilson HM, Davies JS, Weatherhead S. Trainee therapists’ experiences of supervision during training: a meta-synthesis. Clinl Psychol Psychother. 2016;23:340–51. https://doi.org/10.1002/cpp.1957 .
Noelker LS, Ejaz FK, Menne HL, Bagaka’s JG. Factors affecting frontline workers’ satisfaction with supervision. J Aging Health. 2009;21(1):85–101. https://doi.org/10.1177/0898264308328641 .
Download references
The research team would like to thank all participants for their collaboration, the HSE steering group members and Carmel Hoey, NMPDU Director, HSE West Mid West, Dr Patrick Glackin, NMPD Area Director, HSE West, Annette Cuddy, Director, Centre of Nurse and Midwifery Education Mayo/Roscommon; Ms Ruth Hoban, Assistant Director of Nursing and Midwifery (Prescribing), HSE West; Ms Annette Connolly, NMPD Officer, NMPDU HSE West Mid West.
The authors declare that there are no sources of funding associated with this paper.
Authors and affiliations.
Department of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland
Owen Doody, Kathleen Markey, Claire O. Donnell & Louise Murphy
Department of Nursing and Midwifery, Sheffield Hallam University, Sheffield, UK
James Turner
You can also search for this author in PubMed Google Scholar
OD: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Project administration, Funding acquisition. COD: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. KM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. JT: Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing. LM: Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Funding acquisition.
Correspondence to Owen Doody .
Ethics approval and consent to participate.
This study was approved by two health service institutional review boards University Hospital Limerick (Ref: 091/19) and Galway University Hospitals (Ref: C.A. 2199). The study was conducted in accordance with the principles of the Declaration of Helsinki and all study details were fully disclosed to participants, who were assured of the voluntary nature of participation and withdrawal. The study questionnaires were coded, and identities were not disclosed to guarantee participants’ anonymity and all participants provided written informed consent before interviews.
No identifying images or other personal or clinical details of participants are presented in this paper that would compromise anonymity and all participants were aware and informed through the Participant Information Leaflet that the data collected may be reported through article and/or conference publications and this was reiterated during the qualitative data collection stage.
The authors declare no competing interests.
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Below is the link to the electronic supplementary material.
Supplementary material 2, supplementary material 3, rights and permissions.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, 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 you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. 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-nc-nd/4.0/ .
Reprints and permissions
Cite this article.
Doody, O., Markey, K., Turner, J. et al. Clinical supervisor’s experiences of peer group clinical supervision during COVID-19: a mixed methods study. BMC Nurs 23 , 612 (2024). https://doi.org/10.1186/s12912-024-02283-3
Download citation
Received : 04 January 2024
Accepted : 22 August 2024
Published : 02 September 2024
DOI : https://doi.org/10.1186/s12912-024-02283-3
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
ISSN: 1472-6955
share this!
August 28, 2024
This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:
fact-checked
peer-reviewed publication
trusted source
by King's College London
Despite being highly confident that they can understand the minds of people with opposing viewpoints, the assumptions humans make about others are often wrong, according to new research from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King's College London, in partnership with the University of Oxford.
"Poorer representation of minds underpins less accurate mental state inference for out-groups" was published in Scientific Reports . The research explores the psychology behind why people come to the wrong conclusions about others, and suggests how society could start to change that.
In all, 256 participants were recruited from the U.S. and split evenly between those with left- and right-leaning political views. They were presented with various political statements (e.g. Immigrants are beneficial to society) and asked to rate on a 5-point scale how much they agreed with it (i.e. strongly agree to strongly disagree).
For each statement, the participant would then be presented with someone else's response to the same statement. If the two shared a similar opinion, they were deemed "in-group" to one another. If the two held different opinions, they were deemed "out-group" to each other.
The participant was then asked to predict the other person's response on a second statement (e.g. all women should have access to legal abortion), and to state their confidence in their answer, from "Not at all' to "Extremely."
Participants could then choose to receive up to five more of the other person's responses to different statements to help the participant build up a better idea—or "representation"—of the other person's mind. After receiving any further information, participants could update their initial prediction and reclarify their confidence on their final answer.
Analysis of the data found that, even though participants were prepared to seek out as much—and often more—information about someone they disagreed with, their predictions were consistently incorrect, even after receiving further information about them.
Participants demonstrated a high degree of confidence in their answers, suggesting that participants thought they had a good understanding of the people in their out-group, despite this not being the case. In comparison, participants could consistently make accurate predictions about those in their in-group with less information.
"Our study shows that people have a good understanding of people who are similar to themselves and their confidence in their understanding is well-placed. However, our understanding of people with different views to our own is demonstrably poor. The more confident we are that we can understand them, the more likely it is that we are wrong. People have poor awareness of their inability to understand people that differ from themselves," says Dr. Bryony Payne.
"There are clear consequences to this lack of awareness, and we have seen countless real-world examples. The recent UK riots were borne out of a small group of people who were probably very confident in their (mis)understanding of the views and beliefs of Muslims and asylum seekers , and these misconceptions are often fueled by disinformation on social media or echoed back to them by others within their in-group."
Dr. Caroline Catmur, Reader in Cognitive Psychology at King's IoPPN and the study's senior author, said, "We live in an increasingly polarized society and many people are very confident in their understanding of those who don't share their beliefs. However, our research shows that people are willing to reconsider once they are made aware of their mistakes.
"While there is no quick fix in a real-world setting, if everyone interacted with a more diverse group of people, talked directly to them and got to know them, it's likely we would understand each other better. Conversations with people who hold different beliefs could help challenge our incorrect assumptions about each other."
Journal information: Scientific Reports
Provided by King's College London
Explore further
Feedback to editors
2 hours ago
14 hours ago
15 hours ago
Relevant physicsforums posts, definition of maoil.
7 hours ago
Sep 2, 2024
Talent worthy of wider recognition, favorite mashups - all your favorites in one place, cover songs versus the original track, which ones are better.
Sep 1, 2024
More from Art, Music, History, and Linguistics
Jun 12, 2024
Jun 27, 2024
Jul 31, 2024
Oct 30, 2023
Dec 17, 2018
Dec 6, 2022
16 hours ago
17 hours ago
20 hours ago
Let us know if there is a problem with our content.
Use this form if you have come across a typo, inaccuracy or would like to send an edit request for the content on this page. For general inquiries, please use our contact form . For general feedback, use the public comments section below (please adhere to guidelines ).
Please select the most appropriate category to facilitate processing of your request
Thank you for taking time to provide your feedback to the editors.
Your feedback is important to us. However, we do not guarantee individual replies due to the high volume of messages.
Your email address is used only to let the recipient know who sent the email. Neither your address nor the recipient's address will be used for any other purpose. The information you enter will appear in your e-mail message and is not retained by Phys.org in any form.
Get weekly and/or daily updates delivered to your inbox. You can unsubscribe at any time and we'll never share your details to third parties.
More information Privacy policy
We keep our content available to everyone. Consider supporting Science X's mission by getting a premium account.
We believe everyone should be able to make financial decisions with confidence. And while our site doesn’t feature every company or financial product available on the market, we’re proud that the guidance we offer, the information we provide and the tools we create are objective, independent, straightforward — and free.
So how do we make money? Our partners compensate us. This may influence which products we review and write about (and where those products appear on the site), but it in no way affects our recommendations or advice, which are grounded in thousands of hours of research. Our partners cannot pay us to guarantee favorable reviews of their products or services. Here is a list of our partners .
Many, or all, of the products featured on this page are from our advertising partners who compensate us when you take certain actions on our website or click to take an action on their website. However, this does not influence our evaluations. Our opinions are our own. Here is a list of our partners and here's how we make money .
How much money should you have in your emergency fund? What percentage of your income should you be saving for retirement?
Financial questions like these can be high-stakes. And reaching the right decision on them can seem complex and difficult, in part because there’s just so much information out there.
If you feel daunted by making financial decisions like these, you’re not alone. Less than half (47%) of Americans feel confident in their ability to make good financial decisions, according to a recent NerdWallet survey conducted online by The Harris Poll in July.
People’s confidence in their financial decision-making increases with their age, income and education.
Less than a third (30%) of Gen Zers (ages 18-27) say they are confident in their ability to make good financial decisions. Thirty-nine percent of Millennials (ages 28-43), 47% of Gen Xers (ages 44-59), and 62% of baby boomers (ages 60-78) say they are confident.
Just 38% of Americans with an annual household income of less than $50,000 reported feeling confident in their ability to make good financial decisions. That compares with 49% of those making $75,000-$99,999 and 55% of those making $100,000 and more.
It’s a similar story when it comes to education.
Thirty-seven percent of Americans with a high school diploma or less education reported feeling confident in their ability to make good financial decisions, while 45% of Americans who attended some college and 58% of Americans who graduated from college felt the same way.
The first step in making smart financial decisions is knowing where to go to gather reliable information. And you likely already have access to many free or low-cost resources .
Financial institution: Consider starting with your bank or credit union. Many financial institutions offer online and in-person resources to help guide their customers to solid financial decisions. In addition to informational content related to the products they offer — such as checking accounts and certificates of deposit — employees on the other end of customer service phone numbers or in a local bank branch can provide answers to some of the more common and basic banking questions.
Employers: Many companies offer financial planning services to their employees — either through a financial planning service with which they partner or through the company that manages their retirement plan. If you’re uncertain whether your job offers this kind of perk, ask your human resources department.
Online brokerages: If you currently invest, there’s a good chance you can access educational materials and possibly even advisors through your brokerage. They can help with topics such as how to invest , how much to invest and how to help ensure you’re on track for retirement.
Nonprofit foundations or trade associations: Some financial advisors offer their services for free or at a reduced rate to people who might not otherwise be able to afford them. The Financial Planning Association is one example of a trade organization that offers pro bono financial planning services. Local community organizations and even public libraries may host financial education events, too.
Phone apps: There are also many free or low-cost apps you can use for tasks such as creating and sticking to a budget , checking your credit score and understanding what it means, and analyzing your credit card usage.
This survey was conducted online within the United States by The Harris Poll on behalf of NerdWallet from July 11-15, 2024, among 2,096 U.S. adults ages 18 and older. The sampling precision of Harris online polls is measured by using a Bayesian credible interval. For this study, the sample data is accurate to within +/- 2.5 percentage points using a 95% confidence level. For complete survey methodology, including weighting variables and subgroup sample sizes, please contact [email protected] .
NerdWallet disclaims, expressly and impliedly, all warranties of any kind, including those of merchantability and fitness for a particular purpose or whether the article’s information is accurate, reliable or free of errors. Use or reliance on this information is at your own risk, and its completeness and accuracy are not guaranteed. The contents in this article should not be relied upon or associated with the future performance of NerdWallet or any of its affiliates or subsidiaries. Statements that are not historical facts are forward-looking statements that involve risks and uncertainties as indicated by words such as “believes,” “expects,” “estimates,” “may,” “will,” “should” or “anticipates” or similar expressions. These forward-looking statements may materially differ from NerdWallet’s presentation of information to analysts and its actual operational and financial results.
