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Carrying out systematic literature reviews: an introduction

Alan Davies

Lecturer in Health Data Science, School of Health Sciences, University of Manchester, Manchester

View articles · Email Alan

Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making.

Since their inception in the late 1970s, systematic reviews have gained influence in the health professions ( Hanley and Cutts, 2013 ). Systematic reviews and meta-analyses are considered to be the most credible and authoritative sources of evidence available ( Cognetti et al, 2015 ) and are regarded as the pinnacle of evidence in the various ‘hierarchies of evidence’. Reviews published in the Cochrane Library ( https://www.cochranelibrary.com) are widely considered to be the ‘gold’ standard. Since Guyatt et al (1995) presented a users' guide to medical literature for the Evidence-Based Medicine Working Group, various hierarchies of evidence have been proposed. Figure 1 illustrates an example.

Systematic reviews can be qualitative or quantitative. One of the criticisms levelled at hierarchies such as these is that qualitative research is often positioned towards or even is at the bottom of the pyramid, thus implying that it is of little evidential value. This may be because of traditional issues concerning the quality of some qualitative work, although it is now widely recognised that both quantitative and qualitative research methodologies have a valuable part to play in answering research questions, which is reflected by the National Institute for Health and Care Excellence (NICE) information concerning methods for developing public health guidance. The NICE (2012) guidance highlights how both qualitative and quantitative study designs can be used to answer different research questions. In a revised version of the hierarchy-of-evidence pyramid, the systematic review is considered as the lens through which the evidence is viewed, rather than being at the top of the pyramid ( Murad et al, 2016 ).

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Decision-making in nursing practice: An integrative literature review

• Nursing, College of

Research output : Contribution to journal › Review article › peer-review

Aims and objectives: To identify and summarise factors and processes related to registered nurses’ patient care decision-making in medical–surgical environments. A secondary goal of this literature review was to determine whether medical–surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Background: Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making. Design: PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Results: Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy. Conclusions: Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research. Relevance to clinical practice: Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses’ decision-making for enhanced patient outcomes.

• clinical decision-making
• decision-making
• evidence-based practice
• literature review
• naturalistic decision making
• nursing practice
• nursing research

ASJC Scopus subject areas

• General Nursing

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• Literature Review Nursing and Health Professions 100%
• Nursing Practice Nursing and Health Professions 100%
• Acute Care Nursing Nursing and Health Professions 100%
• Naturalistic Decision Making Keyphrases 100%
• Emergency Care Nursing and Health Professions 75%
• Treatment Outcome Nursing and Health Professions 50%
• Nurse Decision-making Keyphrases 50%
• Clinical Practice Nursing and Health Professions 25%

T1 - Decision-making in nursing practice

T2 - An integrative literature review

AU - Nibbelink, Christine W.

AU - Brewer, Barbara B.

N1 - Publisher Copyright: © 2017 John Wiley & Sons Ltd

PY - 2018/3

Y1 - 2018/3

N2 - Aims and objectives: To identify and summarise factors and processes related to registered nurses’ patient care decision-making in medical–surgical environments. A secondary goal of this literature review was to determine whether medical–surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Background: Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making. Design: PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Results: Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy. Conclusions: Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research. Relevance to clinical practice: Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses’ decision-making for enhanced patient outcomes.

AB - Aims and objectives: To identify and summarise factors and processes related to registered nurses’ patient care decision-making in medical–surgical environments. A secondary goal of this literature review was to determine whether medical–surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Background: Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making. Design: PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Results: Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy. Conclusions: Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research. Relevance to clinical practice: Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses’ decision-making for enhanced patient outcomes.

KW - acute care

KW - clinical decision-making

KW - decision-making

KW - education

KW - evidence-based practice

KW - literature review

KW - naturalistic decision making

KW - nursing practice

KW - nursing research

UR - http://www.scopus.com/inward/record.url?scp=85040860423&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85040860423&partnerID=8YFLogxK

U2 - 10.1111/jocn.14151

DO - 10.1111/jocn.14151

M3 - Review article

C2 - 29098746

AN - SCOPUS:85040860423

SN - 0962-1067

JO - Journal of Clinical Nursing

JF - Journal of Clinical Nursing

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Home > Books > Teaching and Learning in Nursing

Assessment of Clinical Nursing Competencies: Literature Review

Submitted: 14 September 2016 Reviewed: 27 December 2016 Published: 17 May 2017

DOI: 10.5772/67362

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Introduction: In Slovene nursing higher education, there is a lack of empirical evidence to support the choice of tolls for assessment of clinical skills and competencies. This literature review aims to critically discuss identified methods of clinical nursing skills assessment and competencies currently used in nursing higher education in other countries.

• clinical skill
• clinical competence
• nursing competencies

Author Information

Nataša mlinar reljić *.

• Faculty of Health Sciences, University of Maribor, Maribor, Slovenia

Mateja Lorber

Dominika vrbnjak, brian sharvin, maja strauss.

*Address all correspondence to: [email protected]

1. Introduction

Nursing students have to develop clinical knowledge, skills, and attitudes for professional practice, and nursing educators have to assess and evaluate students’ core skills readiness for clinical practice [ 1 ], and the assessment should be a real indicator of knowledge [ 2 ]. Assessment in clinical practice can either be formative or summative [ 3 ], with the formative often used to discuss and analyze students’ performance [ 4 ] and the summative examining practical performance in the clinical or simulation environment [ 5 ]. Both methods should ensure that the criteria for assessment reference the intended learning outcomes [ 6 ].

Three approaches to assessment of assessing nursing students’ nursing competencies were identified from the literature and include observation methods [ 1 , 7 ], self-perception methods [ 8 ] and methods combining both approaches [ 9 ]. Of these methods, observation of student performance and the use of skills checklists appear to be the most common [ 10 , 11 ]. This can be done either by direct observation in the clinical environment [ 7 , 12 ] or by observing the student in the clinical skills laboratory (CLS) using scenarios and clinical skills checklists to measure performance [ 1 ]. Other multimethod approaches are used and include clinical portfolio evaluation [ 13 ], along with critical incident reports, case-based assessment, peer assessment [ 9 ], and reflection [ 14 ]. Reflection is important because nurses need to think critically and reflection develops responsibility in clinical practice [ 15 ].

The last decade has seen the emergence of new measurement tools being developed and tested for validity and reliability [ 16 ]. These include the objective structured clinical examinations (OSCEs) [ 1 ] that have numerous advantages over other observation tools [ 17 ], such as the development of student’s self-confidence [ 18 ], the grounding of more expressive learning [ 19 ], and the assessment of not only psychomotor skills but also allows for the assessment of knowledge and attitudes [ 20 ]. The OSCE, however, is not the only assessment tool used in nursing education. There are numbers of different scales for assessing student’s competencies and psychometric properties [ 21 – 23 ]. This literature reviews, therefore, set out to identify and critically analyze current methods of clinical nursing skills assessment and competencies used in nursing higher education in other countries with regard to developing a comprehensive and effective method for assessing clinical competency in Slovene nursing higher education.

The aim of this literature review is to identify methods of clinical nursing skills assessment and competencies currently used in nursing higher education in other countries.

2.1. Eligibility criteria

Studies were included if they met the following inclusion criteria: empirical research primarily focused on methods of clinical nursing skills and competencies assessment and their reliability and validity, full-text available articles published in peer-reviewed journals and written in English, published between 2010 and 2016. Exclusion criteria were systematic review articles, assessment of clinical nursing skills in vocational training, assessment of special clinical nursing skills, editorial and commentary pieces, and all other literature not meeting the inclusion criteria.

2.2. Search strategy and study identification

Three electronic databases were searched for relevant literature: Medline, CINAHL, and PubMed. Key word combinations that were used included competency, competence, clinical competency, clinical competencies, clinical skill, clinical competence, professional competence, competency based education, assessment, measuring, measurement, test, scale, standards, validity, reliability, generalizability, and nursing student. Literature published within the last 5 years was searched due to the contemporary interest in clinical skills and competencies assessment in nursing.

2.3. Study selection and extraction

Identified references were merged with reference software EndNote, and duplicates were removed. The titles and abstracts of the identified results were then assessed for eligibility criteria by two of the authors (DV, ML). Studies not relevant to this review were removed. After retrieval of the full text, two of the authors (DV, ML) independently screened the studies and made decisions concerning final inclusion of the studies. A further two reviewers were then consulted (NMR, MS). Disagreements were solved by discussion. Data were extracted by predefined criteria, which included source, country, objectives, methods, and main findings.

2.4. Assessment of study quality

The Mixed Methods Appraisal Tool (MMAT) was used for assessing their quality. The tool is useful for appraising quantitative, qualitative, and mixed methods studies [ 24 ]. Methodological quality criteria are scored on a nominal scale. The tool includes two screening questions and four criteria for qualitative studies, quantitative randomized controlled trials, quantitative nonrandomized studies, quantitative descriptive studies, and three criteria for mixed methods. The score is based on the number of criteria met divided by four (from one criteria met—25% to all criteria met—100%) [ 24 ]. Each study was checked for quality by one author (NMR) and then rechecked by two other authors (ML, MS). Disagreements were solved by discussion until consensus was reached.

2.5. Data synthesis

A convergent qualitative synthesis design was selected and results from the identified studies were transformed into qualitative findings [ 25 ], using a narrative synthesis as described by Harrison et al. [ 26 ] and Dixon-Woods et al. [ 27 ]. This approach was selected as studies were heterogeneous.

3.1. Study selection and its characteristics

The search revealed a total of 160 records. Figure 1 provides a flow diagram of the literature selection process.

Figure 1.

Flow diagram of literature selection.

The flow diagram ( Figure 1 ) shows that after removing duplicates, 129 records were screened by title and abstract for their relevance, leading to the exclusion of 77 records. The remaining 52 full texts were assessed for eligibility. Critical reading of the full text led to 12 studies being retained for inclusion in the review.

3.2. Methodological quality of studies

The selected studies were conducted in Australia, Sweden, Iran, Canada, Ireland, Spain, Pakistan, and Taiwan. The studies have utilized different study designs, and a number of different methods were identified including a variety of assessment tools, OSCE, complex approaches, and others. There are presented selected studies objectives, design, main findings, and the MMAT score in Table 1 .

Characteristics of studies included in the literature review.

Table 1 provides a detailed description of the individual studies included in the review. There are five columns in the table. The first column provides details of the source and origin of the study and are presented in alphabetical order. The second and third columns list the key objectives and the research design. The main findings are presented in the fourth column, and the final column lists the MMAT score.

The quality of studies identified was mixed ( Table 1 ). Two of twelve studies were judged with a low quality score (25%) with the main reasons for the low quality score being the use of a nonrepresentative sample and uncontrolled testing. Four studies were judged with high quality (75%). Three studies were evaluated as moderate quality (50%), and three studies as very high quality (100%).

The studies identified in Table 1 were heterogonous that is why they were transformed into qualitative findings using a narrative synthesis [ 25 ]. The results were grouped into four assemblages according to the thematic approach: assessment tools, objective structured clinical examination (OSCE), complex assessment approaches, and other approaches.

3.3. Assessment tools

Hsu and Hsieh [ 21 ] developed an instrument known as the Competency Inventory of Nursing Students (CINSs) for measuring nursing students’ competencies and testing psychometric qualities of baccalaureate nursing students in Taiwan. They used a cross-sectional survey including 599 nursing students. This inventory assesses eight categories that cover ethics and accountability, general clinical skills, lifelong learning, biomedical science, caring, critical thinking, communication, and team working. Ulfvarson and Oxelmark [ 22 ] used the social constructivist process to develop a tool for assessing knowledge, and clinical practice contains four domains: nursing, documentation, caring, and skills and manual handling. The tool was tested and found to be valid to measure nursing skills not only of the nursing student’s ability to perform a task but also the quality of nursing care. This Assessment of Clinical Education (AClEd) tool evaluated learning outcomes during clinical practice. MMAT score for this study was very low, only 25%. The reliability of the assessment tool was not detected. Nilsson et al. [ 8 ] developed a Nurse Professional Competence (NPC) scale for measuring self-reported professional competence that covers eight factors: nursing care, value-based nursing care, medical/technical care, teaching/learning and support, documentation and information technology, legislation in nursing and safety planning, leadership in the development of nursing care, education, and supervision of staff/students. They developed a new scale and evaluated its psychometric properties on a large sample of newly graduated nurse students ( n  = 1086) from 11 educational institutions in Sweden. This tool can be used to estimate the outcomes of nursing education programs. It can assess nurses’ competence in relation to the needs of healthcare organizations, and it can help identify self-reported capabilities and assist in modifying introduction programs for newly employed nurses [ 8 ]. Face validity was evaluated by asking students to critically review the item and their understanding of the item within the questionnaire. The data quality was described by mean score, and the construct validity and reliability were described with orthogonal rotation [ 8 ]. We recorded the MMAT score for Nilsson et al.’s [ 8 ] study very high (100%). Ossenberg et al. [ 12 ] based their Australian Nursing Standards Assessment Tool (ANSAT) on the National Competency Standards for the Registered Nurse in Australia, covering professional practice, critical thinking and analysis, provision and coordination of care, and collaborative and therapeutic practice. The validation and acceptability of ANSAT was conducted in a pilot study on 23 clinical assessors, interviews, and with the posttest survey. The recorded MMAT score of study was 25%. More psychometric testing is needed to address current deficits [ 34 ]. Iglesias-Parra et al. [ 30 ] developed an evaluation system of clinical competencies for the practicum of nursing students based on the Nursing Interventions Classification (NIC). They have prepared a list of 73 NIC interventions that were associated with each of the 26 competencies in nine domains. They took a psychometric validation study in two phases and the cross-sectional study on the population of undergraduate nursing students and clinical tutors. It was found that the competency system, structured on the NIC assessment tool, is a reliable method for assessing and evaluating nursing interventions. Reliability and construct validity were tested by the clinical mentors on 107 students. The survey was conducted with the Delphi technique. The MMAT score was very high (100%). The assessment tool represents a multidimensional approach in formative and combined assessing [ 30 ].

3.4. Objective structured clinical examination

Meskell et al. [ 33 ] and Walsh et al. [ 7 ] both examined OSCE. Meskell et al. [ 33 ] evaluated the benefits of using an electronic OSCE assessment system in undergraduate students ( n  = 203). The electronic software facilitated the storage and analysis of results, thus offering significant time savings. Walsh et al. [ 7 ] were focused on the development of a Novice OSCE that included the following competencies: safety, asepsis, knowledge, organization, and caring. An instrument-testing design on a sample of nursing students ( n  = 565) was used. The MMAT score of both papers was 50%. Some psychometric analysis, reliability, and stability of OSCE tool should be done. OSCE is shown as a formative assessing tool, and it is argued that students should also be assessed in critical thinking and problem-solving skills in addition to clinical skills performance [ 1 , 35 ].

