Journal of Modern Multidisciplinary Research
Journal of Modern Multidisciplinary Research (JMMR) is a peer-reviewed, open-access journal publishing high-quality research across diverse disciplines, including science, engineering, health, social sciences, business, and humanities. The journal welcomes original research articles, review papers, and short communications that advance knowledge and practice through multidisciplinary perspectives. JMMR is committed to research integrity, editorial transparency, and timely publication.
The rapid advancement of digital health technologies has significantly transformed healthcare delivery and expanded the use of remote healthcare services. Telerehabilitation has emerged as an important approach for providing rehabilitation services through information and communication technologies, enabling healthcare professionals to deliver assessment, intervention, monitoring, and patient education remotely. Despite its increasing adoption across healthcare systems, the concept of telerehabilitation remains inconsistently defined in the literature, leading to variability in its interpretation and implementation. Therefore, this study aimed to analyze and clarify the concept of telerehabilitation using the Walker and Avant concept analysis framework. A review of relevant literature addressing telerehabilitation, digital rehabilitation technologies, and remote rehabilitation services was conducted to identify the defining attributes, antecedents, consequences, and empirical referents of the concept. The analysis revealed five key defining attributes of telerehabilitation: remote delivery of rehabilitation services, the use of information and communication technologies, interaction between healthcare professionals and patients, monitoring and feedback mechanisms, and the implementation of structured therapeutic rehabilitation interventions. The findings also identified important antecedents, including technological infrastructure, access to digital devices, trained healthcare professionals, and institutional support, while the main consequences included improved access to rehabilitation services, enhanced patient engagement, and clinical outcomes comparable to traditional face-to-face rehabilitation. Clarifying the concept of telerehabilitation contributes to a stronger theoretical understanding of remote rehabilitation services and supports the development of standardized definitions and clinical frameworks that may guide future research and practice in rehabilitation sciences.
The Determinants of Knee Osteoarthritis Management; A Systematic Review
Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders worldwide and represents a major cause of pain, disability, and reduced functional capacity among adults. Effective management of knee osteoarthritis typically involves a combination of therapeutic approaches aimed at reducing symptoms and improving joint function; however, treatment outcomes are often influenced by multiple determinants related to patient behavior, rehabilitation strategies, and healthcare delivery. This systematic review aimed to identify and synthesize the key determinants influencing the management of knee osteoarthritis. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. A comprehensive literature search was performed across four major electronic databases: PubMed, Scopus, Web of Science, and CINAHL, using keywords related to knee osteoarthritis, management strategies, exercise therapy, rehabilitation, treatment adherence, and self-management. A total of 237 records were initially identified, and after screening and eligibility assessment, 20 studies were included in the final synthesis. The findings indicate that exercise-based management and physiotherapy interventions represent fundamental components in improving pain reduction and physical function among individuals with knee osteoarthritis. Psychosocial factors, including motivation, beliefs about treatment effectiveness, and perceived barriers to physical activity, were also identified as important determinants influencing patient engagement in rehabilitation programs. In addition, treatment adherence plays a critical role in determining the effectiveness of management strategies. Emerging evidence also highlights the potential role of digital self-management and telehealth-based interventions in improving patient participation and access to rehabilitation services. Overall, the management of knee osteoarthritis is influenced by multiple interrelated determinants, and integrating these factors into patient-centered management strategies may enhance treatment effectiveness and improve long-term clinical outcomes.
The Determinants of Quality Management Systems; A Systematic Review
Quality Management Systems have become important organizational mechanisms for improving process consistency, service quality, customer satisfaction, compliance, and organizational performance. However, the effectiveness of QMS implementation varies across sectors because organizations differ in leadership commitment, quality culture, resources, employee involvement, process control, and external pressures. This systematic review aimed to identify, classify, and synthesize the main determinants influencing the implementation and effectiveness of Quality Management Systems across organizational contexts. A systematic review approach was used to identify and synthesize relevant studies on QMS, ISO 9001, total quality management practices, implementation barriers, success factors, and performance outcomes. The review process followed the logic of PRISMA 2020, including identification, screening, eligibility assessment, and inclusion. A total of 30 studies were included and summarized using a literature review matrix. The findings showed that QMS implementation is shaped by managerial, organizational, human, technical, and external determinants. Leadership and management commitment, quality culture, employee involvement and training, resources, process documentation, audit and monitoring systems, customer focus, external factors, and implementation barriers were the most frequently reported themes. QMS was also associated with outcomes such as operational performance, customer satisfaction, service quality, stakeholder satisfaction, sustainability, environmental innovation, risk reduction, and organizational learning. QMS effectiveness depends on integrated implementation rather than certification alone. Organizations are more likely to achieve positive outcomes when QMS is supported by leadership, quality culture, employee capability, adequate resources, process discipline, and continuous monitoring.
Nurse Commitment: A Concept Analysis Using Walker and Avant’s Method
Nurse commitment is frequently linked to retention, quality of care, and patient safety, yet the concept is applied inconsistently across nursing and health services research. This concept analysis clarifies “nurse commitment” using Walker and Avant’s method by identifying defining attributes, antecedents, consequences, and empirical referents. A search was conducted in PubMed, CINAHL, Scopus, Web of Science, and Google Scholar for English-language, peer-reviewed sources published between 2021 and January 2026 addressing nurses’ professional commitment, organizational commitment, or commitment-related outcomes. Findings indicate that nurse commitment is a multidimensional psychological bond integrating professional and organizational orientations. Five defining attributes emerged: emotional attachment to nursing, sustained investment in professional development, alignment with nursing values, intention to remain in nursing practice, and dedication to patient-care excellence. Common antecedents included transformational leadership, perceived organizational support, adequate staffing and supportive work environments, professional values, autonomy, and effective socialization. Reported consequences encompassed lower turnover intention, reduced missed nursing care, improved patient safety and quality, and stronger organizational performance. Nurse commitment is distinct from job satisfaction or engagement and reflects an enduring professional–organizational bond shaped by leadership and work conditions and expressed in care excellence and intent to remain.