On a similar note...
on Capitalize's website
Pay off debt: tools and tips, monthly 50/30/20 budget calculator.
Journal of Eating Disorders volume 12 , Article number: 132 ( 2024 ) Cite this article
Metrics details
Anorexia nervosa (AN) is a severe psychiatric disorder, from which recovery is often protracted. The role of prior specialized inpatient treatment on subsequent treatment attempts for adults with chronic AN and predictors of treatment response for severe and enduring AN (SE-AN) are needed to improve outcomes.
Participants ( N = 135) with chronic AN (ill ≥7 years) admitted to an integrated inpatient-partial hospitalization eating disorders (ED) unit with prior ED hospitalization(s) (+ PH; n = 100) were compared to those without prior ED hospitalizations (-PH; n = 35) on admission characteristics (BMI, length of illness, outpatient ED treatment history, symptomatology (ED, anxiety, and depressive), history of suicide attempts or non-suicidal self-injury (NSSI)), treatment motivation and recovery self-efficacy, and discharge outcomes (discharge BMI, rate of weight gain, length of stay, clinical improvement).
Groups were similar with regard to age, years ill, and admission BMI. The + PH group had lower desired weight, lifetime nadir BMI and self-efficacy for normative eating, and higher state and trait anxiety than the -PH group. +PH were also more likely to endorse history of NSSI and suicide attempt. Regarding discharge outcomes, most patients achieved weight restoration at program discharge (mean discharge BMI = 19.8 kg/m 2 ). Groups did not differ on rate of weight gain, likelihood of attending partial hospital, partial hospital length of stay, program discharge BMI, or likelihood of clinical improvement ( p ’s > 0.05) although inpatient length of stay was longer for the + PH group.
Participants with chronic AN + PH exhibited more severe psychiatric comorbidity and lower self-efficacy for normative eating than AN -PH, however short-term discharge outcomes were similar. Future research should determine whether weight restoration and targeting comorbidities impacts relapse risk or need for rehospitalization among chronic and severe + PH. Despite similar illness durations, those with chronic AN -PH may be able to transition to partial hospital earlier. Conversely there is risk of undertreatment of chronic AN + PH given the recent shift promoting briefer self-directed admissions for adults with SE-AN. Research comparing + PH and -PH adults with chronic AN may facilitate efforts to individualize care and characterize relapse risk following intensive treatment.
Some individuals with longstanding anorexia nervosa (AN) remain ill despite multiple attempts at intensive treatment. Others reach a high level of specialty care (e.g. inpatient or residential) for the first time only late in their illness. This study compared 100 hospitalized patients with chronic AN (ill ≥ 7 years) who previously received specialty inpatient eating disorder care to 35 hospitalized patients with chronic AN and no prior intensive treatment. Participants completed questionnaires at admission and weight change and hospital course were assessed at program discharge by chart review. At admission, individuals with prior hospitalizations reported greater difficulties with anxiety and suicidal behavior, lower confidence for changing their eating habits, and lower desired body weight compared to those with no prior inpatient treatment. Both groups had similar weight change and clinical improvement during treatment with mean discharge BMI consistent with weight restoration. These outcomes suggest equivalent short term improvement and weight restoration for individuals with chronic AN regardless of whether they previously received inpatient treatment and call into question whether the recent shift to brief admissions for those with chronic and severe AN may result for some in undertreatment, given that weight restoration remains the strongest predictor of long-term recovery.
Anorexia nervosa (AN) is a severe, complex psychiatric disorder from which recovery is often protracted. An estimated 20% of individuals with AN experience a chronic or persistent course [ 1 ], often referred to as severe and enduring anorexia nervosa (SE-AN) [ 2 , 3 ]. Improving outcomes for SE-AN is critical given the medical sequelae, healthcare utilization costs, and high mortality associated with chronic AN [ 1 , 4 , 5 , 6 ]. Research aimed at clarifying the etiology, maintenance, and course of those with chronic AN is urgently needed to improve treatment efficacy.
One challenge is the lack of an accepted definition of SE-AN, with current definitions emphasizing illness duration (7 years being the most common duration cutoff but some advocating for as few as 3 years) [ 2 , 7 ]. Some definitions also require a history of non-response to evidence-based specialized eating disorder (ED) treatment [ 7 , 8 ]. Problematically, however, most that include this criterion do not clearly specify how to define an adequate attempt at treatment [ 8 ]. Is a previous failure of outpatient cognitive-behavioral therapy (CBT) or a brief hospitalization for medical stabilization sufficient? Or should failure include at least one past admission and achievement of weight restoration in an intensive behavioral specialty treatment program for eating disorders? Or in the case of those who leave intensive treatment against medical advice or due to other family or financial concerns, how many premature discharges from intensive treatment constitute treatment failure? Few empirical studies of SE-AN have incorporated measures of treatment history when defining groups [ 9 , 10 ], and results are mixed with some finding poorer outcomes among patients with previous ED treatment [ 11 , 12 , 13 ] and others not finding a relationship between history of previous treatment [ 14 ] or number of previous inpatient treatments [ 15 ] and outcomes.
The rationale for including treatment history in definitions of SE-AN is that individuals who do not improve, do not achieve remission, or quickly relapse following evidence-based treatment may represent a particularly vulnerable group for greater persistence of illness and for whom more targeted treatments are needed. Including prior treatment history in definitions of SE-AN is complicated, however. First, many individuals with diagnosable AN never seek treatment or receive inadequate treatment [ 16 ]. Others experience a long duration of untreated illness prior to engaging in evidence-based treatment [ 17 ] or engage in treatment, sometimes repeatedly, but drop out prematurely [ 18 ]. Potential obstacles to treatment include practical barriers (e.g., cost of treatment, wait times, geographic access to specialized care), stigma, low motivation to change, ambivalence or anxiety about intensive treatment, negative attitudes towards seeking help, low health literacy, and lack of social encouragement [ 19 , 20 , 21 , 22 , 23 ]. Additional barriers, such as low insight or lack of recognition of illness severity [ 19 , 20 , 23 ] may predict the severity or chronicity of AN [ 15 , 24 ]. Thus, those who do not seek or complete treatment or who have a long duration of untreated illness may themselves represent a group more vulnerable to chronic, severe AN. In one retrospective study, individuals with a longer duration of untreated illness were less likely to have achieved remission at 20-year follow-up [ 25 ]. Finally, another challenge in incorporating prior treatment attempts in the definition of SE-AN is the issue of how best to classify type and intensity of treatment (e.g., brief medical stabilization admissions versus achieving full weight restoration in a multidisciplinary intensive behavioral specialty program for eating disorders).
Prior studies often compare individuals with a long duration of illness to those with early-stage AN (e.g., 26 , 27 , 28 , 29 ). Given that individuals with longer duration of illness are more likely to have engaged in prior treatment [ 11 ], it remains unclear whether long illness duration, history of treatment non-response, or both should be included in definitions of SE-AN. On one hand, a longer illness duration may make it more difficult to recover from AN regardless of prior treatment history due to factors such as greater genetic risk, greater physical complications [ 30 ], diminished social and psychological functioning [ 31 , 32 ], and increased habit strength of AN behaviors [ 31 , 33 ]. On the other hand, experiencing prior treatment non-response may uniquely influence subsequent treatment outcomes, by leading to diminished motivation or confidence in treatment [ 34 , 35 ]. There may additionally be iatrogenic risks of treatment (e.g. traumatic experiences of care, or institutionalization) that contribute to persistent illness or treatment avoidance.
Investigating the role of prior treatment attempts independent of illness duration may help clarify definitional criteria and utility of the SE-AN label and inform treatment for severely and chronically ill adults with AN for whom treatment options are often more limited and evidence-based approaches sparse [ 9 , 10 ]. This exploratory study of inpatients admitted to an integrated inpatient partial hospitalization ED program compared patients with long-term AN (ill ≥ 7 years) plus a prior history of inpatient ED behavioral treatment (+ PH) to patients with long-term AN seeking inpatient treatment for the first time (-PH). Groups were compared on admission characteristics, treatment outcomes, and hospital course. Given the exploratory nature of this study, no specific hypotheses were generated.
Data were collected as part of an ongoing, Institutional Review Board approved longitudinal study of response to intensive treatment in patients diagnosed with EDs. All first admissions to the Johns Hopkins Eating Disorder Inpatient-Partial Hospitalization Program between 2003 and 2022 were invited to participate. Eligible participants were individuals with AN who completed at least seven days of treatment, endorsed a length of illness ≥ 7 years at admission, provided informed consent, and completed questionnaires. Participants ( N = 135) were divided into two groups: those who reported no previous specialized high level of ED care or hospitalization (inpatient or residential) at admission (-PH; n = 35) and those who endorsed a history of at least one prior specialized ED inpatient treatment (+ PH; n = 100).
Participants were diagnosed at hospital admission by trained raters, supervised by a licensed clinical psychologist, using the ED section of the Structured Clinical Interview for DSM-5 (SCID-5-RV) [ 36 ]. Participants admitted prior to 2015 were evaluated using the SCID-IV-TR, and diagnoses were later re-assessed using DSM-5 criteria. Participants completed a battery of self-report measures within the first week of admission. Clinical hospital course data were abstracted from the electronic medical record.
The eating disorders program follows a structured behavioral treatment protocol delivered within a multidisciplinary integrated, inpatient-partial hospitalization stepdown program. Primary treatment targets include rapid weight restoration for underweight patients and normalization of eating behaviors. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) informed psychotherapeutic interventions are delivered primarily in group format. Participants admitted below target weight were placed on a previously described standardized weight gain 100% meal-based nutritional protocol [ 37 ]. See Guarda et al. [ 38 ] for additional description of the treatment program.
Age, race, sex, marital status, income, education, and current employment were collected at admission via participant questionnaires. Measures pertaining to ED treatment history and illness course, including age of ED onset, length of illness (years), number of hospitalization(s) on a specialized ED unit prior to this admission, history of outpatient ED treatment, lifetime nadir body mass index (BMI), age at lifetime nadir BMI, and desired weight, were also gathered at admission. The + PH group was asked to report the length of stay (days) of their longest prior hospitalization for an ED.
Height and gowned morning weight at program admission and discharge were used to calculate admission and discharge BMI. Individual target weight was set as a four-pound range (1.8 kg) based on the patient’s age, sex, and height centered on a BMI of 20.5 kg/m 2 for patients over age 25 [ 37 ]. For those aged 18–24, target weight was adjusted by subtracting one pound (0.45 kg) per year of age below 25.
The University of Rhode Island Change Assessment (URICA) [ 39 ], a self-report measure of motivational readiness to change, was administered at admission. A 12-item version of the measure was adapted from the alcohol reduction version [ 40 ]. Responses were rated on a 5-point scale from 1 (Strongly Disagree) to 5 (Strongly Agree) and used to compute four Stage of Change subscales: pre-contemplation, contemplation, preparation or action, and maintenance. The URICA Readiness Score was computed by summing the contemplation, preparation or action, and maintenance subscales, and then subtracting the precontemplation subscale. Higher readiness scores indicate greater readiness to change.