3.5. Complex assessment approaches

Three studies focused on more complex approaches. Athlin et al. [ 28 ] developed a model of a National Clinical Final Examination (NCFE). Their model integrates knowledge from theoretical and practical studies and includes knowledge, skills, capacity of critical thinking, problem-solving, ethical reasoning, independence, and readiness to act. They prepared a two-part examination. This included a written theoretical test with problem-solving characteristics and a bedside test performing nursing care by using observation. Their model was used to assess theoretical and practical knowledge. They found that the model was highly appreciated, and its relevance, usability, and validity were considered as “quite good” for the assessment of nursing students’ clinical competence at the final stage of their education. This study recorded a high MMAT score (75%). There is a need to evaluate the model on extensive students’ groups because the study was completed using a relatively small sample in theoretical test ( n  = 73) and a bedside test ( n  = 68). The model for evaluation of theoretical and practical knowledge used a holistic approach with opportunities for feedback and reflection for students. Imanipour and Jalili [ 31 ] developed an assessment system including multiple methods. They used a combination of oral examination and direct observation of a procedural skill. The cognitive knowledge was evaluated by oral exam, and clinical skills were evaluated by direct observation using a global rating scale. The exam includes some generic procedures and two specific procedures. Clinical work sampling was used to evaluate undergraduate bachelor of nursing students’ ( n  = 38) professional behavior. They found that the students and instructors were very satisfied with a comprehensive clinical performance assessment system. Levett-Jones et al. [ 32 ] describe the design, implementation, and evaluation of the Structured Observation and Assessment of Practice (SOAP) model used to assess the third-year undergraduate nursing students’ ( n  = 1031) clinical competences. While significant enhancements have been identified in students’ overall performance, the SOAP approach has discovered an insufficiency in the learning outcomes of some students.

3.6. Other approaches

Khan et al. [ 14 ] evaluated nursing students’ perceptions about the effectiveness of utilized teaching and learning strategies of clinical education in improving students’ knowledge, skills, and attitudes: demonstration, reflection, and problem-based learning, and concept map. They used both qualitative and quantitative methods in a descriptive cross-sectional study of 74 nursing students to identify nursing students’ perceptions about the efficacy of the applied teaching and learning strategies used in clinical education. Problem-based learning and the use of concept maps were perceived to be effective teaching and learning strategies. Hengameh et al. [ 29 ] compared the routine evaluation method (a subjective judgment of an instructor about general skills of the student during their clinical course, hence the scoring) with direct observation of procedural skills (DOPS) (clinical activities evaluated based on direct observation using the checklists). They found that applying direct observation of procedural skills (DOPS) significantly enhanced clinical skills and students’ scores in clinical procedures.

4. Discussion

The aim of this chapter was to review the literature and critically discuss in relation to identified methods of clinical nursing skills assessment and competencies currently used in nursing higher education. Multidimensional approaches in nursing assessment should be based on a number of differing assessments methods [ 1 ]. It should be the combination of knowledge, critical thinking, caring and communication [ 1 , 7 , 30 ], problem-solving, and reflection [ 36 ]. Holistic assessment was found to encourage students to be more person-centered [ 37 ], rather than purely task-oriented [ 32 ]. The literature review identified a wide variety of tools and assessment methods, each with their own advantages and disadvantages. Some were evaluated by nursing students, others by nurses and clinical experts. The studies reviewed were completed in different countries from differing nursing education curriculum and this, along with the range of sample size and approaches used, has proved difficult to make any direct comparison. Nurse educators have a responsibility to ensure that graduates are well prepared for the demands and challenges they will encounter in practice [ 32 ]. There is a current imperative to implement a modern and appropriate method of clinical evaluation in nursing education [ 9 , 29 ]. The current trend requires moving from a generic, technical approach to a more holistic model of clinical assessment, which supports the nurturing and development of competent nursing professionals [ 34 ]. The OSCE is a practical test [ 17 , 38 ] in a simulation area, where the student shows the skills [ 22 ] and technical performance [ 7 ]. It is also a well-established method to assess clinical skills [ 33 ], using a checklist [ 1 ] to assess all students with the same set of criteria in order to determine the level of competency achieved in their performance [ 17 , 39 ]. It provides a level of objectivity in how competency is assessed [ 32 ]. The review identified a number of benefits from using OSCE including the achievement of deeper meaningful learning [ 19 ], deeper consequential learning [ 20 ], and an increase in students’ confidence in practice [ 33 ]. The OSCE was also identified as a means to facilitate the assessment of psychomotor skills, as well as knowledge and attitudes [ 20 ]. As an assessment method, the OSCE helps in the identification of strengths and weaknesses and can focus more on the student getting constructive feedback with or without the consequence of a subsequent examination [ 40 ]. In addition to the previous advantages already outlined, Ulfvarson and Oxelmark [ 22 ] found that the OSCE can also be used for examining learning outcomes especially those comprising practical skills, such as medical techniques and interpretation of results. It has been recognized as a reliable and valid method to assess clinical skills competency [ 16 , 39 – 41 ], and Carraccio and Englander [ 42 ] have suggested that the OSCE becomes a key standard for assessing clinical competence. Some criticisms of the OSCE have, however, been identified.

The lack of authenticity due to students not being observed in a real clinical context was identified by Levett-Jones et al. [ 32 ], and they further criticized how the OSCE focused on the measurement of technical skills rather than the whole caring situation including the use examination of empathy and interpersonal relationships. The OSCE, however, should be used in conjunction with other evaluation methods [ 36 , 43 ]. Evaluation methods should be coherent with curriculum and learning out comes. The holistic evaluation methods motivate nursing students’ learning, stimulates critical reflective thinking, and make their readiness for professional practice more preferable. Good assessment tools should also be valid and reliable [ 44 ].

4.1. Implications for nursing education

Assessment of clinical nursing skills requires collaboration between clinical partners and academia to enhance the clinical experiences of students, the professional development of preceptors or mentors, and the clinical credibility of academics [ 34 ]. The findings from the literature review represent a first opportunity to prepare our own assessment tools, according to the cultural and clinical environment, material and economic conditions, national nursing standards, capabilities and purposes of nursing care in Slovenia. There is now an opportunity for all educational institutions with the nursing study programs in the country to prepare assessment tool with cooperation of students, educational experts, and clinical nursing experts.

4.2. Limitations

The findings from the literature review must be considered with respect to the limitations of the studies reviewed and the methods used. Some relevant work may have been omitted due to the inclusion of material only in the English language. The methodological quality of included studies varied from very low [ 12 , 22 ] to very high [ 8 , 29 ]. The validity and reliability of the different approaches used were not always discussed, and therefore, our conclusions should be drawn with caution. The MMAT is considered as an efficient tool, although its reliability could be further improved as it appraises only the methodological quality of included studies and not the quality of their reporting [ 45 , 46 ]. Narrative summary is considered as a more informal approach and can, therefore, be subject to criticism, because of its lack of transparency [ 27 ].

5. Conclusion

Despite the heterogeneity of designs and methodology, the findings from the literature review present an overview of current clinical skills assessment tools in practice and in the simulation environment. The assessment of nursing students should include a variety of methods and procedures. It should include the assessment of knowledge, clinical skills, and critical problem-solving in nursing care. There is a need for further research to develop a holistic clinical assessment tool with a reasonable level of validity and reliability, and it must be tested before being applied to the nursing curriculum.

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Moderating effect of family structure on the relationship between early clinical exposure and emotional labor of nursing students: a cross-sectional study

• Ruiyang Xu 1 ,
• Shan Wang 1 ,
• Meng Zhao 1 ,
• Sijing Peng 2 ,
• Xinning Peng 1 ,
• Qingyuan Ye 1 ,
• Chen Wu 1 &
• Kefang Wang 1  

BMC Nursing volume  23 , Article number:  606 ( 2024 ) Cite this article

Metrics details

Emotional labor is an essential component of nursing practice and is important for Generation Z nursing students born from the mid-1990s to early 2010s. They will become the backbone of the nursing workforce but present more emotional regulation problems. Studies on emotional labor are limited to clinical nurses and influencing factors at the individual level. The impacts of external systems on emotional labor of nursing students have not been explored. This study aimed to quantify the relationship between early clinical exposure and emotional labor and test the moderating effect of family structure on the relationship.

The cross-sectional study recruited 467 nursing students using convenience sampling from seven colleges and universities in mainland China. An e-survey created on WJX.CN was used to collect data in January 2023. Emotional labor (surface acting and deep acting) was measured with the Emotional Labor scale. Early clinical exposure (exposure or not and times of exposure) and family structure (nuclear family, extended family, and single-parent family) were assessed with self-reported questions. Descriptive statistics and the linear mixed-effects modeling were used to do the analyses.

The mean scores of surface acting and deep acting were 26.66 ± 5.66 and 13.90 ± 2.40, respectively. A significant difference in scores of surface acting was not observed for exposure or not, whereas such a significant difference was found for times of exposure. Nursing students from extended families demonstrated significantly lower scores on surface acting while exposed to clinical practice compared with those from nuclear families. Family structure moderated the relationship between times of exposure and surface acting of nursing students when exposed to clinical practice for one time, but the significance disappeared when the times of exposure increased. No significant findings of early clinical exposure on deep acting were observed.

Conclusions

Early clinical exposure influenced emotional labor, and students from extended families were more likely to get benefits from early clinical exposure. Studies are needed to help students from nuclear families get comparable benefits on emotional labor as those from extended families, and improve deep acting by early clinical exposure.

Peer Review reports

Emotional labor is an inevitable form of labor in nursing practice [ 1 ], and is the regulation of feelings and expressions to fulfill the interpersonal role expectations at work [ 2 ]. Emotional labor includes two emotional coping strategies: surface acting and deep acting. Surface acting is defined as the act of individuals trying to meet others’ expectations by suppressing negative and exaggerating positive expressions when interacting with people at work; deep acting is bringing feelings in line with observable expressions as required by display rules [ 3 , 4 ]. Understanding the emotional labor among Generation Z (born from the mid-1990s to early 2010s) nursing students is particularly vital. Generation Z nursing students will become the backbone of the nursing workforce shortly [ 5 ]; in addition to requiring nurses to master proficient clinical skills, modern nursing work requires nurses to express appropriate emotion when communicating with patients, which is more emotionally challenging. Further, Generation Z was more likely (36%) than millennials (27%) and Generation X (20%) to report that their mental health and emotional well-being were as poor or only fair [ 6 ], and they present more emotional regulation problems under different conditions [ 7 , 8 ].

Most studies on emotional labor were designed to quantify the impacts of emotional labor on clinical nurses’ health and work performances [ 9 , 10 , 11 , 12 ]; surface acting was found to be disadvantageous for nurses’ well-being [ 9 , 13 ]and their professional performances [ 10 ], whereas deep acting was found to be constructive [ 10 , 14 ]. Few studies were designed to explore influencing factors of emotional labor among nursing students. The human body is an open system, and individuals are exposed and influenced by various external systems, such as family, school, and workplace [ 15 , 16 ]. Grandey et al. proposed in the model of emotional labor that external systems should be taken into consideration when investigating individuals’ emotional labor [ 3 ]. Therefore, we aimed to explore the impacts of representative external systems (i.e., school system and family system) on emotional labor of nursing students.

Early clinical exposure and emotional labor

Undergraduates spent most of their time at school, and traditional education programs were designed to enrich their knowledge and skills, but limited information was designed to tailor to students’ emotional labor. Early clinical exposure may be taken as a candidate factor to understand the status of emotional labor. Early clinical exposure is a unique element in the school system for medical students, which fosters students to expose to the patients as early as the first year of medical college and includes teaching and learning activities such as observation, clinical bedside teaching and case-based learning lectures [ 17 ]. In China, early clinical exposure has been adopted into the training programs by some nursing schools in recent years.

Early clinical exposure brings some benefits and challenges to students in medical relevant education programs. Empirical evidence demonstrated that medical students in their first two or three years (i.e., the time when their learning is often from books or lectures in school) benefit from their encounters with patients [ 17 ], and the benefits include a better understanding of professional knowledge, and the enhancement of the clinical skills and professional attitudes [ 18 ]. A recent qualitative study also found that early clinical exposure may expose students to challenges that can evoke various strong emotions (i.e., bad, angry or scared), and nursing students would conduct surface acting when interacting with patients [ 19 ]. Furthermore, nursing students with higher scores of surface acting would have a stronger turnover intention in clinical practicum [ 20 ]. However, the effect of early clinical exposure on nursing students’ emotional labor remained unclear.

Family structure and emotional labor

In addition to the school, family is a predominant system for cultivating individuals’ emotional regulation as individuals contact with their family of origin throughout their lives [ 21 ]. Family structure, an important variable of the family was found to be the significant contributor to emotional labor of individuals. Nuclear family, extended family and single-parent family are three common types of family structure. The nuclear family is often defined in literature as a family that consists only of parents and children [ 22 ]; the extended family is taken as an expansion of the nuclear family to a wider circle of relatives within the resident clan, and all the members should live close together, pool resources and undertake family responsibilities [ 23 ]; the single-parent family is comprised of a parent/caregiver and one or more dependent children without the presence and support of a spouse or adult partner who is sharing the responsibility of parenting [ 24 ]. When encountering emotional challenges, adolescents living with more family members would obtain more support, and that would empower them to regulate their feelings and expressions under different contexts; therefore, they would demonstrate more favorable emotional status [ 25 , 26 , 27 ]. For example, it was found that adolescents from extended families had less emotional problems and fewer risks of suffering from depression compared with those from nuclear families [ 25 ]; adolescents in nonnuclear homes were happier and less sad when interacting with older siblings or extended family members [ 26 ]. But within our knowledge, the relationship between family structure and emotional labor remained unclear among nursing students.

Moderation effect of family structure

Existing studies limited studies to explore the association of factors in one system on individuals’ well-being while ignoring the interaction of factors of multiple systems. As proposed in the social-ecological model [ 16 ], there are multifaceted and interactive effects of systems and individuals. When students embark on their college/university education, school system is physically closer to students compared with family system, and the time of their interactions with school system is longer than that with their family system. Therefore, we aimed to explore the direct effect of school system (i.e., early clinical exposure) on emotional labor and the moderating effect of family system (i.e., family structure), and we proposed two hypotheses as follows.

Hypothesis 1

Early clinical exposure is significantly associated with emotional labor of nursing students.

Hypothesis 2

Family structure moderates the relationship between early clinical exposure and emotional labor of nursing students.