The Nurse Turnover Intentions; A Systematic Review
Nurse turnover intention (TI) has become a critical concern for healthcare systems worldwide due to its impact on workforce shortages, financial costs, and patient safety. High TI is a strong predictor of actual turnover, threatening the stability of healthcare delivery and exacerbating global nursing shortages. This systematic review aimed to synthesize empirical evidence on the prevalence and determinants of nurse turnover intention, evaluate the role of organizational and psychosocial factors, and identify research and policy gaps to inform workforce retention strategies. The review followed PRISMA 2020 guidelines. Electronic searches were conducted across PubMed, Scopus, Web of Science, and Google Scholar, covering literature from January 2000 to March 2025. Eligible studies included peer-reviewed empirical research and systematic reviews that examined turnover intention among nurses. Exclusion criteria included non-English language studies, theoretical papers, and studies without measurable outcomes on turnover intention. Screening and data extraction were performed independently by two reviewers, with quality appraisal guided by the JBI and MMAT tools. A total of 25 studies met the inclusion criteria. The prevalence of turnover intention among nurses ranged from 30% to over 50%, with the highest rates observed in intensive care and emergency settings. Key determinants included job dissatisfaction, burnout, stress, poor work environments, and lack of organizational support. Protective factors were supportive leadership, recognition, professional commitment, and vocational calling. The COVID-19 pandemic significantly increased turnover intention, with studies reporting heightened emotional exhaustion and new dynamics such as quiet quitting. Nurse turnover intention is a multifactorial issue shaped by individual, organizational, and systemic factors. Effective retention strategies must go beyond individual resilience-building to include structural reforms, such as improving staffing adequacy, strengthening leadership and recognition systems, and expanding mental health support. Addressing turnover intention proactively is vital for workforce sustainability, healthcare quality, and patient safety.
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The Determinants of Patient Safety Outcomes; A Systematic Review
Background: Patient safety is a key dimension of healthcare quality, yet preventable adverse events remain a global concern. Evidence suggests that safety outcomes are shaped by interacting determinants at individual, organizational, and system levels, necessitating a comprehensive synthesis of current research. Objective: This systematic review aimed to identify and synthesize key determinants of patient safety outcomes and examine their associations with adverse events, near misses, reporting practices, and overall safety performance. Methods: Following PRISMA 2020 guidelines, peer-reviewed studies published between 2020 and 2025 were systematically searched across major electronic databases. Eligible studies examined determinants influencing patient safety outcomes in healthcare settings. Data were extracted and thematically synthesized, with determinants categorized into behavioral, organizational, and contextual domains. Results: Patient safety outcomes were influenced by multiple interacting determinants. Behavioral factors included clinical competence, communication, fatigue, and professional conduct. Organizational determinants encompassed safety culture, leadership support, staffing adequacy, workload, reporting systems, and organizational learning. Contextual factors involved policy environments, resource availability, accreditation processes, and broader system constraints. These determinants were consistently associated with adverse events, healthcare-associated infections, medication errors, near misses, and mortality. Conclusions: Patient safety outcomes are multifactorial, arising from interactions across individual, organizational, and contextual levels. Improving safety requires integrated, system-wide strategies that address workforce behavior, organizational structures, and contextual conditions. A holistic, learning-oriented approach is essential to reduce preventable harm and enhance healthcare system resilience.
Patient safety outcomes; patient safety determinants; safety culture; adverse events; systematic review
The Determinants of Patient Safety Culture; A Systematic Review
Background: Patient safety culture is a cornerstone of high-quality healthcare, shaping patient outcomes and workforce performance. Despite global initiatives to improve safety, adverse events, underreporting of errors, and staff burnout persist, indicating gaps in the effective implementation of safety culture. Understanding its determinants is critical for guiding organizational strategies and policy interventions. Objective: This systematic review synthesizes empirical evidence on the prevalence, determinants, and outcomes of patient safety culture, with emphasis on behavioral, organizational, and contextual influences. Methods: The review followed PRISMA 2020 guidelines. Major electronic databases were systematically searched for studies examining patient safety culture among healthcare professionals. Eligible studies included quantitative research, systematic reviews, scoping reviews, and meta-analyses across diverse healthcare settings. Data were extracted and narratively synthesized using a structured review matrix. Results: Thirty studies were included. Patient safety culture was generally reported at low to moderate levels. Key determinants included leadership support, teamwork, communication openness, adequate staffing, training, and non-punitive responses to error. Strong safety culture was associated with reduced adverse events, improved incident reporting, higher patient safety ratings, and better staff well-being. Conversely, weak safety culture was linked to burnout, job stress, and increased turnover intentions. Conclusions: Patient safety culture is a multidimensional construct shaped by behavioral, organizational, and contextual factors. Enhancing leadership engagement, promoting teamwork and open communication, and addressing systemic workplace challenges are essential for improvement. A holistic, systems-based approach is necessary to achieve sustained gains in patient outcomes and workforce sustainability.
