scoping review nursing literature

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A scoping review of scoping reviews: advancing the approach and enhancing the consistency

a Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, N1G 2W1, Canada

b Division of Public Health Risk Sciences, Laboratory for Foodborne Zoonoses, Public Health Agency of Canada, 160 Research Lane, Suite 206, Guelph, Ontario, N1G 5B2, Canada

Andrijana Rajić

c Food Safety and Quality Unit, Food and Agriculture Organization of the United Nations, Viale delle Terme di Caracalla, 00153, Rome, Italy

Judy D Greig

Jan m sargeant.

d Centre for Public Health and Zoonoses, Ontario Veterinary College, University of Guelph, Guelph, Ontario, N1G 2W1, Canada

Andrew Papadopoulos

Scott a mcewen, associated data.

The scoping review has become an increasingly popular approach for synthesizing research evidence. It is a relatively new approach for which a universal study definition or definitive procedure has not been established. The purpose of this scoping review was to provide an overview of scoping reviews in the literature.

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in four bibliographic databases and the gray literature to identify scoping review studies. Review selection and characterization were performed by two independent reviewers using pretested forms.

The search identified 344 scoping reviews published from 1999 to October 2012. The reviews varied in terms of purpose, methodology, and detail of reporting. Nearly three-quarter of reviews (74.1%) addressed a health topic. Study completion times varied from 2 weeks to 20 months, and 51% utilized a published methodological framework. Quality assessment of included studies was infrequently performed (22.38%).

Conclusions

Scoping reviews are a relatively new but increasingly common approach for mapping broad topics. Because of variability in their conduct, there is a need for their methodological standardization to ensure the utility and strength of evidence. © 2014 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd.

1. Background

The scoping review has become an increasingly popular approach for synthesizing research evidence (Davis et al. , 2009 ; Levac et al. , 2010 ; Daudt et al. , 2013 ). It aims to map the existing literature in a field of interest in terms of the volume, nature, and characteristics of the primary research (Arksey and O'Malley, 2005 ). A scoping review of a body of literature can be of particular use when the topic has not yet been extensively reviewed or is of a complex or heterogeneous nature (Mays et al. , 2001 ). They are commonly undertaken to examine the extent, range, and nature of research activity in a topic area; determine the value and potential scope and cost of undertaking a full systematic review; summarize and disseminate research findings; and identify research gaps in the existing literature (Arksey and O'Malley, 2005 ; Levac et al. , 2010 ). As it provides a rigorous and transparent method for mapping areas of research, a scoping review can be used as a standalone project or as a preliminary step to a systematic review (Arksey and O'Malley, 2005 ).

Scoping reviews share a number of the same processes as systematic reviews as they both use rigorous and transparent methods to comprehensively identify and analyze all the relevant literature pertaining to a research question (DiCenso et al. , 2010 ). The key differences between the two review methods can be attributed to their differing purposes and aims. First, the purpose of a scoping review is to map the body of literature on a topic area (Arksey and O'Malley, 2005 ), whereas the purpose of a systematic review is to sum up the best available research on a specific question (Campbell Collaboration, 2013 ). Subsequently, a scoping review seeks to present an overview of a potentially large and diverse body of literature pertaining to a broad topic, whereas a systematic review attempts to collate empirical evidence from a relatively smaller number of studies pertaining to a focused research question (Arksey and O'Malley, 2005 ; Higgins and Green, 2011 ). Second, scoping reviews generally include a greater range of study designs and methodologies than systematic reviews addressing the effectiveness of interventions, which often focus on randomized controlled trials (Arksey and O'Malley, 2005 ). Third, scoping reviews aim to provide a descriptive overview of the reviewed material without critically appraising individual studies or synthesizing evidence from different studies (Arksey and O'Malley, 2005 ; Brien et al. , 2010 ). In contrast, systematic reviews aim to provide a synthesis of evidence from studies assessed for risk of bias (Higgins and Green, 2011 ).

Scoping reviews are a relatively new approach for which there is not yet a universal study definition or definitive procedure (Arksey and O'Malley, 2005 ; Anderson et al. , 2008 ; Davis et al. , 2009 ; Levac et al. , 2010 ; Daudt et al. , 2013 ). In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping reviews with the aims of clarifying when and how one might be undertaken. They proposed an iterative six-stage process: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing and reporting the results, and (6) an optional consultation exercise (Arksey and O'Malley, 2005 ). Arksey and O'Malley intended for their framework to stimulate discussion about the value of scoping reviews and provide a starting point toward a methodological framework. Since its publication, a few researchers have proposed enhancements to the Arksey and O'Malley framework based on their own experiences with it (Brien et al. , 2010 ; Levac et al. , 2010 ; Daudt et al. , 2013 ) or a review of a selection of scoping reviews (Anderson et al. , 2008 ; Davis et al. , 2009 ).

In recent years, scoping reviews have become an increasingly adopted approach and have been published across a broad range of disciplines and fields of study (Anderson et al. , 2008 ). To date, little has been published of the extent, nature, and use of completed scoping reviews. One study that explored the nature of scoping reviews within the nursing literature found that the included reviews ( N = 24) varied widely in terms of intent, procedure, and methodological rigor (Davis et al. , 2009 ). Another study that examined 24 scoping reviews commissioned by a health research program found that the nature and type of the reports were wide ranging and reported that the value of scoping reviews is ‘increasingly limited by a lack of definition and clarity of purpose’ (Anderson et al. , 2008 ). Given that these studies examined only a small number of scoping reviews from select fields, it is not known to what extent scoping reviews have been undertaken in other fields of research and whether these findings are representative of all scoping reviews as a whole. A review of scoping reviews across the literature can provide a better understanding of how the approach has been used and some of the limitations and challenges encountered by scoping review authors. This information would provide a basis for the development and adoption of a universal definition and methodological framework.

The purpose of this paper is to provide an overview of existing scoping reviews in the literature. The four specific objectives of this scoping review were to (1) conduct a systematic search of the published and gray literature for scoping review papers, (2) map out the characteristics and range of methodologies used in the identified scoping reviews, (3) examine reported challenges and limitations of the scoping review approach, and (4) propose recommendations for advancing the approach and enhancing the consistency with which they are undertaken and reported.

This scoping review began with the establishment of a research team consisting of individuals with expertise in epidemiology and research synthesis (Levac et al. , 2010 ). The team advised on the broad research question to be addressed and the overall study protocol, including identification of search terms and selection of databases to search.

The methodology for this scoping review was based on the framework outlined by Arksey and O'Malley ( 2005 ) and ensuing recommendations made by Levac et al . ( 2010 ). The review included the following five key phases: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. The optional ‘consultation exercise’ of the framework was not conducted. A detailed review protocol can be obtained from the primary author upon request.

2.1. Research question

This review was guided by the question, ‘What are the characteristics and range of methodologies used in scoping reviews in the literature?’ For the purposes of this study, a scoping review is defined as a type of research synthesis that aims to ‘map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research’ (Daudt et al. , 2013 ).

2.2. Data sources and search strategy

The initial search was implemented on June 17, 2011, in four electronic databases: MEDLINE/PubMed (biomedical sciences, 1946–present), SciVerse Scopus (multidisciplinary; 1823–present), CINAHL/EBSCO (nursing and allied health; 1981–present) and Current Contents Connect/ISI Web of Knowledge (multidisciplinary current awareness; 1998–present). The databases were selected to be comprehensive and to cover a broad range of disciplines. No limits on date, language, subject or type were placed on the database search. The search query consisted of terms considered by the authors to describe the scoping review and its methodology: scoping review, scoping study, scoping project, literature mapping, scoping exercise, scoping report, evidence mapping, systematic mapping, and rapid review. The search query was tailored to the specific requirements of each database (see Additional file 1).

Applying the same search string that was used for the search in SciVerse Scopus (Elsevier), a web search was conducted in SciVerse Hub (Elsevier) to identify gray literature. The a priori decision was made to screen only the first 100 hits (as sorted by relevance by Scopus Hub) after considering the time required to screen each hit and because it was believed that further screening was unlikely to yield many more relevant articles (Stevinson and Lawlor, 2004 ). The following websites were also searched manually: the Health Services Delivery Research Programme of the National Institute for Health Research ( http://www.netscc.ac.uk/hsdr/ ), the National Co-ordinating Centre for NHS Service Delivery and Organisation ( http://php.york.ac.uk/inst/spru/pubs/main.php ), NHS Evidence by the National Institute for Health and Clinical Excellence ( http://evidence.nhs.uk/ ), the University of York Social Policy Research Unit ( http://php.york.ac.uk/inst/spru/pubs/main.php ), the United Kingdom's Department of Health ( http://www.dh.gov.uk/en/index.htm ), and Google ( http://www.google.com ).

The reference lists of 10 randomly selected relevant articles (Hazel, 2005 ; Vissandjee et al. , 2007 ; Gagliardi et al. , 2009 ; Meredith et al. , 2009 ; Bassi et al. , 2010 ; Ravenek et al. , 2010 ; Sawka et al. , 2010 ; Churchill et al. , 2011 ; Kushki et al. , 2011 ; Spilsbury et al. , 2011 ) and eight review articles on scoping reviews (Arksey and O'Malley, 2005 ; Anderson et al. , 2008 ; Davis et al. , 2009 ; Grant and Booth, 2009 ; Hetrick et al. , 2010 ; Levac et al. , 2010 ; Rumrill et al. , 2010 ; Armstrong et al. , 2011 ) were manually searched to identify any further scoping reviews not yet captured. A ‘snowball’ technique was also adopted in which citations within articles were searched if they appeared relevant to the review (Hepplestone et al. , 2011 ; Jaskiewicz and Tulenko, 2012 ).

A follow-up search of the four bibliographic databases and gray literature sources was conducted on October 1, 2012 to identify any additional scoping reviews published after the initial search [see Additional file 1]. A search of Google with no date restrictions was also conducted at this time; only the first 100 hits (as sorted by relevance by Google) were screened.

2.3. Citation management

All citations were imported into the web-based bibliographic manager RefWorks 2.0 (RefWorks-COS, Bethesda, MD), and duplicate citations were removed manually with further duplicates removed when found later in the process. Citations were then imported into the web-based systematic review software DistillerSR (Evidence Partners Incorporated, Ottawa, ON) for subsequent title and abstract relevance screening and data characterization of full articles.

2.4. Eligibility criteria

A two-stage screening process was used to assess the relevance of studies identified in the search. Studies were eligible for inclusion if they broadly described the use of a scoping review methodology to identify and characterize the existing literature or evidence base on a broad topic. Because of limited resources for translation, articles published in languages other than English, French, or Spanish were excluded. Papers that described the scoping review process without conducting one and reviews of scoping reviews were excluded from the analysis, but their reference list was reviewed to identify additional scoping reviews. When the same data were reported in more than one publication (e.g., in a journal article and electronic report), only the article reporting the most complete data set was used.

2.5. Title and abstract relevance screening

For the first level of screening, only the title and abstract of citations were reviewed to preclude waste of resources in procuring articles that did not meet the minimum inclusion criteria. A title and abstract relevance screening form was developed by the authors and reviewed by the research team (see Additional file 2). The form was pretested by three reviewers (M. P., J. G., I. Y.) using 20 citations to evaluate reviewer agreement. The overall kappa of the pretest was 0.948, where a kappa of greater than 0.8 is considered to represent a high level of agreement (Dohoo et al. , 2012 ). As there were no significant disagreements among reviewers and the reviewers had no revisions to recommend, no changes were made to the form. The title and abstract of each citation were independently screened by two reviewers. Reviewers were not masked to author or journal name. Titles for which an abstract was not available were included for subsequent review of the full article in the data characterization phase. Reviewers met throughout the screening process to resolve conflicts and discuss any uncertainties related to study selection (Levac et al. , 2010 ). The overall kappa was 0.90.

2.6. Data characterization

All citations deemed relevant after title and abstract screening were procured for subsequent review of the full-text article. For articles that could not be obtained through institutional holdings available to the authors, attempts were made to contact the source author or journal for assistance in procuring the article. A form was developed by the authors to confirm relevance and to extract study characteristics such as publication year, publication type, study sector, terminology, use of a published framework, quality assessment of individual studies, types of data sources included, number of reviewers, and reported challenges and limitations (see Additional file 3). This form was reviewed by the research team and pretested by all reviewers (M. P., A. R., J. G., I. Y., K. G.) before implementation, resulting in minor modifications to the form. The characteristics of each full-text article were extracted by two independent reviewers (M. P. and J. G./K. G.). Studies excluded at this phase if they were found to not meet the eligibility criteria. Upon independently reviewing a batch of 20 to 30 articles, the reviewers met to resolve any conflicts and to help ensure consistency between reviewers and with the research question and purpose (Levac et al. , 2010 ).

2.7. Data summary and synthesis

The data were compiled in a single spreadsheet and imported into Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA) for validation and coding. Fields allowing string values were examined for implausible values. The data were then exported into STATA version 12 (StataCorp, College Station, TX) for analyses. Descriptive statistics were calculated to summarize the data. Frequencies and percentages were utilized to describe nominal data.

3.1. Search and selection of scoping reviews

The original search conducted in June 2011 yielded 2528 potentially relevant citations. After deduplication and relevance screening, 238 citations met the eligibility criteria based on title and abstract and the corresponding full-text articles were procured for review. Four articles could not be procured and were thus not included in the review (Levy and Sanghvi, 1986 ; Bhavaraju, 1987 ; Centre for Reviews and Dissemination, 2004 ; Connell et al. , 2006 ). After data characterization of the full-text articles, 182 scoping reviews remained and were included in the analysis. The updated search in October 2012 produced 758 potentially relevant citations and resulted in another 162 scoping reviews being included. In total, 344 scoping reviews were included in the study. The flow of articles through identification to final inclusion is represented in Figure ​ Figure1 1 .

PRISMA flowchart of study selection process.

Many citations were excluded upon screening at the title and abstract level as several terms used in the search algorithm also corresponded to other study designs. For example, the term ‘scoping study’ was also used to describe studies that assessed the chemical composition of samples (e.g., Behrens et al. , 1998 ; Banks and Banks, 2001 ; Forrest et al. , 2011 ) and preliminary mining studies (Butcher, 2002 ; Bhargava et al. , 2008 ). ‘Scoping exercise’ also described studies that scoped an issue using questionnaires, focus groups, and/or interviews (e.g., Malloch and Burgess, 2007 ; Willis et al. , 2011 ; Norwood and Skinner, 2012 ). ‘Rapid review’ was also used to describe the partial rescreening of negative cervical smears as a method of internal quality assurance (e.g., Faraker and Boxer, 1996 ; Frist, 1997 ; Shield and Cox, 1998 ). ‘Systematic mapping’ was also used in studies pertaining to topographic mapping (e.g., Noda and Fujikado, 1987 ; Gunnell, 1997 ; Liu et al. , 2011 ) and mapping of biomolecular structures (e.g., Camargo et al. , 1976 ; Descarries et al. , 1982 ; Betz et al. , 2006 ).

3.2. General characteristics of included scoping reviews

The general characteristics of scoping reviews included in this study are reported in Table ​ Table1. 1 . All included reviews were published between 1999 and October 2012, with 68.9% (237/344) published after 2009. Most reviews did not report the length of time taken to conduct the review; for the 12.8% (44/344) that did, the mean length was approximately 5.2 months with a range of 2 weeks to 20 months. Journal articles (64.8%; 223/344) and government or research station reports (27.6%; 95/344) comprised the majority of documents included in the review. The number of journal articles was slightly underrepresented as 10 were excluded as duplicates because the same scoping review was also reported in greater detail in a report. The included reports ranged greatly in length, from four pages (Healthcare Improvement Scotland, 2012 ) to over 300 pages (Wallace et al. , 2006 ).