Design and sampling

We conducted a cross-sectional study with a convenience sampling strategy to collect data from students pursuing their bachelor’s degrees in the schools of nursing in mainland China. This study was launched in January 2023. Baccalaureate nursing education programs are typically four years in China. The first three years include courses on humanities character, social sciences, basic medicine and nursing, and students will start their internship in hospitals, community healthcare centers, and mental health centers in the fourth year. The inclusion criteria were full-time undergraduates enrolled in a four-year nursing education program; these students were in their first, second or third year of study and provided informed consent. Nursing students who have suspended their studies over six weeks for diseases or other reasons were excluded. According to Kendall’s sample size calculation method [ 28 ], the sample size is 5–10 times the number of independent variables, and this study used a total of 10 independent variables. Considering the loss of 20% samples, the sample size was 120 [ n  = 10 × 10 × (1 + 20%)].

Measurements

Sample characteristics were assessed with a self-reported questionnaire. Age, sex (male/female), grade (freshman/sophomore/junior), single child (yes/no), and key decision maker on major selection (by myself/by my parents/by other relatives or friends/by the school) were assessed with close questions; video games play in daily life were assessed with open questions: “Do you play video games in daily life? What are they?”; nursing students who play interactive games that run on electronic media platforms, e.g., Honor of Kings, Counter-Strike: Global Offensive, League of Legends and Eggy Party in their daily lives were categorized as video gamers, and those left no response to these questions were categorized as non-video gamers.

Emotional labor was assessed with the Chinese version of the Emotional Labor scale [ 29 ]. This scale has 7 items to assess surface acting and 3 items to assess deep acting. Each item is graded on a 6-point Likert scale from 1 = strongly disagree to 6 = strongly agree. The higher sum score for each subscale indicates that individuals were more likely to act or display the corresponding emotional labor. The Chinese version of the Emotional Labor scale demonstrated satisfactory validity, and Cronbach’s α coefficients for surface acting and deep acting were 0.711 and 0.826, respectively [ 29 ].

Early clinical exposure was assessed with a self-reported questionnaire. In China, early clinical exposure was designed in some schools to bridge theoretical courses and clinical practice; it intersperses among the semesters or the vacations before the final-year internship, the schedule of which differs across schools; early clinical exposure once designed, students are mandatory to participate to get credits, and the predominant setting of exposure is the hospital. Guided by the interpretation of early clinical exposure proposed by Tayade and Latti [ 17 ] and the facts in China, we set up two open questions as follows to measure the early clinical exposure of nursing students.

Did you have a specialty practice in the hospital? ( thereafter , exposure or not)

Times of hospital exposure ( thereafter , times of exposure)

Family structure was assessed with one self-reported question “What was your family structure?” and responses were graded as nuclear family, extended family, and single-parent family with corresponding descriptions to assist in answering.

Data collection

Seven medical colleges and universities were contacted for participation. Once the agreement was obtained from the director of the Office of Student Affairs, an e-survey created on WJX.CN along with a short descriptive text would be disseminated by students’ counselors to WeChat class groups. Nursing students could identify the link of the e-survey to respond to the questionnaire and were asked to provide informed consent at the first screen of the e-survey before proceeding. It takes approximately 10 min to complete the e-survey. A total of 559 responses were recorded for this study. After removing respondents who refused to participate ( n  = 89), 470 valid questionnaires were obtained.

Data analysis

No outlier or missing value was detected in the data; we deleted the category of the single-parent family from the data because there were only 3 cases. Descriptive statistics were run for all variables. To assess the effect of early clinical exposure on students’ emotional labor, linear mixed-effects models were run, and each was used to regress one variable representative of early clinical exposure, family structure, and all sample characteristics (fixed effects) except school and grade (random effects) on surface acting or deep acting. In consideration of the cross-over interaction, an interaction term created by early clinical exposure × family structure was added to the model to estimate the significance of the moderation effect no matter whether the significant finding of the variable representative of early clinical exposure was observed in the reduced model. IBM SPSS Statistics Desktop 24.0 was used for all analyses. The effect size of each variable was estimated and reported with a 95% confidence interval (CI), and a p -value of lower than 0.05 was taken as statistically significant.

Sample characteristics

In Tables  1 and 467 Generation Z nursing students were analyzed in this study. More than 50% of the students aged between 19 and 20 years old, and selected the major of nursing primarily by themselves. More than 80% of the students were female and lived in nuclear families, and more than two-thirds of them were not the single child of their parents. Almost 50% of the students were freshmen, and the majority of students (64.2%) enrolled in this study were not video gamers. There were 51% (238/467) of the students reported the experience of early clinical exposure, and of them, 49 and 49 exposed to hospitals 1 time and 2 times, respectively, and 140 reported the experience of exposing to hospitals 3 times or more. The average score of surface acting was 26.66 ± 5.66, while that of deep acting was 13.90 ± 2.40.

Effects of early clinical exposure on surface acting and moderating effects of family structure

As demonstrated in Tables  2 and 3 , exposure or not had no significant effect on surface acting ( β = -0.497, 95%CI [-1.931, 0.938], p  = 0.494); times of exposure demonstrated a significant effect on surface acting ( p  = 0.045). When the interaction term of family structure × exposure or not was added to the model, we found students living in extended families would benefit more from early clinical exposure ( β = -4.101, 95%CI [-7.219, -0.982], p  = 0.010) compared with those living in nuclear families, i.e., their scores of surface acting decreased significantly after exposing to early clinical practice, see Table  4 , Fig.  1 (a) ; meanwhile, the interaction term of family structure × times of exposure was found to be significant after being added to the model ( p  = 0.036), see Table  5 . As shown in Fig.  1 (b) and Table  5 , students living in extended families demonstrated significantly lower scores on surface acting when exposed to clinical practice for one time compared with those living in nuclear families ( β = -6.436, 95%CI [-10.921, -1.951], p  = 0.005), but the significance disappeared when the times of exposure increased.

Moderating effects of family structure between early clinical exposure and surface acting of nursing students

Effects of early clinical exposure on deep acting and moderating effects of family structure

As demonstrated in Tables  2 and 3 , exposure or not had no significant effect on deep acting ( β = -0.158, 95%CI [-0.696, 0.379], p  = 0.562); times of exposure also had no significant effect on deep acting ( p  = 0.320). The effect of the interaction term of family structure × exposure or not was not significant when being added to the model ( β = -0.015, 95%CI [-1.357, 1.326], p  = 0.982), see Table  4 , Fig.  2 (a) ; the effect of the interaction term of family structure × times of exposure was not significant when being added to the model ( p  = 0.971), see Table  5 , Fig.  2 (b) .

Moderating effects of family structure between early clinical exposure and deep acting of nursing students

Emotional labor is often overlooked yet it is essential for nursing education, especially for Generation Z nursing students, as the nursing occupation is filled with emotional events, and emotional problems were frequently observed among this age cohort. This study was conducted to quantify the emotional labor of nursing students and investigate the impacts of variables from two closely related external systems, i.e., school and family on their emotional labor. We found some evidence to support the hypotheses that early clinical exposure was associated with emotional labor, and family structure moderated the relationship between early clinical exposure and emotional labor of nursing students.

Surface acting and deep acting are two compatible forms of emotional labor, which are conducted to respond to the service demands of patients and hospitals. Higher surface acting was a contributor to emotional exhaustion and depression [ 20 , 30 , 31 ], while higher deep acting would benefit individuals’ mental health [ 32 ]. Nursing students in this study demonstrated higher surface acting and lower deep acting in contrast with nurses working more than one year in tertiary hospitals [ 33 ], indicating that clinical environment may influence the development of individuals’ emotional labor.

In this study, we found exposure or not was not significantly associated with surface acting, yet times of exposure had a significant effect on surface acting. This further consolidated the findings of previous qualitative studies that early clinical exposure would evoke strong emotions and lead to emotional labor of students [ 19 , 27 ]. Furthermore, family structure moderated the relationship, and students from extended families had lower surface acting than students from nuclear families once exposed to hospitals, that indicated students from extended families experienced more benefits from early clinical exposure. Specifically, students from extended families demonstrated reduced scores on surface acting when exposed to hospitals one time, two times, and 3 times or more, but that was not the case for students from nuclear families. Meanwhile, we found that the scores of surface acting of students from extended families were significantly lower than those among students from nuclear families during their first time of clinical exposure. Students may encounter unexpected emotional events (e.g., witness patients’ or their caregivers’ sorrow or hear stories of patients tortured by diseases) while exposed to the clinical setting; students from extended families would have more coping resources to buffer these clinical emotional challenges [ 34 ]. For example, extended family members might share some of their experiences with students to help them adapt to the emotional challenges [ 25 , 27 ]. As such, students from extended families would be more likely to experience benefits. We did not capture the significant benefits along with the increase in the “dosage” of exposure, and this might be explained by that we did not investigate or take measures to balance the content of clinical exposure. Future studies may consider the content of early clinical exposure to elucidate the impacts of early clinical exposure on surface acting, and extra attention should be paid to students from nuclear families to understand how to help them get comparable benefits in reducing the scores of surface acting with those from extended families.

We failed to corroborate that early clinical exposure was significantly associated with deep acting in this study, nor did we find the moderation effect of family structure on such a relationship. Deep acting is a process where an individual psyches himself or herself to the desired emotion, which needs more emotional involvement [ 35 ]. In the literature, nursing students were found to prioritize learning procedural knowledge of different clinical tasks over learning how to interact with patients during early clinical exposure [ 36 ]. Some students reported that they would avoid deeply communicating with patients in poor conditions, such as cancer patients because they lacked of necessary communication skills and were fear of hurting patients [ 37 ]. These issues might explain the insignificant findings on the relationship between early clinical exposure and deep acting from this study. Future studies should explore complex interventions to deepen the involvement of nursing students in clinical exposure, such as developing strategies covering components of awareness raising, communication skills advancement, and encouraging deep interaction with patients during the exposure.

Limitations

This study had several limitations. First, the inherited disadvantages including lack of sample representativeness and unable to make causal inferences of the cross-sectional study using convenience sampling strategy are nonnegligible. Future studies may want to launch cohort studies in representative samples to corroborate findings from this study. Second, family function is an important variable of family systems and may also influence the emotional labor of nursing students. We failed to address this variable in our study due to the diversity of its operationalizations across studies, and that its relationship with emotional labor has not been empirically identified. Meanwhile, family structure only included three common family types: nuclear family, extended family and single-parent family. Future studies may enroll students from other family structures, e.g., blended family and orphaned family, and assess the heterogeneity of their emotional labor. Third, we operationalized early clinical exposure as exposure or not and times of exposure, and one internship was considered as one exposure. However, exposure duration and exposure content might also be important parameters of early clinical exposure. Future researchers may want to measure high-resolution early clinical exposure and provide more sound evidence about the contributions of early clinical exposure to emotional labor of nursing students. Fourth, many other factors may influence individuals’ general emotional regulation including social interactions, physiological factors, and lifestyle choices, which may be potential influencing factors of emotional labor among nursing students, but the assessment of these variables is out of scope of this study. Future studies may want to collect data on these variables and use statistical methods such as the dominance analysis to present a comprehensive picture of factors associated with emotional labor.

This study set out to verify the impacts of early clinical exposure and family structure on emotional labor of Generation Z nursing students. This study provided preliminary evidence supporting the significant contributions of early clinical exposure to surface acting, and the significant moderating role of family structure on this relationship. More efforts are needed to help students from nuclear families get benefits from early clinical exposure and to improve the deep acting of nursing students in general during nursing education.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to data privacy but are available from the corresponding author on reasonable request.

Abbreviations

Confidence Interval

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Acknowledgements

We appreciate the contribution of Zixin Liu from School of Nursing and Rehabilitation, Shandong University, who assisted in editing the references section of this manuscript.

This work was supported by the College Students’ Innovation and Entrepreneurship Training Programs [grant number #2023338].

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Contributions

L.L. made substantial contributions to the conception and design of the work, analyzed and interpreted data and made a major contributor in writing the manuscript. RY. X. analyzed and interpreted the data regarding early clinical exposure and emotional labor and drafted the manuscript. S.W., M.Z., SJ.P., XN.P. and QY.Y. substantively revised the manuscript. C.W. and KF.W. made substantial contributions to the conception and design of the work and interpretation of data, and substantively revised the manuscript. All authors have read and approved the final version of the manuscript.

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Correspondence to Chen Wu or Kefang Wang .

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The ethical approval of this study was obtained from the Institutional Review Board of School of Nursing and Rehabilitation, Shandong University (No. 2023-R-044). Informed consent was obtained from all nursing students. It had no impact on nursing students’ academic achievements or other welfare whether or not they participated in this study.

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Li, L., Xu, R., Wang, S. et al. Moderating effect of family structure on the relationship between early clinical exposure and emotional labor of nursing students: a cross-sectional study. BMC Nurs 23 , 606 (2024). https://doi.org/10.1186/s12912-024-02149-8

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Reflective writing in undergraduate clinical nursing education: A literature review

Affiliations.

• 1 OsloMet - Oslo Metropolitan University (former Oslo and Akershus University College of Applied Sciences), Department of Nursing and Health Promotion, St. Olavs plass pb 4, 0130 Oslo, Norway. Electronic address: [email protected].
• 2 Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway. Electronic address: [email protected].
• PMID: 30660960
• DOI: 10.1016/j.nepr.2018.11.013

The aim of this review was to explore the evidence of learning from reflective writing in undergraduate clinical nursing education. A combination of 17 quantitative and qualitative studies were included and three main categories emerged Development of clinical reasoning skills, Professional self-development and Facilitators and barriers for learning. The results revealed that reflective writing enhanced the students' reasoning skills and awareness in clinical situations. However, most students reflected primarily at a descriptive level, showing only limited and varied development of reflective skills. They focused on self-assessment; on their own emotional reactions and ability to cope in clinical situations, but had difficulties reflecting on the process of thinking and learning. Learning was promoted through instructive guidelines, scaffolding and detailed feedback from a trusted, available and qualified faculty teacher. Factors that facilitated learning included student maturity, individual cognitive skills, student collaboration and mixed tools for learning. Time constraints, conflicting values, lack of feedback and support, and lack of trust acted as barriers for learning. Reflective writing is a tool for students' professional learning, but above all for the students' personal development in becoming a professional nurse.

Keywords: Clinical education; Learning; Literature review; Reflective writing; Undergraduate nursing students.

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The right care in the right place: a scoping review of digital health education and training for rural healthcare workers

• Leanna Woods 1 , 2 ,
• Priya Martin 3 ,
• Johnson Khor 1 , 4 ,
• Lauren Guthrie 1 &
• Clair Sullivan 1 , 2 , 5  

BMC Health Services Research volume  24 , Article number:  1011 ( 2024 ) Cite this article

Metrics details

Digital health offers unprecedented opportunities to enhance health service delivery across vast geographic regions. However, these benefits can only be realized with effective capabilities and clinical leadership of the rural healthcare workforce. Little is known about how rural healthcare workers acquire skills in digital health, how digital health education or training programs are evaluated and the barriers and enablers for high quality digital health education and training.