The Eating Disorder Inventory-2 (EDI-2) [ 41 ] is a 91-item self-report questionnaire designed to measure psychological features and behavioral traits commonly associated with AN and bulimia nervosa (BN). The Drive for Thinness, Bulimia, and Body Dissatisfaction subscales were included in the current study. The EDI-2 has demonstrated good reliability and validity in individuals with EDs [ 42 ]. Internal consistencies in this study ranged from good to excellent (Drive for Thinness, α = 0.88; Bulimia, α = 0.92; Body Dissatisfaction, α = 0.91). The Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ) [ 43 ] is a 23-item self-report measure of self-efficacy to cope with eating disorder behaviors and attitudes. The Normative Eating Self-Efficacy subscale measures confidence to eat without engaging in disordered behavior and without undue distress. The Body Image Self-Efficacy subscale measures confidence to maintain a realistic body image and not place undue influence of body weight and shape on self-esteem. The EDRSQ has demonstrated good validity and reliability [ 43 , 44 ]. In the current study, internal consistencies for Normative Eating and Body Image were excellent (α = 0.96, α = 0.90). Frequency of Compensatory Behaviors was assessed via three self-report items at admission; participants rated their frequency of vomiting, laxative use to control weight, and excessive exercise over the past 8 weeks on a scale from 1 (Never) to 7 (More than once a day).
The State-Trait Anxiety Inventory (STAI) [ 45 ] is a 40-item self-report scale measuring anxiety experienced in the moment (state anxiety) and as a stable personality trait (trait anxiety). The STAI has demonstrated good reliability and validity [ 46 , 47 ]. The STAI state (STAI-S) and trait (STAI-T) subscale total raw scores demonstrated excellent internal consistencies in this study (α = 0.94, α = 0.91). Beck Depression Inventory-II (BDI-II) [ 48 ], a 21-item self-report measure of depression symptoms, has strong psychometric properties, including internal consistency and factor validity [ 49 ]. Internal consistency was excellent in the current study (Cronbach’s α = 0.91). Non-Suicidal Self-Injury (NSSI) was measured dichotomously as history of self-injurious behavior. Participants were asked if they had ever engaged in the following self-injurious behaviors (yes or no): cutting, burning, bruising, scratching. Due to low rates of endorsement for most of these behaviors and to avoid potential problems caused by zero-inflated data, the current study used only the responses for cutting to represent NSSI, as this was the most frequently endorsed behavior of those listed. Suicide Attempt was measured dichotomously with a yes or no to, “Have you ever attempted suicide in the past?”
Length of Stay (days) for inpatient and partial hospital was calculated by subtracting admission date from discharge date for each participant. Reason for Discharge was dichotomized into “for clinical improvement” versus “not for clinical improvement” with the latter including discharge for non-compliance, elopement, financial reasons, patient/family reasons, or transfer. Partial Hospital Attendance was examined as percentage of participants per group transitioning to an integrated stepdown partial hospitalization program following inpatient treatment. Rate of Weight Gain was measured as kilograms gained per week and computed by dividing total weight gained in kilograms by the number of weeks spent on a weight gain nutritional protocol.
Data were analyzed in SPSS version 28. Mann-Whitney U tests (continuous variables) and chi-square analyses (dichotomous variables) were conducted to explore differences between groups on demographic, clinical, and self-report measures at admission and discharge. Mann-Whitney U tests were chosen in lieu of independent-samples t -tests due to unequal sample sizes between groups and non-normality of variables. To test for differences between groups in discharge BMI, a linear regression model was conducted to control for admission BMI. Differences between groups were determined by examining the significance value and confidence intervals for the group variable coefficient. To account for non-normality and unequal sample sizes between groups, robust statistical methods for regression were employed (bootstrapping with confidence intervals and standard errors based on 1000 bootstrapped samples). All available data was utilized, and missing data is reported for each analysis.
Descriptive data for participant sociodemographic characteristics are presented in Table 1 . The majority of the sample was White (94.8%) and female (97.8%) with a mean age of 36.9 ( SD = 11.2, range = 18–70) years. Participants with prior hospitalizations were more likely to be single or never married ( n = 66, 67%) compared to those in the first-time hospitalization group ( n = 14, 40%). Groups did not differ on age, sex, race, education, source of income, or current employment. The sample was highly educated with 90% of participants having at least some college education, however approximately half the sample reported their primary source of income as coming from social security or disability payments and only 28% earned income from salary/wages.
Results of analyses comparing groups by weight and ED history at admission are presented in Table 2 . Both groups had similar age and length of illness at admission. The mean admission BMI for the sample was 15.52 kg/m 2 ( SD = 1.98). Groups did not significantly differ on admission BMI, however participants in the + PH group endorsed a lower desired body weight ( Mdn = 45.35 kg) compared to the -PH group ( Mdn = 49.89 kg) and a lower lifetime nadir BMI ( Mdn = 13.60) compared to the -PH group ( Mdn = 15.01). Groups did not differ with regard to age of lifetime nadir BMI ( M = 30.41, SD = 11.35), age of ED onset ( M = 17.92, SD = 6.89), or length of illness ( M = 19.01, SD = 9.84). The + PH group was significantly more likely to have received outpatient ED treatment, with 85% of the + PH group endorsing a history of outpatient ED treatment compared to 63% in the -PH group.
Participants in the + PH group were asked to respond to a multiple-choice question that queried them on the length of stay for their longest previous ED admission: 67% reported at least one prior admission lasting more than 30 days and only 8% reported that their longest prior stay was less than 15 days. These findings indicate that the majority of + PH participants had at least one prolonged hospitalization prior to the current admission.
With regard to treatment motivation, no differences between groups were observed for URICA Readiness Score at admission (Table 2 ). The majority of the sample fell within the pre-contemplation or contemplation stages of change ( n = 104, 77.6%) as opposed to the preparation or action stage of change ( n = 30, 22.4%).
Results from analyses comparing groups by AN subtype and ED symptomatology at admission are displayed in Table 2 . 64% of the sample was diagnosed with AN-BP ( n = 86) and 36% was diagnosed with AN-R ( n = 49). The proportion of AN-R subtype vs. AN-BP subtype did not differ by group. Groups did not differ on frequency of vomiting, laxative use, or excessive exercise over the past 8 weeks. The full sample reported vomiting ( M = 3.45, SD = 2.63) and excessive exercise ( M = 3.37, SD = 2.42) somewhere between several times per month and once per week, on average, and engaged in laxative use ( M = 2.21, SD = 2.11) somewhere between once a month and several times per month, on average. Regarding self-report ED measures at admission, participants in the + PH group endorsed lower self-efficacy for normative eating ( Mdn = 1.64) compared to participants in the -PH group ( Mdn = 2.50). No differences between groups were observed for EDI-2 subscales or EDRSQ body image self-efficacy.
Group comparisons on comorbid psychopathology are presented in Table 3 . The majority of the sample ( n = 75, 56%) met cutoffs for severe depression on the BDI-II (scores ≥ 29) at admission. No differences between groups were observed for BDI-II total ( M = 29.88, SD = 12.55). With regard to anxiety, only 59% of the sample ( n = 79) had data available on the STAI (60% in the -PH group and 58% in the + PH group) as the STAI was added to the study protocol in 2008. Using all available data, results show that the + PH group had significantly higher State Anxiety total scores ( Mdn = 63) and Trait Anxiety total scores ( Mdn = 65) compared to the -PH group (STAI-S: Mdn = 52; STAI-T: Mdn = 57). Of the participants with valid STAI data, approximately 47% and 65% fell into the clinically significant range (i.e., T-score ≥ 75) for state and trait anxiety, respectively. Participants in the + PH group were also significantly more likely to endorse a history of suicide attempt and NSSI (cutting) compared to the -PH group.
Results from the regression model testing whether group membership at admission (+ PH or -PH) was associated with BMI at program discharge, controlling for admission BMI, are displayed in Table 4 . Across the sample, the average BMI at discharge was 19.81 kg/m 2 ( SD = 1.99). Group membership at admission was not associated with BMI at discharge controlling for BMI at admission.
Results of Mann-Whitney U tests and Chi-square analyses comparing groups on discharge outcomes are presented in Table 5 . No group differences were observed for rate of weight gain during treatment (inpatient: M = 1.91 kg/week, SD = 0.88; partial hospital: M = 1.29 kg/week, SD = 0.68), however, individuals in the + PH group had a longer length of inpatient stay ( Mdn = 37 days) compared to those in the -PH group ( Mdn = 30 days). No group differences were observed for partial hospital length of stay ( M = 33.72 days, SD = 19.79) or likelihood of attending partial hospital, with 65% of the total sample transitioning from the inpatient to the partial hospitalization program. Groups also did not differ with regard to likelihood of discharge for clinical improvement, with 52% of the full sample classified as discharged for clinical improvement.
Effective treatments for adults with SE-AN are currently lacking and opinion is divided on how to best meet the needs of this chronically ill patient group characterized by high rates of morbidity, mortality, and functional impairment and lower quality of life [ 2 , 4 , 50 ]. Amongst psychiatric conditions, many patients with SE-AN account for disproportionate health care utilization costs [ 51 , 52 ]. Long-term follow up studies, however, suggest that a majority of individuals with chronic AN will eventually recover, sometimes following several decades of illness, or multiple prolonged hospitalizations [ 53 ]. Weight restoration is the strongest predictor of recovery from AN, however relapse is not uncommon even among those discharged at a normative BMI [ 34 ]. It is unclear, however, whether successful weight restoration in a specialized inpatient behavioral treatment program confers longer term therapeutic advantages compared to brief admissions for medical stabilization or outpatient therapy alone for this group of patients. This is an important question for the field given the recent focus of the SE-AN literature on approaches to care that prioritize patient autonomy and choice, and focus on maximizing quality of life [ 3 ]. These priorities, along with economic forces and limited availability of intensive treatment, especially for severely and chronically ill adults with AN, have contributed to a shift favoring brief patient-directed admissions aimed at medical stabilization in lieu of repeated prolonged hospitalizations targeting full weight restoration and normalization of eating behavior. The purpose of the current study was to contribute to ongoing efforts within the field to clarify definitional criteria and utility of the SE-AN label to improve clinical decision-making and develop more effective treatments for chronic AN.