Patient safety culture; safety climate; healthcare quality; leadership
The Determinants of Digital Transformation in Public Institutions; A Systematic review
This study seeks to systematically review the key determinants of digital transformation in public institutions, addressing the growing need for a comprehensive understanding of this complex and multidimensional phenomenon. Digital transformation has emerged as a strategic priority for governments worldwide, driven by increasing demands for efficiency, transparency, and citizen-centric service delivery. A systematic literature review (SLR) was conducted using the PRISMA framework to ensure methodological rigor and transparency. A total of 20 peer-reviewed articles published between 2019 and 2024 were selected from major academic databases, including Scopus, Web of Science, and ScienceDirect. The selected studies were examined through thematic analysis to identify and classify the principal determinants influencing digital transformation. The findings indicate that digital transformation in public institutions is shaped by four primary dimensions: technological, organizational, environmental, and individual factors. Among these, technological, organizational, and environmental determinants are the most influential, whereas individual-level factors remain relatively underexplored. The analysis also underscores the growing importance of advanced technologies, particularly artificial intelligence, in accelerating transformation initiatives. Furthermore, the study highlights that successful digital transformation requires a holistic and integrated approach that aligns technological infrastructure with organizational readiness, supportive policy frameworks, and human capabilities. This research contributes to the existing literature by offering a comprehensive framework that synthesizes fragmented insights from prior studies. It also provides practical implications for policymakers and public sector leaders, emphasizing the need for balanced and coordinated strategies. Future research should focus on individual-level determinants and empirically validate the proposed framework across diverse institutional contexts.
Digital Transformation; Public Sector; E-Government; Artificial Intelligence; Systematic Review
The mediating role of organizational agility in the relationship between digital leadership and organizational excellence in Saudi SMEs
This study investigates the mediating role of organizational agility in the relationship between digital leadership and organizational excellence in Saudi small and medium-sized enterprises. The study was motivated by the growing importance of digital transformation and the increasing need for SMEs to strengthen their adaptability and competitive capacity within a rapidly changing business environment. A quantitative, deductive, and cross-sectional research design was adopted. Data were collected through a structured questionnaire from 352 managers, supervisors, department heads, team leaders, and decision-makers working in Saudi SMEs. The collected data were analyzed using Partial Least Squares Structural Equation Modeling to assess both the measurement model and the structural relationships among the study variables. The findings revealed that digital leadership has a significant positive effect on organizational agility and organizational excellence. The results also showed that organizational agility has a significant positive effect on organizational excellence. In addition, the indirect effect analysis confirmed that organizational agility mediates the relationship between digital leadership and organizational excellence. These findings indicate that digital leadership enhances organizational excellence not only directly, but also indirectly by strengthening the organization’s ability to respond flexibly and effectively to environmental and strategic change. The study contributes to the understanding of how digital leadership and organizational agility jointly support excellence in SMEs. It also offers practical insight for SME leaders seeking to improve organizational performance by combining digital capability with adaptive organizational processes.
Digital leadership; Organizational agility; Organizational excellence; Saudi SMEs; PLS-SEM.
The Determinants of Nursing Continuous Professional Development: A Systematic Review
<span style="font-size: 12.0pt; mso-bidi-font-size: 11.0pt; line-height: 150%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; color: black; mso-themecolor: text1; mso-font-kerning: 0pt; mso-ligatures: none; mso-ansi-language: EN-GB; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">Continuous professional development (CPD) is essential for sustaining nursing competence, supporting career progression, and strengthening care quality in health systems characterised by rapid clinical and technological change. Yet nurses’ engagement in CPD remains uneven across settings because participation is shaped by interacting personal, organisational, and contextual determinants. This systematic review synthesises evidence on determinants of nursing CPD, with specific attention to barriers, facilitators, and implementation conditions that influence sustained participation. The review was conducted using a structured systematic design guided by established reporting and evidence-synthesis standards. Across the included studies, nurses consistently recognised CPD as professionally necessary and clinically valuable for updating knowledge, strengthening confidence, and enhancing patient care. However, participation was frequently constrained by time pressure, high workload, staffing shortages, financial costs, scheduling inflexibility, and limited managerial support. Stable facilitators included clear relevance of CPD to practice, supportive leadership, protected learning time, accessible delivery formats (including blended and online approaches), and organisational cultures that value learning. The synthesis further indicates that CPD needs and barriers vary by career stage, with novice and experienced nurses facing different motivational drivers and practical constraints. Overall, the evidence supports a systems perspective in which CPD participation is produced through alignment between individual professional goals and organisational and policy mechanisms that enable equitable access, workload planning, and context-sensitive programme design.
Continuous Professional Development in Nursing: A Concept Analysis
This paper presents a comprehensive concept analysis of Continuous Professional Development (CPD) in nursing, utilizing the systematic framework proposed by Walker and Avant. The proliferation of medical knowledge, technological advancements, and evolving healthcare demands necessitates that nursing professionals engage in ongoing learning to maintain and enhance their competence. Despite its critical importance, the concept of CPD often suffers from definitional ambiguity and varied interpretations across different contexts and regulatory bodies. This analysis aims to clarify the concept of CPD by identifying its defining attributes, antecedents, and consequences, drawing upon contemporary literature from 2021 to 2026. A model case, borderline case, related case, and contrary case are presented to illustrate the concept's application and boundaries. Furthermore, the paper explores empirical referents for measuring CPD, discusses prevalent barriers and enablers to its engagement, and highlights its global perspectives. The findings underscore the multifaceted nature of CPD and its profound implications for nursing practice, patient safety, and professional growth, offering a refined understanding that can inform educational strategies, policy development, and future research in nursing
Team Cohesion Among Nursing; A Systematic Review
This systematic review examines the role of team cohesion among nurses and its influence on professional, organizational, and patient‐related outcomes across healthcare settings. Drawing on evidence from quantitative, qualitative, and mixed-methods studies, the review synthesizes how team cohesion is formed, the conditions that strengthen or weaken it, and the consequences it produces within nursing teams. The findings show that cohesion among nurses is shaped by a combination of interpersonal relationships, leadership practices, psychological safety, work environment, and organizational stability. High levels of cohesion are associated with improved teamwork, stronger job satisfaction, lower burnout and turnover intentions, better communication, and enhanced patient safety and care quality. Conversely, fragmented teams characterized by poor communication, weak leadership, and high staff turnover demonstrate reduced collaboration, higher levels of missed care, and lower performance. The review further indicates that cohesive teams are more resilient during periods of crisis and change, allowing nurses to adapt, support one another, and maintain effective care delivery under pressure. Overall, the evidence positions team cohesion as a central mechanism through which nursing teams achieve both workforce wellbeing and high-quality patient outcomes, highlighting the importance of organizational strategies that foster trust, collaboration, and shared purpose in healthcare environments.