To conduct a scoping review to identify and synthesize existing evidence on digital health education and training of the rural healthcare workforce.

Inclusion criteria

Sources that reported digital health and education or training in the healthcare workforce in any healthcare setting outside metropolitan areas.

We searched for published and unpublished studies written in English in the last decade to August 2023. The databases searched were PubMed, Embase, Scopus, CINAHL and Education Resources Information Centre. We also searched the grey literature (Google, Google Scholar), conducted citation searching and stakeholder engagement. The JBI Scoping Review methodology and PRISMA guidelines for scoping reviews were used.

Five articles met the eligibility criteria. Two case studies, one feasibility study, one micro-credential and one fellowship were described. The mode of delivery was commonly modular online learning. Only one article described an evaluation, and findings showed the train-the-trainer model was technically and pedagogically feasible and well received. A limited number of barriers and enablers for high quality education or training of the rural healthcare workforce were reported across macro (legal, regulatory, economic), meso (local health service and community) and micro (day-to-day practice) levels.

Conclusions

Upskilling rural healthcare workers in digital health appears rare. Current best practice points to flexible, blended training programs that are suitably embedded with interdisciplinary and collaborative rural healthcare improvement initiatives. Future work to advance the field could define rural health informatician career pathways, address concurrent rural workforce issues, and conduct training implementation evaluations.

Review registration number

Open Science Framework: https://doi.org/10.17605/OSF.IO/N2RMX .

Peer Review reports

Introduction

Globally, healthcare workers (HCWs) face multiple pressures simultaneously: increasing demand for care, co-morbidities and condition complexity, budget pressures, and rapid digital disruption [ 1 ]. The digital disruption in healthcare promises an unprecedented circumstance to improve outcomes and strengthen health systems [ 2 ]. However, this opportunity depends on a capable healthcare workforce with adequate skills and knowledge in data and emerging technologies [ 3 ]. HCW capability in digital health and clinical informatics is increasingly acknowledged as an essential component to the delivery of high-quality patient care [ 4 ]. Universities do not yet routinely teach these curricula in clinical degrees, and the capability gap in the current workforce is often filled by brief, reactive, and on-the-job training [ 5 ]. Sustainability of healthcare includes developing a skilled healthcare workforce educated and competent in digital health [ 6 ].

The rural healthcare workforce is faced with the location-based issues of resource constraints, workforce shortages, high staff turnover rates, stress, burnout, and an ageing workforce [ 7 ]. The World Health Organization has acknowledged in a recent report (2021) the complex challenge of shortage of healthcare workers globally in rural areas [ 7 ]. This report has acknowledged that the workforce density is lower than national averages in most of these areas. In places where there isn’t a national shortage, maldistribution of the workforce has been noted [ 7 ]. Digitally enabled models of care are well placed to enhance health service delivery across vast and distributed geographic regions. However, rural health service organizations require uplift to align with their metropolitan counterparts in workforce digital readiness [ 8 ]. Building digital health capability in rural settings is critical because higher digital health capability is associated with better outcomes, including the ability to maintain an accurate patient health record, track patient experience data, track the patient journey, and mitigate clinical risks [ 9 ]. Rurality is contributing to widening digital health inequities [ 10 ] with significant efforts required to adequately manage the rural digital divide [ 11 , 12 ]. Building digital capabilities of healthcare providers in rural and remote settings through education, training and support is needed [ 13 ].

Existing evidence on the education and training the rural healthcare workforce is limited. Firstly, while health science faculties are progressively integrating digital health into the undergraduate curricula for the future workforce [ 14 , 15 , 16 ], it is unclear how the education of current HCW is approached [ 14 ]. Despite global exemplars such as fellowship training for physicians [ 17 ], certification for nurses [ 18 ], and advanced education for clinical and non-clinical professionals [ 19 ], limited evidence of successful workforce programs to build digital health skills exist [ 4 ]. None focus on the rural healthcare setting.

Secondly, in literature reporting digital health in rural settings, there is a notable scarcity on workforce training programs. Existing studies focus on efficacy of delivered healthcare [ 20 , 21 ], workforce perceptions of digital health tool implementation [ 22 , 23 ] or are limited to training of specific interventions (e.g., clinical telehealth [ 24 ]). This review sought to explore the literature where these two gaps coexist, the intersection of digital health education and training and the rural healthcare workforce, and synthesize the available evidence on digital health education and training for the rural healthcare workforce.

Review question

The research questions for this review were:

What are the existing practices and approaches to digital health education and training for rural HCWs?

How has digital health education and training been evaluated following implementation?

What are the barriers and enablers for high quality digital health education and training in the rural healthcare workforce?

Participants

The review considered studies and reports on any members of the workforce in healthcare settings outside of metropolitan areas. The healthcare workforce refers to ‘all individuals who deliver or assist in the delivery of health services or support the operation of health care facilities’ [ 3 ]. All clinical (e.g., medical doctors, nurses, allied health professionals, pharmacists, Indigenous HCWs, pre-registration/qualification students undertaking placements in health care facilities) and non-clinical workers (e.g., administration, executive and management, clinical support, and volunteers) were considered regardless of professional body or government registration status. Patients, healthcare consumers, and the public were excluded.

The core concepts of digital health and training were combined in this review. Digital health and clinical informatics are often used interchangeably, and both were considered in this review. While digital health refers to the use of digital technologies for health [ 25 ], clinical informatics refers to more specialized practice of analyzing, designing, implementing and evaluating information and communication systems [ 26 ]. Specific digital health systems (e.g., IT infrastructure, telehealth, electronic medical records) were included. Training relates to the education or training initiatives (e.g., programs, curriculum, course) that build an individuals’ digital health capability to confidently use technologies to respond to the needs of consumers now and into the future [ 1 ]. Both education and training activities were considered. Education often refers to theoretical learning (e.g., by an academic institution, qualification), and training often teaches practical skills (e.g., employer-provided professional development, ‘just-in-time’ training) [ 3 , 24 ]. This review did not consider HCW education delivered at a distance through technologies (e.g., telesupervision for clinical skills training).

This review considered studies and reports from rural healthcare settings defined as outside metropolitan cities, inclusive of regional, rural, remote, and very remote settings. When the term ‘rural’ is used in this review, it refers to all areas outside major metropolitan cities as described by authors of individual studies and reports. All healthcare facilities across primary, secondary, and tertiary care settings were included in any country.

Types of sources

All research studies, irrespective of the study design, were considered. Reviews, conference abstracts and non-research sources (e.g., policy documents, program or course curriculum) were considered. The grey literature was included to capture reactionary training developed by rural health services that were not published as peer-reviewed research studies.

This review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [ 27 ] and reported as per the Preferred Reporting of Systematic Reviews and Meta-analyses for scoping reviews (PRISMA-ScR) [ 28 ] (Additional file 1 ). The review protocol was registered in Open Science Framework [ https://doi.org/10.17605/OSF.IO/N2RMX ].

A scoping review approach was chosen over a systematic review to address a general, formative review question on this topic that is emerging in the literature and where the literature is complex and heterogenous [ 29 ]. An initial preliminary search of the topic in the academic databases, Cochrane Library, Open Science Framework and Prospero registry resulted in a very small number of relevant articles. It was determined that a broader search strategy and inclusion of non-research sources was required, consistent with the scoping review methodology [ 29 ]. Scoping review format is also well suited to the vast, diverse healthcare education topic across different disciplines, interventions and outcomes realised [ 30 ]. Mapping and synthesis across sources in this scoping review aims to inform research agendas and identify implications for policy and practice [ 31 ].

Deviations from the protocol

There were no deviations to the protocol.

Search strategy

The three phase JBI search process was followed. An initial limited search of PubMed was performed to identify keywords on the topic, followed by an analysis of the text words and index terms contained in the title and abstract. A subsequent preliminary search in Prospero registry, Cochrane Library and Open Science Framework informed the development of a full search strategy in PubMed. The search strategy, including all identified keyworks and index terms, was adapted for each included database and information source after refining the strategy with an information specialist. The reference lists of all included sources of evidence were screened for additional studies.

The review included only studies and reports in English (due to translation resourcing limitations) in the last 10 years (due to the relative novelty of the digital transformation of healthcare). The search was conducted in August 2023. The databases searched included PubMed, Scopus, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Embase, and Education Resources Information Center (ERIC). Scopus was chosen over Web of Science as it provides 20% more coverage and the relative recency of articles indexed (publish date after 1995 [ 32 ]) was not a concern for our research question. The search for unpublished studies and grey literature included Google and Google Scholar, using a modified search strategy as required. In addition, national and international stakeholders ( n  = 29) from Asia, the Pacific Islands, Australia, USA and the UK known to have subject matter expertise on the topic were contacted via direct email. Stakeholders were asked to share any relevant work underway or otherwise undiscoverable using our scoping review methods. The full search strategy for each information source is provided in Additional file 2 .

Study selection

Following the search, identified articles were collated and uploaded into Covidence review software (Veritas Health Innovation Ltd; Melbourne, Australia) and duplicates removed. Two reviewers (among LW, JK and LG) then independently screened the title and abstract of each citation and selected studies that met the inclusion criteria. The full text articles were retrieved and uploaded into Covidence. These studies and reports were assessed independently by two reviewers (listed previously) for full assessment against the inclusion criteria. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with an additional reviewer (among LG and PM). Three meetings occurred to discuss any voting conflicts that occurred during title and abstract screening and full-text screening. Articles that did not satisfy the criteria were excluded with reasons for exclusion recorded. Search results and study selection process is presented in accordance to the PRISMA-ScR flow diagram (Fig. 1 ) [ 28 ]. Quality appraisal of selected studies was not conducted, consistent with scoping reviews methods [ 33 ].

Search results and source selection and inclusion process

Data extraction

Extracted data included the specific details about the participants, concept, context, study methods and key findings relevant to each review question. Data was extracted by one reviewer (JK) and checked by a second reviewer (LW). Data were extracted using the data extraction tool developed and piloted by the team (Additional file 3 ).

Data synthesis and presentation

The characteristics of the included studies were analyzed and organized in tabular format, accompanied by a narrative summary. Results of each research question was presented under separate headings. The data analysis for research question three (barriers and enablers of high-quality digital health education and training) was enhanced. We adopted the socio-institutional framework described by Smith et al [ 34 ] and used in education research [ 35 ] to classify macro, meso, micro level enablers and barriers to help improve the generalizability of the synthesized insights and identify stakeholders that are able to influence change. Gaps and limitations of the current literature were discovered from the evidence with recommendations for policy, practice and future research provided.

Study inclusion

Database searching yielded 1005 articles and stakeholder engagement yielded two articles. After removing duplicates, 660 articles were screened for title and abstract, after which 29 articles underwent full text review. Of the 29 articles, 24 articles were excluded: the setting was metropolitan or otherwise inadequately described as non-metropolitan ( n  = 6); the intervention was not a training or education initiative for digital health or clinical informatics ( n  = 16), or the population was not rural healthcare workers ( n  = 2). In total, following full-text screening, five articles were included in the final review (Fig.  1 ).

Characteristics of included studies

Of the five included articles, three were academic publications including two case studies [ 36 , 37 ] and one feasibility study [ 38 ] (Table 1 ). The two articles identified through stakeholder engagement presented course summaries [ 39 , 40 ] where one described a micro-credential [ 40 ] and the other described a fellowship [ 39 ]. Most articles ( n  = 3) were published recently between 2021 and 2023 [ 38 , 39 , 40 ]. Healthcare workforce settings were distributed across the continents of the United States of America [ 36 ], Asia [ 37 ], Africa [ 38 ] and Australia [ 39 , 40 ], with no articles reporting a setting in the European continent. Further study characteristics are available in Table 1 .

Review findings

What are the existing approaches to digital health education and training for rural hcws.

Training and education programs were needed due to identified gaps in knowledge, skills and expertise to support healthcare delivery in rural contexts with digital health [ 36 , 37 , 38 ], [ 40 ]. One article reported the target learners as village doctors, who may have “limited training and inadequate medical knowledge, yet they are generally the mainstay of health services” [ 37 ]. The mode of teaching in the included studies were four modular online learning courses [ 36 , 37 , 38 ], [ 40 ] and one fellowship [ 39 ]. Of the four modular online learning courses, one was supplemented by a facilitator-led train-the-trainer model [ 38 ], informed by an academic framework [ 41 ], with cohort-based discussion via a social media platform. The second was a certification in the form of a self-paced micro-credential completed individually [ 40 ]. Of the four modular online learning courses, the number of modules ranged from three to eight and covered a variety of digital health topics including innovation, commercialization, bioinformatics, technology use, data and information, professionalism, implementation and evaluation. One had a particular focus on information and communication technology tool use [ 37 ] while another focused on remote consulting [ 38 ]. The mode of delivery of the fellowship was not reported in the article.

Four [ 36 , 37 , 39 , 40 ] of the five included articles did not report an evaluation. One article in rural Tanzania described the evaluation of the train-the-trainer digital health training program using a mixed-method design [ 38 ]: (1) questionnaire informed by Kirkpatrick’s model of evaluation to capture knowledge gained and perceived behavior change on a Likert scale, (2) qualitative interviews to explore training experiences and views of remote consulting, and (3) document analysis from texts, emails and training reports [ 38 ]. Of the tier 1 trainees (senior medical figure trainers who were trained to educate their peers) that completed the questionnaire ( n  = 10, 83%), nine (90%) recommended the training program and reported receiving relevant skills and applying learning to daily work, demonstrating satisfaction, learning and perceived behavior change [ 38 ]. Overall, the feasibility study confirmed that remotely delivered training supported by cascade training was technically and pedagogically feasible and well received in rural Tanzania [ 38 ].

What are the barriers and enablers for high quality digital health education and training of the rural healthcare workforce?

Reported enablers and barriers are presented using the macro, meso, micro framework [ 34 ] (Table 2 ).

This scoping review reflects the scarcity of reported digital health education and training programs in existence for rural HCWs globally. This review responds to the World Health Organization (WHO) recommendation to design and enable access to continuing education and professional development programs that meet the needs of rural HCWs [ 7 ], and the Sustainable Development Goal for inclusive and equitable quality education [ 42 ].