General characteristics of included scoping reviews ( n = 344)

The included scoping reviews varied widely in terms of the terminology used to describe the methodology. ‘Scoping review’ was the term most often used, reported in 61.6% (212/344) of included studies. An explicit definition or description of what study authors meant by ‘scoping review’ was reported in 63.1% (217/344) of articles. Most definitions centered around scoping reviews as a type of literature that identifies and characterizes, or maps, the available research on a broad topic. However, there was some divergence in how study authors characterized the rigor of the scoping review methodology. The terms ‘systematic’, ‘rigorous’, ‘replicable’, and ‘transparent’ were frequently used to describe the methodology, and several authors described scoping reviews to be comparable in rigor to systematic reviews (Gagliardi et al. , 2009 ; Liu et al. , 2010 ; Ravenek et al. , 2010 ; Feehan et al. , 2011 ; Heller et al. , 2011 ). In contrast, some studies described the methodology as less rigorous or systematic than a systematic review (Cameron et al. , 2008 ; Levac et al. , 2009 ; Campbell et al. , 2011 ). Brien et al. ( 2010 ) commented that scoping reviews were ‘often misinterpreted to be a less rigorous systematic review, when in actual fact they are a different entity’.

Some reviews were conducted as stand-alone projects while others were undertaken as parts of larger research projects. Study authors reported that a main purpose or objective for the majority of articles (97.4%; 335/344) was to identify, characterize, and summarize research evidence on a topic, including identification of research gaps. Only 6.4% (22/344) of included articles conducted the scoping review methodology to identify questions for a systematic review. As response options were not mutually exclusive, some reviews reported multiple purposes and/or objectives. A commissioning source was reported in 31.4% (108/344) of reviews; some reported that they were specifically commissioned to advise a funding body as to what further research should be undertaken in an area (e.g., Arksey et al. , 2002 ; Carr-Hill et al. , 2003 ; Fotaki et al. , 2005 ; Baxter et al. , 2008 ; Williams et al. , 2008 ; Trivedi et al. , 2009 ; Crilly et al. , 2010 ; Brearley et al. , 2011 ).

The majority of the included scoping reviews addressed a health topic, making up 74.1% (255/344) of reviews. The use of scoping reviews in software engineering—or ‘systematic mapping’ as termed in the sector—has increased in recent years with 92.7% (38/41) published after 2010. The topics examined in the included scoping reviews ranged greatly, spanning from data on multiplayer online role-playing games (Meredith et al. , 2009 ), to factors that influence antibiotic prophylaxis administration (Gagliardi et al. , 2009 ). The topics investigated were generally broad in nature, such as ‘what is known about the diagnosis, treatment and management of obesity in older adults’ (Decaria et al. , 2012 ). Some reviews that were conducted under short time frames (e.g., 1 month) addressed more specific questions such as ‘what is the published evidence of an association between hospital volume and operative mortality for surgical repair (open and endovascular) of unruptured and ruptured abdominal aortic aneurysms?’ (Healthcare Improvement Scotland, 2011 ).

3.3. Methodological characteristics of included scoping reviews

The methodological characteristics of included scoping reviews are reported in Table ​ Table2. 2 . Approximately half of the reviews (50.6%; 174/344) reported using one or more methodological frameworks for carrying out the scoping review. Framework use varied greatly between reviews from different sectors, such as in 85.4% (35/41) of reviews from the software engineering sector and in 44.0% (89/202) of health sector reviews. Overall, the Arksey and O'Malley ( 2005 ) framework was the most frequently used, reported in 62.6% (109/174) of studies that reported using a framework. Among reviews from the software engineering sector that reported using a framework, frameworks by Kitchenham and Charters ( 2007 ) (40.0%; 14/35) and Petersen et al . ( 2008 ) (51.4%; 18/35) were most commonly employed. The use of a framework increased over time, from 31.6% (6/19) of reviews published from 2000 to 2004, to 42.5% (37/87) of reviews from 2005 to 2009, and to 55.3% (131/237) of reviews published from 2010 onward.

Methodological characteristics of included reviews ( n = 344)

Following the search, 79.7% (174/344) of reviews used defined inclusion and exclusion criteria to screen out studies that were not relevant to the review question(s). Among these, only six reviews explicitly reported that criteria were redefined or amended on a post hoc basis during the review process (While et al. , 2005 ; Marsella, 2009 ; Crooks et al. , 2010 ; Johnston et al. , 2010 ; Snyder et al. , 2011 ; Victoor et al. , 2012 ). The selection criteria in a few reviews were unclear due to ambiguous wording such as ‘real paper’ (Saraiva et al. , 2012 ), ‘scientific papers’ (Victoor et al. , 2012 ), and ‘culling low-interest articles’ (Catts et al. , 2010 ). Compared with the study selection process, fewer details were generally reported about the data characterization (or charting) of individual studies. Nearly a quarter of reviews (23.8%; 82/344) did not report any detail as to how the included studies were characterized, and it was unclear in 33.4% (115/344) as to how many reviewers were involved.

The majority of included reviews (77.7%, 267/344) did not assess the methodological quality of individual studies. A number of these studies reported that quality assessment was not conducted as it is not a priority in scoping reviews or part of the scoping review methodology. Two studies reported the use of publication in a peer-reviewed publication as a proxy for good quality (Baxter et al. , 2008 ; Pita et al. , 2011 ) and another reported using studies included in existing reviews or meta-analyses to ‘overcome’ the lack of quality assessment (MacDougall, 2011 ). Of the 22.4% (77/344) of articles that reported a critical appraisal step, the rigor with which it was conducted ranged from the reviewer's subjective assessment using a scale of high, medium, or low (Roland et al. , 2006 ), to the use of published tools such as the Jadad scale (Jadad et al. , 1996 ) for randomized control trials (Deshpande et al. , 2009 ; Borkhoff et al. , 2011 ).

The level of detail reported about the search strategy varied considerably across the reviews. Table ​ Table3 3 displays information about the search strategy reported in the included reviews by time. Overall, the detail of reporting for the search increased numerically over time. For example, 78.06% of reviews published after 2009 reported complete strings or a complete list of search terms, compared with 57.89% of reviews published between 2000 and 2004 and 67.82% of reviews published between 2005 and 2009.

Search strategy details reported in included reviews, by year

Table ​ Table4 4 summarizes how some of the results of the included reviews were reported and ‘charted’. A flow diagram was used to display the flow of articles from the initial search to final selection in 35.8% of reviews (123/344). Characteristics of included studies were often displayed in tables (82.9%; 285/344), ranging from basic tables that described the key characteristics of each included study, to cross-tabulation heat maps that used color-coding to highlight cell values. Study characteristics were also mapped graphically in 28.8% (99/344) of reviews, often in the form of histograms, scatterplots, or pie charts. Reviews from the software engineering sector frequently used bubble charts to map the data (Figure ​ (Figure2 2 is an example of a bubble chart). In summarizing the reviewed literature, 77.6% (267/344) of reviews noted gaps where little or no research had been conducted, and 77.9% (268/344) recommended topics or questions for future research.

Reporting of results the included scoping reviews

Bubble plot of scoping reviews published by year and sector. The size of a bubble is proportional to the number of scoping reviews published in the year and sector corresponding to the bubble coordinates.

Stakeholder consultation is an optional sixth-step in the Arksey and O'Malley ( 2005 ) framework and was reported in 39.8% (137/344) of reviews. This optional step was reported in 34.9% (38/109) of reviews that used the Arksey and O'Malley framework, compared with 42.13% (99/235) of reviews that did not. Stakeholders were most often consulted at the search phase to assist with keyword selection for the search strategy or help identify potential studies to include in the review (74.5%; 102/137). Stakeholders were less frequently involved in the interpretation of research findings (30.7%; 42/137) and in the provision of comments at the report writing stage (24.1%; 33/137). Ongoing interaction with stakeholders throughout the review process was reported in 25.9% (89/344) of all reviews. Comparing between sectors, the proportion of reviews that reported consulting with stakeholders was highest in the social sciences sector (71.4%; 10/14) and lowest in the software engineering sector (2.4%; 1/41).

3.4. Reported challenges and limitations

Limitations in the study approach were reported in 71.2% (245/344) of reviews. The most frequent limitation reported in the reviews was the possibility that the review may have missed some relevant studies (32.0%; 110/344). This limitation was frequently attributed to database selection (i.e., searching other databases may have identified additional relevant studies), exclusion of the gray literature from the search, time constraints, or the exclusion of studies published in a language other than English. In comparison with systematic reviews, one review noted that it was ‘unrealistic to retrieve and screen all the relevant literature’ in a scoping review due to its broader focus (Gentles et al. , 2010 ), and a few noted that all relevant studies may not have been identified as scoping reviews are not intended to be as exhaustive or comprehensive (Cameron et al. , 2008 ; Levac et al. , 2009 ; Boydell et al. , 2012 ).

The balance between breadth and depth of analysis was a challenge reported in some reviews. Brien et al. ( 2010 ) and Cronin de Chavez et al . ( 2005 ) reported that it was not feasible to conduct a comprehensive synthesis of the literature given the large volume of articles identified in their reviews. Depth of analysis was also reported to be limited by the time available to conduct the review (Freeman et al. , 2000 ; Gulliford et al. , 2001 ; Templeton et al. , 2006 ; Cahill et al. , 2008 ; Bostock et al. , 2009 ; Brodie et al. , 2009 ).

The lack of critical appraisal of included studies was reported as a study limitation in 16.0% (55/344) of reviews. One review commented that this was the primary limitation of scoping reviews (Feehan et al. , 2011 ), and others noted that without this step, scoping reviews cannot identify gaps in the literature related to low quality of research (Hand and Letts, 2009 ; Brien et al. , 2010 ). Additionally, two reviews reported that their results could not be used to make recommendations for policy or practice because they did not assess the quality of included studies (Bostrom et al. , 2011 ; Churchill et al. , 2011 ). Conversely, Njelesani et al . ( 2011 ) noted that ‘by not addressing the issues of quality appraisal, this study dealt with a greater range of study designs and methodologies than would have been included in a systematic review’, and McColl et al. ( 2009 ) commented that ‘the emphasis of a scoping study is on comprehensive coverage, rather than on a particular standard of evidence’.

4. Discussion

In this paper, we provided an overview of scoping reviews identified in the gray and published literature. Our search for scoping reviews in the published and gray literature aimed to be comprehensive while also balancing practicality and available resources. It was not within the remit of this scoping review to assess the methodological quality of individual scoping reviews included in the analysis. Based on the characteristics, range of methodologies and reported challenges in the included scoping reviews, we have proposed some recommendations for advancing the scoping review approach and enhancing the consistency with which they are undertaken and reported.

4.1. Overview of included scoping reviews

Our results corroborate that scoping reviews are a relatively new approach that has gained momentum as a distinct research activity in recent years. The identified reviews varied in terms of terminology, purpose, methodological rigor, and level of detail of reporting; therefore, there appears to be a lack of clarity or agreement around the appropriate methodology for scoping reviews. In a scoping review that reviewed 24 scoping reviews from the nursing literature, Davis et al. ( 2009 ) also reported that the included scoping reviews varied widely in terms of intent, procedural, and methodological rigor. Given that scoping reviews are a relatively new methodology for which there is not yet a universal study definition, definitive procedure or reporting guidelines, the variability with which scoping reviews have been conducted and reported to date is not surprising. However, efforts have been made by scoping review authors such as Arksey and O'Malley ( 2005 ); Anderson et al. ( 2008 ); Davis et al. ( 2009 ); Brien et al. ( 2010 ); Levac et al. ( 2010 ) and Daudt et al. ( 2013 ) to guide other researchers in undertaking and reporting scoping reviews, as well as clarifying, enhancing, and standardizing the methodology. Their efforts seem to be having some impact given the increase in the number of scoping reviews disseminated in the published and gray literature, the growth in the use of a methodological framework, and the greater amount of detail and consistency with which scoping review processes have been reported.

4.2. Recommendations

Levac et al. ( 2010 ) remarked that discrepancies in nomenclature between ‘scoping reviews’, ‘scoping studies’, ‘scoping literature reviews’, ‘scoping exercises’, and so on lead to confusion, and consequently used the term ‘scoping study’ for consistency with the Arksey and O'Malley framework. We agree that there is a need for consistency in terminology; however, we argue that the term ‘scoping review’ should be adopted in favor of ‘scoping study’ or the other terms that have been used to describe the method. Our review has found that ‘scoping review’ is the most commonly used term in the literature to denote the methodology and that a number of the other terms (i.e., scoping study, scoping exercise, and systematic mapping) have been used to describe a variety of primary research study designs. Furthermore, we find that the word ‘review’ more explicitly indicates that the term is referring to a type of literature review, compared with ‘study’ or ‘exercise’.

As scoping reviews share many of the same processes with the more commonly known systematic review, many of the included reviews compared and contrasted the two methods. We concur with Brien et al. ( 2010 ) that scoping reviews are often misinterpreted as a less rigorous version of a systematic review, when in fact they are a ‘different entity’ with a different set of purposes and objectives. We contend that researchers adopting a systematic review approach but with concessions in rigor to shorten the timescale, refer to the process as a ‘rapid review’. Scoping reviews are one method among many available to reviewing the literature (Arksey and O'Malley, 2005 ), and researchers need to consider their research question or study purpose when deciding which review approach is most appropriate. Additionally, given that some of the included reviews took over 1 year to complete, we agree that it would be wrong to necessarily assume that scoping reviews represent a quick alternative to a systematic review (Arksey and O'Malley, 2005 ).

There is an ongoing deliberation in the literature regarding the need for quality assessment of included studies in the scoping review process. While Arksey and O'Malley stated that ‘quality assessment does not form part of the scoping (review) remit’, they also acknowledged this to be a limitation of the method. This may explain why quality assessment was infrequently performed in the included reviews and why it was reported as a study limitation among a number of these reviews. In their follow-up recommendations to the Arksey and O'Malley framework, Levac et al. ( 2010 ) did not take a position on the matter but recommended that the debate on the need for quality assessment continue. However, a recent paper by Daudt et al. ( 2013 ) asserts that it is a necessary component of scoping reviews and should be performed using validated tools. We argue that scoping reviews should include all relevant literature regardless of methodological quality, given that their intent is to present an overview of the existing literature in a field of interest without synthesizing evidence from different studies (Arksey and O'Malley, 2005 ). In doing so, scoping reviews can provide a more complete overview of all the research activity related to a topic. However, we also recognize that some form of quality assessment of all included studies would enable the identification of gaps in the evidence base—and not just where research is lacking—and a better determination of the feasibility of a systematic review. The debate on the need for quality assessment should consider the challenges in assessing quality among the wide range of study designs and large volume of literature that can be included in scoping reviews (Levac et al. , 2010 ).

The lack of consistency among the included reviews was not surprising given the lack of a universal definition or purpose for scoping reviews (Anderson et al. , 2008 ; Davis et al. , 2009 ; Levac et al. , 2010 ; Daudt et al. , 2013 ). The most commonly cited definition scoping reviews may be the one set forth by Mays et al . ( 2001 ) and used by Arksey and O'Malley: ‘scoping studies aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as standalone projects in their own right, especially where an area is complex or has not been reviewed extensively before’. However, we believe that a recently proposed definition by Daudt et al . ( 2013 ) is more straightforward and fitting of the method: ‘scoping studies aim to map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research’. While we would replace the term ‘scoping studies’ with ‘scoping reviews’, we endorse the Daudt et al . definition because it clearly articulates that scoping reviews are a type of literature review and removes the emphasis away from being ‘rapid’ process.