Nursing Team Cohesion: A Concept Analysis Using Walker and Avant’s Method
Nursing team cohesion is increasingly recognized as a critical determinant of communication quality, collaborative decision-making, staff well-being, and patient safety; however, the concept remains insufficiently defined and is often conflated with related constructs, including teamwork, collaboration, and psychological safety. This concept analysis aimed to clarify nursing team cohesion as a distinct construct within nursing science by identifying its defining attributes, antecedents, consequences, empirical referents, and conceptual boundaries. Walker and Avant’s eight-step method guided the analysis, supported by a systematic search of peer-reviewed English-language studies published between 2020 and 2025 in Google Scholar, OpenAlex, and PubMed Central. Using PRISMA 2020 procedures, 28 studies were selected and thematically synthesized. The analysis identified five defining attributes: mutual trust and respect, effective communication, shared goals, interpersonal harmony, and emotional intelligence. Key antecedents included transformational leadership, conflict resolution training, emotional intelligence, and structured team-building initiatives. Consequences were evident at individual, team, and organizational levels, including improved job satisfaction, reduced burnout, enhanced collaboration, greater psychological safety, better patient outcomes, and lower turnover. Empirical referents included the Team Climate Inventory, TeamSTEPPS instruments, and qualitative assessments. Overall, nursing team cohesion emerged as a multidimensional, measurable construct with substantial relevance for leadership, workforce stability, intervention design, and healthcare quality improvement.
Food Safety in Healthcare Institutions; A Systematic Review
Food safety in healthcare institutions constitutes a critical dimension of patient safety because hospitalized populations are disproportionately susceptible to foodborne infections, cross-contamination, and adverse outcomes arising from compromised immunity and clinical vulnerability. This systematic review synthesizes contemporary evidence on the prevalence, determinants, and outcomes of food safety practices in healthcare settings, with particular attention to the effectiveness of Hazard Analysis and Critical Control Point (HACCP) systems, food safety culture, staff training, and emerging digital technologies. Guided by PRISMA 2020, the review examined peer-reviewed studies published between 2020 and 2025 across major academic databases, including empirical and review-based research addressing hospital food hygiene, outbreak prevention, contamination control, and institutional determinants of compliance. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal tools. The evidence indicates that food safety performance in healthcare institutions is shaped by an interaction of behavioral, organizational, and contextual factors. Food handlers’ knowledge, attitudes, and practices consistently emerged as central determinants of hygienic compliance, while leadership commitment, continuous training, inspection frequency, and regulatory enforcement strengthened adherence to established standards. Infrastructure-related conditions, particularly water quality, sanitation, storage capacity, and temperature control, further influenced the success of preventive measures. The review also found that HACCP implementation and structured quality assurance systems were associated with reduced contamination rates and improved operational control, whereas predictive analytics, machine learning, and Industry 4.0 applications enhanced monitoring capability and decision quality. Overall, the findings demonstrate that effective food safety management in healthcare institutions requires more than procedural compliance; it depends on embedding safety within institutional governance, organizational culture, and technological systems. Strengthening staff competence, managerial accountability, regulatory oversight, and digitally enabled monitoring is therefore essential to minimizing hospital-related foodborne risks and protecting patient health.
The Determinants of Digital Health immunization technology; A Systematic Review
Digital health technologies have become central to modern immunization systems, replacing paper-based processes with electronic registries, mobile health applications, interoperable platforms, and digital decision-support tools. While these innovations promise improvements in vaccination coverage, data quality, and program efficiency, their adoption and effectiveness vary widely across health system contexts. Fragmented evidence, diverse technologies, and inconsistent outcomes have made it difficult to understand what truly enables or constrains successful digital immunization implementation. This study therefore aimed to systematically identify and synthesize the key determinants of digital health immunization technology across global settings. A systematic review was conducted following PRISMA 2020 guidelines, drawing on multiple academic databases and applying clear inclusion and exclusion criteria to select empirical studies relevant to digital immunization systems. Thirty peer-reviewed studies were analysed using thematic synthesis to categorize determinants into technological, behavioural, organizational, and contextual domains. The findings reveal that electronic immunization registries, community-based mHealth tools, system interoperability, workforce capacity, governance structures, and digital infrastructure are the most influential determinants of performance. Positive outcomes were most consistently observed in vaccination coverage, timeliness, data reliability, and workflow efficiency, particularly when digital tools were embedded within well-coordinated health systems. The review concludes that digital immunization technologies are most effective when technological innovation is accompanied by strong leadership, sustained investment, user-cantered design, and supportive policy environments, rather than being implemented as isolated technical solutions.