Concurrent challenges of people (workforce), setting (rural) and content (digital health) are reported in included articles alongside enablers and barriers to education and training programs. Included studies reported a shortage of doctors and specialists [ 36 ], lack of technical knowledge [ 36 ] (people); higher cost of delivering rural healthcare, high burden of illness [ 40 ], medically underserved population due to rural hospital closures [ 36 ] (setting); and limited use of digital health tools due to coordination challenges among non-government organisations [ 37 ] (content). These additional macro, meso and micro level factors are described by authors firstly as influencing the need for digital health programs in rural settings, and secondly, as contributing to the challenges of implementing effective programs. The rural health workforce challenges in digital health education and training reflect the broader workforce development issues experienced globally [ 7 ]. While this review sought to identify workforce development programs, the WHO model indicates the need for attractiveness, recruitment and retention to enable workforce performance (i.e., appropriate and competent multidisciplinary teams providing care) and health system performance (i.e., improving universal health coverage) [ 7 ].

In low-resource settings such as rural areas, education and training may not be prioritized among other competing workload demands. As the value of digital health transformations are realized for strengthening healthcare systems [ 25 , 43 ], the value of digital health education or training programs may become realized. This value was evidenced in the implementation of the teleconsulting training intervention in rural Tanzania [ 38 ] in rapid response to supporting care delivery during the COVID-19 pandemic period. With evaluations of programs largely absent from an already small number of programs globally, it will be important for future research to focus on implementation evaluation studies. As Table 2 presents only limited enablers and barriers, more evidence is needed to build on the findings from this scoping review to inform strategies for policy and practice.

The interdisciplinarity of digital health presents challenges and opportunities for nurturing digital health expertise across the rural healthcare workforce. Included articles largely described the target learners of education and training programs as clinicians, practitioners and healthcare workforce. Walden et al. further indicated that users of online content may extend beyond rural health clinicians to healthcare administrators, researchers and providers relevant to address the regulatory factors of clinical validation and implementation [ 36 ]. Therefore, for their program of work, the University of Arkansas for Medical Sciences identified and fostered collaboration with an interprofessional team of clinicians, researchers, informaticists, a bioethicist, lawyers, technology investment experts, and educators [ 36 ]. No articles in the review described education or training health informaticians or similar digital health leadership role types, yet building defined career pathways for health informaticians is recommended [ 4 ]. Existing pedagogy shows that the learning principles of interprofessional practice is grounded in understanding one’s own practice as well as the practice of other health professionals and remains aligned to the educational needs of specific professions [ 44 ] (i.e., medicine, nursing, pharmacy). Defining new career pathways for interdisciplinary leaders in digital health within a specific clinical context, like the ‘rural health informatician’, will be important to identify or define the (hidden) specialized workforce.

Local, informal organizational initiatives for digital health learning were discovered alongside formal education or training programs in included studies. Programs were often reported in articles alongside concurrent digital health implementation or healthcare improvement programs, sometimes referred to as ‘outreach’ [ 36 ] activities. These informal initiatives included special interest groups, in-person conferences, networking events, working groups [ 36 ] and seminars [ 37 ]. Current evidence from this scoping review suggests that the efficacy and sustainability of education or training programs are reliant on integrated approaches, like the train-the-trainer [ 38 ] or academic organization approach [ 36 ], that foster translational research for rural healthcare improvement. As illustrated by Walden et al., success in digital health is likely to require a foundational environment where technologies can be discussed, developed and deployed [ 36 ]. Success in rural digital health skills acquisition likely requires a similar, longitudinal and collaborative approach beyond the confines of an online course completed individually. Previous research shows us that blended learning, which merges face-to-face with online learning, translates to better knowledge outcomes [ 44 ]. Blended learning can also overcome the barrier of rural HCWs travelling large distances to attend face-to-face training that comes at a great cost to themselves and the work unit. A key recommendation to improve the digital health training program described by Downie et al. was more face-to-face time with trainers, from the perspective of both trainee and facilitator [ 38 ]. This, however, can only be realized with targeted planning and budgeting of such offerings by involved rural healthcare organizations.

The opportunities to advance digital health education and training for rural HCWs are presented across the macro, meso and micro levels in the socio-institutional framework, with suggested relevant stakeholders suited to actioning the recommendations (Table  3 ). While the context for this is likely to vary across the globe, these recommendations and stakeholders are expected to provide a starting point to initiate a dialogue that can influence change. These recommendations are not meant to be prescriptive or rigid, but rather meant to flag actionable solutions that can be contextualized for any given setting.

Strengths and limitations

It is possible that there is a greater number of published educational and training programs than those reported in this review (i.e., publication bias). To mitigate this, we used a scoping review methodology and stakeholder engagement activity to identify unpublished or emerging programs that answer the review question but may not be discoverable in the academic databases. The review is limited to articles available in the English language. The small number of programs, heterogeneity of programs and limited evaluation of programs significantly limit generalizability of findings. Due to data availability, the barriers and enablers findings summary contain an overrepresentation from a small number of studies limiting conclusions that can be drawn.

Digital health offers the best opportunity for innovative sustainable change to address critical issues in health and care in rural settings. Workforce education and training initiatives in rural healthcare settings are scarce, largely delivered via online training, and are rarely evaluated. Current best practice points to flexible, blended (online and face-to-face) training programs that are suitably embedded with interdisciplinary, collaborative rural healthcare improvement initiatives. More research will expand the evidence base to deliver high-quality digital health education to strengthen rural healthcare delivery. Future work to advance the field could define rural health informatician career pathways, address concurrent rural workforce issues, and conduct implementation evaluations.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Cumulative Index for Nursing and Allied Health Literature

Education Resources Information Centre

Healthcare worker

Joanna Briggs Institute

Preferred Reporting of Systematic Reviews and Meta-analyses for scoping reviews

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Additional File 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional File 2. Full search strategy for each information source.

Additional file 3. data extraction instrument template., rights and permissions.

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Woods, L., Martin, P., Khor, J. et al. The right care in the right place: a scoping review of digital health education and training for rural healthcare workers. BMC Health Serv Res 24 , 1011 (2024). https://doi.org/10.1186/s12913-024-11313-4

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Metabolic syndrome drug therapy: the potential interplay of pharmacogenetics and pharmacokinetic interactions in clinical practice: a narrative review.

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Share and Cite

Knežević, S.; Filippi-Arriaga, F.; Belančić, A.; Božina, T.; Mršić-Pelčić, J.; Vitezić, D. Metabolic Syndrome Drug Therapy: The Potential Interplay of Pharmacogenetics and Pharmacokinetic Interactions in Clinical Practice: A Narrative Review. Diabetology 2024 , 5 , 406-429. https://doi.org/10.3390/diabetology5040031

Knežević S, Filippi-Arriaga F, Belančić A, Božina T, Mršić-Pelčić J, Vitezić D. Metabolic Syndrome Drug Therapy: The Potential Interplay of Pharmacogenetics and Pharmacokinetic Interactions in Clinical Practice: A Narrative Review. Diabetology . 2024; 5(4):406-429. https://doi.org/10.3390/diabetology5040031

Knežević, Sandra, Francesca Filippi-Arriaga, Andrej Belančić, Tamara Božina, Jasenka Mršić-Pelčić, and Dinko Vitezić. 2024. "Metabolic Syndrome Drug Therapy: The Potential Interplay of Pharmacogenetics and Pharmacokinetic Interactions in Clinical Practice: A Narrative Review" Diabetology 5, no. 4: 406-429. https://doi.org/10.3390/diabetology5040031

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• v.10(2); 2023 Feb

Mapping research findings on change implementation in nursing practice: A scoping literature review

Israa salma.

1 École des Hautes Etudes en Santé Publique, Inserm U 1309‐RSMS, CNRS UMR 6051 ‐ ARENES, Rennes France

Mathias Waelli

2 Global Health Institute, Geneva University, Geneve Switzerland

Associated Data

Datasets used and/or analyzed during this study (i.e., the study database and extracted data) are available from the corresponding author upon reasonable request

The aim of this study was to map the diverse factors impacting change implementation in nursing practices and investigate different implementation strategies.

Scoping literature review following PRISMA‐ScR extension.

Data were collected from PubMed, Ebsco, Scopus and ScienceDirect databases from 1990 onwards. Only English peer‐reviewed studies reporting an implementation of change in nursing practice were included. Of 9,954 studies, 425 abstracts were scanned and 98 full‐text articles were screened. Finally, 28 studies were selected.

A multifaceted approach, with a tailored intervention, was the most effective implementation strategy. Most identified factors were considered systematic, for example resource availability, leadership and knowledge. However, others related to local social and material context were identified in fewer number of studies. These seem to be operational elements for implementation processes. Both types of factors are essential and must be considered for successful implementation.

We advocate the development of framework including systematic factors and which capture the local context flexibility.

1. INTRODUCTION

In the last decades, quality improvements (QI) initiatives and guidelines have been expanded widely in nursing practices to improve patient care quality and outcomes (Margonary et al.,  2017 ; Singh et al.,  2021 ). However, integrating these initiatives into routine practice is reported to be difficult and complex, and the results are often unpredictable (McArthur et al.,  2021 ; Rycroft‐Malone et al.,  2012 ), as it requires to change the current behaviour of professionals to develop a new one (Holleman et al.,  2009 ). Thus, considerable evidence has been observed in terms of implementation strategies and interventions to drive optimal and successful implementation of quality improvement initiatives or research findings into professionals' practices (Phelan et al.,  2018 ; Spoon et al.,  2020 ). For instance, interactive educational approach, audit and feedback strategy, involving frontline professionals, presence of opinion leadership (Jeffs et al.,  2013 ; Wensing et al.,  2020 ). In addition to, a thoughtful consideration of anticipated barriers (Jabbour et al.,  2018 ) and/or facilitators, which promote or hinder implementation processes (Curtis et al.,  2017 ; González‐María et al.,  2020 ). This approach allows leaders to develop and apply tailored interventions responding to each contextual situation, thereby reach successful implementation processes (Bauer et al.,  2015 ; Renolen et al.,  2018 ). In the same vein, several studies have advocated the use of models and change management theories to design effective implementation processes (Jabbour et al.,  2018 ). In nursing, 47 knowledge translation models have been developed for the subject of implementation, and from different perspectives (Mitchell et al.,  2010 ). However, although these efforts, there is a lack of empirical evidence to support only one particular theory or framework in guiding strategies' development to implement a change in nursing practices (Davies,  2002 ). Also, there is no clear basis to suggest which specific interventions are useful for which barriers in order to improve change implementation (Koh et al.,  2008 ). Additionally, recent reflections have been raised calling for the impact of the local context of the professional's activity on implementation processes; and how it can lead to a successful intervention in one setting and its failure in others (Squires et al.,  2019 ).

To summarize, in nursing, understanding the different elements hindering or supporting an innovation integration in practice is primarily based on individual empirical research, as well as is directed towards specific interventions or innovations. There is a need to compile these efforts in overall comprehensive vision in order to identify literature gaps and requirements, and also to help researchers better understand implementation processes for practice changes initiatives in different contexts. In this study, we used “change in nursing practice” to refer the changes based on scientific evidence.

2. THE REVIEW

This scoping review aim to answer the following questions:

• What are the different factors previously identified impacting the implementation of change in nursing practices? As well as, what are the most effective used implementation strategies?
• How these factors were interrelated in terms of their different types?
• What change models were used for implementation initiatives in nursing practice?

2.2. Design

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) extension checklist (PRISMA‐ScR,  2018 ; Appendix  S1 ).

2.3. Methods

Relevant studies were investigated using PubMed (MEDLINE), ScienceDirect (scientific, technical and medical research), Scopus (Elsevier database of peer‐reviewed literature for science, technology, medicine and the social sciences) and CINHAL Ebsco (cumulative index for nursing and allied health literature) databases from 1990 onwards. This time point was chosen as the implementation research in health care has grown considerably since the earlier 1990s (Damschroder et al.,  2009 ). Study collection step was conducted by one author (blinded for review) and revised by a second author (blinded for review).

2.4. Keywords and eligibility criteria

A structured database search was conducted to identify peer‐reviewed articles related to implementation processes or strategies for change based on scientific evidence in nursing. This was including innovations, evidence‐based practice (EBP) and quality procedures (accreditation or certification procedures or QI initiatives) in nurse practices. Also, we used predefined keywords and eligibility criteria by both authors, prior to databases search. Keywords were Implementation, integration, adoption, dissemination, introduction, certification, accreditation, or quality evaluation mechanisms, quality assurance, professionals, caregivers and nurse. We used medical subject headings (MeSH) terms with Boolean operators (“OR” and “AND”) to perform searches in PubMed, and similar combinations were used for other databases. Also, some “additional filters” were added during the database search process, for example subject, field or domain, and journal topic (Tables  1 and ​ and2 2 ).

Databases search queries

Table 1 presents the search queries for each database source aligned with the output of articles. The “after using additional filters” term refers to added selection criteria to the search output, for example subject, field or domain and journal topic.

Databases eligibility criteria

2.5. Study outcomes

Study selection process was presented following the PRISMA flow diagram (Figure  1 ) (Moher et al.,  2010 ). The initial search strategy generated 9,950 articles and then 9,369 after removing duplications. The title scan based on the predefined terms yielded 425 potentially relevant abstracts. The abstract inspection yielded 94 studies for full‐text assessment. Finally, 28 studies were selected as adhering to inclusion and exclusion criteria and study objectives (Table  3 ). The selection process and final output were discussed and approved by both authors.

Study identification, screening and eligibility based on the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) protocol (Moher et al.,  2010 )

Included studies: A summary of the included studies in the review

Abbreviation: A & F, audit and feedback; CFIR: Consolidated Framework for Implementation Research; PARIHS, Promoting Action on Research Implementation in Health Service; NHS, National Health Services.

Table 3 presents a summary of the included studies. It compromises the studied subject, the aim of study, the country, the study design and methodology, the used model or framework if presents, the context where the study was carried out, the main results with brief description of main findings, in addition to the quality appraisal score.

2.6. Quality appraisal

We used two critical appraisal tools to minimize the risk of bias in evaluating methodologies and results. One author (blinded for review) conducted the quality assessment in the first step, and then, it was discussed and revised by the second author (blinded for review) in the second step.

• The Mixed Methods Appraisal Tool (MMAT; Hong et al.,  2018 ) was used to assess the methodological quality of different studies. The MMAT is designed for the appraisal stage of reviews with mixed type studies: qualitative research, randomized controlled trials, non‐randomized studies, quantitative descriptive studies and mixed‐methods studies (Lotfi et al.,  2019 ).
• To assess the quality of included reviews, we used the Critical Appraisal Skills Program (CASP) checklist for systematic reviews. The appraisal process consisted of three steps: (1) article validity, (2) summary of study results and (3) determining the usefulness of results (CASP,  2018 ). It was useful to appraise articles by transparently evaluating study quality and the evidence within. The CASP tool is a user‐friendly option for researcher and is endorsed by the Cochrane Library and the World Health Organization for qualitative evidence synthesis (Long et al.,  2020 ).