It has been suggested that the optimal scoping review is ‘one that demonstrates procedural and methodological rigor in its application’ (Davis et al. , 2009 ). We found that some scoping reviews were not reported in sufficient detail to be able to demonstrate ‘rigor in its application’. When there is a lack of clarity or transparency relating to methodology, it is difficult to distinguish poor reporting from poor design. We agree that it is crucial for scoping review authors to clearly report the processes and procedures undertaken—as well as any limitations of the approach—to ensure that readers have sufficient information to determine the value of findings and recommendations (Arksey and O'Malley, 2005 ; Davis et al. , 2009 ). The development of reporting guidelines for scoping reviews would help to ensure the quality and transparency of those undertaken in the future (Brien et al. , 2010 ). Given that reporting guidelines do not currently exist for scoping reviews (Brien et al. , 2010 ), researchers conducting scoping reviews may want to consider using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( http://prisma-statement.org/ ) as a guide, where applicable.

4.3. Strengths and limitations of this scoping review

This scoping review used rigorous and transparent methods throughout the entire process. It was guided by a protocol reviewed by a research team with expertise in knowledge synthesis and scoping reviews. To ensure a broad search of the literature, the search strategy included four electronic bibliographic databases, the reference list of eighteen different articles, two internet search engines, the websites of relevant organizations, and the snowball technique. The relevance screening and data characterization forms were pretested by all reviewers and revised as needed prior to implementation. Each citation and article was reviewed by two independent reviewers who met in regular intervals to resolve conflicts. Our use of a bibliographic manager (RefWorks) in combination with systematic review software (DistillerSR) ensured that all citations and articles were properly accounted for during the process. Furthermore, an updated search was performed in October 2012 to enhance the timeliness of this review.

This review may not have identified all scoping reviews in the published and gray literature despite attempts to be as comprehensive as possible. Our search algorithm included nine different terms previously used to describe the scoping process; however, other terms may also exist. Although our search included two multidisciplinary databases (i.e., Scopus, Current Contents) and Google, the overall search strategy may have been biased toward health and sciences. Searching other bibliographic databases may have yielded additional published scoping reviews. While our review included any article published in English, French or Spanish, our search was conducted using only English terms. We may have missed some scoping reviews in the gray literature as only the first 100 hits from each Web search were screened for inclusion. Furthermore, we did not contact any researchers or experts for additional scoping reviews we may have missed.

Other reviewers may have included a slightly different set of reviews than those included in this present review. We adopted Arksey and O'Malley's definition for scoping reviews at the outset of the study and found that their simple definition was generally useful in guiding study selection. However, we encountered some challenges during study selection with reviews that also reported processes or definitions more typically associated with narrative, rapid or systematic reviews. We found that some reviews blurred the line between narrative and scoping reviews, between scoping and rapid reviews, and between scoping and systematic reviews. Our challenges echoed the questions: ‘where does one end and the other start?’ (Arksey and O'Malley, 2005 ) and ‘who decides whether a particular piece of work is a scoping (review) or not?’ (Anderson et al. , 2008 ). For this review, the pair of reviewers used their judgment to determine whether each review as a whole sufficiently met our study definition of a scoping review. On another note, characterization and interpretation of the included reviews were also subject to reviewer bias.

5. Conclusions

This scoping review of scoping reviews characterized and described the nature of scoping reviews in the published and gray literature. Scoping reviews are a relatively new approach to reviewing the literature, which has increased in popularity in recent years. As the purpose, methodological process, terminology, and reporting of scoping reviews have been highly variable, there is a need for their methodological standardization to maximize the utility and relevance of their findings. We agree that the establishment of a common definition and purpose for scoping reviews is an important step toward enhancing the consistency with which they are conducted (Levac et al. , 2010 ); this would provide a common platform from which debates regarding the methodology can ensue, and the basis for future methodological frameworks and reporting guidelines. We hope that the results of our study can contribute to the ongoing collective work of a number of researchers to further clarifying and enhancing the scoping review methodology.

Acknowledgments

Funding for this project was provided by the OMAFRA-University of Guelph Knowledge Translation and Transfer Program (#299514).

We would like to thank our project collaborators Lisa Waddell, Dr. Barbara Wilhelm, and Dr. Ian Young for their expertise and guidance throughout the project. We would also like to acknowledge Dr. Ian Young and Kathleen Gropp for their assistance in screening articles for the review.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

A. R. and S. M. conceived of the study. M. P., A. R., and S. M. participated in the design of the study. M. P., J. G., and A. R. undertook the literature review process. All authors drafted the manuscript. All authors read and approved the final manuscript.

Supporting Information

Additional supporting information may be found in the online version of this article at the publisher's web site.

Supporting info item

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• What is a scoping review?
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• http://orcid.org/0000-0002-2121-7167 Daniel Rodger 1 , 2 ,
• http://orcid.org/0009-0005-1989-6542 Aneesa Admani 1 ,
• http://orcid.org/0000-0002-9415-0469 Mark Thomas 1
• 1 Institute of Health and Social Care , London South Bank University , London , UK
• 2 Department of Psychological Sciences , Birkbeck University of London , London , UK
• Correspondence to Daniel Rodger, London South Bank University, Institute of Health and Social Care, London, UK; daniel.rodger{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2024-103969

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There are various types of literature reviews; the most appropriate review type will be determined by the research questions, aims and objectives. Other considerations can be more pragmatic, such as time and the size of the research team. A scoping review is typically selected to investigate a broad research question that aims to identify and map all the available and emerging evidence. An example of a research question used for a scoping review is: ‘What blended learning approaches are currently used in undergraduate nursing education?’ 1

What is the purpose of a scoping review?

The purpose of a scoping review is to identify the types of available evidence in a given area; summarise the existing evidence; identify gaps in the literature; and make recommendations for future research. 2 In recent years, scoping reviews have become increasingly popular among nurses and other healthcare professionals. For example, a PubMed search of the term ‘scoping review’ yielded 53 309 results as of January 2024—more than double the results from just 4 years ago. Unlike a systematic review, a scoping review is not intended to inform clinical guidance, policy and practice. 3 A scoping review aims to provide a descriptive summary of the sources of evidence without necessarily assessing the quality of the sources. Therefore, assessing the quality and risk of bias of the included studies is not required, however, some researchers choose to do so. Importantly, scoping reviews should be conducted systematically and transparently and be reproducible. It is recommended that a university or hospital librarian should assist with the development of a search strategy.

Scoping review methodology

Key steps of a scoping review.

The key steps in a scoping review are as follows:

Identifying clear aims, objectives and research question/s.

Developing a protocol (eg, including eligibility criteria, screening process, search strategy and selecting databases to search).

Conducting a systematic search of the literature.

Managing results using citation management software (eg, EndNote, Mendeley).

Screening results that meet the eligibility criteria.

Charting the data.

Analysing the evidence.

Writing up the evidence.

Presenting findings.

Having clear aims, objectives and research question/s is essential for conducting a coherent scoping review. The population, concept and context framework can be a useful guide for developing comprehensive eligibility criteria and ensuring that the research question is clear. 6 Developing a protocol will help clarify the kinds of studies that will be eligible for inclusion, the process of screening and the search terms that will be used to identify relevant sources. A search strategy will include but is not limited to the keywords, Boolean operators (eg, AND, OR, NOT) and the specific fields (eg, author, title, abstract) that will be used to search for sources that meet the eligibility criteria. It is also worth searching to see if anyone has published a scoping review protocol that might have or has explored a similar research question. The databases that are searched will depend on the topic of the research question, but in healthcare, it is common to search some of the following databases: PubMed (includes MEDLINE); Cumulative Index to Nursing and Allied Health Literature; Embase; Scopus; and ScienceDirect.

While there may be some overlap when searching the different databases, it is important to search more than one database. Given the broad nature of a scoping review, it is common to use additional search methods such as a manual search of the reference list of included studies and the grey literature. Grey literature is evidence that has not been commercially published (eg, in a journal) and can include public policy documents, government reports and PhD thesis. Once the searches are complete, the results should then be reviewed, documented and managed using citation management software. The search results will then need to be screened against the eligibility criteria. The first step will include reading the titles and abstracts and identifying sources that will require full-text screening. The second step will require reading the full text of those sources that were considered to meet the eligibility criteria following initial screening—a team approach is recommended. Following this, a decision must be made about what sources should be included in the scoping review based on the inclusion and exclusion criteria. The next step is data charting, which describes extracting relevant information from eligible studies into a descriptive summary. This requires the use of a data charting form where appropriate information can be recorded—importantly, only information relevant to the objectives and research question should be charted. Some of the following information is considered key for data charting 9 :

Year of publication.

Origin/country of origin (where the study was published or conducted).

Aims/purpose.

Study population and sample size (if applicable).

Methodology/methods.

Intervention type/duration, comparator and outcome measures (if applicable).

Key findings that relate to the scoping review question/s.

Analysis of the extracted evidence should be descriptive and can be organised into categories using basic coding and frequency counting. 10 Where appropriate to the objectives, basic qualitative content analysis can also be used. 6 The evidence can be presented in several different ways including tables, diagrams, bubble charts and a narrative format—many researchers use a combination of the different presentations. Tables and charts might record the distribution of the year of publication, countries where the studies were conducted and the journals the studies were published. Finally, the last step is to present the findings by writing and reporting it according to transparent standards. An additional benefit of writing up the scoping review according to recognised criteria is that the review is unlikely to require too much additional work to format for submission to a journal.

In summary, a scoping review is a flexible and rigorous approach to evidence synthesis that can be used to address broader research questions. The method has been increasingly adopted by healthcare researchers to identify gaps in the literature, summarise the existing or emerging evidence and make recommendations for future research.

Ethics approval

Not applicable.

• Ritchie L ,
• Tricco AC ,
• Zarin W , et al
• Peters MDJ ,
• Stern C , et al
• Colquhoun H ,
• Pollock D ,
• Khalil H , et al
• Joanna Briggs Institute
• Davies EL ,
• Peters MDJ , et al

X @philosowhal, @chiromdt

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

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University of Houston Libraries

• Literature Reviews in the Health Sciences
• Review Comparison Chart
• Decision Tools
• Systematic Review
• Meta-Analysis
• Scoping Review
• Mapping Review
• Integrative Review
• Rapid Review
• Realist Review
• Umbrella Review
• Review of Complex Interventions
• Diagnostic Test Accuracy Review
• Narrative Literature Reviews
• Standards and Guidelines

Navigate the links below to jump to a specific section of the page:

When is a Scoping Review methodology appropriate?

Outline of stages, methods and guidance, examples of scoping reviews, supplementary resources.

According to Colquhoun et al. (2014) , a scoping review can be defined as: "a form of knowledge synthesis, which incorporate a range of study designs to comprehensively summarize and synthesize evidence with the aim of informing practice, programs, and policy and providing direction to future research priorities" (p.1291).

Characteristics

• Answers a broad question
• Scoping reviews serve the purpose of identifying the scope and extent of existing research on a topic
• Similar to systematic reviews, scoping reviews follow a step-by-step process and aim to be transparent and replicable in its methods

When to Use It: A scoping review might be right for you if you are interested in:

• Examining the extent, range, and nature of research activity
• Determining the value of undertaking a full systematic review (e.g. Do any studies exist? Have systematic reviews already been conducted?)
• Summarizing the disseminating research findings
• Identifying gaps in an existing body of literature

The following stages of conducting a review of complex interventions are derived from  Peters et al. (2015)  and Levac et al. (2010) .

Timeframe:  12+ months, (same amount of time as a systematic review or longer)

*Varies beyond the type of review. Depends on many factors such as but not limited to: resources available, the quantity and quality of the literature, and the expertise or experience of reviewers" ( Grant & Booth, 2009 ).

Question:  Answers broader and topic focused questions beyond those relating to the effectiveness of treatments or interventions. A priori review protocol is recommended. 

Is your review question a complex intervention? Learn more about  Reviews of Complex Interventions .

Sources and searches:  Comprehensive search-may be limited by time/scope restraints, still aims to be thorough and repeatable of all literature. May involve multiple structured searches rather than a single structured search. This will produce more results than a systematic review. Must include a modified PRISMA flow diagram.

Selection:  Based on inclusion/exclusion criteria, due to the iterative nature of a scoping review some changes may be necessary. May require more time spent screening articles due to the larger volume of results from broader questions.

Appraisal:  Critical appraisal (optional), Risk of Bias assessment (optional) is not applicable for scoping reviews. 

Synthesis:  (Tabular with some narrative) The extraction of data for a scoping review may include a charting table or form but a formal synthesis of findings from individual studies and the generation of a 'summary of findings' (SOF) table is not required. Results may include a logical diagram or table or any descriptive form that aligns with the scope and objectives of the review. May incorporate a numerical summary and qualitative thematic analysis.

Consultation:  (optional) 

The following resources provide methods and guidance in the field of scoping reviews.

Methods & Guidance

• Cochrane Training: Scoping reviews: what they are and how you can do them A series of videos presented by Dr Andrea C. Tricco and Kafayat Oboirien. Learn the about what a scoping review is, see examples, learn the steps involved, and common methods from Dr. Tricco. Oboirien presents her experiences of conducting a scoping review on strengthening clinical governance in low and middle income countries.
• Current Best Practices for the Conduct of Scoping Reviews by Heather Colquhoun An overview on best practices when executing a scoping review.
• Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. Chapter 11: Scoping Reviews An extensive and detailed outline within the JBI Manual for Evidence Synthesis on how to properly conduct a scoping review.