The Professional Autonomy of Nurse Practitioners: A Concept Analysis
Professional autonomy is central to nurse practitioner (NP) practice, yet the concept remains inconsistently defined across regulatory, organizational, and outcome-oriented literature. This paper analyzes professional autonomy of nurse practitioners as a multidimensional construct comprising clinical decision-making authority, independent practice capability, and professional accountability. A structured concept-oriented review of recent peer-reviewed literature published between 2021 and 2025 was used to identify the defining attributes, antecedents, mediating mechanisms, contextual conditions, and consequences associated with the concept. The analysis shows that professional autonomy cannot be reduced to independence alone. Rather, it refers to the legitimate authority to make advanced clinical decisions, enact practice without unnecessary external control, and remain answerable for the quality, safety, ethics, and outcomes of care. Role clarity emerged as the central mediating mechanism because autonomy is translated into advanced nursing practice effectiveness only when responsibilities, jurisdictional boundaries, and expectations are clearly understood by nurse practitioners, physicians, managers, and policymakers. Advanced nursing practice effectiveness was identified as the principal consequence of well-enacted autonomy and was reflected in access, timeliness, continuity, patient outcomes, and service efficiency. Organizational support and regulatory environment were identified as contextual conditions that can either enable or constrain the practical realization of autonomy. The paper contributes a conceptually integrated framework that explains how the internal structure of NP autonomy operates within workplace and policy contexts and identifies key research gaps related to measurement consistency, cross-country comparability, and implementation beyond formal legal authority.
The Determinants of Professional Autonomy of Nurse Practitioners; A Systematic Review
Professional autonomy is a core attribute of nurse practitioner practice and a critical determinant of workforce effectiveness, role sustainability, and quality of care, yet its realization varies substantially across clinical and policy contexts. This systematic review synthesizes contemporary evidence on the determinants of professional autonomy among nurse practitioners, focusing on behavioural, organizational, and contextual influences, as well as associated outcomes. Guided by PRISMA 2020 guidelines, peer-reviewed quantitative, qualitative, mixed-methods, and review studies were systematically identified, screened, and analysed using a standardized literature review matrix and narrative synthesis approach. The findings demonstrate that professional autonomy is shaped by the interaction of individual competence, self-efficacy, and professional identity; organizational factors such as leadership style, governance structures, interprofessional relationships, and work environments; and external regulatory and policy frameworks, particularly scope-of-practice regulations. Higher levels of autonomy were consistently linked to positive outcomes, including greater job satisfaction, enhanced professional fulfilment, improved patient safety activities, and more efficient utilization of nurse practitioner roles, whereas restrictive organizational cultures and regulatory constraints limited the translation of formal authority into everyday practice. Overall, the review highlights that professional autonomy is a dynamic and multidimensional capability that requires coordinated educational, organizational, and policy-level strategies to be effectively realized in modern healthcare systems.
A Digital Health Immunization Technology Framework for Nursing Practice
Digital transformation in healthcare has significantly reshaped immunization services, yet the mechanisms through which digital technologies influence nursing practice remain insufficiently theorized and empirically integrated. This paper proposes a Digital Health Immunization Technology Framework for Nursing Practice that explains how digital immunization technologies affect nursing outcomes through both direct and indirect pathways. Grounded in a socio-technical perspective, the study conceptualizes Digital Health Immunization Technology as the independent variable, Nursing Practice as the dependent variable, and Digital Competence and Technology Adoption as parallel mediators. The framework synthesizes insights from digital health, nursing informatics, and technology adoption research to clarify how technological environments shape professional capabilities and behavioral engagement in immunization settings. The paper first reviews theoretical foundations related to socio-technical change, digital leadership, digital competence, and contemporary nursing practice in digital immunization. It then develops a series of hypotheses linking digital technology to competence, adoption, and practice, including two mediation pathways. A gap analysis highlights limitations in existing literature, particularly the fragmented treatment of technology, competence, and adoption as separate constructs. The proposed conceptual model integrates these elements into a coherent structure that explains how digital immunization systems can enhance documentation quality, decision-making, workflow efficiency, and continuity of care. The paper concludes by outlining practical implications for nursing leaders, policymakers, and educators, emphasizing the need for user-centered system design, continuous digital competence development, and supportive organizational environments to maximize the benefits of digital immunization technologies for nursing practice and public health outcomes.
The Determinants of Employee Engagement in Nursing: A Systematic Review
Employee engagement in nursing has become a strategic concern because engaged nurses are more likely to remain in post, sustain performance under pressure, and support safer care delivery. This systematic review synthesized the determinants of employee engagement in nursing and developed an integrated multilevel framework. Following PRISMA 2020 guidance, searches were conducted across major health and interdisciplinary databases and were supplemented with Google Scholar for English-language studies published between January 2015 and December 2025. After screening, eligibility assessment, and methodological appraisal using MMAT 2018, 53 studies were included in the final narrative synthesis. The evidence indicated that engagement in nursing is shaped by interacting individual, relational, work-design, and contextual determinants. Leadership, structural empowerment, favorable practice environments, psychological capital, emotional intelligence, core self-evaluation, self-efficacy, resilience, meaningful work, decent work, social support, and job crafting consistently strengthened engagement. By contrast, burnout, hindrance stress, compassion fatigue, perceived overqualification, organizational dehumanization, illegitimate tasks, and poor work-life fit weakened engagement or limited its sustainability. More recent evidence also suggests that digital literacy and nursing informatics capability function as emerging job resources rather than peripheral technical attributes. The literature remains dominated by cross-sectional self-report designs, limiting causal inference and weakening understanding of how engagement is built and sustained over time. This review contributes a clearer analytic structure by distinguishing foundational job resources, personal resources, and demand-related constraints. It also offers practical guidance for nursing leaders seeking to strengthen retention, well-being, and quality of care through deliberate engagement-building strategies.