Both tools consisted of checklist questions and criteria. Each question was answered with “yes,” “no” or “cannot tell” if the criteria were met, unmet or partially met, respectively. Summary tables (1, 2, 3 and 4) for the study appraisal checklist are shown (Appendix  S2 ). An overall score was accorded to each study based on the following met criteria. To ensure that only medium and high‐quality studies are included, we decided for both tools that studies with a score <50 will be excluded.

2.7. Ethics

Research Ethics Committee approval was not required given the documentary nature of this study and the lack of human participants.

3.1. Study characteristics: design, settings and subjects

The 28 studies were conducted in 11 countries: the United States ( n  = 7), the United Kingdom ( n  = 7), Australia ( n  = 5), Sweden ( n  = 1), Japan ( n  = 1) China ( n  = 2), Austria ( n  = 1), Norway ( n  = 1), Denmark ( n  = 1), Singapore ( n  = 1) and Zambia ( n  = 1). In terms of study topics, those reporting implementation changes in clinical practice such as evidence‐based practice (EBP) and clinical practice guidelines (CPG) were over the half ( n  = 15), whereas only two studies reported the implementation of informatics technology. The majority of studies focused on the identification of barriers and facilitators or factors impacting implementation process ( n  = 25). In terms of study design and methodology, the majority of studies ( n  = 17) were qualitative in nature (Abbott et al.,  2014 ; Aitken et al.,  2011 ; Allen,  2013 ; Barr,  2002 ; Christensen & Christensen,  2007 ; Colson et al.,  2019 ; Grealish et al.,  2019 ; Isaac et al.,  2019 ; Jansson et al.,  2011 ; Katowa‐Mukwato et al.,  2021 ; Kirk et al.,  2016 ; Kite,  1995 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Renolen et al.,  2019 ; Wolak et al.,  2020 ; Yagasaki & Komatsu,  2011 ). Five studies have used mixed‐methods approaches (Breimaier et al.,  2015 ; Keiffer,  2015 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Robert et al.,  2011 ). Two have followed a quantitative design, with data collection based on cross‐sectional surveys (Koh et al.,  2008 ; Stewart & Bench,  2018 ). The four remaining studies were reviews (Dulko,  2007 ; Jun et al.,  2016 ; May et al.,  2014 ; Solomons & Spross,  2011 ), comprising integrative and systematic reviews (two each). Studies reporting innovation implementations in critical care units ( n  = 9) and medical wards ( n  = 5) were more frequent than other sectors. Twenty‐two studies used at least one theoretical model as part of the research methodology (Abbott et al.,  2014 ; Aitken et al.,  2011 ; Barr,  2002 ; Breimaier et al.,  2015 ; Christensen & Christensen,  2007 ; Colson et al.,  2019 ; Dulko,  2007 ; Grealish et al.,  2019 ; Jansson et al.,  2011 ; Katowa‐Mukwato et al.,  2021 ; Keiffer,  2015 ; Kirk et al.,  2016 ; Kite,  1995 ; Koh et al.,  2008 ; Lin et al.,  2019 ; May et al.,  2014 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Robert et al.,  2011 ; Solomons & Spross,  2011 ; Stewart & Bench,  2018 ; Wolak et al.,  2020 ). These models were used either as a guide for study methodology ( n  = 15) and/or to guide change implementation ( n  = 8). Further information is shown in (Tables  3 and ​ and4 4 ).

Different models used across studies

A summary of the different frameworks and/or models in each study. The table shows the frequency of each model according to how it was used.

In terms of study quality, all studies achieved an overall quality score of ≥50 (Table  3 ); thus, they all were included. All studies were clear in terms of objectives and research questions. However, some qualitative studies required better justification for design and methodology choice (Aitken et al.,  2011 ; Allen,  2013 ; Barr,  2002 ; Christensen & Christensen,  2007 ; Katowa‐Mukwato et al.,  2021 ; Lin et al.,  2019 ; Renolen et al.,  2019 ). In some quantitative studies, we queried whether the selected sample was representative or not, and whether confounders were accounted for in the design (Stewart & Bench,  2018 ). Additionally, in some mixed‐methods studies, the rationale for a mixed‐method design approach was unclear (Breimaier et al.,  2015 ; Keiffer,  2015 ; Robert et al.,  2011 ). For reviews, we observed a lack of quality assessments for studies (Dulko,  2007 ; May et al.,  2014 ; Solomons & Spross,  2011 ). In addition, information about results precision was absent; however, this could be related to the type of the included reviews.

3.2. Analysis of findings

Our review included multiple study designs with different aims and findings. In the following sections, we describe results according to study findings type.

3.2.1. Implementation strategies

Multiple implementations strategies and interventions were identified for successful process of change integration. The majority of studies used multifaceted approaches, which combined two or more strategies (Foy et al.,  2005 ). In addition, tailored interventions target identified or perceived barriers to promote implementation (Abbott et al.,  2014 ; Breimaier et al.,  2015 ; Grealish et al.,  2019 ; Kite,  1995 ; Koh et al.,  2008 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Yagasaki & Komatsu,  2011 ). Different interventions and implementation strategies from 26 out of the 28 studies are shown in Appendix  S3 . The most frequently used or recommended strategies were training and ongoing education and resource allocation; ongoing communication between different participants; process monitoring; outcome evaluations; providing policies and administrative support; a leadership approach; and participant involvement. Some studies proposed specific interventions, such as partnering with patients or families (Grealish et al.,  2019 ; Lin et al.,  2019 ), the use of role models or opinion leaders (Jansson et al.,  2011 ; Kite,  1995 ; Munroe et al.,  2018 ; Qin et al.,  2020 ) and pilot schemes to test intended changes (Abbott et al.,  2014 ; Aitken et al.,  2011 ; Christensen & Christensen,  2007 ; Grealish et al.,  2019 ; Kite,  1995 ; Stewart & Bench,  2018 ; Wolak et al.,  2020 ). The use of an appropriate change model was also suggested by more than half of the studies (54%), either to guide an implementation process or as a tool to identify and understand what factors could influence a change practice implementation (Abbott et al.,  2014 ; Aitken et al.,  2011 ; Breimaier et al.,  2015 ; Christensen & Christensen,  2007 ; Colson et al.,  2019 ; Dulko,  2007 ; Grealish et al.,  2019 ; Jansson et al.,  2011 ; Katowa‐Mukwato et al.,  2021 ; Koh et al.,  2008 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Stewart & Bench,  2018 ; Wolak et al.,  2020 ).

3.2.2. Identified factors, their types and interrelationship

The majority of studies (25 of 28) provided a wide range of factors that are considered transversal, as they are seen across multiple organizational settings and in multiple type of practice change implementation. (Appendix  [Link] , [Link] ). The top five recurrent transversal elements were (1) resource availability, for example time, materials, administrative duties and staff, (2) knowledge and/or education, (3) participants' perception, attitude, skills, experiences and motivation, (4) organizational culture and participant involvement and (5) leadership and communication, and associated channels. Koh et al.,  2008 reported that 73.3% of respondents (nurses) perceived a lack of facilities and materials as major barriers to the implementation of all‐prevention guidelines. However, the availability of such materials and tools did not guarantee their use (Kite,  1995 ). Kirk et al.,  2016 , explained that new tools brought change and potentially threatened the daily responsibilities of professionals. This is because these tools affected their relative power, resources and identities. Therefore, users tended to resist change. Thus, it was essential to consider not only the organizational level, but also the individual level (Colson et al.,  2019 ). We observed factors that were related to the subject of innovation itself, for example credibility in terms of safety and feasibility in practice and its attractiveness for patients and families (Colson et al.,  2019 ). Understanding the meaning and sense of new innovation was identified as an important precondition for successful implementation (Kirk et al.,  2016 ). Similarly, the implemented changes must be in the interest of professionals and seen as valuable agents for care improvement (Allen,  2013 ). The lowest cited factors were links between external change agencies, developers and adopters of change (Breimaier et al.,  2015 ; Colson et al.,  2019 ; Robert et al.,  2011 ; Yagasaki & Komatsu,  2011 ); stakeholder aims and needs (Breimaier et al.,  2015 ; Jansson et al.,  2011 ; Solomons & Spross,  2011 ; Yagasaki & Komatsu,  2011 ); and supporting shared objectives (Allen,  2013 ; Katowa‐Mukwato et al.,  2021 ; Wolak et al.,  2020 ; Yagasaki & Komatsu,  2011 ).

We identified also another type of factors related to activity level, but this was seen in fewer number of studies (20%), for example socio‐material contexts were identified in only three studies (Allen,  2013 ; Grealish et al.,  2019 ; May et al.,  2014 ). Socio‐materiality “arises from the interplay between particular configurations of not only material phenomena, but also material arrangements set up by individuals to discover these phenomena and the knowledge practices established in time” (Parmiggiani & Mikalsen,  2013 ). Also, team dynamics or approaches were identified in only three studies (Breimaier et al.,  2015 ; May et al.,  2014 ; Yagasaki & Komatsu,  2011 ), and the major seen barriers to practice change implementation (by 56%) were time constraints and increased workloads (McKee et al.,  2017 ). Other barriers were similarly identified such as the lack of participant authority to change practices (Keiffer,  2015 ; May et al.,  2014 ; Renolen et al.,  2019 ; Solomons & Spross,  2011 ; Wolak et al.,  2020 ; Yagasaki & Komatsu,  2011 ); professional resistance to change and reduced staffing (Jun et al.,  2016 ; Katowa‐Mukwato et al.,  2021 ; Kirk et al.,  2016 ; Munroe et al.,  2018 ; Yagasaki & Komatsu,  2011 ). These barriers can create an imbalance between the integration of practice innovation and daily professional responsibilities (Aitken et al.,  2011 ; Allen,  2013 ; Breimaier et al.,  2015 ; Grealish et al.,  2019 ; Isaac et al.,  2019 ; Jun et al.,  2016 ; Katowa‐Mukwato et al.,  2021 ; Keiffer,  2015 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Renolen et al.,  2019 ; Robert et al.,  2011 ; Solomons & Spross,  2011 ; Wolak et al.,  2020 ; Yagasaki & Komatsu,  2011 ).

4. DISCUSSION

In this scoping literature review, we mapped previous research on change implementation in nursing practices. This is in order to identify what type of factor can impact implementation processes; how these factors were interrelated in terms of their different types and investigated different implementation strategies.

Firstly, we showed that previous research on change implementation in nursing practices predominantly has followed a qualitative design. This can be explained by the type of study subject, which is “implementation science” that requires consideration of study context. In addition, research efforts in implementation science have been limited. However, improvement guidelines and requirements for nursing practices have been steadily increasing. It is acknowledged that the dissemination of desired changes could not guarantee their integration into professional practice (Francke et al.,  2008 ; Spoon et al.,  2020 ; Yagasaki & Komatsu,  2011 ). It takes approximately 17 years to translate 14% of all evidence‐based research into nursing practice (Beauchemin et al.,  2019 ). Additionally, critical care units were the most frequently studied environments when compared to other hospital departments. This may have been related to environmental complexity about patient status and care, and also the potentially challenging incorporation of practices changes in these critical environments (Phelan et al.,  2018 ). Intensive care units were shown struggling with the integration of screening and management strategies (Stewart & Bench,  2018 ). Meanwhile other contexts were poorly addressed, we suggest further empirical research on change implementation in nursing practices and investigating multiple organizational contexts. This will undoubtedly identify more challenges and factors impeding or enabling implementation processes.

Secondly, we reported different suggested and used implementation strategies, and mapped different types of factors impacting implementation processes on multiple organizational levels. As a result, this study contributes with a practical outline for both implementers and researchers (Table  5 ). The latest summarizes the studies' output, which can be useful to support knowledge in implementation sciences. Our contribution gives insights on different elements, barriers or facilitators, and the most effective implementation interventions to consider when implementing change in nursing practice. This is regardless to multiple type of clinical practice changes and contextual settings as well.

Synthesis of different elements

Note : A summary of the overall synthesis of previous results in terms of barriers and facilitators as well as the most effective implementation interventions to consider in implementing change in nursing practice.

In terms of implementation strategies, a multifaceted approach with tailored interventions was identified as the most effective way to generate change (Abbott et al.,  2014 ; Breimaier et al.,  2015 ; Grealish et al.,  2019 ; Kite,  1995 ; Koh et al.,  2008 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Yagasaki & Komatsu,  2011 ). Multiple factors were interacting with each other requiring multiple strategies to generate effective implementation and positive results. Prevalent interventions were the allocation of resources (time, staff and materials); policy allocation and administrative support; knowledge provision; education and training; monitoring and evaluation; frequent and ongoing communications; leadership approaches; participant involvement; organizational culture and support creation; the use of key actors as champions; role models and opinion leaders (Aitken et al.,  2011 ; Grealish et al.,  2019 ; Jansson et al.,  2011 ; Katowa‐Mukwato et al.,  2021 ; Koh et al.,  2008 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Qin et al.,  2020 ; Solomons & Spross,  2011 ; Wolak et al.,  2020 ). Also, some specific interventions were related to contextual implementation such as partnering with patients and families (Grealish et al.,  2019 ; Lin et al.,  2019 ) and using reminder systems (Aitken et al.,  2011 ; Barr,  2002 ; Colson et al.,  2019 ; Katowa‐Mukwato et al.,  2021 ; Koh et al.,  2008 ; Lin et al.,  2019 ; Munroe et al.,  2018 ; Solomons & Spross,  2011 ; Stewart & Bench,  2018 ). These interventions confirmed the implementation strategies identified by Cochrane's Effective Practice and Organization of Care (EPOC) taxonomy guidelines (EPOC,  2015 ). In addition, the use of appropriate change models was highly promoted. They can be used either as supports to operationalize implementation strategies, or to guide implementation processes. Also, they can be considered as tools to identify what barriers and facilitators could impact an implementation process (Abbott et al.,  2014 ; Breimaier et al.,  2015 ; Christensen & Christensen,  2007 ; Colson et al.,  2019 ; Dulko,  2007 ; Grealish et al.,  2019 ; Jansson et al.,  2011 ; Katowa‐Mukwato et al.,  2021 ; Koh et al.,  2008 ; Munroe et al.,  2018 ; Qin et al.,  2020 ; Stewart & Bench,  2018 ; Wolak et al.,  2020 ). However, we observed potential flaws in some models related to the specificity of local contexts for change implementation (Yagasaki & Komatsu,  2011 ). For example, Breimaier et al. ( 2015 ) suggested adding “stakeholder aims and stakeholder wishes/needs” to the Consolidated Framework for Implementation Research. This was in order to adapt them to local contexts and identify and manage barriers and facilitators when implementing innovations. This confirms Nilsen ( 2015 ) who stated that there is no grand implementation theory, since implementation was too multifaceted and complex a phenomenon to facilitate universal explanation. These observations demonstrated a requirement to build integrated approaches while considering robust factors and local implementation contexts.