Reporting Guideline

• PRISMA for Scoping Reviews (PRISMA-ScR) Contains a 20-item checklist for proper reporting of a scoping review plus 2 optional items.
• Håkonsen, S. J., Pedersen, P. U., Bjerrum, M., Bygholm, A., & Peters, M. (2018). Nursing minimum data sets for documenting nutritional care for adults in primary healthcare: a scoping review .  JBI database of systematic reviews and implementation reports ,  16 (1), 117–139. doi: 10.11124/JBISRIR-2017-003386
• Kao, S. S., Peters, M., Dharmawardana, N., Stew, B., & Ooi, E. H. (2017). Scoping review of pediatric tonsillectomy quality of life assessment instruments .  The Laryngoscope ,  127 (10), 2399–2406. doi: 10.1002/lary.26522
• Tricco, A. C., Zarin, W., Rios, P., Nincic, V., Khan, P. A., Ghassemi, M., Diaz, S., Pham, B., Straus, S. E., & Langlois, E. V. (2018). Engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process: a scoping review .  Implementation science: IS ,  13 (1), 31. doi: 10.1186/s13012-018-0717-x

Anderson, S., Allen, P., Peckham, S., & Goodwin, N. (2008). Asking the right questions: scoping studies in the commissioning of research on the organisation and delivery of health services .  Health research policy and systems ,  6 , 7. doi: 10.1186/1478-4505-6-7

Arksey, H., & O'Malley, L. (2005). Scoping studies: towards a methodological framework .  International journal of social research methodology, 8 (1), 19-32. doi: 10.1080/1364557032000119616

Armstrong, R., Hall, B. J., Doyle, J., & Waters, E. (2011). Cochrane Update. 'Scoping the scope' of a cochrane review .  Journal of public health (Oxford, England) ,  33 (1), 147–150. doi: 10.1093/pubmed/fdr015

Colquhoun, H. (2016). Current best practices for the conducting of scoping reviews . Symposium Presentation - Impactful Biomedical Research: Achieving Quality and Transparency . https://www.equator-network.org/wp-content/uploads/2016/06/Gerstein-Library-scoping-reviews_May-12.pdf

Colquhoun, H. L., Levac, D., O'Brien, K. K., Straus, S., Tricco, A. C., Perrier, L., Kastner, M., & Moher, D. (2014). Scoping reviews: time for clarity in definition, methods, and reporting .  Journal of clinical epidemiology ,  67 (12), 1291–1294. doi: 10.1016/j.jclinepi.2014.03.013

Davis, K., Drey, N., & Gould, D. (2009). What are scoping studies? A review of the nursing literature .  International journal of nursing studies ,  46 (10), 1386–1400. doi: 10.1016/j.ijnurstu.2009.02.010

Khalil, H., Peters, M., Godfrey, C. M., McInerney, P., Soares, C. B., & Parker, D. (2016). An evidence-based approach to scoping reviews .  Worldviews on evidence-based nursing ,  13 (2), 118–123. doi: 10.1111/wvn.12144

Levac, D., Colquhoun, H., & O'Brien, K. K. (2010). Scoping studies: advancing the methodology .  Implementation science: IS ,  5 , 69. doi: 10.1186/1748-5908-5-69

Lockwood, C., Dos Santos, K. B., & Pap, R. (2019). Practical guidance for knowledge synthesis: scoping review methods .  Asian nursing research ,  13 (5), 287–294. doi: 10.1016/j.anr.2019.11.002

Morris, M., Boruff, J. T., & Gore, G. C. (2016). Scoping reviews: establishing the role of the librarian .  Journal of the Medical Library Association: JMLA ,  104 (4), 346–354. doi: 10.3163/1536-5050.104.4.020

Munn, Z., Peters, M., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach .  BMC medical research methodology ,  18 (1), 143. doi: 10.1186/s12874-018-0611-x

O'Brien, K. K., Colquhoun, H., Levac, D., Baxter, L., Tricco, A. C., Straus, S., Wickerson, L., Nayar, A., Moher, D., & O'Malley, L. (2016). Advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps .  BMC health services research ,  16 , 305. doi: 10.1186/s12913-016-1579-z

Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews .  International journal of evidence-based healthcare ,  13 (3), 141–146. doi: 10.1097/XEB.0000000000000050

Peters, M. D. J., Godfrey, C., McInerney, P., Munn, Z., Tricco, A. C., & Khalil, H. (2020). Chapter 11: Scoping Reviews . In Aromataris, E. & Munn, Z. (Eds.),  JBI Manual for Evidence Synthesis . Joanna Briggs Institute. doi: 10.46658/JBIMES-20-12

Peters, M., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2021). Updated methodological guidance for the conduct of scoping reviews .  JBI evidence implementation ,  19 (1), 3–10. doi: 10.1097/XEB.0000000000000277

Pham, M. T., Rajić, A., Greig, J. D., Sargeant, J. M., Papadopoulos, A., & McEwen, S. A. (2014). A scoping review of scoping reviews: advancing the approach and enhancing the consistency .  Research synthesis methods ,  5 (4), 371–385. doi: 10.1002/jrsm.1123

Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., Lewin, S., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation .  Annals of internal medicine ,  169 (7), 467–473. doi: 10.7326/M18-0850

Tricco, A., Oboirien, K., Lotfi, T., & Sambunjak, D. (2017, August).  Scoping reviews: what they are and how you can do them . Cochrane Training. https://training.cochrane.org/resource/scoping-reviews-what-they-are-and-how-you-can-do-them

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Other Names for a Scoping Review

• Scoping Study
• Systematic Scoping Review
• Scoping Report
• Scope of the Evidence
• Rapid Scoping Review
• Structured Literature Review
• Scoping Project
• Scoping Meta Review

Limitations of a Scoping Review

The following challenges of conducting a scoping review are derived from Grant & Booth (2009) , Peters et al. (2015) , and O'Brien (2016) .

• Is not easier than a systematic review.
• Is not faster than a systematic review; may take longer .
• More citations to screen.
• Different screening criteria/process than a systematic review.
• Often leads to a broader, less defined search.
• Requires multiple structured searches instead of one.
• Increased emphasis for hand searching the literature.
• May require larger teams because of larger volume of literature.
• Inconsistency in the conduct of scoping reviews.

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What are scoping studies? A review of the nursing literature

2009, International Journal of Nursing Studies

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Open Access

Peer-reviewed

Research Article

Nurses’ experiences and preferences around shift patterns: A scoping review

Roles Data curation, Methodology, Writing – original draft, Writing – review & editing

Affiliations School of Health Sciences, University of Southampton, Southampton, United Kingdom, National Institute for Health Research Applied Research Collaboration (Wessex), Southampton, United Kingdom

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Ourega-Zoé Ejebu, 
• Chiara Dall’Ora, 
• Peter Griffiths

• Published: August 16, 2021
• https://doi.org/10.1371/journal.pone.0256300
• Reader Comments

21 Jun 2022: Ejebu OZ, Dall’Ora C, Griffiths P (2022) Correction: Nurses’ experiences and preferences around shift patterns: A scoping review. PLOS ONE 17(6): e0270446. https://doi.org/10.1371/journal.pone.0270446 View correction

To explore the evidence on nurses’ experiences and preferences around shift patterns in the international literature.

Data sources

Electronic databases (CINHAL, MEDLINE and Scopus) were searched to identify primary studies up to April 2021.

Papers reporting qualitative or quantitative studies exploring the subjective experience and/or preferences of nurses around shift patterns were considered, with no restrictions on methods, date or setting. Key study features were extracted including setting, design and results. Findings were organised thematically by key features of shift work.

30 relevant papers were published between 1993 and 2021. They contained mostly qualitative studies where nurses reflected on their experience and preferences around shift patterns. The studies reported on three major aspects of shift work: shift work per se (i.e. the mere fact of working shift), shift length, and time of shift. Across all three aspects of shift work, nurses strive to deliver high quality of care despite facing intense working conditions, experiencing physical and mental fatigue or exhaustion. Preference for or adaptation to a specific shift pattern is facilitated when nurses are consulted before its implementation or have a certain autonomy to self-roster. Days off work tend to mitigate the adverse effects of working (short, long, early or night) shifts. How shift work and patterns impact on experiences and preferences seems to also vary according to nurses’ personal characteristics and circumstances (e.g. age, caring responsibilities, years of experience).

Conclusions

Shift patterns are often organised in ways that are detrimental to nurses’ health and wellbeing, their job performance, and the patient care they provide. Further research should explore the extent to which nurses’ preferences are considered when choosing or being imposed shift work patterns. Research should also strive to better describe and address the constraints nurses face when it comes to choice around shift patterns.

Citation: Ejebu O-Z, Dall’Ora C, Griffiths P (2021) Nurses’ experiences and preferences around shift patterns: A scoping review. PLoS ONE 16(8): e0256300. https://doi.org/10.1371/journal.pone.0256300

Editor: Barbara Schouten, Universiteit van Amsterdam, NETHERLANDS

Received: April 30, 2021; Accepted: August 3, 2021; Published: August 16, 2021

Copyright: © 2021 Ejebu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data (i.e. references used for the scoping review) are within the manuscript with the corresponding URL or DOI.

Funding: PG received funding from NIHR Applied Research Collaboration Wessex; https://www.arc-wx.nihr.ac.uk/research-areas/workforce-and-health-systems/nursing-shift-patterns-in-acute-community-and-mental-health-hospital-wards/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Shift work is an established feature of working life for many hospital nurses, who work to provide 24-hour healthcare. Several directives and regulations influence how shift work is organised, including the European Working Time Directive of 2003 [ 1 ] and the US Fair Labor Standards Act of 1938 [ 2 ]. Such directives limits the maximum number of weekly hours or regulate the frequency of work breaks. Notwithstanding such regulations, shift work can be organised in a variety of ways, in terms of shift length, overtime, weekly hours, rotating and/or permanent schedules. How shift patterns are organised play a key role in factors influencing nurses’ wellbeing and performance, as well as patient outcomes and health systems’ productivity [ 3 ].

For instance, shift work may require nurses to work overnight causing adverse health effects, such as increased sleepiness at the end of the shift [ 4 ] or disturbed sleep [ 5 ]. Shift work schedules can also have unintended consequences depending on whether they are rotating or permanent. Working permanent night shifts is associated with higher long-term sickness absence rates in comparison to day-shifts only [ 6 ]. In the same vein, working as part of a rotating schedule is associated with increased levels of acute fatigue [ 7 ], errors [ 8 ] and higher risks of alcohol consumption [ 9 ]. These factors can in turn jeopardise the quality of care.

While a three-shift pattern with two 8-hour day shifts and a night shift remains common, long shifts of 12 hours or more as part of a two-shift system have become standard in many countries including Ireland, Poland, the USA and increasingly in the UK [ 10 , 11 ]. Despite a number of claims that a two-shift system is more efficient, there is no evidence of productivity gain when working long shifts [ 12 ] and job dissatisfaction is higher among nurses working long shifts [ 11 , 13 , 14 ]. Working long shifts is also associated with nurses reporting reduced educational opportunities, fewer opportunities to discuss patient care [ 15 ], increased delayed or missed care [ 16 ] and higher (pneumonia) mortality rates [ 17 ] in comparison to shorter shifts. Nurses working long shifts are also more likely to experience burnout and report intention to leave in comparison to their counterparts [ 13 , 14 ].

Despite such adverse outcomes, some literature suggest certain nurses prefer working long shifts, as evidenced by their higher job and schedule satisfaction, as well as their lower emotional exhaustion level [ 18 ]. Preference for long shifts is also attributed to improved work-life balance [ 19 ], higher number of days off and opportunities for greater continuity of care [ 20 ]. However, the mechanisms explaining such preferences, how nurses experience these shift patterns, and how these shift patterns interact with other aspects of their life remains unclear.

The evidence on nurses’ subjective experience and preferences around shift patterns has not been summarised, as quantitative studies reporting associations dominate the field. In these studies, adverse experiences are indirectly inferred from (for example) reported associations between shift patterns and burnout. The purpose of such quantitative studies is generally not to capture nurses’ perspectives. Yet, insights from nurses’ perspective are key to better understand mechanisms of preference and choice around shift patterns. Studies where nurses’ perspectives are directly obtained (rather than inferred by the researcher) could shed further light on the contradictions arising from the quantitative body of evidence. Nursing staff form the largest group in the health workforce, and comprehending their experience and preferences around shift patterns is key to effectively improve nursing working conditions, enhance nurses’ job satisfaction and increase quality of care. This review focusses only on nurses because the experience of shift work is specific to the occupation and the context specific [ 21 ]. Therefore, the aim of this review is to examine and summarise the extent, range and nature of research activity on nurses’ subjective experience and preferences around shift patterns.

Because of our broad research question, we conducted a scoping review [ 22 , 23 ], aiming to summarise existing evidence and highlight gaps.

Search and inclusion/exclusion strategy

We searched CINAHL, Medline and Scopus with terms pertaining to nurses’ experience and preferences around shift patterns. Searches were undertaken up to April 2021. Table 1 provides a detailed list of the key terms that we used for the search. We limited our search to studies with an English language abstract. There was no restriction on the publication date to ensure the review of research was comprehensive.

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https://doi.org/10.1371/journal.pone.0256300.t001

Because we were interested in nurses’ experience and preferences around shift patterns from their perspective, we only included papers that contained explicit comments or views as reported by nursing staff, whilst excluding papers that made indirect inferences. Papers that were not specific to nursing, as well as news articles and opinions were excluded from the scoping review.

OE applied the inclusion/exclusion criteria to screen all titles and abstracts, after which CDO and PG reviewed the selections. All authors agreed that the sample of articles selected for full-text review were relevant for the research question. OE extracted data from relevant studies and met regularly with CDO and PE to discuss findings. It was during these meetings that the key concepts were discussed and refined. Any uncertainties about inclusions and exclusions were also discussed between OE, CDO and PG. The Prisma flow diagram describes the literature search and screening process in details ( Fig 1 ).

https://doi.org/10.1371/journal.pone.0256300.g001

To understand the landscape of the literature, we extracted publication date, respondents’ roles (i.e. registered vs unregistered nurse), working place and shift characteristics for each study. Using Excel ® , we tabulated a spreadsheet where results were recorded and organised by themes based on the authors’ findings. Using an iteration process by re-reading and analysing our results, we separated results based on the advantages and disadvantages of various shift patterns. Results reported on three core aspects of shift work, namely shift work per se , shift length and time of shift.

Firstly, we provide a description of our literature findings based on the number of articles published by date, geographic setting, clinical setting, research methodology and type/length of shift. Secondly, we use a narrative to synthetize the results of the scoping review based on the three aspects of shift work that emerged from the review.

Numerical analyses of included studies

Three thousand four hundred and six (N = 3,406) records were retrieved from the database searches ( Fig 1 ). 30 papers published between 1993 and 2021 were judged eligible. Half of the papers (n = 16) were published between 2018 and 2021. The largest group of papers came from the USA (n = 8). The UK (n = 7) and Australia (n = 6) had the second highest output. Other papers came from Asia (Iran, n = 2, China, n = 1, India, n = 1 and Cambodia, n = 1), other European countries (one each from Germany, Norway and Sweden respectively) and Canada (n = 1).

Most studies were undertaken with staff working in Acute Hospital wards (n = 27), 2 studies took place in Acute Mental Health Trusts and one study used staff from multiple settings (i.e. Acute Hospitals, Community Trusts and Care Home). The majority of papers included only registered nurses (RNs) (n = 23), whilst other papers included other nursing staff (healthcare assistant and other staff, n = 2, nursing assistant, n = 2, midwives, n = 1 and student nurse, n = 1). One paper focussed solely on unregistered healthcare staff (n = 1). The number of participants ranged between 10 [ 24 ] and 1355 [ 25 ], with female participants representing the majority of the sample.

Fifteen papers used semi-structured interviews. Four papers used questionnaire with open-ended questions and another four papers used qualitative interviews. Two papers used mixed-methods with a qualitative component and five papers used focus groups. Each paper included a discussion about nurses’ experiences and preferences around shift work from their perspective.

Overview of themes

The studies we found reported on three aspects of shift work: namely (i) shift work per se (e.g. the mere fact of working shift without referring to its length or time), (ii) shift length, and (iii) time of shift, referring to when shifts were occurring (i.e. morning, evening, or night); and, in some cases, whether these shifts were worked as part of a rotating or fixed schedule.

Discussions on shift work per se were never the focus of a whole study. Rather, nurses were in certain case describing the impact of shift work on their work or life without referring to the length or time. This concerns more than half of the studies (n = 18). When we consider the length of shift, studies focussing on long (12+ hour) shifts were more common (n = 8, including one study investigating 24-hour shifts, Koy, Yunibhand [ 26 ]). Seven studies compared 12 hour shifts with other lengths of shift, such as 4, 8 or 10 hours. In these studies, discussion and results were mainly focussed on 12 hours shifts, however. Studies focussing specifically on nurses working short shifts were less common (n = 2).