We compared voluntarily hospitalized adult patients with chronic AN who had previously received inpatient treatment to those hospitalized for the first time on admission characteristics, treatment outcomes, and hospital course. Sample descriptives and demographics were consistent with an adult SE-AN cohort. Average age was mid- to late thirties, average length of illness was 19 years, lifetime nadir BMI was reflective of extreme AN and the cohort had elevated rates of disability and functional impairment. Despite a high-level of educational attainment, the majority relied on social security or family or spousal financial support. Groups were similar at admission on age, duration of illness, BMI, ED and depressive symptomatology, and on motivation (readiness to change), although some cross-sectional group differences were observed suggestive of lower psychopathology in the -PH group on several admission variables including desired weight, lifetime nadir BMI, self-efficacy for normative eating, anxiety symptomatology, history of non-suicidal self-injury, and past suicide attempts. These differences may prove helpful in distinguishing illness course amongst those with chronic AN, independent of illness duration. For example, those with a lower lifetime nadir BMI in the + PH group may have been more likely to be identified or pressured into intensive treatment earlier by healthcare providers or social supports due to unstable labs or other medical or psychological symptoms. The -PH group were more likely to be married; having a spouse may reflect lower psychopathology or represent a protective factor by decreasing isolation and providing support. Conversely, a spouse may inadvertently accommodate the illness thereby facilitating treatment avoidance despite illness severity. The presence of greater psychiatric comorbidity (anxiety, NSSI, suicide) in the + PH vs. the –PH group is consistent with research indicating that comorbid mental health problems facilitate earlier help-seeking among individuals with EDs [ 16 ]. Higher psychiatric comorbidity may also explain the + PH group’s longer length of hospitalization despite similar admission BMI and rate of weight gain to the -PH group. Specific symptoms, for example greater behavioral dysregulation, comorbid anxiety, or self-injury, may have influenced the treatment team’s clinical assessment of readiness and safety to transition to a lower level of care. Despite these differences, both groups achieved similar short-term weight restoration and clinical outcomes at discharge.
Findings are consistent with previous research indicating that illness duration is not a good indicator for likelihood of weight restoration [ 26 , 27 ] and suggest prior non-response to inpatient treatment in adults with SE-AN is not a strong predictor of subsequent short-term weight restoration and discharge outcomes. However, further research is clearly needed to clarify longer term outcomes (e.g., relapse rates 1-year post-discharge) following weight restoration among those with SE-AN.
Study findings have several important clinical and research implications. Some have called for alternative treatment approaches for individuals with SE-AN or for those with prior treatment non-response or relapsing illness [ 54 ]. These alternative approaches often emphasize harm reduction, focus on improving quality of life, and de-emphasize weight restoration and typically do not achieve weight restoration despite statistical increases in BMI [ 50 , 55 , 56 ]. More recently a focus on palliative care as a primary approach for some patients with SE-AN has also been promoted [ 57 ] and in rare cases recommendations have included consideration of hospice care, or in the extreme physician assisted suicide or medical aid in dying for some individuals with SE-AN [ 58 ]. The need for a primary palliative approach in SE-AN, however, remains controversial [ 59 ]. Principles of palliative care are already inherent in the competent practice of psychotherapy, including focus on quality of life and wellbeing as well as more targeted behavioral, supportive, and motivational approaches that promote clinical improvement and foster hope in eventual recovery.
Findings from this exploratory study suggest caution in deploying a harm reduction approach for individuals with chronic AN. Regardless of prior treatment history, most participants with long-term AN met criteria for weight restoration with an average discharge BMI of 19.8 kg/m 2 across groups. The timing or likelihood of AN recovery can be difficult to predict, and the possibility of eventual recovery even in protracted cases of AN [ 11 , 26 , 27 , 60 ] argues for maintaining an optimistic stance even for those who may not have responded to prior attempts at intensive treatment. As others have noted, we lack a reliable staging model for AN predictive of prognosis or of intensive treatment response [ 7 , 61 ]. Similarly, a uniform definition for what comprises optimal evidence-based multidisciplinary inpatient treatment remains elusive and confounds any definition of SE-AN based on past treatment non-response. Both treatment length and context matter. Brief admissions for medical stabilization are unlikely to be as effective as achievement of full weight restoration in a multidisciplinary behavioral specialty treatment program for eating disorders. And for those who achieve weight restoration yet subsequently relapse, we do not know whether each successful cycle through treatment decreases both the gravitational pull of the eating disorder and the risk of relapse. AN is increasingly seen as a disorder of learning [ 31 , 33 ] in which repeated behaviors become increasingly automatic and cue driven over time. Recovery, however, may also be a process of learning and repeated cycles of treatment associated with weight restoration may incrementally increase likelihood of eventual recovery. Qualitative interviews of recovered individuals with SE-AN and longitudinal studies are needed to assess this question. We do not know, for example, whether skills learned in prior treatment can be implemented by patients at a later date when motivation for recovery increases.
This study has several important limitations. Missing data for some variables as well as a limited sample size in the -PH group resulted in unequal sample sizes between groups. Measures were taken during data analyses to address these issues; however, results should be replicated with larger sample sizes and multisite research. Two central limitations relate to challenges presented by the lack of an accepted definition of SE-AN [ 2 ]. We based duration of illness ≥ 7 years on patients’ recall of the “age symptoms started to interfere with functioning”. Others, however, have defined illness onset as age at which all DSM diagnostic criteria are first met. Second, there is no accepted definition of what constitutes prior intensive treatment [ 3 , 62 ]. We focused on history of inpatient ED treatment consistent with several extant studies [ 12 , 63 ] but did not have information as to whether past treatments included achievement of weight restoration or were ended prematurely. This is especially significant given that the former remains the best predictor of recovery for AN [ 64 ]. Approximately two thirds of the -PH group had a history of outpatient ED treatment however close to one-third were treatment naïve. Future studies should also assess factors that may contribute to longer duration of untreated illness (e.g., lack of availability of specialized treatment units, inadequate insurance coverage) and/or individual factors (e.g., treatment anxiety or avoidance, low motivation).
Although correlational and exploratory in nature, this study provides novel contributions to our understanding of intensive treatment for adults with chronic AN. Study findings help inform our understanding of differences in presenting characteristics and treatment course for individuals with chronic AN who have never been admitted compared to those with previous specialized ED hospitalizations. In the absence of a meaningful construct or definition of evidence-based intensive treatment, we believe these data support continued attempts to encourage patients to engage in active treatment with the goal of normalizing eating and weight control behaviors, treating co-occurring psychiatric conditions, restoring weight, and improving quality of life and functional level. Results support hopefulness for a good response to treatment even in those with chronic AN, whether or not they have received prior intensive treatment and reinforce the need for longitudinal studies of SE-AN that assess treatment course and predictors of outcome.
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Anorexia nervosa, restricting type
Anorexia nervosa, binge/purge type
Severe and enduring anorexia nervosa
Eating disorder
Prior hospitalization
No prior hospitalization
Body mass index
Non-suicidal self-injury
Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002;159(8):1284–93.
PubMed Google Scholar
Broomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring anorexia nervosa: a systematic review and critical analysis. Int J Eat Disord. 2017;50(6):611–23.
Wonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: update and observations about the current clinical reality. Int J Eat Disord. 2020;53(8):1303–12.
Agras WS. The consequences and costs of the eating disorders. Psychiatr Clin North Am. 2001;24(2):371–9.
Fichter MM, Quadflieg N. Mortality in eating disorders - results of a large prospective clinical longitudinal study. Int J Eat Disord. 2016;49(4):391–401.
Fichter MM, Quadflieg N, Hedlund S. Twelve-year course and outcome predictors of anorexia nervosa. Int J Eat Disord. 2006;39(2):87–100.
Hay P, Touyz S. Classification challenges in the field of eating disorders: can severe and enduring anorexia nervosa be better defined? J Eat Disord. 2018;6:41.
PubMed PubMed Central Google Scholar
Broomfield C, Noetel M, Stedal K, Hay P, Touyz S. Establishing consensus for labeling and defining the later stage of anorexia nervosa: a Delphi study. Int J Eat Disord. 2021;54(10):1865–74.
Zhu J, Hay PJ, Yang Y, Le Grange D, Lacey JH, Lujic S, et al. Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa. Cochrane Database Syst Rev. 2023;8(8):CD011570.
Zhu J, Yang Y, Touyz S, Park R, Hay P. Psychological treatments for people with severe and Enduring Anorexia Nervosa: a Mini Review. Front Psychiatry. 2020;11:206.
Fernandez-Aranda F, Treasure J, Paslakis G, Aguera Z, Gimenez M, Granero R, et al. The impact of duration of illness on treatment nonresponse and drop-out: exploring the relevance of enduring eating disorder concept. Eur Eat Disord Rev. 2021;29(3):499–513.
Fichter MM, Quadflieg N, Crosby RD, Koch S. Long-term outcome of anorexia nervosa: results from a large clinical longitudinal study. Int J Eat Disord. 2017;50(9):1018–30.
Zipfel S, Lowe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study. Lancet. 2000;355(9205):721–2.
Wildes JE, Forbush KT, Hagan KE, Marcus MD, Attia E, Gianini LM, et al. Characterizing severe and enduring anorexia nervosa: an empirical approach. Int J Eat Disord. 2017;50(4):389–97.
Errichiello L, Iodice D, Bruzzese D, Gherghi M, Senatore I. Prognostic factors and outcome in anorexia nervosa: a follow-up study. Eat Weight Disord. 2016;21(1):73–82.
Hart LM, Granillo MT, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases. Clin Psychol Rev. 2011;31(5):727–35.
Neubauer K, Weigel A, Daubmann A, Wendt H, Rossi M, Lowe B, et al. Paths to first treatment and duration of untreated illness in anorexia nervosa: are there differences according to age of onset? Eur Eat Disord Rev. 2014;22(4):292–8.
Wallier J, Vibert S, Berthoz S, Huas C, Hubert T, Godart N. Dropout from inpatient treatment for anorexia nervosa: critical review of the literature. Int J Eat Disord. 2009;42(7):636–47.
Ali K, Farrer L, Fassnacht DB, Gulliver A, Bauer S, Griffiths KM. Perceived barriers and facilitators towards help-seeking for eating disorders: a systematic review. Int J Eat Disord. 2017;50(1):9–21.
Ali K, Fassnacht DB, Farrer L, Rieger E, Feldhege J, Moessner M, et al. What prevents young adults from seeking help? Barriers toward help-seeking for eating disorder symptomatology. Int J Eat Disord. 2020;53(6):894–906.
Hamilton A, Mitchison D, Basten C, Byrne S, Goldstein M, Hay P, et al. Understanding treatment delay: perceived barriers preventing treatment-seeking for eating disorders. Aust N Z J Psychiatry. 2022;56(3):248–59.
Regan P, Cachelin FM, Minnick AM. Initial treatment seeking from professional health care providers for eating disorders: a review and synthesis of potential barriers to and facilitators of first contact. Int J Eat Disord. 2017;50(3):190–209.
Weigel A, Rossi M, Wendt H, Neubauer K, von Rad K, Daubmann A, et al. Duration of untreated illness and predictors of late treatment initiation in anorexia nervosa. J Public Health. 2014;22(6):519–27.
Google Scholar
Greenfeld DG, Anyan WR, Hobart M, Quinlan DM, Plantes M. Insight into illness and outcome in anorexia nervosa. Int J Eat Disord. 1991;10(1):101–9.