In terms of the identified factors' types and how they are interrelated, this work showed that the majority of studies adopted a strategic perspective, which emphasized transverse elements. These are considered as systematic factors in our review. These components were important and generic as they could be useful in multiple contexts and different management levels. Although, they remained outside the parameters of the local implementation context. Among these systematic factors, we identified distinct and robust elements regardless of the implementation context and type of change. These were divided mainly across two levels: first, the organizational level (resource availability, leadership approaches, organizational culture, effective communications, and managerial and organizational support). Second, the professional level (knowledge, education and skills, participant perceptions and involvement) (Aitken et al.,  2011 ; Colson et al.,  2019 ; Keiffer,  2015 ; Lam et al.,  2016 ; Qin et al.,  2020 ; Robert et al.,  2011 ; Wolak et al.,  2020 ; Yagasaki & Komatsu,  2011 ). The lack in any of these factors could generate major barriers to effective change integration. For example, organizational cultures were considered as learning contexts, not only as facilitators for change implementation processes (Kirk et al.,  2016 ). An absence of leadership support could also induce hesitation in nurses to integrate new or unusual practices; practitioners reported the need for support from nurse leaders, who in turn required support from their leaders (Gifford et al.,  2018 ). However, our findings showed that champions, expert clinicians but with informal leader roles (Mark et al.,  2014 ), were identified in less than half of studies (36%; Abbott et al.,  2014 ; Aitken et al.,  2011 ; Christensen & Christensen,  2007 ; Grealish et al.,  2019 ; Kite,  1995 ; Stewart & Bench,  2018 ; Wolak et al.,  2020 ). This may be explained by the presence of other actors as role models and/or opinion leaders (Barr,  2002 ; Breimaier et al.,  2015 ; Colson et al.,  2019 ; Keiffer,  2015 ; Kirk et al.,  2016 ; Kite,  1995 ; Lin et al.,  2019 ; Qin et al.,  2020 ). Opinion leaders are respected, influential, passionate and competent personnel (Mark et al.,  2014 ) whose decisions and behaviours are generally accepted by other peer professionals (Qin et al.,  2020 ). Additionally, staff engagement in the design and implementation process promoted ownership and made it more probably to be accepted in practice (Lin et al.,  2019 ). This occurred through favourable professional attitudes, perceptions (Jun et al.,  2016 ), motivation and practice preferences (Colson et al.,  2019 ; Isaac et al.,  2019 ). Staff buy‐in generated benefits at the onset of improvement projects in terms of managing and sharing results (Wolak et al.,  2020 ). The widespread participation of professionals in change processes was acknowledged as the most frequently used approach to avoid resistance to change (Nilsen et al.,  2020 ). Also, factors related to the patient and family were observed, including knowledge, attitudes, health status and ethnicity (Colson et al.,  2019 ; Grealish et al.,  2019 ; Jun et al.,  2016 ; Keiffer,  2015 ; Koh et al.,  2008 ; Lam et al.,  2016 ; Lin et al.,  2019 ; Munroe et al.,  2018 ). Koh et al. ( 2008 ) reported that the inability to reconcile patient health status and ethnicity with guidelines was a barrier to change. In other contexts, the links between the adopter of change and an external change agency and/or researcher were essential for the change adoption (Breimaier et al.,  2015 ; Colson et al.,  2019 ; Robert et al.,  2011 ; Yagasaki & Komatsu,  2011 ). This may be related to the effects of these external agencies (i.e. the role of accreditation agencies) in imposing such knowledge and requirements into practice. Also, other healthcare‐provider competencies promoted change adoption and integration (Colson et al.,  2019 ; Yagasaki & Komatsu,  2011 ).

However, the operationalization of these previous cited factors in the local context was challenging. Therefore, other researchers investigated the implementation of change in nursing practice from an activity‐level perspective (Allen,  2013 ; Grealish et al.,  2019 ; May et al.,  2014 ). These factors highlighted other types of elements related to local socio‐material context. For example, when implementing multidisciplinary guidelines for cancer care, an equal working partnership between multidisciplinary team members was important for effective integration. In a previous study, teamwork factors were essential in creating and supporting a work culture between professionals (Yagasaki & Komatsu,  2011 ). Other studies argued the importance of multiple “affordances” of innovations or technologies in understanding general mechanisms of an artefact and its unintentional consequences (Allen,  2013 ). In other words, how innovation affordances were related to the socio‐material infrastructures into which they were introduced (Allen,  2013 ). May et al. ( 2014 ) suggested that nurses' capability to implement and embed a CPG depended on the degree to which guidelines were workable. This way, the inter‐relations between the implemented change, actor and context must be considered. Moreover, importantly, it accounted for how these relationships were reciprocally adapted to generate positive effects for different purposes (Allen,  2013 ).

To conclude, we indicated two different types of factors, systematic and contextual factors. Generally, these factors were elaborated independently in previous studies. Systematic factors were identified by the majority of studies, with strategic perspectives identified in terms of elements impacting on change implementation. As well as, these studies were based on cross‐sectional models, which agreed with the previous literature (May et al.,  2016 ; Melo & Bishop,  2020 ). Contextual factors were related to social and material interactions. This separation between factors could be problematic for management, especially in terms of manager's roles, where a strategic perspective differs from a nurses' local reality (Salma & Waelli,  2022 ). However, considering both factor types and how they are interrelated could be challenging for managers. Therefore, we need to develop operational framework which considers both implementation approaches; combining both systematic and contextual factors (Salma & Waelli,  2021 ). Finding the best practices for effectively implementing changes into routine practices is beneficial for healthcare system. Especially, in front of critical situations where we need implementing a change in the best effective way, for example pandemic, nursing shortage, increasing cost of care and other looming factors impacting our health care system.

4.1. Limitations

This study had several limitations. Firstly, in terms of research output, we were limited to four research databases, which may have contributed to the low number of selected studies. However, to address this and identify maximum, quality studies, a robust three‐step study selection method was incepted. Secondly, the subject of change was not specified, potentially leading to diverse and unsynchronized results. However, our interest was to map different factors and interventions, and not compare literature findings. Thus, factors responding to the same perspective were classified together, for example mentorship programmes, ongoing education and training were combined as staff skills and information under the factor or element.

4.2. Recommendations and perspectives

On the strength of our review, we recommend for managers and implementers to explore and adapt the key elements for implementation processes, as well as to consider the specificity of local context of implementation. This can be through the identification of different factors related to the socio‐material context during implementation processes. In these perspectives, it seems essential to develop an integrated framework that considers both types of factors. In order to develop this framework, the whole process of change implementation must be investigated, and in different types of hospital sectors. This can also be beneficial to identify more specific factors, as well as problems or challenges that can emerge during implementation processes in the real context of work. Accordingly, we can identify more pragmatic and directed solutions supporting implementation initiatives in nursing practice.

5. CONCLUSION

This scoping review provides a contemporary summary of studies on the implementation of change in nursing practices; therefore, it fills an important knowledge gap in the literature. Previous research had focused on the universal concept of systematic components underpinning implementation processes. However, our review helped to identify the importance to contextualize these elements in the local context. By exploring social–material factors combined with systematic factors, managers acquire a broader vision for what may impact the implementation of change in nursing practice. Also, they understand how the local context which involves professionals and their activities, content and actions are interrelated in implementation process. This supports the importance to create an organizational culture where change implementation and evidence are valued.

AUTHOR CONTRIBUTIONS

IS and MW: Idea conception, critical feedback, shaping research analyses and manuscript and final version approval. IS with the help of MW: Study design. IS: Data collection and selection according to inclusion and exclusion criteria and writing—first draft and final draft generation in collaboration with MW. MW: Selected studies approval, analytical methods verification, correction proposal and overall supervision. All steps were reviewed and verified by MW.

CONFLICT OF INTEREST

The authors declare no competing interests.

RESEARCH ETHICS COMMITTEE APPROVAL AND CONSENT TO PARTICIPATE

Research Ethics Committee approval was not required given the documentary nature of this study and the lack of human participants (see www.ucd.i.e/researchethics ).

Supporting information

Appendix S1

Appendix S2

Appendix S3

Appendix S4

ACKNOWLEDGEMENTS

The authors acknowledge Dr. John P Phelan for editing and proofreading the manuscript.

Salma, I. , & Waelli, M. (2023). Mapping research findings on change implementation in nursing practice: A scoping literature review . Nursing Open , 10 , 450–468. 10.1002/nop2.1369 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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• Systematic Review
• Open access
• Published: 03 September 2024

Effects of oral health interventions on cognition of people with dementia: a systematic review with meta-analysis

• Haiying Guo 1 , 2 ,
• Zongqin Wang 3 ,
• Chun Hung Chu 2 ,
• Alice Kit Ying Chan 2 ,
• Edward Chin Man Lo 2 &
• Chloe Meng Jiang 2  

BMC Oral Health volume  24 , Article number:  1030 ( 2024 ) Cite this article

Metrics details

Increasing studies have shown that poor oral health contributes to the progression of dementia. It is meaningful to find out the role of oral health interventions in maintaining people’s cognition levels and delaying the progression of dementia. Thus, we conducted this review to summarize the present evidence on the effect of oral health interventions on the cognition change of people with dementia.

Literature search was conducted in the databases of PubMed, Embase, Web of Science, Cochrane library, and Dentistry and Oral Sciences by two independent reviewers from inception to 6 March 2024. Clinical studies such as randomized controlled trials reporting on the effect of oral health interventions on the cognition of people with dementia were included in this review. Mini-Mental State Examination (MMSE) scores were used to measure cognition level. The mean deviation (MD), generated by subtracting the baseline MMSE score from the MMSE score at follow-up was used to assess the change in cognition. Studies with oral hygiene practice as an oral health intervention were further conducted with a meta-analysis.

A total of 6646 references were identified by the literature search, and 5 studies were eligible to be included in this review. Among the included studies, 4 studies reported the cognition change after having various oral hygiene practice as oral health intervention, while the other study adopted oral exercises as the intervention. Two studies presented positive MD values after intervention provided, indicating improved cognition level at follow-up (MD = 0.6, MD = 0.9, respectively). Another two studies reported less cognition deterioration with smaller absolute MD values in the intervention group, (intervention vs. control, -0.18 vs. -0.75, p  < 0.05 and − 1.50 vs. -3.00, p  < 0.05, respectively). The random-effect model was selected in the meta-analysis, and the weighted mean difference (WMD) was 1.08 (95% confidence interval, 0.44 to 1.71), favoring the intervention group.

With limited evidence, oral hygiene care may play a positive role in maintaining the cognition level of people with dementia. However, further studies are needed to provide direct evidence on the effectiveness of oral health interventions on oral health conditions as well as cognition status and to disclose the rationale behind it.

Peer Review reports

Dementia is a group of related symptoms caused by various diseases including Alzheimer’s disease (AD), vascular dementia (VD), and Lewy body dementia. These diseases impair people’s ability of memory, problem-solving and language, and interfere with their daily life [ 1 ]. A well-known risk factor for dementia is the increasing age, and most cases are those older adults aged over 65 [ 2 ]. According to the World Alzheimer Report 2018, there will be more than 152 million people suffering from dementia by the year 2050, and the total estimated worldwide cost of dementia will rise to 2 trillion by the year 2030 [ 3 ]. An inevitable aging society will bring great challenges to healthcare systems globally. At present, there is no cure for dementia, and medications are used to manage symptoms [ 4 ]. Thus, slowing the progress of dementia and maintaining patients’ cognition levels are of great importance [ 5 ].

Though the mechanism of dementia remains unclear, several studies show the relationship between oral health conditions and the progression of dementia. Specifically, periodontitis, a common oral disease, contributes to the progression of dementia [ 6 , 7 , 8 ]. A recently published review presented evidence that periodontal disease is associated with cognitive disorders (relative risk of 1.25) and cognitive impairment (relative risk of 3.01); and dementia (relative risk of 1.22) [ 9 ]. Periodontal pathogens and cytokines can induce neuroinflammation, a common pathological feature of dementia [ 6 , 8 , 10 , 11 ]. Besides, tooth loss and poor mastication may contribute to dementia via decreasing prefrontal activations and cerebral blood flow [ 12 , 13 ]. Dementia also has impacts on oral health. The amyloid-β, a major pathological molecular of dementia, disturbs the balance of oral microbiome [ 14 ]. Besides, people with dementia may have difficulties in taking routine oral hygiene practice such as toothbrushing and cleaning. This may worsen the oral health condition of people with dementia [ 15 , 16 ]. Poor oral health and dementia may have interactive adverse impacts on each other, leading to a vicious circle. However, the rationale behind this is worth further investigation. It is necessary to find out the role of oral health interventions in maintaining people’s cognition levels and delaying the progression of dementia.

Aiming to improve people’s cognition levels, researchers have made efforts to provide a wide range of oral health interventions. However, current research findings are inconclusive. A clinical trial conducted in Japan showed that various oral health interventions such as oral hygiene instructions and oral function exercises were effective in improving oral health and executive function of cognitive function assessed via Trail Making Test (TMT), but this improvement could not be confirmed with another measurement scale, Mini-Mental State Examination (MMSE) [ 17 ]. Some studies found that daily oral care, provision of denture prosthesis and periodontal treatment could slow down the progress of cognition impairment, reduce the risk of developing dementia and improve patients’ cognition [ 18 , 19 , 20 ]. Despite this, some studies found that masticatory muscle training could not slow down the progress of cognition impairment [ 21 , 22 ]. There are research gaps, e.g., does oral health intervention have a positive influence on the cognition of people with dementia? If so, what is the effective intervention? Who is supposed to provide the intervention? To answer the questions, we conducted a systemic review to assess the evidence, and to compare the cognition status of people with dementia after they had received oral health interventions.

The PICO question of this study was defined as follows

For people with dementia (P), what is the effect of oral health interventions (I) on the change of their cognition levels (O) compared with those without oral health interventions received (C). As oral health interventions varied among different studies, we intended to provide a full-view picture for readers by including all possible oral health interventions such as oral hygiene care and oral exercises. This systematic review and meta-analysis was reported according to the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement [ 23 ].