The third aspect of shift work describes shifts based on their occurrence during the day (n = 11), including studies with night shifts as sole focus (n = 9). The remaining studies (n = 4) described shifts as follows. Epstein, Söderström [ 27 ] used a basic shift description, such as ‘morning and evening’ or ‘morning, evening and night’. Gifkins, Loudoun [ 28 ] referred to nursing schedule as shift including ‘late night’ or ‘overnight work’. de Cordova, Phibbs [ 29 ] used the terminology off-shift (night and weekend), whilst Bauer [ 30 ] simply mentioned ‘early shift’ (6 to 7 am start) without indicating the overall number of hours of the shift worked. Table 2 provides a summary of all studies included in the scoping review.

https://doi.org/10.1371/journal.pone.0256300.t002

Findings from the review are summarised and presented according to these three aspects of shift work, namely shift work per se , shift length, and time of shift. Within each aspect of shift work the impacts of shift pattern on experience and preferences are discussed.

Shift work per se

An aspect discussed by nurses when reflecting on shift patterns was shift work per se , meaning the mere fact of working shifts as opposed to a regular “9 to 5” day job.

Nurses often reported detrimental mental and physical health as a result of working shifts, as well as failure to adopt healthy strategies, such as walking or exercising when working shifts [ 31 ]. Working shifts could also act as a barrier to healthy eating with nurses reporting unhealthy eating practices [ 32 , 33 ], such as overconsumption of caffeine and energy drinks, resulting in poor sleep and health outcomes [ 34 ]. Such habits could stem from different sources, including exhaustion and job-related stress which further exacerbated circadian rhythm disruption [ 33 ]. Notwithstanding the negative effect of shift work on nurses’ health and wellbeing, presenteeism (i.e. going to work when being sick resulting in lower engagement and productivity) was often brought up, in particular by nurses who are mothers. They reported feeling guilty about calling in sick, because staff shortages would mean that their shift would have to be covered by a colleague forced to do overtime [ 24 ]. This was amplified by nurses experiencing increased workload as a result of staff shortages during their shifts [ 25 , 26 , 35 , 36 ].

Nurses asserted that working shifts could in certain cases not be conducive for rest and napping [ 34 ] or restricting access to planned break periods [ 37 – 39 ]. Fatigue was often discussed in relation to shift work, and it was found to be exacerbated by working more than two consecutive long shifts [ 37 , 40 ]. Noticeably, nurses observed that the reduction in consecutive shifts decreased work absence [ 38 ]. Fatigue could be manifested by physical pain [ 41 ], difficulty to transition from day to night-time (and vice-versa) [ 42 ], reduced concentration [ 27 , 37 ], difficulty in taking decisions or emotional manifestation, such as being easily annoyed or unengaged during shift [ 27 ].

One study revealed that preference for shift work varied depending on the length of time (i.e. experience) in working shift [ 28 ]. Experienced nurses (i.e. at least three years of shift work experience) had a preference for shift work because it aided in their work-life balance. They benefited from the support of their family, friends and senior nurses which positively impacted on their domestic and children caring responsibilities. In contrast, inexperienced nurses reported being isolated and missing out on family and social activities, because friends (more often than family) did not always understand the time constraints of working shifts [ 28 ]. The ability to request for their own roster also helped nurses to cope with shift work [ 28 ]. Relatedly, nurses choosing their own roster were more satisfied with their job [ 43 ]. In contrast, nurses were more reluctant to accept, adapt or prefer a particular shift pattern when it was mandatorily imposed [ 26 , 37 , 44 ].

One study by Gao et al. [ 35 ] offered a perspective on how the experience of shift work was affected by the COVID-19 pandemic. As a result of the increase in patient numbers and their acuity, and, consequently in workload, nurses highlighted the need to adjust shift patterns dynamically according to the workload. They also emphasised the importance to account for nurses’ knowledge, skills and abilities during shift scheduling, as well as considering their physical and mental experience [ 35 ]. Based on their shift experiences during the COVID-19 pandemic, nurses asserted that their perspectives should be taken into consideration to humanise shift patterns. Besides, communication between managers and front-line nurses should be strengthened to understand nurse perspective when scheduling shift schedules [ 35 ].

Shift length

Nurses reflected on their experience and preferences around the length of shifts. Our review report on two main lengths of shift, short shifts (<12 hours), including 4-hours [ 35 ], 8- or 10-hour shifts; and long shifts (≥ 12 hours and more), including one study focussing on 24-hour shifts [ 26 ].

A factor discussed by nurses in relation to different shift lengths was handovers. Studies consistently highlighted how nurses believe the additional handovers resulting from shorter shifts posed a threat to safety in terms of miscommunication of patient information. One study found that nurses were concerned about the additional handover when moving from long to short shifts, such that the information did not always reach the next shifts [ 36 ]. Nurses believed the introduction of an additional handover as a result of moving to 8 hour shifts had led to a higher risk of information being miscommunicated, similar to a Chinese Whispers effect [ 36 ]. When the length of shifts was reduced from 8 to 4-hour during the COVID-19 pandemic, nurses described how they felt shorter shifts had led to more handover errors [ 35 ]. In another study, nurses reported that communication with all levels of senior staff improved, probably as a result of the extra time that long shifts offered [ 45 ]. However, not all studies concluded that long shifts were beneficial to improve communication. One study mentioned that implementing long shifts led to a disruption in communication with colleagues [ 38 ].

The loss of one handover when implementing 12 hour shifts limited opportunities for clinical education [ 38 ]. It also led to a decrease in informal social support, reduced opportunities for sharing good practices and reflection time. Nurses reported being more isolated, because core staff increasingly worked alongside agency staff which worsened collegiality [ 46 ]. In contrast, in one study, nurses reported an increased access to professional development education after 12 hour shifts were introduced. The higher rate of professional development leave was supported by organisational data [ 45 ]. One study highlighted how the ability to study was affected by the subsequent tiredness after working long shifts [ 47 ]. In some instances, the introduction of 12 hour shifts also reduced nurse confidence in their clinical skills and knowledge following extended time away from a dynamic ward environment [ 44 , 46 ]. Nurses working short shifts also declared having limited access to education, teaching or staff development as a result of work intensity [ 36 ].

Nurses believed there had been an increase in staff turnover after 8 hour shifts were imposed, because staff did not like or did not adapt to the new shift pattern [ 36 ]. Some nurses feared 12 hour shifts would cause recruitment challenges of adequately trained nurses [ 47 ]. In contrast, another study reported that nurses believed 12 hour shifts would improve retention of experienced staff due to the shift flexibility and ability to increase nurses’ morale, possibly because those nurses reported a strong preference for this shift pattern [ 45 ]. Relatedly, some nurses believed the implementation of long shifts had improved staffing levels, with more nurses available during the shifts [ 38 ].

Across different studies there were contrasting results for nurses’ views about the impact of long shifts on the quality and continuity of care after 12 hour shifts were implemented. Long shifts were perceived by unregistered healthcare staff [ 37 ] and nurses to improve patient and continuity of care [ 38 , 41 , 42 , 45 , 46 , 48 , 49 ]. The implementation of long shifts rendered possible the full completion of their nursing tasks, as evidenced by fewer interruptions of work tasks and the possibility to focus on their tasks for longer [ 41 , 42 ]. Nurses perceived improved communication with patients [ 42 ], as they were able to care for the same patients throughout their shifts [ 48 ]. They also reported achieving more nursing care with their patients resulting from the extra time long shifts offered [ 37 , 41 , 42 ].

However, in a few studies nurses reported a deterioration in the quality of care they were delivering in the last (four) hours of the shifts [ 47 ]. Nurses also had mixed views about the effect of short or long shifts on quality of care, stating their uncertainty about which shifts improved patient care [ 36 , 40 ]. Nurses reported that the introduction of 12 hour shifts amplified their job strain and left some nursing tasks incomplete because of the intensity of work over an extended period of time [ 46 ]. Another study revealed that frequent changes in assignments during long shifts could negatively impact continuity of care, as nurses could not complete their nursing care with the same patients throughout their shifts [ 48 ]. The perceived increase in continuity of care over time, in the control over nursing tasks completion, and in the improved communication with patients as reasons for preferring 12 hour shifts [ 37 , 42 ].

Fatigue (or tiredness) was a feature reported by nurses across all shift lengths, suggesting nurse endure a physical burden when working shifts irrespective of their length. Nursing staff working short [ 37 , 43 ] and long shifts [ 27 , 38 , 40 – 42 , 44 , 47 – 49 ] reported experiencing fatigue when working shifts. Nurses reported having to pace themselves to complete their shifts, reflecting the necessity for increased physical, mental and emotional stamina when working long shifts [ 44 , 46 ]. Exhaustion during and after working long shifts was also a common feature reported by nurses [ 26 , 33 , 44 ]. They described that working long shifts led to burnout, reduction in physical and mental health [ 49 ].

Nurses’ sleep patterns were reported to be negatively affected by both short [ 43 ] and long shifts alike [ 27 , 33 ], apart for one study where nurses reported an increase in their sleep hours after moving to 12 hour shifts [ 45 ]. Some nurses working 12 hour shifts reported fatigue was more manageable since they benefited from more days off-work to recover [ 38 , 45 , 47 ]. In one study, some nurses recognised that fatigue was an adverse effect of long shifts, but they found this was mitigated by the increased number of days off-work [ 46 ]. The extra days off and improved work-life balance were often mentioned as the reason for a preference for long shifts [ 36 , 38 , 41 , 42 , 44 – 49 ]. Work-life balance was also positively rated by nurses working 8 hour shifts [ 49 ]. Noticeably, one study reported that nurses’ views of shift length on their leisure was mixed. The contrast may stem from the fact that the population of interest were student nurses, whose educational commitments may restrict their leisure time [ 47 ].

Long shifts was associated with anticipated anxiety to return to work, where nurses apprehended returning to a challenging and unpredictable workplace [ 44 ]. Stress could also stem from the changes in skill mix resulting from the implementation of 12 hour shifts. For instance, nurses’ supervision increased as a result of using extensive agency and bank staff to cover for sickness absence. Indeed, these temporary staff were unfamiliar with the ward and needed more support from substantive staff [ 44 ]. In contrast, in one study nurses felt that working long shifts reduced sickness and/or family leave, as nurses could benefit from extra days off work [ 45 ]. Nurses also reported being able to take more planned breaks when working long shifts [ 41 , 42 ], albeit this was dependent on patient acuity and case mix [ 38 ].

Whilst two studies revealed nurses were satisfied or had a preference for short shifts [ 42 , 49 ], more studies showed nurses preferring long shifts [ 37 , 38 , 41 , 45 , 47 , 49 ]. Acceptance of 12 hour shifts was facilitated when staff were consulted prior to moving to long shifts, and, in some cases, when the request to change to 12 hour shifts came from staff themselves [ 41 , 45 , 47 ]. Individual characteristics and personal circumstances (e.g. age, marital status, grade or presence of children) influenced the extent to which nurses could adapt to the new shift patterns. For instance, the strain of long shifts on wellbeing was particularly intense for older nurses [ 25 , 44 , 46 ]. A further predictor of adaptation to 12 hour shifts was public healthcare commitment: when nursing staff were devoted to the National Health Service (NHS) and their Trust, nurses expressed they accepted the move to 12 hour shifts because they wanted to be helpful towards a struggling sector and employer [ 46 ]. Furthermore, nurses reported wanting to be seen to be coping with long shifts as a means of improving their team’s morale [ 46 ]. Nurses also reported that childcare costs were reduced when working long shifts as they allowed them to spend more days at home caring for their children [ 42 ].

Time of shift

Nurses working night shifts described how the lack of resources, for example other healthcare professionals and administrative staff, led to higher collaboration among them, higher sense of cohesion and better teamwork [ 25 , 29 ], but also led to difficulty to taking their breaks [ 50 ]. Nurses working night shifts experienced increased autonomy and fewer interruptions to planned healthcare as a result of fewer family visits [ 25 , 51 ]. More specifically, working night shifts allowed nurses to carry out indirect (e.g. administrative) as well as direct clinical patient care with more autonomy [ 25 ]. Relatedly, night working enabled nurses to feel more independent and more skilled, fostering their desire to continue working at night [ 32 , 52 ].

However, lack of resources and of support from other professionals during the night shift led to significant concerns for nursing staff, who reported feeling not considered and appreciated by staff on day shifts [ 51 ]. Communication problems between day and night shift nurses could occur, where night nurses felt disconnected from and neglected by day nurses, and struggled to access relevant (patient) information [ 25 ]. They perceived their role as under-appreciated by other nurses [ 29 ], referring to a universal consensus that night shift nurses are perceived to be practising less or not all [ 51 ]. Some nurses experienced fear and insecurity in the last hours of their night shifts resulting from lack of resources [ 52 ], exacerbating worries around patient and professional safety [ 25 ]. Other nurses denounced inferior working conditions in comparison to their daytime counterparts, including a perception of minimal leadership [ 51 ], as well as a lack of welfare facilities [ 52 ]. Staffing levels and skill mix were also discussed in relation to night work; night shifts were often covered by temporary staff, and substantive staff felt this was a positive thing because staffing levels could be maintained [ 29 ].

Nurses working night shifts valued patient care, as evidenced by the importance they placed in knowing their patients’ conditions and care needs [ 51 ]. Nurses’ sense of duties and responsibilities firstly towards their patients also meant they could neglect taking their breaks [ 50 ]. The more ‘relaxed’ pace during weekend day shifts allowed nurses to focus more on their patients [ 29 ]. However, nurses reported that staffing levels were often inadequate at night [ 25 ] or workload was too high [ 51 ]; leading staff to report that the quality of care they delivered was negatively affected. Inexperienced nurses (less than one year nursing experience) perceived increased work pressure when working night shifts [ 52 ]. Relatedly, nurses experienced tremendous workload when working early shifts, which rendered the work unappealing altogether [ 30 ]. Nurses working off-shifts (night and weekend) also revealed they completed more tasks as a result of inadequate staffing level during these shifts [ 29 ].

Nights shifts gave rise to educational and clinical learning opportunities from which nurses benefited [ 25 , 32 , 52 ]. Nurses stated that night shifts were more relaxed and some e-learning not available during the day were available at night [ 25 ]. In contrast, nurses also reflected on the conundrum of night shifts where their learning opportunities were perceived as suboptimal. This was evidenced by a reduced or lack of education access in comparison to their daytime counterparts, despite added responsibility [ 51 ].

Depression, tiredness [ 31 ] and fatigue were experienced by nurses working night [ 25 , 51 , 52 ] and day (including evening) [ 27 ] shifts. Nurses working night shifts also experienced drowsy driving after completing their shifts [ 53 ]. Nurses adopted unhealthy strategies to combat fatigue and adapt to late or night shifts. This included caffeinated drinks and snacking on sugary foods, as well as drinking alcohol to rest and recover after night shifts [ 27 , 28 , 39 ]. Most common strategies to combat drowsy driving after night shifts included listening to music, talking on the phone with relatives, as well as unhealthy snacking [ 53 ]. Nurses working early shift also reported being exhausted, as evidenced by their physiological system not being used to start working so early [ 30 ].

Nurses asserted their sleep patterns were negatively affected by both early [ 30 ] and night shifts [ 25 , 27 , 31 , 32 , 52 ]. Sleep deprivation stemmed from nurses’ inability to rest between late to early shifts [ 30 ], insomnia [ 52 ], feeling sleep-deprived while working or the difficulty to achieve a normal sleep pattern after the completion of night work [ 25 ]. Nurses reported suffering from anxiety, nutritional imbalance, changed physical appearance and skin pigmentation as a result of working night shifts [ 32 ]. Early shifts also caused anticipated anxiety to return to work, with nurses finding difficult to disconnect from work and over-processing their nursing tasks while at home [ 30 ]. Stress could also results from dysfunctional organisational structures or poor workplace conditions when nurses worked night shifts [ 52 ].