The Determinants of Work-Life Balance in Nursing: A Systematic Review
Work-life balance is a persistent challenge in nursing because caregiving is delivered within chronically demanding, time-sensitive, and emotionally intensive environments. This systematic review aimed to identify, critically appraise, and synthesize empirical evidence on the determinants of work-life balance among nurses. The review was conducted and reported in line with PRISMA 2020 guidance. A structured search of PubMed/MEDLINE, CINAHL, Scopus, Web of Science, PsycINFO, and the Cochrane Library was undertaken for English-language studies published between January 2015 and December 2024. Quantitative, qualitative, and mixed-methods studies that examined work-life balance, work-family balance, work-family conflict, or closely related constructs among nurses were eligible. Twenty-four studies met the inclusion criteria and were synthesized narratively because of substantial heterogeneity in design, setting, and outcome measurement. Across the included studies, the most consistent determinants of poorer work-life balance were high workload, understaffing, rotating and night shifts, long working hours, schedule unpredictability, weak managerial support, unsupportive organizational climate, caregiving burden, stress, emotional exhaustion, sleep disruption, fatigue, and physical pain. Protective factors included family support, resilience, positive coping, schedule flexibility, and family-supportive leadership. Overall, the evidence indicates that nurses’ work-life balance is shaped less by personal preference alone than by the interaction between individual resources and organizational conditions. Improving work-life balance in nursing therefore requires multilevel action, particularly staffing reform, healthier scheduling systems, family-supportive leadership, and policy environments that protect recovery time and sustainable practice.
The midwifery profession plays a vital role in ensuring the health and well-being of mothers and newborns, yet midwives often face significant workload-related challenges that impact both their performance and the quality of care provided. This paper explores the concept of midwifery workload, analyzing its defining attributes, antecedents, consequences, and empirical referents. Through a comprehensive review of existing literature, the study identifies several key factors that contribute to high workloads in midwifery, including inadequate staffing, high patient acuity, and insufficient organizational support. These factors lead to increased stress, burnout, and job dissatisfaction among midwives, which in turn negatively affects patient care outcomes. The study also discusses the role of external elements such as socio-cultural expectations, resource availability, and institutional factors in shaping midwifery workload. This research highlights the complex nature of midwifery workload and underscores the need for targeted interventions to address the negative consequences of high workload. The findings suggest that improving staffing levels, providing organizational support, and fostering a positive work environment are essential strategies for reducing workload-related stress and enhancing job satisfaction among midwives. Furthermore, the study calls for the development of standardized workload measurement tools to better quantify and manage midwifery workload across healthcare settings. The paper concludes by emphasizing the importance of addressing midwifery workload to ensure the sustainability of the midwifery workforce and to improve the quality of care delivered to mothers and newborns. By implementing strategies that reduce workload-related stress and support midwives in their professional roles, healthcare systems can promote better outcomes for both healthcare providers and patients, ultimately contributing to a more effective and sustainable midwifery workforce.
The determinants of Maternal Satisfaction; A Systematic Review
Maternal satisfaction is widely recognized as a key indicator of the quality of maternity care and an important determinant of women’s future use of health services. It reflects women’s perceptions of interpersonal care, clinical practices, and health system responsiveness across antenatal, intrapartum, and postnatal services. Despite growing attention to respectful and woman-centered care, evidence on the prevalence, determinants, and outcomes of maternal satisfaction remains fragmented across regions and service types. This systematic review synthesized existing evidence on the prevalence of maternal satisfaction with maternity care and identified its key behavioral, organizational, and contextual determinants, as well as its outcomes for women and health systems. A systematic literature search was conducted across multiple academic databases in accordance with PRISMA 2020 guidelines. Peer-reviewed empirical studies and systematic reviews addressing maternal satisfaction with antenatal, intrapartum, postnatal, or vaccination services were included. Studies were screened using predefined eligibility criteria, and data were extracted on study design, setting, sample characteristics, measurement tools, prevalence estimates, determinants, and reported outcomes. Due to heterogeneity in study designs and measurement instruments, a narrative synthesis approach was applied. The review revealed substantial variation in reported levels of maternal satisfaction across countries and care settings, with generally higher satisfaction in well-resourced facilities and lower satisfaction in settings characterized by long waiting times, inadequate privacy, and limited respectful care. Key determinants of satisfaction included quality of communication, respectful treatment, shared decision-making, waiting time, facility cleanliness, availability of supplies, mode of delivery, labor duration, and women’s prior expectations and experiences. Maternal satisfaction was consistently associated with greater confidence in the maternal role, improved health-seeking behavior, and a higher likelihood of recommending services to others. Overall, maternal satisfaction is a multidimensional construct shaped by both interpersonal interactions and health system factors. Enhancing respectful maternity care, improving communication, and strengthening facility resources are critical strategies for improving women’s experiences and promoting positive maternal and child health outcomes. Future research should adopt standardized measurement tools and comparative designs to enable stronger cross-country evidence synthesis.