Andres-Pepina S, Plana MT, Flamarique I, Romero S, Borras R, Julia L, et al. Long-term outcome and psychiatric comorbidity of adolescent-onset anorexia nervosa. Clin Child Psychol Psychiatry. 2020;25(1):33–44.
Calugi S, El Ghoch M, Dalle Grave R. Intensive enhanced cognitive behavioural therapy for severe and enduring anorexia nervosa: a longitudinal outcome study. Behav Res Ther. 2017;89:41–8.
Raykos BC, Erceg-Hurn DM, McEvoy PM, Fursland A, Waller G. Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from cognitive behaviour therapy. J Consult Clin Psychol. 2018;86(8):702–9.
Takakura S, Aso CS, Toda K, Hata T, Yamashita M, Sudo N. Physical and psychological aspects of anorexia nervosa based on duration of illness: a cross-sectional study. Biopsychosoc Med. 2019;13:32.
Redgrave GW, Schreyer CC, Coughlin JW, Fischer LK, Pletch A, Guarda AS. Discharge body Mass Index, not illness chronicity, predicts 6-Month Weight Outcome in patients hospitalized with Anorexia Nervosa. Front Psychiatry. 2021;12:641861.
Robinson P. Severe and enduring eating disorders: recognition and management. Adv Psychiatr Treat. 2018;20(6):392–401.
Treasure J, Willmott D, Ambwani S, Cardi V, Clark Bryan D, Rowlands K et al. Cognitive interpersonal model for Anorexia Nervosa Revisited: the perpetuating factors that contribute to the development of the severe and Enduring Illness. J Clin Med. 2020;9(3).
Arkell J, Robinson P. A pilot case series using qualitative and quantitative methods: biological, psychological and social outcome in severe and enduring eating disorder (anorexia nervosa). Int J Eat Disord. 2008;41(7):650–6.
Davis L, Walsh BT, Schebendach J, Glasofer DR, Steinglass JE. Habits are stronger with longer duration of illness and greater severity in anorexia nervosa. Int J Eat Disord. 2020;53(5):413–9.
Berends T, Boonstra N, Van Elburg A. Relapse in anorexia nervosa: a systematic review and meta-analysis. Curr Opin Psychiatry. 2018;31(6):445–55.
Carter JC, Mercer-Lynn KB, Norwood SJ, Bewell-Weiss CV, Crosby RD, Woodside DB, et al. A prospective study of predictors of relapse in anorexia nervosa: implications for relapse prevention. Psychiatry Res. 2012;200(2–3):518–23.
First MB, Williams JB. Structured clinical interview for DSM-5: Research Version (SCID-5-RV): Biometrics Research, Psychiatry. Columbia University at the New York State; 2017.
Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, et al. Refeeding and weight restoration outcomes in anorexia nervosa: challenging current guidelines. Int J Eat Disord. 2015;48(7):866–73.
Guarda AS, Cooper M, Pletch A, Laddaran L, Redgrave GW, Schreyer CC. Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa. Int J Eat Disord. 2020;53(12):2032–7.
McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy: measurement and sample profiles. Psychotherapy: Theory Res Pract. 1983;20(3):368.
Soderstrom CA, DiClemente CC, Dischinger PC, Hebel JR, McDuff DR, Auman KM, et al. A controlled trial of brief intervention versus brief advice for at-risk drinking trauma center patients. J Trauma. 2007;62(5):1102–11. discussion 11 – 2.
Garner DM. Eating disorder Inventory-2: Professional Manual. Psychological Assessment Resources; 1991.
Clinton D, Birgegard A. Classifying empirically valid and clinically meaningful change in eating disorders using the eating disorders Inventory, version 2 (EDI-2). Eat Behav. 2017;26:99–103.
Pinto AM, Heinberg LJ, Coughlin JW, Fava JL, Guarda AS. The Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ): change with treatment and prediction of outcome. Eat Behav. 2008;9(2):143–53.
Marinilli Pinto A, Guarda AS, Heinberg LJ, Diclemente CC. Development of the eating disorder recovery self-efficacy questionnaire. Int J Eat Disord. 2006;39(5):376–84.
Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G. State trait anxiety inventory for adults manual. Palo Alto. CA: Mind Garden; 1983.
Guillen-Riquelme A, Buela-Casal G. [Meta-analysis of group comparison and meta-analysis of reliability generalization of the state-trait anxiety Inventory Questionnaire (STAI)]. Rev Esp Salud Publica. 2014;88(1):101–12.
Oei TP, Evans L, Crook GM. Utility and validity of the STAI with anxiety disorder patients. Br J Clin Psychol. 1990;29(4):429–32.
Beck AT, Steer RA, Brown G. Beck depression inventory–II. Psychological assessment; 1996.
Steer RA, Clark DA. Psychometric characteristics of the Beck Depression Inventory-II with college students. Meas Evaluation Couns Dev. 1997;30(3):128–36.
Hay PJ, Touyz S, Sud R. Treatment for severe and enduring anorexia nervosa: a review. Aust N Z J Psychiatry. 2012;46(12):1136–44.
Kaye WH, Bulik CM. Treatment of patients with Anorexia Nervosa in the US-A Crisis in Care. JAMA Psychiatry. 2021;78(6):591–2.
Guarda AS, Schreyer CC, Fischer LK, Hansen JL, Coughlin JW, Kaminsky MJ, et al. Intensive treatment for adults with anorexia nervosa: the cost of weight restoration. Int J Eat Disord. 2017;50(3):302–6.
Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry. 2017;78(2):184–9.
Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord. 2022;10(1):135.
Hay P, Touyz S. Treatment of patients with severe and enduring eating disorders. Curr Opin Psychiatry. 2015;28(6):473–7.
Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychol Med. 2013;43(12):2501–11.
Yager J. Managing patients with severe and Enduring Anorexia Nervosa: when is Enough. Enough? J Nerv Ment Dis. 2020;208(4):277–82.
Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):23.
Guarda AS, Hanson A, Mehler P, Westmoreland P. Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined. J Eat Disord. 2022;10(1):79.
Lowe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med. 2001;31(5):881–90.
Crow SJ. Terminal anorexia nervosa cannot currently be identified. Int J Eat Disord. 2023;56(7):1329–34.
Austin A, Flynn M, Richards K, Hodsoll J, Duarte TA, Robinson P, et al. Duration of untreated eating disorder and relationship to outcomes: a systematic review of the literature. Eur Eat Disord Rev. 2021;29(3):329–45.
Marzola E, Longo P, Sardella F, Delsedime N, Abbate-Daga G. Rehospitalization and revolving door in Anorexia Nervosa: are there any predictors of Time to Readmission? Front Psychiatry. 2021;12:694223.
Frostad S, Rozakou-Soumalia N, Darvariu S, Foruzesh B, Azkia H, Larsen MP et al. BMI at Discharge from Treatment predicts Relapse in Anorexia Nervosa: a systematic scoping review. J Pers Med. 2022;12(5).
Download references
Thank you to the research participants and to all the patients and staff of Johns Hopkins Eating Disorders Program.
Supported in part by the Stephen and Jean Robinson Family Professorship Fund.
Authors and affiliations.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Mary K. Martinelli, Colleen C. Schreyer & Angela S. Guarda
You can also search for this author in PubMed Google Scholar
MM contributed to the conceptualization of the project, conducted data analysis, wrote the original draft, and reviewed and edited the manuscript. CS contributed to the study design and reviewed and edited the manuscript. AG conceived of the study, provided supervision, and reviewed and edited the manuscript.
Correspondence to Mary K. Martinelli .
Ethics approval and consent to participate.
This study was reviewed and approved by the Johns Hopkins University Institutional Review Board. Written informed consent was obtained from study participants.
Not applicable.
The authors declare no competing interests.
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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/ .
Reprints and permissions
Cite this article.
Martinelli, M.K., Schreyer, C.C. & Guarda, A.S. Comparing hospitalized adult patients with chronic anorexia nervosa with versus without prior hospitalizations. J Eat Disord 12 , 132 (2024). https://doi.org/10.1186/s40337-024-01092-y
Download citation
Received : 17 May 2024
Accepted : 21 August 2024
Published : 04 September 2024
DOI : https://doi.org/10.1186/s40337-024-01092-y
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
ISSN: 2050-2974
BMC Medical Education volume 24 , Article number: 935 ( 2024 ) Cite this article
Metrics details
Traditional radiology education for medical students predominantly uses textbooks, PowerPoint files, and hard-copy radiographic images, which often lack student interaction. PACS (Picture Archiving and Communication System) is a crucial tool for radiologists in viewing and reporting images, but its use in medical student training remains limited.
This study investigates the effectiveness of using PACS (Picture Archiving and Communication System) for teaching radiology to undergraduate medical students compared to traditional methods.
Fifty-three medical students were divided into a control group (25 students) receiving traditional slide-based training and an intervention group (28 students) using PACS software to view complete patient images. Pre- and post-course tests and satisfaction surveys were conducted for both groups, along with self-evaluation by the intervention group. The validity and reliability of the assessment tools were confirmed through expert review and pilot testing.
No significant difference was found between the control and intervention groups regarding, gender, age, and GPA. Final multiple-choice test scores were similar (intervention: 10.89 ± 2.9; control: 10.76 ± 3.5; p = 0.883). However, the intervention group demonstrated significantly higher improvement in the short answer test for image interpretation (intervention: 8.8 ± 2.28; control: 5.35 ± 2.39; p = 0.001). Satisfaction with the learning method did not significantly differ between groups (intervention: 36.54 ± 5.87; control: 39.44 ± 7.76; p = 0.129). The intervention group reported high familiarity with PACS capabilities (75%), CT principles (71.4%), interpretation (64.3%), appropriate window selection (75%), and anatomical relationships (85.7%).
PACS-based training enhances medical students’ diagnostic and analytical skills in radiology. Further research with larger sample sizes and robust assessment methods is recommended to confirm and expand upon theses results
Peer Review reports
Radiology is a fundamental component in basic medical education, bridging the gap between anatomy and clinical practice. Like other fields of medical education, radiology education faces the challenge of transitioning from passive learning to interactive and experiential learning [ 1 , 2 ]. With the expansion of the field of radiology, radiology education has undergone a revolution. Doctors used to carry plain films and show them using projectors or view boxes because plain films were the only main diagnostic method in radiology during the 1970s. Since the introduction of computed tomography (CT) and magnetic resonance imaging (MRI) in the late 1980s, the increase in the amount of image data associated with these imaging modalities has led to a greater demand for compatible information storage systems. Therefore, the picture archiving and communication system (PACS), capable of storing, retrieving, distributing, analyzing, and digitally processing medical images, has become an essential tool in clinical work today [ 3 , 4 , 5 ]. However, due to hardware and software limitations, the use of PACS in radiology education remains somewhat limited [ 6 , 7 ]. Currently, most radiology education still relies heavily on textbooks and traditional computer media such as PowerPoint or Word files both of which lack student interaction. PACS offers advantages such as interactive image viewing, 3D reconstruction capabilities, and the ability to simulate real-life radiology practice, which traditional methods lack. These features enhance students’ understanding and interpretation of radiological images, addressing the shortcomings of conventional methods. There is a minimal probability for a medical student to see whole images like a real radiologist in class. It is often a challenge for them to understand 3D anatomical images, as well as a comprehensive view of diseases. Consequently, some students may attempt to independently identify abnormal findings and analyze and formulate radiological diagnoses. According to one study, only a limited number of final-year medical students had satisfactory basic radiology interpretation skills, which necessitates the search for a more effective method of training [ 8 ].