Nurses worked a variety of shift work schedules (i.e. permanent or rotating) and preferences for shift patterns could vary depending on the shift work schedules they were assigned to. For instance, there is evidence nurses preferred working permanent night shifts in comparison to rotating shifts [ 24 , 25 , 31 ]. And there is also evidence that nurses working night shifts on a permanent basis were satisfied with this shift pattern [ 29 ]. Whilst working night shifts was exhausting, it also gave nurses a sense of fulfilment [ 32 ]. Nurses stated that the environment was more relaxed at night, as evidenced by reduced noise, fewer nursing task interruptions and increased focus-thinking time.

Nurses were able to care for their family when working late or night shifts, despite financial and non-financial constraints for single-parent families [ 25 ], or pervasive fatigue [ 51 ]. For instance, nurses working night shifts declared benefiting from shared parental responsibility and their presence at home during the day meant they avoided using after-school care [ 25 ]. However, nurses also described their sense of guilt when leaving their children to work night shifts, as well as the difficulty in co-ordinating their family and social life [ 24 ]. Working early [ 30 ] or night shifts could also result in nurses being or feeling isolated from family and friends due to unsociable working hours [ 25 , 28 , 31 , 51 , 52 ].

This is, to our knowledge, the first scoping review to provide a comprehensive overview of research on nurses’ experiences and preferences around shift patterns in the nursing literature. A broad range of international studies were found and included, reflecting the global interest in understanding nurses’ perspectives when reflecting on the impact of shift patterns. Findings mostly focussed on either the mere fact of working shifts, the length of shifts or the time of shift, although issues such as number of days worked in a row and ability to choose shifts also emerged. We found that all different aspects of shift work elicited a variety of positive and negative views from nursing staff, with no single shift pattern described as without limitations. In the same vein, we found that some topics or issues reported by nurses align or contrast with the corresponding quantitative evidence on nursing shifts ( Table 3 ).

https://doi.org/10.1371/journal.pone.0256300.t003

For example, exhaustion, physical and mental fatigue were outcomes reported by all nurses engaged in working shifts, regardless of their length or time of day. Quantitative research has shown that fatigue increases with the length of shift [ 57 ] and is more acute when nurses work during their days off [ 56 ]. Inter-shift fatigue (i.e. not feeling recovered from previous shift at the start of the next shift) is also prominent among nurses [ 4 ]. In our review, fatigue and exhaustion were recurring outcomes identified across all shift patterns, and they were further exacerbated by high number of consecutive shifts and the COVID-19 pandemic. Notwithstanding the frequent reports of fatigue, nurses did not seem to deploy effective coping systems. For example, studies reported how nurses resorted to unhealthy eating and drinking to survive night and/or long shifts. In addition, a number of studies highlighted how even when fatigued or ill, nurses expressed a sense of guilt towards colleagues and patients and a need to self-sacrifice, which led nurses to work when sick (i.e. presenteeism) and to miss breaks during their shifts.

This feeling of obligation towards colleagues, patients and the healthcare system is well reflected in recent studies [ 78 ] and it exemplifies the “Supernurse” culture [ 79 ], according to which nurses feel they need to sacrifice themselves, their health or their children’s health [ 24 ] for the greater good (i.e. the nursing team and/or their patients). This is a major barrier to nurses taking their breaks, calling in sick when needed and, consequently, to reducing their fatigue levels. This might be further exacerbated by the fact that the majority of nurses are women, including mothers, who feel pressured to juggle their work and childcare responsibilities [ 80 ]. Whilst fatigue was often mentioned by nurses, there was little description of their experience of fatigue. Capturing fatigue levels and its manifestation from a subjective perspective is essential, and any interventions that modify shift patterns should consider how fatigue could be impacted from the nurses’ perspective. Having enough days off to recover from shift work-related fatigue was noted in several studies. Changes and adaptations to shift patterns should consider the sequencing of days off between shifts and the cumulative number of days worked and not simply the total days off within the (arbitrary) seven day week.

We found that personal characteristics including age, length of experience, and caring responsibilities affected the experience and preferences around different shift patterns. While these were often mentioned by nurses, there was no discussion on how such personal characteristics represented a constraint for nurses when choosing or working shifts. Further research may explore the extent to which personal circumstances are constraining nurses when choosing or working shifts. Especially considering the evidence that personal circumstances are not consistently taken into account by health services when designing rotas, which are often designed based primarily on service demands rather than staff needs [ 46 , 58 , 59 ].

The majority of the studies included in this review were conducted in Acute Care Hospitals, indicating there is a dearth of investigation of nurses’ experiences and preferences around shift patterns in other settings. These include community and mental health hospitals. Research conducted in these areas is needed, as experiences of nurses working in those settings may differ significantly from those in acute care hospitals.

The perceived impact of shift patterns on patient care and capacity building was inconclusive, with nurses stating both negative and positive views. Some nurses reported higher continuity of care, and a lower risk of information being miscommunicated when working long shifts. In contrast, nurses in some studies felt that continuity was decreased because they were away from the ward for longer due to having more days off. Other studies found no evidence that nurses working 12 hour shifts reported improved continuity of care and less miscommunication of information compared to nurses working shorter shifts [ 15 ]. Similarly, there were contrasting views when it came to educational opportunities and shift length. Yet, an observational study found that nurses working 8 hour shifts reported having more education opportunities in comparison to those 12 hour shifts [ 15 ]. Large observational studies also show that nurses working 12 hour shifts are less likely to report high quality care or improving safety on their wards compared to those working shorter shifts [ 10 , 68 ].

We found that nurses tend to prefer shift patterns when they were involved in designing those shift patterns, or, even more, when changes had been adopted based on requests from staff. Two studies captured nurses’ preferences for long shifts using a longitudinal design, enabling to elicit nurses’ preferences before, during and after the implementation of 12 hour shifts [ 41 , 44 ]. Results confirmed that the mandatory imposition of changes in shift patterns [ 44 ] in contrast to a voluntary approach [ 41 ] increased the likelihood of nurses disapproval. Having choice and flexibility around shift patterns is a known predictor of increased wellbeing and health [ 65 , 81 ]. Hence, interventions aimed at modifying shift patterns should consider involving nursing staff to maintain a certain degree of choice.

Our findings that many nurses prefer long shifts and believe working long shifts does not affect patient care largely contradicts the quantitative evidence, where those working long shifts are likely to report lower quality of care and job satisfaction and higher levels of burnout [ 10 , 13 , 14 , 68 ]. Higher rates of sickness absence have also been reported for nurses working 12 hour shifts [ 63 ]. This contrast between qualitative and quantitative evidence needs further exploring; specifically, further research is required to better understand the mechanisms that lead nurses to prefer some shifts, for example whether a higher degree of choice around shift patterns is a consistent moderating factor for the negative outcomes of long shifts for either staff or patients. Previous research does not seem to indicate this [ 82 ], but a deeper investigation including triangulation of roster data and qualitative reports might shed more light.

The evidence from large observational studies does not directly link individual preferences for shifts with patient and care outcomes [ 62 , 83 ], but it could be that nurses exercise choice for shift patterns that lead to less favourable working conditions because of external considerations, such as childcare. The need to accommodate responsibilities such as childcare might explain why nurses could sacrifice job satisfaction in order to balance demands. This could explain some of the apparent contradiction between these two bodies of research, such that nurses could prefer particular shifts despite the association with occupational burnout and decreased job satisfaction. Indeed, the staff themselves may not make the direct attribution even if their shift patterns played a causal role.

Whilst the scoping review has shed some light on nurses’ experiences and preferences around shift patterns, our study is not without limits. Following the scoping review process, we did not conduct a systematic appraisal of the qualities of studies [ 22 ]. Whilst this approach widens the scope of studies included in the review, it may also bias the conclusion of our findings as the strength of the evidence is not being assessed. Noticeably, we also found that most studies come from the USA, UK and Australia, and these findings might not apply to nurses working in other parts of the world. As expected in qualitative research, the sample size may appear small, but since generalisability was not the focus of our work, the themes identified in our work are still a valuable starting point that merits further investigation. However, the scoping review provides an overview of the topic under consideration, including the gaps in the literature.

Across all shift patterns, nurses describe how they strive to deliver high quality of care and resort to various mechanisms to cope with an ever-changing and demanding work environment. From the current literature, it is evident that shift patterns are often organised in ways that are detrimental to nurses’ health and wellbeing, to their job performance, and consequently, to the patient care they provide. Our findings highlight a number of factors that may be important in influencing nurses’ choice of shift patterns and the resulting outcomes for quality of care and the staff themselves.

While important issues such as individual differences, accommodating preferences and the need to manage fatigue are highlighted by these findings, it is not clear how best to organise shifts. The mixed findings on experience and preference for both long shifts and night work are in contrast with observational studies that show long shifts to be associated with adverse outcomes. Further research should explore the extent to which nurses’ preferences are considered when choosing or being imposed shift work patterns. Research should also strive to better describe and address the constraints nurses face when it comes to choice around shift patterns, including childcare or any other caring responsibilities, as well as individual factors such as age, with the aim to consider these constraints when restructuring shift patterns.

Supporting information

S1 checklist. prisma-p 2015 checklist..

https://doi.org/10.1371/journal.pone.0256300.s001

https://doi.org/10.1371/journal.pone.0256300.s002

• 1. European Commission. Working Conditions—Working Time Directive 2021. https://ec.europa.eu/social/main.jsp?catId=706&langId=en&intPageId=205 .
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Integrative Review

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The impact of whole of patient nursing assessment frameworks on hospital inpatients: A scoping literature review

• School of Nursing and Midwifery

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

Introduction: A comprehensive patient assessment is essential for safe patient care. Patient assessment frameworks for nurses are generally restricted to patients who already have altered vital signs and are at risk of deterioration, or to specific risks or body systems such as falls, pressure injury and the Glasgow Coma Score. Comprehensive and structured evidence-based nursing assessment frameworks that consider the whole patient and extend beyond vital signs, specific risks and single systems are not routinely used in inpatient settings but are important to establish early risks for patient deterioration. Aim: The aim of this review was to identify nursing assessment tools or frameworks used to holistically assess hospitalized patients and to identify the impact of these tools on patient and health service outcomes. Methods: A scoping literature review was conducted. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Dissertations and Thesis, Embase and Scopus were databases used in the search. The initial search was conducted in August 2021 and repeated in November 2022. No date parameters were set. The Participants, Concept, Context (PCC) framework was used to guide the development of the research question and consolidate inclusion and exclusion criteria. The PRISMA-ScR Checklist Item was followed to ensure a methodologically sound checklist was used. Results: Ten primary research studies evaluating six nursing assessment frameworks were included. Of the five nursing assessment frameworks, none were explicitly designed for general ward nursing, but rather the emergency department or specific patient cohorts, such as oncology. Four studies reported on reliability and/or validity; two reported on patient outcomes and four on staff satisfaction. Conclusion: Evidence-based nursing patient assessment frameworks for use in general inpatient wards are lacking. Existing assessment tools are largely designed for specific patient cohorts, specific body systems or the already deteriorating patient. Implications for the Profession and Patient Care: A framework to enable a structured approach to patient assessment in this environment is needed for patient safety, consistency in assessment, nursing staff enablement and confidence to escalate care. Routine systematic nursing assessment could also aid timely patient escalation. Impact: What problem did the study address? This study addresses the lack of evidence-based nursing assessment frameworks for use in hospitalized patients. The impact of this is that it highlights the need for an evidence-based, whole of patient assessment framework for use by nurses for patients admitted to a ward environment. What were the main findings? This review identified limited comprehensive, patient assessment frameworks for use in general ward inpatient areas. Those identified were not validated for this patient cohort and are aimed at patients already deteriorating. Where and on whom will the research have an impact? This review has the potential to impact future research and patient care. It highlights that most research is focussed on processes to detect and escalate care for the already deteriorating patient. There is a need for an evidence-based routine nursing assessment framework for patients admitted to a ward environment to promote positive patient outcomes and prevent deterioration. Patient and Public Contribution: This review contributes to existing knowledge of nursing patient assessment frameworks, yet it also highlights several gaps. Currently, there are no known, validated, holistic, structured nursing patient assessment frameworks for use in general ward inpatient settings. However, areas that do use such assessment frameworks (e.g. the emergency department) have shown positive patient outcomes and staff usability. Hospitalized ward patients would benefit from routine, structured nursing assessments targeting positive patient outcomes prior to the onset of deterioration.

• assessment framework
• assessment tool
• nursing assessment
• patient assessment
• patient deterioration
• scoping review
• ward nursing

Access to Document

• 10.1111/jan.16025 Licence: CC BY-NC-ND

Other files and links

• Link to publication in Scopus

T1 - The impact of whole of patient nursing assessment frameworks on hospital inpatients

T2 - A scoping literature review

AU - Wiseman, Taneal

AU - Kourouche, Sarah

AU - Jones, Tamsin

AU - Kennedy, Belinda

AU - Curtis, Kate

N1 - Publisher Copyright: © 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

N2 - Introduction: A comprehensive patient assessment is essential for safe patient care. Patient assessment frameworks for nurses are generally restricted to patients who already have altered vital signs and are at risk of deterioration, or to specific risks or body systems such as falls, pressure injury and the Glasgow Coma Score. Comprehensive and structured evidence-based nursing assessment frameworks that consider the whole patient and extend beyond vital signs, specific risks and single systems are not routinely used in inpatient settings but are important to establish early risks for patient deterioration. Aim: The aim of this review was to identify nursing assessment tools or frameworks used to holistically assess hospitalized patients and to identify the impact of these tools on patient and health service outcomes. Methods: A scoping literature review was conducted. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Dissertations and Thesis, Embase and Scopus were databases used in the search. The initial search was conducted in August 2021 and repeated in November 2022. No date parameters were set. The Participants, Concept, Context (PCC) framework was used to guide the development of the research question and consolidate inclusion and exclusion criteria. The PRISMA-ScR Checklist Item was followed to ensure a methodologically sound checklist was used. Results: Ten primary research studies evaluating six nursing assessment frameworks were included. Of the five nursing assessment frameworks, none were explicitly designed for general ward nursing, but rather the emergency department or specific patient cohorts, such as oncology. Four studies reported on reliability and/or validity; two reported on patient outcomes and four on staff satisfaction. Conclusion: Evidence-based nursing patient assessment frameworks for use in general inpatient wards are lacking. Existing assessment tools are largely designed for specific patient cohorts, specific body systems or the already deteriorating patient. Implications for the Profession and Patient Care: A framework to enable a structured approach to patient assessment in this environment is needed for patient safety, consistency in assessment, nursing staff enablement and confidence to escalate care. Routine systematic nursing assessment could also aid timely patient escalation. Impact: What problem did the study address? This study addresses the lack of evidence-based nursing assessment frameworks for use in hospitalized patients. The impact of this is that it highlights the need for an evidence-based, whole of patient assessment framework for use by nurses for patients admitted to a ward environment. What were the main findings? This review identified limited comprehensive, patient assessment frameworks for use in general ward inpatient areas. Those identified were not validated for this patient cohort and are aimed at patients already deteriorating. Where and on whom will the research have an impact? This review has the potential to impact future research and patient care. It highlights that most research is focussed on processes to detect and escalate care for the already deteriorating patient. There is a need for an evidence-based routine nursing assessment framework for patients admitted to a ward environment to promote positive patient outcomes and prevent deterioration. Patient and Public Contribution: This review contributes to existing knowledge of nursing patient assessment frameworks, yet it also highlights several gaps. Currently, there are no known, validated, holistic, structured nursing patient assessment frameworks for use in general ward inpatient settings. However, areas that do use such assessment frameworks (e.g. the emergency department) have shown positive patient outcomes and staff usability. Hospitalized ward patients would benefit from routine, structured nursing assessments targeting positive patient outcomes prior to the onset of deterioration.