Data searching and extraction

Literature search was conducted in the databases PubMed, Web of Science, Embase, Cochrane library, and Dentistry and Oral Sciences by two independent reviewers from inception to 6 March 2024. Clinical studies reporting on the effect of oral health interventions on the cognition of people with dementia or cognitive impairment were identified. The searching strategy was (“oral health” OR “dental health” OR “oral intervention” OR “dental intervention” OR “oral treatment” OR “dental treatment” OR “periodontal treatment”) AND (“dementia” OR “cognitive impairment” OR “cognition decline” OR “cognition” OR “cognitive defect” OR “Alzheimer’s disease”) (Appendix 1 ). No gray literature was included in the present review. Studies and publications were excluded if they were (1) clinical study without oral health intervention provided; (2) clinical study not reporting the change of cognition in any data format; (3) clinical study not conducted in dementia or cognitive impairment population; (4) laboratory study; (5) review, conference abstract, comment, case report and protocol; and (6) not written in English.

After the removal of duplicates, two independent reviewers screened titles and abstracts of the identified references, and the potential eligible references were retrieved for full-text reading. The above same reviewers conducted data extraction of the included studies. The main data extracted were the mean and standard deviation (SD) values of the cognition index MMSE, and the sample size of each included study. The MMSE score is commonly used to measure cognition and to assess the degree of dementia. A score ranging from 21 to 25 is considered as mild dementia, 11 to 20 as moderate dementia, and 10 and below as severe dementia [ 24 ]. A lower MMSE score indicates a worse cognition level. Besides, related information, i.e., authors, study region, publication year, participant’s age, and oral health interventions in study and control groups, were extracted and summarized. If there were disagreements on study inclusion or data extraction, a third independent investigator would join the discussion to arrive at a consensus.

Quality assessment

The Cochrane risk-of-bias tool for randomized trials (RoB 2), which considers five domains of potential bias, i.e., randomization process, deviations from the intended interventions, missing outcome data, outcome measurement, and selective reporting, was adopted in this review to assess the risk of bias of the included studies [ 25 ]. The overall risk of bias of an included study was considered as ‘low’ when all the five domains were assessed as low risk. The overall risk of bias was ‘high’ if at least one domain was at high risk. Apart from the above-mentioned conditions, the overall risk of bias of the study was considered with “some concerns”.

Statistical analysis

The mean deviation (MD) was used to assess the change in cognition at follow-up. The MD was generated by subtracting the baseline MMSE score from the MMSE score at follow-up. Meta-analysis was conducted using the software Review Manager 5.2. The statistical heterogeneity among studies was assessed by I 2 test and Chi 2 test. I 2 value more than 40% and Chi 2 value less than 0.1 suggested a statistical heterogeneity according to the Cochrane guidance [ 25 ]. The random-effect model was used to combine the data of the included studies. The weighted mean deviation (WMD) with 95% confidence interval (CI) was used to study the effect of oral health interventions on the cognition of these included studies. The inverse variance method was used to calculate the WMD. The statistical significance level for all tests was set at 5%.

Study selection

A total of 6646 references were identified by literature search (Fig.  1 ). After the removal of duplicates ( n  = 4150), titles and abstracts of the remaining references were screened. Subsequently, 2477 records were excluded for reasons, clinical study without oral health interventions provided ( n  = 1122), laboratory study ( n  = 265), review paper ( n  = 576), conference abstract ( n  = 221), comment ( n  = 81), case report ( n  = 40), protocol ( n  = 20), not written in English ( n  = 152). After full-text reading, 14 papers were further excluded because (1) not reporting the change in cognition ( n  = 9), and (2) study population without dementia or cognitive impairment ( n  = 5). Lastly, 5 studies were included in the present review [ 21 , 26 , 27 , 28 , 29 ].

Flowchart of the selection process.CI: cognitive impairment

Risk assessment of the included studies

Four of the included studies were ranked as high risk overall [ 21 , 27 , 28 , 29 ], and the other one was assessed as “some concerns” [ 26 ] ( Fig.  2 and Appendix 2 ).

Assessment of risk of bias of the included studies. MMSE, Mini-Mental State Examination

Study characteristics

Table  1 shows the characteristics of the five included studies. Three studies were conducted in Japan [ 27 , 28 , 29 ], one was in China [ 26 ], and the other one was in Thailand [ 21 ]. The mean age of the participants ranged from 74 to 86. The follow-up period of the included studies ranged from 1 to 24 months [ 21 , 26 , 27 , 28 , 29 ]. Four studies employed various oral hygiene practice as intervention, while the other study adopted oral exercises as intervention. Daily oral care was adopted in the control group of all five studies.

Although oral hygiene practice was adopted as the oral health intervention in four studies, they used various ways to implement the practice in regards to toothbrushing method (frequency, provider, using toothpaste or not), agent for tongue, palatal and mucosa cleaning, and denture cleaning (Table  2 ). One study adopted oral exercises, i.e., tongue-strengthening, oral diadochokinesis and mouth-opening exercise as the intervention, where individuals were advised to take these exercises three days per week (on non-consecutive days) for 3 months [ 21 ].

Cognition of participants in the included studies

At baseline, participants’ cognition status varied among different studies. The mean MMSE score in the intervention group ranged from 12.80 ± 9.31 to 20.00 ± 1.39 (Table  3 ). At follow-up, two studies [ 21 , 28 ] presented increased MMSE scores in the intervention group, with positive MD values (MD = 0.60, MD = 0.90, respectively). However, one study [ 21 ] failed to show significant differences between intervention and control groups (intervention vs. control, 0.60 vs. 0.40, p  = 0.895). Another three studies [ 26 , 27 , 29 ] reported decreased MMSE scores in both intervention and control groups with negative MD values, while intervention groups had lower absolute MD values compared with control groups (intervention vs. control, -0.18 vs. -0.75 ( p  < 0.05) [ 26 ], and − 1.50 vs. -3.00 ( p  < 0.05) [ 29 ], respectively), indicating less cognition deterioration in the intervention group. It should be pointed out that the study [ 27 ] only presented a diagram to show the changes in MMSE scores at 6-month and 12-month follow-ups (i.e., the MMSE scores decreased), but did not report the exact values of the MMSE scores at follow-ups.

Meta-analysis

Data of the three studies [ 26 , 28 , 29 ] reporting on the change in MMSE scores after receiving oral hygiene care were extracted for further meta-analysis. It should be pointed out that we excluded the data of the study [ 21 ] from meta-analysis because the oral health intervention adopted in the study [ 21 ] was oral exercises. Due to the different nature of the two interventions, i.e., oral exercises and oral hygiene care, it is not appropriate to pool the data to conduct meta-analysis. Figure  3 shows the forest plot of the cognition difference between the intervention and control groups. The mean difference (95% CI) of MMSE scores between the intervention and control groups ranged from 0.10 (-4.89, 5.09) to 1.21 (0.45, 1.97), and the WMD was 1.08 (0.44, 1.71) favoring intervention.

Forest plot of cognition difference between intervention and control groups

In the present review, the findings of the meta-analysis show that the cognition status of intervention group is better than that of control group, favoring intervention (oral hygiene care). With limited evidence, we find that the provision of oral hygiene care as the oral health intervention has a beneficial effect on the cognition of people with dementia as assessed by MMSE scores. One study reported increased MMSE score (improved cognition level) in the intervention group at follow-up [ 28 ]. As for other included studies, even though reduced MMSE scores (worse cognition level) in both intervention and control groups can be observed at follow-ups, the cognition impairment is less severe in the intervention groups, which implies the potential benefits of provision of oral hygiene care [ 26 , 29 ]. It should be pointed out that three studies were eligible to be included in the meta-analysis, but two [ 28 , 29 ] out of the three studies were assessed with high risk of bias. Despite this, all the three studies showed the same direct, i.e., favoring oral hygiene care as the intervention. Even though we excluded the two high risk studies, this would not change the direct of the conclusion, still in favor of the intervention. The study [ 27 ] cannot be included in meta-analysis because it only presented a diagram to show the changes in MMSE scores at 6-month and 12-month follow-ups, but no exact values of the MMSE scores at follow-ups were reported. Thus, no data could be extracted for meta-analysis. Indeed, we did not exclude the study from the present review because we would like to provide readers a comprehensive summary of the current available evidence. On the other hand, current evidence fails to show positive effect of oral exercises on cognition level of people with dementia. Home-based oral exercises are found to be effective for improving oral function in terms of tongue strength and tongue-lip motor function in people with mild to moderate dementia, but this could not help with their cognition status [ 21 ].

Although the rationale of the correlation between oral hygiene practice and maintenance of cognition level remains unclear, the promising finding is supported by related studies. In animal studies, oral infection could induce cognitive impairment in mice by increasing the neuroinflammation and amyloid-β accumulation [ 30 , 31 ], while inhibiting oral infection could alleviate cognitive impairment by decreasing the neuroinflammation and amyloid-β accumulation [ 32 , 33 ]. Besides, periodontitis-related salivary microbiota aggravated AD pathogenesis through crosstalk of the gut-brain axis in APP swe /PS1 ΔE9 (PAP) transgenic mice [ 34 ]. Meanwhile, Lactobacillus pentosus and Bifidobacterium bifidum , probiotics to treat periodontitis, suppressed cognitive impairment behaviors in the Porphyromonas gingivalis induced cognitive impairment mice model via regulating gut microbiota [ 35 ]. Moreover, tooth loss could induce a reduction of pyramidal cells in brain areas related to memory, learning and cognition in mice and a volume reduction in the hippocampus in human brains [ 36 , 37 ]. Dentures for rats, on the contrary, could significantly increase the pyramidal cell density in hippocampal subfields, and improve the spatial learning and memory in rats [ 38 ]. Further, poor chewing could activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to a hippocampal neurogenesis hyperactivity and eventually inducing a cognitive impairment [ 39 ]. While masticatory stimulation could attenuate the hyperactivity of the HPA axis, and alleviate cognitive deficits [ 39 ]. Thus, the findings of animal studies showed possible improvement and/or maintenance of cognition levels through different oral health interventions.

Despite this, it is found that the effects of oral health interventions on cognition were reported inconsistently among different clinical studies. This may be explained by three reasons. First, the type of dementia was different in the included studies. One study selected AD patients [ 26 ], while another study recruited AD patients, VD patients and mixed dementia patients [ 21 ]. The ability of AD patients to carry out simple tasks declines slowly as time goes by, while the ability declines sharply in VD patients [ 40 , 41 ]. Besides, VD patients have a common concomitant symptom, physical disability, such as weakness or paralysis on one side of the body [ 42 ]. Different dementia types and characteristics may influence participants’ cooperation with oral health interventions, thus, differences in cognition changes may be detected among different studies. Second, the severity of dementia was different among the included studies. Three studies selected dementia individuals varying from mild to severe dementia [ 27 , 28 , 29 ], while one study only included individuals with mild dementia [ 26 ]. The different severity of dementia may result in a difference in the completion of oral health intervention and further lead to different outcomes perceived. Specifically, moderate and severe dementia patients could refuse to receive oral health interventions, and/or show limited cooperation, while patients with mild dementia had better cooperation [ 43 , 44 ]. Third, the follow-up period of the included studies varied, ranging from 1 to 24 months. It is concerned that a short period may not be sufficient to observe the effect of the intervention. As we observed, three studies using the same oral health interventions with different follow-up periods showed inconsistent results [ 27 , 28 , 29 ]. The study with 1 month follow-up period reported no significant change [ 28 ], while the other two studies with longer follow-up periods found significant changes in cognition after provision of interventions [ 27 , 29 ].

Although the present study was conducted based on up-to-date evidence, limitations of the included clinical studies should be pointed out, and the findings should be interpreted with caution. First, oral health status before and after intervention was not assessed and reported by the included studies. Oral health interventions are expected to improve oral health condition and function, so as to further improve and/or maintain cognition of dementia patients. Without assessment of oral health status, we have no clue regarding the effectiveness of oral health interventions, and further we couldn’t relate cognition changes with oral health interventions. Second, it is not clear whether the included studies have controlled confounders, such as depression and physical disability. Depression leads to a loss of motivation, and this will further affect the individual’s compliance with the intervention [ 45 ]. Moreover, physical disability compromises the patient’s ability to conduct daily oral hygiene practice, which would further influence the effect of oral hygiene interventions on cognition [ 46 ]. Polypharmacy (5 or more drugs) and malnutrition is another issue worth noting in dementia population. Several medications may negatively affect nutritional status via different mechanisms [ 47 ], and polypharmacy was found significantly associated with the incidence of dementia [ 48 ]. Thus, it is recommended to consider the above-mentioned factors in future studies. Third, although the MMSE score is commonly used in studies to measure cognition level, its sensitivity to detect small changes in cognition has been questioned [ 49 ]. It is suggested that cognition assessment tools with high sensitivity should be used to monitor the changes in cognition in future interventional studies. For example, the Montreal Cognitive Assessment (MoCA) may be a good tool to measure cognitive function [ 50 ]. Besides, various indirect changes, including brain activities, cerebral blood flow, and pathological features, could also be used to assist in the assessment of cognition changes. Overall, more well-designed high-quality clinical trials are needed to investigate the effect of oral health interventions on the cognition of people with dementia. Future studies should take several factors into consideration, for instance, causes and severity of dementia, oral health conditions (e.g., functional natural dentition vs. edentulous jaw), polypharmacy, and nutritional status. Strong and reliable evidence is demanded to guide clinicians as well as patients to take effective measures to slow down the cognition decline.

With limited evidence, oral hygiene care may play a positive role in maintaining the cognition level of people with dementia. However, further studies are needed to provide direct evidence on the effectiveness of oral health interventions on oral health conditions as well as cognition status, and to disclose the rationale behind it.

Data availability

Data is provided within the manuscript and supplementary information files.

Abbreviations

Alzheimer’s disease

Confidence interval

Hypothalamic-pituitary-adrenal axis

Mean deviation

Mini-Mental State Examination

Montreal Cognitive Assessment

Standard deviation

Vascular dementia

Weighted mean difference

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This work was supported by the National Natural Science Foundation of China (grant number: 82301091).

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Haiying Guo, Chun Hung Chu, Alice Kit Ying Chan, Edward Chin Man Lo & Chloe Meng Jiang

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Haiying Guo participated in designing the study, screening papers, data extracting, statistical analysis and drafting the manuscript. Zongqin Wang participated in designing the study, screening papers and data extraction. Chun Hung Chu participated in designing the study and revising the manuscript. Alice Kit Ying Chan and Edward Chin Man Lo participated in the study conceptualization. Chloe Meng Jiang participated in designing the study, interpreting the data and revising the manuscript.

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Guo, H., Wang, Z., Chu, C.H. et al. Effects of oral health interventions on cognition of people with dementia: a systematic review with meta-analysis. BMC Oral Health 24 , 1030 (2024). https://doi.org/10.1186/s12903-024-04750-4

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