Recent advancements in radiology teaching methods have previously been reported in addition to face-to-face teaching, including problem-based learning (discussion of a case or scenario consistent with curriculum objectives and students’ independent research to complete subject knowledge and share findings), case-based learning (showing several radiographs of the same subject and discussing them), and team-based learning (student collaboration by creating learning groups) [ 8 ].
In contrast to these conventional methods, a new method was created under the concept of learning from experience. This virtual method is based on individual learning in the PACS software environment, enabling students in the role of radiologists to interpret and diagnose radiology in a simulation environment. All common items are shown to the student using PACS instead of selected specific images. Students are allowed to see the whole image, do basic reconstructions of the images freely, and find specific features of the image by themselves. During this process, students can access PACS and clinical information, integrating clinical knowledge and 3D reconstruction ability, essential to arriving at radiological diagnoses PACS enables efficient archiving and transfer of medical images. Initially developed in the U.S. in the 1980s, it later expanded to Europe and Asia, including China, Japan, and Korea [ 9 ]. Iran has also implemented PACS, improving its medical imaging infrastructure with global DICOM standards.
The goal of this learning method was to compare the effectiveness of practical radiology training through traditional face-to-face interactive lectures with the virtual practical radiology training method based on individual learning in the PACS software environment for medical students.
The use of PACS in healthcare in Iran has only recently become widespread, primarily for patient management and diagnosis, and is rarely used for educational purposes. Iran, as a country with a rapidly developing healthcare system, faces unique challenges in medical education. This study seeks to compare radiology education in Iran with existing literature and to understand its context in relation to the region and worldwide. Managing medical education effectively is a significant challenge. And this research addresses this by introducing innovative teaching methods. Specifically, current study investigates the effectiveness of using PACS on medical students radiology education compared to traditional methods.
The research population was the medical students of the Islamic Azad University of Mashhad during the academic year 2021–2022. The entry criteria were: being a medical trainee student, consent to enter the study, and the exclusion criteria were: students who had previously graduated in radiology or other medical sciences and students who had renewed their course in radiology. participation in the study was voluntary, and students were informed that it would not impact their end-of-section evaluation After obtaining informed consent, they participated in the study. Ethical approval for this study was obtained from the Virtual University of medical sciences with the reference number [IR.VUMS.REC.1400.022]. This proposal was implemented after being approved by the ethics committee and obtaining the code of ethics.
The sample size was calculated using power analysis to ensure the study had sufficient power to detect a statistically significant difference between the control and intervention groups. Assuming an effect size of 0.5, a significance level (alpha) of 0.05, and a power of 0.80, it was determined that at least 50 participants were needed. To account for potential dropouts and ensure robustness, a total of 53 students were included in the study. According to the calculated sample size, four rotations of radiology internship students were included in the study for each of the control and intervention groups (each rotation is about 5–10 students). Due to the prevention of contamination, the first four rotations were assigned to the control group and the next four rotations to the intervention group.
The validity of the tools used in this study was established through expert review and pilot testing. Content validity was confirmed by 10 faculty members specializing in radiology. Reliability was assessed using Cronbach’s Alpha, yielding a coefficient of 0.91, indicating high internal consistency. In this study, three tools were used: measuring the level of knowledge, measuring the level of performance, and measuring the satisfaction of students in both groups (Appendix 1 ) and self-evaluation for PACS learning in the intervention group (Appendix 2 ). After one month of class, the final exam was taken which was a combination of 20 multiple choice questions and 5 short answer type questions (description and image recognition). The scores of the questions were collected as an objective assessment. To provide a subjective assessment of radiology learning, all students were invited to complete a satisfaction questionnaire on how radiology was taught. Also, the students of the intervention group were invited to complete a questionnaire for their self-evaluation of the amount of PACS learning. A 5-point Likert scale was used in both researcher-made questionnaires. The questionnaire used was created for this study. Informed consent was obtained from each patient whose data was used in the study, ensuring they were fully aware of how their medical images would be utilized for educational purposes.
Before starting the study with the PACS system, students were given an introductory session that covered the basics of PACS functionality, including how to navigate the software, view and manipulate images, and use the various tools available for image analysis.
In the knowledge section, questions evaluated theoretical content, and the performance section involved diagnosing radiographic image. Students described the type of radiography, pathological signs, and the final diagnosis. Multiple-choice questions and short answer questions were used to assess knowledge and performance The specific type of radiography used in this study included plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI). These imaging modalities were chosen to cover a broad spectrum of radiological techniques relevant to the medical curriculum. In the subject of knowledge, 20 multiple-choice questions were proposed based on the objectives of the lesson and the blueprint, which was approved by two colleagues of the radiology department, which must have been consistent with the objectives of the lesson. In the discussion of the performance of 5 of radiology images, which again corresponded to the objectives of the lesson and the blueprint, and it was approved by two colleagues of the radiology department that the objectives of the lesson were covered, they were provided to the students, and the students had to describe and diagnose the radiographies. The radiology images in both groups adequately covered the goals, but they were taught to the students in two different ways described.
This questionnaire aimed to determine student’s satisfaction with the educational method. It consisted of ten questions graded on a 5-point Likert scale the range of scores was between 10 and 50 and higher scores indicating greater satisfaction. The content and form validity were confirmed by 10 faculty members and reliability was obtained by Cronbach’s Alpha test of 0.91.
This questionnaire evaluated the learning rate of the PACS teaching method. It consisted of twelve questions graded on a 5-point Likert scale, and the range of scores was between 12 and 60, and higher scores indicate learning. Content and form validity were confirmed by 10 faculty members and reliability was assessed with a Cronbach’s Alpha of 0.91.
The teaching strategy involved traditional face-to-face interactive lectures using PowerPoint presentations. The practical part included demonstrating selected radiographic images on slides and discussing their interpretation.
This method aimed to develop the student’s ability to diagnose and interpret radiographs through structured lectures and guided discussions. A pre-test was conducted in the first session to determine the student’s initial knowledge and performance levels. The classes were held daily in person. After teaching the theoretical part with a PowerPoint presentation, radiographic images were shown to the control group for interpretation and discussion. This conventional method aimed to develop the ability to diagnose and interpret radiographs. The post-test to determine knowledge and performance was performed and the education satisfaction questionnaire was completed at the end of each rotation.
Bias caused by human factors during the teaching of the two groups was controlled by standardizing the teaching materials and methods across both groups. Additionally, the instructors were blinded to the group assignments to prevent any conscious or unconscious bias in teaching and assessment.
The stages of developing the training course using PACS software and DICOM were as follows: 1). Initial planning and curriculum alignment, 2) Selection of relevant radiographic cases, 3) Configuration of PACS workstations, 4) Training faculty on PACS software, and 5) Implementation of PACS-based learning sessions for students, followed by assessment and feedback.
After the control group, the rotations of the intervention group were included in the study, and the pre-test was administered to the students of the intervention group. Assessment of knowledge with multiple choice questions and performance with radiographic images was with short answer questions. The classes were held daily in person. In the intervention group, after participating in the theoretical part of the course, which was similar to the control group and was held face-to-face, for the practical part, they were trained in a virtual way with Adobe Connect software, and there was no face-to-face class for radiography images. In this way, students were given access to PACS Radiant software (installation on personal desktop). Following the teaching of the theoretical part, based on the goals of the radiology course for medical trainees, a number of images of the brain, lungs, bones, urinary tract, and digestive system (including radiography, CT and MRI) were assigned to the students of the intervention group, and the images of these patients were completely at their disposal.
The computers used were personal desktops with standardized configurations. Adjustments and calibrations were made to ensure all students could view images with consistent quality and brightness, replicating the clinical environment as closely as possible. This software enables students to perform basic operations with images, such as windowing, comparing different MRI sequences, and performing cross-sectional reconstruction (MPR) or 3D reconstruction, exactly as a radiologist does and has the facilities. After studying the material and checking the images, the students were required to announce the completion of their study to the teacher and they were given the opportunity to review the pictures, ask questions, and solve problems with the teacher in the virtual space.
The post-test to determine knowledge and performance was performed in the intervention group. The education satisfaction questionnaire was completed at the end of each rotation. The self-assessment questionnaire for PACS learning was completed at the end of each rotation.
The data was analyzed with SPSS-17 software, IBM, US. Central and dispersion indices were used in the descriptive statistics report, and a T-test was used in the analytical section, independent t-test, paired t-test and, chi-square test were used to compare the data. The confidence level was set at p < 0.05.
A total of 52 students entered this study, 28 students in the intervention group and 25 in the control group. The students were similar in terms of age, gender, and overall academic average ( p = 0.05) (Table 1 ). The average age in the control group is 26.04 ± 3.96 and in the intervention group is 24.29 ± 2.14. The result of the independent t-test shows that the average age in the two groups is not different ( P = 0.060). The average overall academic grade point average of the medical course in the control group is 15.73 and in the intervention group is 16.01, which has no difference ( P = 0.383) (Table 1 ).
The control group included 25 people, 16 of whom were women and 9 of whom were men, and the intervention group included 28 people of whom 16 were women and 12 were men. The result of the chi-square test shows that the two groups do not differ in terms of gender ( P = 0.610). Evaluation result: At the beginning of the exam, there were two parts of a multiple-choice test and a short answer for the interpretation of radiology images (pre-test). The same exam was done twice at the end of the one-month session (post-test). It was a multiple-choice test to check knowledge and a short answer test to check performance.
The result of the independent t-test shows that the score of the multiple-choice test before and after the intervention, as well as the changes in the test score, are not different in the two groups. ( P = 0.084, P = 0.883, P = 0.764) The result of the paired t-test shows that the multiple-choice test scores of the students before and after the intervention differ between the case and control groups, and it is higher after the intervention. ( P < 0.001, P < 0.001) (Table 2 ) The result of the independent t-test shows that the score of the student’s short answer test, which was for the interpretation of radiology images, is not different before and after the intervention ( P = 0.002 and P = 0.444, respectively). The changes in the test scores are different in the two groups and are more in the intervention group. ( P < 0.001) The result of the paired t-test shows that the score of the short answer test of the students before and after the intervention is different according to the case and control groups, and it is higher after the intervention. ( P < 0.001, P < 0.001)
The result of the independent t-test shows that there is no difference in the level of satisfaction with the teaching method between the two control groups with a score of 39.44 ± 7.76 and the intervention group with a score of 36.54 ± 5. ( P = 0.129) (Table 3 ).