AB - Introduction: A comprehensive patient assessment is essential for safe patient care. Patient assessment frameworks for nurses are generally restricted to patients who already have altered vital signs and are at risk of deterioration, or to specific risks or body systems such as falls, pressure injury and the Glasgow Coma Score. Comprehensive and structured evidence-based nursing assessment frameworks that consider the whole patient and extend beyond vital signs, specific risks and single systems are not routinely used in inpatient settings but are important to establish early risks for patient deterioration. Aim: The aim of this review was to identify nursing assessment tools or frameworks used to holistically assess hospitalized patients and to identify the impact of these tools on patient and health service outcomes. Methods: A scoping literature review was conducted. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Dissertations and Thesis, Embase and Scopus were databases used in the search. The initial search was conducted in August 2021 and repeated in November 2022. No date parameters were set. The Participants, Concept, Context (PCC) framework was used to guide the development of the research question and consolidate inclusion and exclusion criteria. The PRISMA-ScR Checklist Item was followed to ensure a methodologically sound checklist was used. Results: Ten primary research studies evaluating six nursing assessment frameworks were included. Of the five nursing assessment frameworks, none were explicitly designed for general ward nursing, but rather the emergency department or specific patient cohorts, such as oncology. Four studies reported on reliability and/or validity; two reported on patient outcomes and four on staff satisfaction. Conclusion: Evidence-based nursing patient assessment frameworks for use in general inpatient wards are lacking. Existing assessment tools are largely designed for specific patient cohorts, specific body systems or the already deteriorating patient. Implications for the Profession and Patient Care: A framework to enable a structured approach to patient assessment in this environment is needed for patient safety, consistency in assessment, nursing staff enablement and confidence to escalate care. Routine systematic nursing assessment could also aid timely patient escalation. Impact: What problem did the study address? This study addresses the lack of evidence-based nursing assessment frameworks for use in hospitalized patients. The impact of this is that it highlights the need for an evidence-based, whole of patient assessment framework for use by nurses for patients admitted to a ward environment. What were the main findings? This review identified limited comprehensive, patient assessment frameworks for use in general ward inpatient areas. Those identified were not validated for this patient cohort and are aimed at patients already deteriorating. Where and on whom will the research have an impact? This review has the potential to impact future research and patient care. It highlights that most research is focussed on processes to detect and escalate care for the already deteriorating patient. There is a need for an evidence-based routine nursing assessment framework for patients admitted to a ward environment to promote positive patient outcomes and prevent deterioration. Patient and Public Contribution: This review contributes to existing knowledge of nursing patient assessment frameworks, yet it also highlights several gaps. Currently, there are no known, validated, holistic, structured nursing patient assessment frameworks for use in general ward inpatient settings. However, areas that do use such assessment frameworks (e.g. the emergency department) have shown positive patient outcomes and staff usability. Hospitalized ward patients would benefit from routine, structured nursing assessments targeting positive patient outcomes prior to the onset of deterioration.

KW - assessment framework

KW - assessment tool

KW - nursing assessment

KW - patient assessment

KW - patient deterioration

KW - scoping review

KW - ward nursing

UR - http://www.scopus.com/inward/record.url?scp=85179738399&partnerID=8YFLogxK

U2 - 10.1111/jan.16025

DO - 10.1111/jan.16025

M3 - Review Article

C2 - 38097522

AN - SCOPUS:85179738399

SN - 0309-2402

JO - Journal of Advanced Nursing

JF - Journal of Advanced Nursing

• Open access
• Published: 03 August 2024

Behavioral change interventions, theories, and techniques to reduce physical inactivity and sedentary behavior in the general population: a scoping review

• Houda El Kirat   ORCID: orcid.org/0000-0003-0804-4545 1 , 2 ,
• Sara van Belle 3 ,
• Asmae Khattabi 1 , 2 &
• Zakaria Belrhiti   ORCID: orcid.org/0000-0002-0115-682X 1 , 2  

BMC Public Health volume  24 , Article number:  2099 ( 2024 ) Cite this article

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Worldwide, physical inactivity (PIA) and sedentary behavior (SB) are recognized as significant challenges hindering the achievement of the United Nations (UN) sustainable development goals (SDGs). PIA and SB are responsible for 1.6 million deaths attributed to non-communicable diseases (NCDs). The World Health Organization (WHO) has urged governments to implement interventions informed by behavioral theories aimed at reducing PIA and SB. However, limited attention has been given to the range of theories, techniques, and contextual conditions underlying the design of behavioral theories. To this end, we set out to map these interventions, their levels of action, their mode of delivery, and how extensively they apply behavioral theories, constructs, and techniques.

Following the scoping review methodology of Arksey and O’Malley (2005), we included peer-reviewed articles on behavioral theories interventions centered on PIA and SB, published between 2010 and 2023 in Arabic, French, and English in four databases (Scopus, Web of Science [WoS], PubMed, and Google Scholar). We adopted a framework thematic analysis based on the upper-level ontology of behavior theories interventions, Behavioral theories taxonomies, and the first version (V1) taxonomy of behavior change techniques(BCTs).

We included 29 studies out of 1,173 that were initially screened/searched. The majority of interventions were individually focused ( n  = 15). Few studies have addressed interpersonal levels ( n  = 6) or organizational levels ( n  = 6). Only two interventions can be described as systemic (i.e., addressing the individual, interpersonal, organizational, and institutional factors)( n  = 2). Most behavior change interventions use four theories: The Social cognitive theory (SCT), the socioecological model (SEM), SDT, and the transtheoretical model (TTM). Most behavior change interventions (BCIS) involve goal setting, social support, and action planning with various degrees of theoretical use (intensive [ n  = 15], moderate [ n  = 11], or low [ n  = 3]).

Discussion and conclusion

Our review suggests the need to develop systemic and complementary interventions that entail the micro-, meso- and macro-level barriers to behavioral changes. Theory informed BCI need to integrate synergistic BCTs into models that use micro-, meso- and macro-level theories to determine behavioral change. Future interventions need to appropriately use a mix of behavioral theories and BCTs to address the systemic nature of behavioral change as well as the heterogeneity of contexts and targeted populations.

Peer Review reports

Currently, physical inactivity (PIA) and sedentary behavior (SB) are considered global health challenges hampering the achievement of the United Nations' (UN) third sustainable development goal (SDG). PIA and SB are responsible for 1.6 million deaths per year (27% due to diabetes and 20% due to cardiovascular disease [CVD]) [ 1 ]. More than 31% of premature deaths attributed to non-communicable diseases (NCDs) occur in physically inactive populations and are responsible for US $54 billion per year of direct care costs and US $14 billion per year of indirect costs (i.e., a loss of productivity) [ 1 ].

It is important to differentiate between three unique concepts: physical activity (PA), PIA, and SB. The WHO defines PA as “ any bodily movement produced by skeletal muscles that requires energy expenditure.” The WHO defines PIA as any activity below the threshold of 150 min per week of moderate or vigorous PA. SB is defined as any waking behavior that leads a person to consume 1.5 metabolic equivalents or less (e.g., sitting, reclining, or lying down) [ 2 ].

A recent meta-analysis revealed that prolonged SB is associated with an elevated risk of morbidity and mortality from NCDs. This risk can be reduced or even eliminated by engaging in PA. However, if SB is very high (SB time exceeding 7 h) the risk of mortality and morbidity from NCDs is independent of the level of PA [ 3 ]. Both PIA and SB carry a high risk of developing an NCD. PIA is a major risk factor for CVD [ 4 ], type 2 diabetes [ 5 ], high blood pressure [ 6 ], cancer [ 7 ] and drug use [ 8 ]. However, SB is associated with a 30% increase in CVD [ 9 ] as well as a 55% increase in the risk of endometrial cancer [ 10 ] and elevated blood pressure [ 11 ]. These risks are exacerbated when combined with insufficient PA [ 12 ]. Thus, interventions aimed at reducing PIA and SB are estimated to reduce the risk of CVD, type 2 diabetes, depression, and cancer by 35%, 40%, and 35%, respectively [ 1 ].

In recent years, increased attention has been given to designing combined interventions, targeting both PIA and SB, to appropriately prevent and contribute to the management of NCDs for better health and well-being outcomes [ 13 ]. These interventions need to involve behavioral changes and to be informed by behavioral theories according to the WHO and other global health institutions, communities of researchers, practitioners, and policymakers [ 14 , 15 , 16 , 17 ].

Behavioral theories and Behavior Change Techniques (BCT)

Behavioral theories explain why, when, and how an individual behavior does (or does not) occur. They highlight that the mechanism of change at play, if targeted, will alter the behavior at the individual, interpersonal, or community level. These mechanisms are central to the design of theory-informed behavior change interventions (BCI) [ 19 ], which are complex social adaptive systems (e.g., multiple health behavioral change interventions (BCIs) targeting simultaneously or sequentially two or more health behaviors, that comprise interacting components and sensitivity to context, with emergent intended and unintended effects at different levels: the individual, interpersonal, community (organizational, environmental, national, and global) levels [ 20 , 21 , 22 , 23 ].

According to Hayden [ 24 ], behavioral theories can be classified into three categories based on their levels of action : 1) Intrapersonal or individual-level theories focus on personal determinants that influence behavior (e.g., knowledge, attitudes, beliefs, and motivation). Examples include the health belief model (HBM) (Hoch, Baum 1958; [ 25 ], the theory of planned behavior (TPB) [ 26 ], and self-determination theory (SDT) [ 27 ]. 2) Interpersonal level theories highlight the influence of others in shaping one’s behavior; social cognitive theory (SCT) [ 28 ] is the most commonly used interpersonal-level theory. 3) Community-level theories aim to affect or modify the social systems within which actors interact. These social systems include organizations institutions, and public policies, among others. Examples of community-level theories include diffusion of innovation theory (Valente & Rogers, 1995) [ 29 ] and the social ecological model (SEM) [ 30 ].

In practice, behavioral theories are translated into BCIs; these are implemented through the use of BCTs, which are interactive, reproducible elements of an intervention that facilitate the alteration of the mechanism of change or the causal pathway toward the intended behavioral outcome [ 31 , 32 ].

Recent research has urged scholars to place more emphasis on understanding how and in which context a BCI addressing PIA or SB will lead to desired or unexpected outcomes and impacts [ 33 ]. However, the answer remains elusive. To close this gap, we aimed to map out the different types of BCIs geared toward PIA and SB and their underlying theories and techniques. We focused on mapping out different interventions to reduce PIA and SB and identified the underlying behavioral theories and BCTs used. We also aimed to assess the extent of behavioral theories use in the design of BCIs. Our review will provide decision-makers and behavioral designers with a unique systematic and comprehensive mapping of BCI targeting PA and SB using behavioral change theories, tools, and techniques.

We adopted the scoping review methodology as defined by Arksey and O’Malley [ 34 ] and refined by the Joanna Briggs Institute (JBI) [ 35 ].

Specifying the review question

During different research team meetings, we iteratively refined our review question as follows: What are the different behavioral theories and BCTs used in theory-informed interventions focused on PIA and SB? To construct a suitable search strategy, we employed the health behavior, health context, exclusion, models, and theories (BeHEMoth) framework [ 36 , 37 ] (see Table  1 ), which is especially relevant for identifying interventions based on behavioral theories. We then followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines to report the results of our scoping review [ 38 ].

We included only interventions addressing PIA and SB or both. We excluded interventions adressing other health behaviors such as,nutrition, smoking, and sleep (see Table  2 ).

Search strategy

We searched four databases (Scopus, Web of Science [WoS], PubMed, and Google Scholar) (see Supplementary file 1 and Table  2 ). We manually searched for gray literature on institutional sites and used reference tracking to identify additional papers. We combined search terms for theories (“Logic model” OR “Theory of change” OR “Outcome of change” OR “Program* theory” OR "Program*logic" OR “Logical framework” AND “Behavioral change intervention”) with search terms addressing BCIs: “Behavioral change interventions” AND keywords for “physical activity” OR “sedentary” OR “physical inactivity” OR “exercise” OR “fitness.”

Study selection

The study selection was carried out by two researchers, HK and ZB. We included only empirical studies of interventions addressing SB, PIA, or PA that explicitly used behavioral theories in the context of healthcare. Table 2 guided the definition of our inclusion criteria using the PCC (population, concept, context) framework (JBI) [ 35 ]. We included papers published in French, English, and Arabic between January 2010 and November 2023. All study designs were included. We excluded reviews, study protocols, feasibility studies, books, book chapters, commentaries, and letters to editors (See supplementary file 2 ).

Data charting

Data extraction was guided by, and adapted from the Cochrane Handbook of Systematic Review of Interventions for describing the characteristics of interventions [ 39 ] (see Table  3 ). We first extracted data about the general characteristics of the included studies (author, year, country, type of article, study population). Then, we extracted data about the following characteristics of behavioral theories -informed interventions: 1) theories, models or conceptual frameworks; 2) types of interventions; 3) behavioral theories; 4) BCTs; 5) targeted behavior (SB, PIA, PA, or both); and 6) level of intervention (individual, interpersonal, and environmental) (see supplementary file 3 ).

Data analysis, coding and synthesis

As we aimed to identify the underlying behavioral theories and BCTs used to inform the design of BCIs, we employed a BCI upper-level ontology [ 40 ] that coded different forms of BCIs. This taxonomy provides a helpful model for systematically and uniformly describing the upper-level components of BCIs; this enabled us to describe BCIs based on theory and to create a map of the different contexts, BCI content, mode of delivery, and BCI outcomes (see Table  4 and supplementary file 4 ).

Mode of delivery

We coded the different modes of delivery using the taxonomy developed by [ 41 ].

Behavioral theories

To comprehensively describe the theories used to inform the design of interventions, we used the taxonomy of behavioral theories developed by Michie [ 19 ] and we refined it based on Hayden [ 24 ]. This taxonomy outlines key behavioral theory constructs (definitions, interest, use, the context of theory development).

We further assessed the intensity and degree of theory use in BCIs (an analysis of how interventions have actually been implemented according to the stated theory) as developed by Michie, 2010 [ 42 ] and refined by Bluethmann, 2017 [ 43 ] to fit the context of PA. This taxonomy included the following criteria: 1) a theory was mentioned, 2) relevant constructs were targeted, 3) each intervention technique was explicitly linked to at least one theoretical construct, 4) participants were selected or screened based on prespecified criteria (e.g., a construct or predictor), 5) interventions were tailored to different subgroups, 6) at least one construct or theory mentioned in relation to the intervention was measured post-intervention, 7) all measures of theory were presented with some evidence of their reliability, and 8) the results were discussed in relation to the theory.

The most prevalent theories are the transtheoretical model (TTM) of change [ 44 ], the TPB [ 26 ], SCT [ 28 ], information motivation behavior (IMB) [ 45 ], the HBM [ 46 ], SDT [ 27 ], and the health action process approach (HAPA) [ 19 , 47 ].

Behavioral change techniques (BCTs)

We finally coded the BCTs using the V1 taxonomy [ 31 ]. The taxonomy of BCTs synthesizes 93 BCTs classified into 16 domains: 1) goals and planning, 2) feedback and monitoring, 3) social support, 4) shaping knowledge, 5) natural consequences, 6) comparison of behavior, 7) associations, 8) repetition and substitution, 9) comparison of outcomes, 10) rewards and threats, 11) regulation, 12) antecedents, 13) identity, 14) scheduled consequences, 15) self-belief, and 16) covert learning.