The Determinants of Nursing Team Effectiveness; A Systematic Review
Background Nursing team effectiveness is increasingly recognized as a critical determinant of high-quality patient care, workforce well-being, and organizational performance in healthcare settings. Effective teamwork among nurses influences communication, coordination, decision-making, and patient safety, while poor teamwork has been linked to missed nursing care, burnout, and adverse clinical outcomes. Despite growing interest in this topic, evidence on the determinants and outcomes of nursing team effectiveness remains fragmented across disciplines, making it necessary to systematically synthesize existing research. Objective This systematic review aims to identify and synthesize contemporary evidence on the determinants of nursing team effectiveness and examine its key outcomes for nurses, healthcare organizations, and patients. Methods A systematic review was conducted following the PRISMA 2020 framework, including the four stages of identification, screening, eligibility, and inclusion. Multiple electronic databases were searched using structured keywords related to nursing teamwork, leadership, communication, staffing, workload, digital tools, and patient safety. Peer-reviewed studies published between 2021 and 2025 were included if they focused on nursing teams in hospital or clinical settings. A standardized literature review matrix was used for data extraction, and findings were synthesized thematically across behavioral, organizational, and contextual domains. Results Thirty studies met the inclusion criteria. The review identified three major categories of determinants influencing nursing team effectiveness: behavioral factors (communication, psychological safety, trust, competence), organizational factors (leadership style, staffing adequacy, workload, work environment), and contextual factors (digital technologies, organizational culture, safety climate). Strong nursing teamwork was consistently associated with positive outcomes, including higher nurse-reported quality of care, reduced missed nursing care, lower occupational fatigue, improved job satisfaction, and enhanced patient-centered care. Conversely, weak teamwork was linked to increased workload strain, higher burnout risk, and compromised patient safety. Conclusions Nursing team effectiveness is a complex, multilevel phenomenon shaped by the interaction of individual, organizational, and contextual factors. Strengthening teamwork requires integrated strategies that address leadership development, staffing policies, communication practices, and digital system design simultaneously. Healthcare organizations should adopt comprehensive, system-wide approaches that foster collaborative cultures and empower nursing teams to deliver safer, higher-quality care.
Nursing Team Effectiveness A Concept Analysis
Background: Nursing team effectiveness is a vital construct in contemporary healthcare systems, influencing care quality, patient safety, and organizational performance. However, its definition remains ambiguous in the literature. Objectives: This study aims to refine the definition of nursing team effectiveness using Walker and Avant’s concept analysis methodology, addressing conceptual inconsistencies and identifying measurable attributes. Methods: A systematic review of empirical and theoretical literature published between 2020 and 2025 was conducted. The analysis followed Walker and Avant’s eight-step method to identify the defining attributes, antecedents, consequences, empirical referents, and conceptual boundaries of nursing team effectiveness. Results: Nursing team effectiveness is defined as the sustained capacity of a nursing team to deliver safe, high-quality, patient-centered care through coordinated practice, effective communication, shared decision-making, and adaptive problem-solving. Key attributes include interprofessional coordination, role clarity, mutual trust, and adaptability. Antecedents include adequate staffing, targeted training, transformational leadership, and a supportive work environment. Consequences involve improved patient outcomes, enhanced nurse well-being, and strengthened organizational performance. Empirical referents such as the Nursing Teamwork Survey and TeamSTEPPS Teamwork Perceptions Questionnaire are identified for measurement and benchmarking. The concept is distinguished from related terms like collaboration and team efficiency. Conclusion: The refined conceptualization of nursing team effectiveness clarifies a previously ambiguous construct in nursing management literature. By defining its core attributes and identifying measurable indicators, this study supports evidence-based interventions, workforce planning, and policy development to enhance team performance and patient care outcomes.
The Determinants of Telemedicine Adoption: A Systematic Review
Telemedicine has shifted from a peripheral service option to an important mode of healthcare delivery, yet adoption remains uneven across settings, professional groups, and patient populations. This systematic review synthesizes the determinants of telemedicine adoption and proposes an integrated multilevel framework. Guided by PRISMA 2020, the review searched PubMed, Scopus, Web of Science, and CINAHL for peer-reviewed English-language studies published between 2016 and 2025. Following screening, eligibility assessment, and quality appraisal, 40 studies were included in the final synthesis. The evidence indicates that adoption is shaped by interacting individual, technological, organizational, and environmental determinants. Perceived usefulness, usability, digital capability, and trust consistently influence acceptance; however, favorable perceptions do not translate into sustained use when connectivity is unreliable, privacy arrangements are ambiguous, workflows are poorly integrated, or reimbursement and regulatory conditions are unclear. Sustained adoption is more likely when organizations provide leadership support, training, technical assistance, interoperability, and implementation-ready workflows. The review also identifies persistent equity challenges, including age-related capability differences, rural connectivity constraints, and socioeconomic disparities in access. An integrative conceptual framework is proposed in which decision confidence and implementation fit mediate the transition from favorable perceptions to sustained adoption outcomes. The review contributes a clearer analytical structure for telemedicine adoption research and offers practical guidance for health systems seeking durable, scalable, and equitable telemedicine delivery.
Telemedicine Adoption; A Concept Analysis
Telemedicine adoption has emerged as a vital component of modern healthcare systems, yet its conceptual boundaries remain unclear and inconsistently applied across the literature. This study aims to clarify the concept of telemedicine adoption through a structured concept analysis using the Walker and Avant framework. A systematic examination of existing literature was undertaken to identify defining attributes, antecedents, consequences, empirical referents, and illustrative cases related to telemedicine adoption. The analysis demonstrates that telemedicine adoption is not limited to initial technology acceptance but represents a sustained, multidimensional process involving regular use, integration into clinical workflows, user competence, organizational support, and enabling policy environments. Key antecedents include technological infrastructure, digital literacy, leadership commitment, and regulatory readiness, while consequences encompass improved access to care, enhanced patient and provider satisfaction, continuity of services, and greater system efficiency. By offering a clear and comprehensive conceptualization, this study provides a theoretical foundation to support consistent measurement, guide implementation strategies, and inform future research and policy initiatives aimed at promoting sustainable and equitable telemedicine integration.