The analysis of the satisfaction questionnaire in the intervention group showed that most students were satisfied with the organization (64%) and interaction of the learning activity (64%) (Table 3 ). Most students use this learning activity to learn radiology (85%). They found it useful. More importantly, a large percentage of students stated that PACS training encouraged personal interest in radiology (82%) as well as satisfaction with the quality of learning (71%). Also, in the intervention group, based on the self-evaluation form, they stated that with the abilities of PACS (75%), the principles of CT (71.4%) and its interpretation (64.3%), choosing the appropriate window (75%), the location of different organs in the image (82.9%) and their vicinity (85.7%) are familiar (Table 3 ). An evaluation of the impact of the intervention on participants’ knowledge is included, showing significant improvements in their understanding and diagnostic skills, highlighting the effectiveness of the PACS-based training method.
Traditional practical radiology training that continues to be used today provides only a cross-section of the entire routine imaging. While this teaching method may be useful in helping students manage the features of routine imaging, it may be inadequate for learning anatomy [ 10 ]. Hence, students may have difficulty interpreting images independently during clinical practice when they are expected to do so [ 11 ]. Although a variety of radiology educational models such as problem-based learning and the use of dynamic images can solve part of this problem, images of the main workplace are the most ideal learning method [ 12 , 13 ]. The experiential learning theory, developed by Dewey, Kolb and others provide explanations for how students learn things in their own way as they react to their perceptions of a real experiences. This concept is explained by principle of constructionism, which is the base of experiential learning [ 13 ].
During this study, a training course using PACS software and DICOM viewer was developed to simulate a work environment that reflects the typical clinical work of a radiologist. The results of the study indicated that this educational approach allows for better clinical guidance, which is necessary to help students form a holistic view of anatomy and pathology. Most importantly, this educational method helps students to develop critical thinking and a systematic approach to formulating imaging interpretation and differential diagnosis, which may be partially due to the exploratory atmosphere of the experiential learning mode. Apart from the objective improvement in imaging descriptions and interpretations, subjective improvements in self-confidence from students’ feedback to self-assessment questionnaires, as well as skills including determining the order of imaging reading, choosing the appropriate window, and also choosing the reconstruction method, which may result under the influence of direct activity during The course of learning and discussion should be free. In addition, the experiential approach allows for better interactions that increase interest in radiology [ 14 ].
To provide students with access to the Radiant PACS software (installed on their personal desktops), following the theoretical section and based on the objectives of the radiology course for medical trainees, a number of images from the brain, lungs, bones, urinary, and gastrointestinal systems (including radiography, CT, MRI) were assigned to the intervention group. These patient images were fully available to them. This software enables students to perform basic operations on images, such as window adjustment, comparing different MRI sequences, and performing multiplanar reconstruction (MPR) or 3D reconstruction, exactly as a radiologist does within the PACS system.
To resolve the issue of patient confidentiality, all patient identifiers were removed from the images before they were made accessible to students. Additionally, access to PACS was restricted to ensure that students could only view and analyze the images without accessing sensitive patient information.
Undergraduate students had limited access to PACS, ensuring they could not modify or delete any content. Additional software controls were implemented to restrict access and prevent any unauthorized changes. This ensured that the integrity of the medical images was maintained, and patient care data was not compromised.
Our study shows the effectiveness of PACS in training in the study of anatomical imaging. Anatomy is the basis of radiology training. In theory, reading CT and MRI images is a good way to study anatomy because continuous scanning helps students understand the three-dimensional concepts of the relative adjacencies of body parts [ 15 , 16 ]. Globally, they concluded that anatomical imaging increases the quality and efficiency of teaching human anatomy [ 17 ]. However, it is difficult to discern the entire anatomical structure from a single cross-section of the image, which increases students’ confusion [ 16 ]. The results of this study provide evidence that continuous scan reading improves students’ comprehensive understanding of anatomy. Furthermore, by using multiple reconstruction methods, 3D images are more comprehensively examined by students, which has been confirmed by other studies [ 18 ].
The integration of PACS in medical education has been shown to enhance the learning experience by providing students with interactive and practical tools for understanding radiological images. Recent advancements in healthcare technology acceptance highlight the importance of user-friendly interfaces and training for successful implementation [ 19 ]. Moreover, the current state of medical education in the UK emphasizes the adoption of advanced technologies like PACS to improve educational outcomes and prepare students for real-world clinical environments [ 20 ]. The utilization of big data technologies in conjunction with PACS further enhances the management and analysis of medical images, facilitating a more personalized and effective learning experience for medical students [ 21 ]. Additionally, recent market reports indicate a steady growth in the adoption of medical imaging technologies, including PACS, driven by advancements in AI and machine learning, which are poised to revolutionize medical education [ 22 ]. These developments collectively underscore the critical role of PACS in modernizing medical education and improving the quality of training for future healthcare professionals. Also, the implementation of PACS could significantly enhance radiology education by providing access to digital imaging resources that may otherwise be unavailable.
Compared to Chen et al.‘s study [ 1 ], the study was conducted on 101 students, but our study was on 52 students. Satisfaction with PACS training in Chen’s study was on average 80% and in our study, it was about 65%. The percentage of being interested in radiology in this study and Chen’s study was almost similar. Also, in our study, similar to Chen’s study, there was no difference in pre-test scores between the two intervention and control groups. Also, the final scores in Chen’s study and our study were not significantly different, but the scores of interpretations of pictures, which in our study were equivalent to a number of stereotypes in the form of PowerPoint with short answer questions, showed a significant difference in both our study and Chen’s study.
In the study of Restauri [ 6 ] and Soman [ 23 ], as in our study, PACS was used to teach medical students, and at the end of the course, only a survey form was filled by the students, and the impact of using PACS on the ability to interpret radiology images by students was not done. In the above two studies, after using PACS, students stated that they gained more confidence on interpreting images and would use PACS in the future, which was similar to the survey results in our study. It takes a lot of effort to do this kind of training. PACS and a suitable DICOM viewer represent basic software requirements for training and to protect patient privacy, DICOM data from PACS rather than linking to the original PACS. Copied In this way, a PACS simulation for medical education was obtained [ 6 ]. In addition, teacher guidance is a vital element in education. A minimum of 3 instructors with experience in standard radiology training is required for a class, as team discussion is a major component of the training. In experimental courses, students need educational help both to guide reading the picture and to answer the questions. Therefore, teaching professors need specific work experience in the radiology department. Having said that, the lack of a radiology professor prevents the use of this training and this training model acts as a limitation on a larger scale. There are several limitations to the study. First, due to the limited number of supervisors, the sample size was correspondingly limited. Secondly, it was a single study center. Thirdly, due to the limitation of the operation, some students did not answer some of the questions in the questionnaire. Although the probability is very low, it still has the chance to bias the result. Fourth, although we control for faculty and teaching standards between the two groups, human bias is still a factor that cannot be completely avoided in practice. Fifth, although we used objective assessment measures, the study also revealed the weakness of our assessment system in radiology education. The study instrument consisted of paper and pencil tests, with most questions consisting of objective items that test memory, such as multiple-choice questions and short answer questions. Furthermore, the mental items used to test application ability are limited. As a result, only a small part of the final test reflects the difference between the experimental training group and the control group. Other test forms such as bedside examinations and multi-station examinations should be used in the future for better evaluation [ 24 , 25 ]. In this study, according to the curriculum, students entered the radiology department with different numbers during different periods, and 4 periods of students were entered into the study for each group. The exams were held at the end of the one-month section, so the exam was held in the control group and in the intervention group at different times, although we tried to make the questions the same in terms of number and content similarity. In the study of Chen et al [ 8 ], the test was conducted at the end of the semester and simultaneously for two groups. If this study is conducted with a larger number of students and in multiple centers, the results will be more valid.
PACS-based training is beneficial for medical students, enhancing their diagnostic and analytical skills in radiology. Further research with larger sample sizes and robust assessment methods is recommended to confirm and expand upon theses results. We believe that our findings suggest that PACS which is used routinely in healthcare diagnostic context, can also be used in medical students’ education and healthcare can be integrated in education.
The demographic and clinical datasets generated and/or analyzed during the current study are available from the corresponding author (Dr. Farnood Rajabzadeh ) upon reasonable request.
Picture Archiving and Communication System
Computed Tomography
Magnetic Resonance Imaging
Grade Point Average
Digital Imaging and Communications in Medicine
Statistical Package for the Social Sciences
Multi planar Reconstruction
Artificial Intelligence
Bhogal P, Booth TC, Phillips AJ, Golding SJ. Radiology in the undergraduate medical curriculum -- who, how, what, when, and where? Clin Radiol. 2012;67(12):1146–52.
Article Google Scholar
Naeger DM, Webb EM, Zimmerman L, Elicker BM. Strategies for incorporating radiology into early medical school curricula. J Am Coll Radiol. 2014;11(1):74 – 9.
Forsberg D, Rosipko B, Sunshine JL. Factors affecting Radiologist’s PACS usage. J Digit Imaging. 2016;29(6):670–6.
Mirsadraee S, Mankad K, McCoubrie P, Roberts T, Kessel D. Radiology curriculum for undergraduate medical studies–a consensus survey. Clin Radiol. 2012;67(12):1155–61.
Arriero A, Bonomo L, Calliada F, Campioni P, Colosimo C, Cotroneo A, Cova M, Ettorre GC, Fugazzola C, Garlaschi G, Macarini L, Mascalchi M, Meloni GB, Midiri M, Mucelli RP, Rossi C, Sironi S, Torricelli P, Beomonte BZ, Zompatori M, Zuiani C. E-learning in radiology: an Italian multicentre experience. Eur J Radiol. 2012;81(12):3936–41.
Restauri N, Bang T, Hall B. Sachs P Development and Utilization of a Simulation PACS in Undergraduate Medical Education. J Am Coll Radiol. 2018;15(2):346–9.
Zafar S, Safdar S, Zafar AN. Evaluation of use of e-Learning in undergraduate radiology education: a review. Eur J Radiol. 2014;83(12):2277–87.
Chen Y, Zheng K, Ye S, Wang J, Xu L, Li Z, Meng Q, Yang J, Feng ST. Constructing an experiential education model in undergraduate radiology education by the utilization of the picture archiving and communication system (PACS). BMC Med Educ. 2019;19(1):383.
Huang -HK. Twenty-five years of Picture Archiving and Communication Systems (PACS). Dev Iran J Radiol. 2007;4(2):1.
Google Scholar
-Pascual TN, Chhem R, Wang SC, Vujnovic S. Undergraduate radiology education in the era of dynamism in medical curriculum: an educational perspective. Eur J Radiol. 2011;78(3):319–25.