Transformational Leadership Training, Motivation and Work-Life Balance Toward Nurse Burnout: A Conceptual Framework
This paper proposes a conceptual framework examining the relationship between transformational leadership training, empowerment, motivation, and nurse burnout within healthcare settings. The framework integrates Transformational Leadership Theory, Empowerment Theory, and Self-Determination Theory (SDT) to explain how leadership development initiatives can enhance nurses’ psychological well-being and reduce burnout. Transformational leadership training is positioned as a critical organizational strategy that equips nurse leaders with the emotional intelligence, communication, and motivational skills necessary to inspire and empower their teams. Empowerment and motivation are identified as dual mediating mechanisms that translate leadership behaviors into improved engagement, job satisfaction, and emotional resilience. By fostering autonomy, competence, and professional purpose, leadership-driven empowerment and motivation are expected to significantly mitigate burnout symptoms such as emotional exhaustion and depersonalization. The model is especially relevant to the Saudi Vision 2030 healthcare transformation agenda, which prioritizes leadership capacity-building, workforce sustainability, and quality of care. This framework offers both theoretical and practical contributions, guiding future empirical studies and leadership interventions aimed at developing psychologically supportive work environments. Ultimately, it underscores the essential role of transformational leadership training in cultivating empowered and motivated nurses capable of delivering high-quality, patient-centered care while maintaining personal well-being and professional fulfillment.
Work-Life Balance in Nursing Field; A Concept Analysis
Work-life balance has become a critical issue within the nursing field due to escalating workloads, workforce shortages, and increasing professional demands. Nurses are required to manage complex clinical responsibilities while maintaining personal, family, and social roles, making work-life balance essential for individual well-being and the sustainability of healthcare systems. Despite extensive discussion in the literature, the concept of work-life balance in nursing remains inconsistently defined and frequently conflated with related constructs such as burnout, job satisfaction, and quality of work life. This study aims to clarify and refine the concept of work-life balance in the nursing field through a systematic concept analysis. Walker and Avant’s eight-step method was employed to analyze the concept. A comprehensive literature search was conducted across major academic databases, and relevant studies were selected and screened using a PRISMA-style process. The analysis involved identifying the various uses of the concept, defining attributes, model and alternative cases, antecedents, consequences, and empirical referents specific to nursing contexts. The findings reveal that work-life balance in nursing is a multidimensional construct characterized by perceived equilibrium between professional and personal roles, organizational and leadership support, flexibility in work arrangements, and holistic well-being. Antecedents of work-life balance include manageable workloads, supportive organizational cultures, effective leadership, flexible scheduling, and personal coping resources. Consequences of achieving work-life balance extend across individual, organizational, and care-delivery levels, including enhanced psychological well-being, increased job satisfaction, improved retention, and better quality of nursing care. This concept analysis provides conceptual clarity and a structured foundation for future research, policy development, and practical interventions aimed at promoting sustainable nursing practice and workforce resilience.
A Digital Health Literacy Framework for Nursing Practice
Digital transformation in healthcare has reshaped immunization services, yet the mechanisms through which digitally enabled information environments improve nursing practice remain insufficiently integrated. This paper proposes a Digital Health Literacy Framework for Nursing Practice in which Digital Health Immunization Technology Capabilities—monitoring capability, integration capability, and decision-support capability—improve Nursing Practice Effectiveness through Decision-Making Quality, while Nursing Innovation Climate strengthens the extent to which these capabilities translate into better decisions. Grounded in a socio-technical perspective, the framework treats digital health literacy in practice as the ability of nurses to access, interpret, integrate, and act on digital information within immunization workflows rather than as an isolated technical skill. The paper reviews relevant theoretical foundations, develops hypotheses for the proposed direct relationships, identifies the moderating role of innovation climate, and highlights gaps in prior literature. Existing studies have examined digital systems, workflow issues, or adoption barriers separately, but they have rarely integrated concrete technology capabilities, organizational climate, decision-making quality, and nursing outcomes within one coherent model. The proposed framework explains how monitoring functions, interoperability, and decision-support tools can improve nursing practice when they are embedded in an innovation-supportive environment that enables sound, timely, and data-driven clinical decisions. The paper concludes with implications for nursing leaders, policymakers, and researchers seeking to strengthen digitally enabled immunization services.
Digital Health Literacy: A Concept Analysis
Digital health literacy has become central to contemporary health care because patients and professionals increasingly rely on patient portals, telehealth platforms, mobile applications, remote monitoring systems, and online information environments to access, interpret, and act on health information. Despite its widespread use, the concept remains inconsistently defined and is frequently conflated with digital literacy, health literacy, and the earlier notion of eHealth literacy. This paper therefore aimed to clarify the meaning, boundaries, antecedents, consequences, and empirical referents of digital health literacy through a concept analysis. Walker and Avant’s method guided the analysis, supported by a structured search of recent peer-reviewed literature and selected foundational works. After verification of the final evidence base, 39 studies were retained for concept-analytic synthesis. The analysis indicates that digital health literacy is a multidimensional socio-technical capability involving access to digital tools, navigation of digital health resources, comprehension of health content, critical appraisal of credibility and relevance, communicative interaction within digital environments, and application of digital information to decision-making and self-management. Major antecedents include basic literacy, health literacy, internet access, digital readiness, trust, motivation, and supportive organizational or social conditions. Major consequences include stronger patient engagement, more effective use of digital services, improved self-management, and better informed decision-making, whereas low digital health literacy increases the risk of exclusion, disengagement, and exposure to misinformation. The concept should therefore be understood as more than technical competence. Clarifying digital health literacy can strengthen nursing theory, measurement, intervention design, and equitable digital health implementation.