-Sendra-Portero F, Torales-Chaparro OE, Ruiz-Gomez MJ, Martinez-Morillo. M.A pilot study to evaluate the use of virtual lectures for undergraduate radiology teaching. Eur J Radiol. 2013;82(5):888–93.
-Zhang S, Xu J, Wang H, Zhang D, Zhang Q, Zou L. Effects of problem-based learning in Chinese radiology education: a systematic review and metaanalysis. Med (Baltim). 2018;97(9):e0069.
Yardley S, Teunissen PW, Dornan T. Experiential learning: transforming theory into practice. Med Teach. 2012;34(2):161–4.
Branstetter BF. Humphrey AL,Schumann JB.The long-term impact of preclinical education on medical students’ pinions about radiology. Acad Radiol. 2008;15(10):1331–9.
Schober A, Pieper CC, Schmidt R, Wittkowski W. Anatomy and imaging: 10 years of experience with an interdisciplinary teaching project in preclinical medical education - from an elective to a curricular course. Rofo. 2014;186(5):458–65.
Jang HW, Oh CS, Choe YH, Jang DS. Use of dynamic images in radiology education: movies of CT and MRI in the anatomy classroom. Anat Sci Educ. 2018;11(6):547–53.
Grignon B, Oldrini G, Walter F. Teaching medical anatomy: what is the role of imaging today? Surg Radiol Anat. 2016;38(2):253–60.
Loke YH, Harahsheh AS, Krieger A, Olivieri LJ. Usage of 3D models of tetralogy of Fallot for medical education: impact on learning congenital heart disease. BMC Med Educ. 2017;17(1):54.
AlQudah, Adi A, Al-Emran M, Khaled Shaalan. Technology Acceptance in Healthcare: a systematic review Applied sciences 2021;11(22):10537. https://doi.org/10.3390/app112210537
GMC. (2022). The state of medical education and practice in the UK.
Geroski T, Jakovljević D, Filipović N. Big Data in multiscale modelling: from medical image processing to personalized models. J Big Data. 2023;10:72. https://doi.org/10.1186/s40537-023-00763-y .
-Visage Imaging. Medical imaging market size. Share & Growth Report; 2024.
Soman S, Amorosa JK, Mueller L, Hu J, Zou L, Masand A, Cheng C, Virk J, Rama H, Tseng I, Patel K, Connolly SE. Evaluation of medical student experience using medical student created StudentPACS flash based PACS simulator tutorials for learning radiological topics. Acad Radiol. 2010;17(6):799–807.
Reddy S, Straus CM, McNulty NJ, Tigges S, Ayoob A, Randazzo W, Neutze J, Lewis P. Development of the AMSER standardized examinations in radiology for medical students. Acad Radiol. 2015;22(1):130–4.
Monticciolo DL. The ACR diagnostic radiology in-training examination: evolution, current status, and future directions. J Am Coll Radiol. 2010;7(2):132–7.
Download references
Farbod Rajabzadeh for helping in data gathering, Ladan Goshayeshi for helping in editing, Lena Goshayeshi for helping in editing.
This study was supported by the Smart university of medical sciences and Mashhad Azad University of Medical Sciences.
Authors and affiliations.
Department of e-Learning in Medical Education, School of Medicine, Center of Excellence for E- learning in Medical Education, Tehran University of Medical Sciences, Tehran, Iran
Mojtahedzadeh Rita & Mohammadi Aeen
Department of Radiology, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad university, Mashhad, Iran
Farnood Rajabzadeh
Department of Community Medicine, University of Medical Sciences, Mashhad, Mashhad, Iran
Akhlaghi Saeed
You can also search for this author in PubMed Google Scholar
RM, FR, designed the study. FR was involved in the data gathering and interpretation of the results. AM and SA performed analyses. FR wrote the first draft of the manuscript. FR and RM edited the final version of the manuscript. All authors read and approved the final version of the manuscript.
Correspondence to Farnood Rajabzadeh .
Ethics approval and consent to participate.
This study was approved by the Ethics Committee of Smart University of Medical Sciences (ethics code: IR.VUMS.REC.1400.022, 4/12/2021) and conformed to the ethical principles contained in the Declaration of Helsinki. For experiments involving human participants the participants signed an informed consent form before the study.
Competing interests.
The authors declare no competing interests.
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Below is the link to the electronic supplementary material.
Supplementary material 2, 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/ .
Reprints and permissions
Cite this article.
Rita, M., Aeen, M., Rajabzadeh, F. et al. Using PACS for teaching radiology to undergraduate medical students. BMC Med Educ 24 , 935 (2024). https://doi.org/10.1186/s12909-024-05919-9
Download citation
Received : 05 December 2023
Accepted : 16 August 2024
Published : 28 August 2024
DOI : https://doi.org/10.1186/s12909-024-05919-9
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
ISSN: 1472-6920
Discover the world's research
IMAGES
VIDEO
COMMENTS
We first define self-confidence and related concepts. Next, an overview of self-efficacy theory is given, along with a review of the relevant research. The third section covers applications of techniques for enhancing self-confidence. Lastly, we note the research questions that follow from what is currently known.
Relevant answer. Ehsan Shabahang. Dec 13, 2023. Answer. Imagery training and self-confidence can significantly impact sports anxiety among junior high school judokas. Imagery training, a mental ...
Self-esteem is an individual's sense of satisfaction with oneself and reflects the relationship between personal self-image and ideal self-image. 1 Self-esteem is a measure of self-assessment because it is considered the most important psychological formula. 2 Self-esteem has 2 types, specific and global. Global self-esteem is more relevant to the psychological aspect, while specific self ...
1. Introduction. Strategies to enhance self-confidence are common sport psychology interventions for athletes [1,2] but evidence of the relationship between self-confidence and athletic performance is equivocal.Several studies have reported significant benefits of self-confidence for athletes [3,4,5,6], whereas other investigations have shown no benefit [7,8,9,10].
Social self confiden ce, sometimes t ermed social self effi cacy, is a strong belief in one's. ability to interact in soci al settings to build and/or maintain interpersonal ties (Bandura, 1993 ...
The self-efficacy theory of Bandura (1986) suggests that confidence is enhanced by four main factors: successful performances (competence), vicarious experience, verbal persuasion (including praise and encouragement), and physiological feedback. Furthermore, Bandura and Locke (2003) have found that one's own belief in self-efficacy can significantly impact on confidence in motivation and ...
In regards of students' confidence in being able to. study independently, 16% of students were extremely con fident, 29.4% of students were more confident, 33.6% of students. were confident, 17. ...
Women are regularly exhorted to demonstrate self-confidence as a strategy to progress their careers, raise their pay, and become more successful at work. Self-help guides commend women to "lean ...
students' and teachers' perceptions of self-confidence and their impact on academic performance. The research was guided by Weiner's attribution and Bandura's self-efficacy theories. The research questions focused on 3 areas: students' and teachers 'perceptions of academic self-confidence as factors impacting students' academic
Specifically, self-confidence and parental support had a significant and positive impact on academic achievement among higher secondary school students. Ballane (2019) reported that self-confidence had significant role in academic performance development, learning and success. Self-confidence was found as a predictor of academic performance.
Participants predicted level on the aspirations and goals scale is equal to 2.591 + 0.445(confidence with self-direction score). That is, a one unit increase on the confidence with self-direction scale leads to an increase of 0.445 on the aspirations and goals scale. 4.4.3. Multiple linear regressions
In either case, a lack of personal worth and value can have a negative impact on life and wellness. Some common signs or symptoms of low self-esteem include: Lack of confidence. External locus of control. Negative social comparisons. Trouble asking for help. Worry and doubt.
Perceived competence is a belief that one has skills in a particular area (e.g., math, spelling, peer relationships). Self-esteem and perceived competence are necessary for students to take risks in their learning and to bounce back after failure or adversity. Low self-esteem or lack of confidence leaves students doubting their ability to ...
The outcome of the study revealed that undergraduates lacked the confidence to ask and answer questions, seek help from lecturers, have a study plan and engage in academic discussion and note-taking. ... a plethora of widely cited academic research about-confidence and many related concepts like self-esteem and self-efficacy emerged.[14][15][16 ...
The steps for future research on the short-term: Design research article into an intervention to increase self-confidence amongst first-year game design students within project-based education at ...
According to Loubazid, Students may experience different 2 psychological barriers including lack of self confidence, language anxiety, shyness and fear … etc. ( 2012, P. 10) 2.3.1 Lack of self confidence Some students who do not trust their abilities in performing oral presentations often feel hesitated and embarrassed, they are afraid of ...
The disruption of health and medical education by the COVID-19 pandemic made educators question the effect of online setting on students' learning, motivation, self-efficacy and preference. In light of the health care staff shortage online scalable education seemed relevant. Reviews on the effect of online medical education called for high quality RCTs, which are increasingly relevant with ...
Background Depression poses a significant challenge globally, including in safety-critical industries such as aviation. In Saudi Arabia, where the aviation sector is rapidly expanding, pilots encounter unique stressors inherent to their profession. However, research on pilot mental health, particularly within the Saudi context, remains limited despite its critical role in flight safety ...
Despite the overall improvement in the headline Index, confidence declined for consumers earning less than $25K. On a six-month moving average basis, consumers earning over $100K remained the most confident. Confidence among consumers earning $15K to $24.9K continued to trend down and was almost as low as for those earning less than $15K."
Manchester Clinical Supervision Scale-26 results. Participants generally viewed peer group clinical supervision as effective (Table 3), the total mean Manchester Clinical Supervision Scale-26 score among all peer group clinical supervisors was 76.47 (SD. 12.801) out of 104, Surpassing the clinical supervision threshold score of 73, which was established by the developers of the Manchester ...
The participant was then asked to predict the other person's response on a second statement (e.g. all women should have access to legal abortion), and to state their confidence in their answer ...
Abstract. This article indicates the level of self-confidence during the oral performance of. the students such as in speaking activities as well as the self-efficacy in their oral task ...
For this study, the sample data is accurate to within +/- 2.5 percentage points using a 95% confidence level. For complete survey methodology, including weighting variables and subgroup sample ...
Anorexia nervosa (AN) is a severe psychiatric disorder, from which recovery is often protracted. The role of prior specialized inpatient treatment on subsequent treatment attempts for adults with chronic AN and predictors of treatment response for severe and enduring AN (SE-AN) are needed to improve outcomes. Participants (N = 135) with chronic AN (ill ≥7 years) admitted to an integrated ...
was to enhance the confidence of students in speaking English by using interactive practices. The present study was conducted at one of the private sector. universities in Lahore, Pakistan. The ...
Background Traditional radiology education for medical students predominantly uses textbooks, PowerPoint files, and hard-copy radiographic images, which often lack student interaction. PACS (Picture Archiving and Communication System) is a crucial tool for radiologists in viewing and reporting images, but its use in medical student training remains limited. Objective This study investigates ...
The data were collected from thirty-three Academic Speaking students using open-ended questions and semi-structured interviews. The findings indicated the causes of the lack of self-confidence ...