Search results

As indicated in Fig.  1 , we identified a total of 1,173 studies during systematic searches in four electronic databases. After removing duplicates ( n  = 165), we screened 1,027 articles for eligibility. We excluded 945 studies during the title and abstract screening. We extracted and analyzed 82 full-text studies for eligibility and excluded 53 (see the reasons for exclusion in Fig.  1 and Supplementary File 2 ). We screened the reference lists of the included studies for additional relevant articles ( n  = 19). We finally included a total of 29 articles.

PRISMA flowchart

In the following paragraphs, we describe the general characteristics of the included studies, the features of theory-informed BCIs (the intervention model, behavioral theories, and BCTs), and the extent of theory use in the included studies.

General characteristics of the included studies

Most of the included studies were carried out in high-income countries ( n  = 23): the US ( n  = 5) [ 48 , 49 , 50 , 51 , 52 ], the UK ( n  = 5) [ 53 , 54 , 55 , 56 ], Australia ( n  = 3) [ 57 , 58 , 59 ], Belgium ( n  = 3) [ 60 , 61 , 62 ], the Netherlands ( n  = 2) [ 63 , 64 ], Canada ( n  = 2) [ 65 , 66 ], Jordan ( n  = 2) [ 67 , 68 ], Iran ( n  = 2) [ 69 , 70 ], Italy ( n  = 1) [ 71 ], Qatar ( n  = 1) [ 72 ], Portugal ( n  = 1) [ 73 ], Spain ( n  = 1) [ 74 ], and Germany ( n  = 1) [ 75 ].

Intervention duration

The duration of the BCIs varied from six weeks to three years. Most interventions were carried out in a short period, ranging from one to four months ( n  = 14); others lasted five to six months ( n  = 7). Only six interventions lasted over twelve months ( n  = 6) (see Table  5 ).

Study design, context, and participants

All studies used experimental designs, including randomized controlled trials ( n  = 13), cluster randomized trials ( n  = 6), and multisite RCTs ( n  = 2) and quasi-experimental studies ( n  = 8). These studies took place in diverse settings and targeted various populations (see Table  5 ).

Nine studies were conducted in the workplace [ 50 , 56 , 57 , 58 , 61 , 63 , 70 , 72 , 75 ]. Seven studies reported interventions for people with chronic illnesses, diabetes ( n  = 3) [ 65 , 69 , 71 ], obesity ( n  = 1) [ 48 ], cardiovascular disease ( n  = 1) [ 68 ], and Parkinson’s disease ( n  = 1) [ 64 ] as well as for survivors of breast cancer ( n  = 1) [ 59 ]. Other studies included different groups such as older adults ( n  = 4) [ 52 , 55 , 66 , 76 ], healthy adults ( n  = 2) (53. 62), university students ( n  = 2) [ 67 , 74 ], and preschool children ( n  = 2) [ 51 , 54 ] (see Table  5 ).

Description of theory based BCI

In our scoping review, we identified 29 articles describing interventions informed by behavioral theories targeting SB and PIA. Among these, fifteen articles aimed to address PIA to meet guideline recommendations, while eleven focused on reducing SB. Three articles combined interventions to reduce SB and increase PA (see Table  6 ).

In the following, we will describe the content of BCIs, levels of interventions, mode of delivery and reported outcomes (see Table  6 ).

Content of BCIs

Most BCI interventions adopted educational methods ( n  = 20) aimed at raising awareness of the importance of meeting PA recommendations and breaking the vicious cycle of SB [ 18 , 48 , 51 , 53 , 54 , 55 , 56 , 59 , 62 , 64 , 65 , 66 , 67 , 69 , 70 , 71 , 73 , 75 , 76 , 79 ]. These interventions also included communication strategies ( n  = 14): motivational interviews ( n  = 4) [ 68 , 75 , 76 , 80 ], and coaching ( n  = 10) (face-to-face consultations or phone calls) [ 18 , 53 , 57 , 59 , 62 , 64 , 65 , 67 , 71 , 73 ]. Social support to implement interventions was used nine times [ 51 , 52 , 56 , 57 , 62 , 66 , 69 , 76 , 79 ], and physical exercise training was used 8 times [ 52 , 54 , 64 , 66 , 70 , 71 , 73 , 74 , 75 , 76 , 80 ]. Finally, digital interventions (devices, desktops, m-health) were used in most interventions ( n  = 16)0.2

Levels of interventions

The majority of interventions involved individual-level BCIs ( n  = 15). Few studies combined the individual level of the interpersonal level (e.g., peer support) ( n  = 6) [ 52 , 56 , 62 , 66 , 69 , 76 ], and six studies combined the individual level with organizational-level interventions ( n  = 6) [ 50 , 51 , 54 , 63 , 71 , 72 ]. Only two studies can be described as systemic BCIs addressing the individual, interpersonal, and organizational levels ( n  = 2) [ 57 , 79 ] (see Table  6 ).

Heterogeneity of modes of delivery

The modes of delivery of BCIs were often mixed. BCIs included face-to-face delivery in most cases ( n  = 24) with single individuals ( n  = 6) [ 57 , 59 , 64 , 65 , 68 , 73 ] or with groups of people ( n  = 10) [ 18 , 48 , 51 , 54 , 56 , 69 , 70 , 71 , 74 , 76 ] or a combination of both modes of delivery ( n  = 8) [ 52 , 53 , 55 , 58 , 62 , 66 , 67 , 75 ]. The electronic mode of delivery was often employed ( n  = 15), including messaging ( n  = 3) [ 67 , 68 , 70 ], computer-based delivery ( n  = 6) [ 48 , 61 , 63 , 72 , 74 , 77 ], and digital devices (wearable or mobile devices) ( n  = 13) [ 18 , 48 , 50 , 53 , 58 , 59 , 61 , 63 , 65 , 66 , 67 , 71 , 74 ]. The printing mode of delivery was also utilized less frequently ( n  = 10).

Reported outcomes

Twenty-five of the 29 interventions mentioned a decrease in PIA and SB, while four studies [ 18 , 54 , 65 , 74 ] found no changes in SB or PIA. These four interventions specifically targeted preschool children, school-age students, and adults at risk of diabetes. Four studies reported mixed results and inconclusive evidence. One study showed a significant decline in SB without any change in the level of PA [ 72 ] (see Table  6 ).

Our scoping review showed that the authors of the included studies referred to 15 behavioral theories ( n  = 15) (see Table  7 and Supplementary file 5 ). Most of the included studies used at least one of the four following theories: SCT ( n  = 14), SDT ( n  = 6), the TTM ( n  = 6), the TPB ( n  = 6), the SEM ( n  = 5), and the HBM ( n  = 5). Most interventions used either a single theory ( n  = 13) or a combination of two BCTs ( n  = 12). Only two interventions did not explicitly define the theoretical constructs guiding the development of the BCIs.

The SCT was the most commonly used theory. Five interventions used SCT as a single theory ( n  = 5) [ 48 , 50 , 51 , 62 , 69 ], whereas eight employed a combination of other behavioral theories: SDT [ 65 ], TPB [ 6 , 68 , 65 ], TTM [ 64 , 65 ], HBM, SEM [ 57 , 64 , 65 , 66 , 79 ], behavioral choice theory [ 18 ], and protection motivation theory (PMT) [ 65 ]. Interventions rooted in SCT addressed specific psychological and social constructs ranging from one to four constructs per intervention. The most frequently used constructs were self-efficacy, self-regulation, observational learning, and positive reinforcement (see Table  5 ). SCT was used almost equally to reduce SB and PIA.

PA interventions mostly involved individual behavioral theories (SDT, SRT, TPB, TTM, HAPA), with a focus on reducing the intention-to-action gap. Conversely, the theories employed to reduce SB are primarily interpersonal (SCT, SET, SiS) and environmental (SEM). They seek to make behavior more socially acceptable, encouraging and influencing the behavior of others. Additionally, restructuring the environment is a central component of interventions aimed at reducing SB in the workplace.

Our scoping review showed that most interventions targetted the following individual-level constructs: self-efficacy ( n  = 16), motivation ( n  = 10), self-regulation [ 9 ], and the interpersonal level illustrated by using subjective norms ( n  = 5) and basic psychological needs ( n  = 4). Few studies have addressed environmental factors (e.g., institutional, community, society) ( n  = 7). The SB interventions used essentially socioecological constructs ( n  = 4) and enhanced self-efficacy ( n  = 6), self-regulation ( n  = 5), and modeling ( n  = 4). PIA BCI interventions were more centered on individual-level constructs such as motivation ( n  = 10), intention ( n  = 5), and controlled volition ( n  = 6) (see Table  8 and Supplementary file number 2 ).

Our scoping review revealed some discrepancies in the characteristics of PIA interventions compared with those of SB interventions. The latter were considered systemic interventions based on SCT and SEM. They combined multilayered actions at the macro-level (environmental restructuring), the meso-level (social and peer pressure) and the micro-level (by activating intrapersonal and interpersonal mechanisms of change). In contrast, BCI targeting PIA were mostly focused on the individual level of change by using individual intrapersonal theories (SDT, TTM, TPB, HAPA, and PMT).

• Behavior change techniques

All interventions were designed as multicomponent interventions integrating various behavior change techniques (see Table  7 ).

Our scoping review revealed that the scholars of the included studies used a set of 25 BCTs. On average, six to nine BCTs were used in an intervention (a minimum of 5 and a maximum of 12).

Social support, which is unspecified, was the most commonly used type of BCTs and involved targeting the interpersonal level (social influence) ( n  = 28), followed by goal setting, targeting the individual level (goal and intention) ( n  = 24); solving problems and identifying barriers at the individual level (belief capability) ( n  = 18); instruction on how to perform behavior at the individual level; self-monitoring of behavior ( n  = 17); feedback on the outcome of behavior at the individual level ( n  = 14); information about health consequences at the individual level ( n  = 14); social rewards targeting the interpersonal level (reinforcement and social influence) ( n  = 9); restructuring the physical environment targeting the environmental level ( n  = 6); and materiel rewards, targeting the interpersonal level (reinforcement) ( n  = 4). In our scoping review, most BCTs targeted the interpersonal level and the individual level followed by the environmental level.

Common characteristics of BCI with no modifications to PIA or SB

These interventions were based on educational, self-monitoring and the use of a coaching strategy involving distinct connected devices that targeted adults at risk of metabolic diseases or diabetes type 2) [ 18 , 65 ] or preschool children, students, and adults at risk of metabolic diseases [ 54 , 74 ], or a single individual level of behavioral change. They used face-to-face training sessions. Key contextual conditions that prevent the effectiveness of theory-informed interventions include the absence of parental involvement in BCTs targeting children [ 54 ], a lack of peer support in interventions involving students [ 74 ], and the absence of illness in interventions targeting adults [ 18 , 65 ].

Description of studies reporting positive changes in PIA and SB

The included studies, mostly carried out in the workplace ( n  = 9), used a combination of education, training, and communication strategies (motivational interviews or coaching), along with social support and environmental restructuring. The included studies emphasized the importance of systemic-level interventions combining actions at the individual (face-to-face and digital interventions using wearable devices, desktops, and apps) and interpersonal (social support and group interventions) levels with macro-level environmental restructuring. Environmental restructuring encompasses interventions such as installing pedals and workstations, sending email reminders, and even using digital health apps [ 50 , 57 , 58 , 63 , 72 ]; it also focuses on reinforcing the knowledge and skills of actors and providing social support through group interventions. In contrast, other studies reported that BCIs targeting individuals with chronic diseases (e.g., CVD [ 68 ], diabetes [ 65 , 69 , 71 ], Parkinson’s disease [ 64 ], obesity [ 48 ], and cancer survivors [ 59 ] are essentially individually focused and underwent substantive changes in PIA and SB. These studies suggest that patients with NCDs are more committed to education and that coaching interventions intrinsically motivate people to follow PA recommendations [ 59 , 64 , 68 , 71 ].

Intensity of theory use

We found heterogeneous use of theory in the implemented interventions. Fifteen interventions involved an intensive degree of theory use (level 3). Eleven interventions entailed moderate levels of theory (Level 2), and three interventions utilized a low level of theory (Level 1) (see Table  9 ).

In sum, our scoping review showed that most interventions used a combination of similar modes of delivery, design, and components (education, training/coaching, regulation, and the use of connected devices), and BCIs were mostly individually focused and based, in most cases, on education and self-monitoring.

Most interventions were focused on individual levels of behavior changes and involved a multitude of intrapersonal behavioral theories and wearable devices for monitoring, using diverse BCTs with a focus on social support and goal setting. Only two studies can be considered systemic level theory informed BCIs addressing both individual intrapersonal drivers (e.g., motivation, attitude, perceived norms, self-efficacy, etc.) combined with interpersonal interventions (group and social support interventions) and macro-level interventions, such as environmental restructuring in the workplace.

Our scoping review indicated that single digital technology-based web apps informed by intrapersonal theories, such as the TPB, self-regulation, and SDT, had no significant effects. Hence, there is a need to combine intrapersonal theories with interpersonal and environmental interventions for better adherence to interventions and the adoption of a desired behavior [ 81 , 82 ]. Indeed, interventions informed by the HBM, aimed at addressing an individual’s perceptions of PA and increasing one’s level of PA, have shown no significant effect [ 83 ].

The relevance of systemic theory informed BCIs stems from the complexity of causal processes underlying SB and PIA, which are considered a consequence of intricate interactions between intertwined levels of structure and agency [ 16 , 18 ]. PIA and SB are influenced by individual, interpersonal, and organizational and broader contextual factors [ 84 ] (Heath et al., 2012). At the individual level, behavior is defined by people’s awareness, cognition, beliefs, and skills. At the interpersonal level, behavior is impacted by the extent to which social support is received from family and friends. At the organizational level, behaviors are constrained by cultural norms and practices in the workplace. At the broader level, behaviors are constrained by contextual factors at the national and global levels, such as legal frameworks, environmental restructuring, political and socioecological factors shaping individuals’ architecture of choice, and their day-to-day decision-making [ 16 , 18 ].

This suggests the importance of considering the notion of “reciprocal determinism,” which refers to the dynamic interaction between personal social, and environment factors and behavior [ 24 ]. The environment plays a significant role in the acquisition of PA behaviors and, consequently, in behavioral change [ 85 ]; it can encompass the immediate environment around the individual (one’s parents, workplace, neighbors, and community) as well as the interpersonal environment of the community. As such, PA is conditioned by the individual’s motivation (which can be intrinsic or extrinsic) [ 86 ], physical ability, social support, the availability of wearable device pedometers or accelerometers [ 87 ]  and the existence of an enabling living environment (sport fields, space, resources), and regulatory enabling policies (breaks/leave from work, health insurance) [ 16 ].

At the national and global levels, individual behaviors are often constrained or facilitated by national legal contexts and restructuring policies of the built environment, including public transit, green spaces, parks, and recreational facilities [ 88 ]. Thus, environmental restructuring can be a good example of the complementarity and synergies of interventions, as shown by Dugdill, who highlighted the relevance of macro-level interventions to alter the workplace, where people spend a great deal of time. Systemic interventions, in line with those used by [ 89 , 90 ], that combine multiple levels of interventions (individual, interpersonal, and environmental) may have synergistic effects on behavioral changes compared with individually focused interventions (face-to-face and digital interventions).

Our review underscores the importance of environmental restructuring as a complementary intervention to individually focused BCIs. In the workplace, this can include promotion of managers’ leadership such that they serve as role models for employees, as suggested by [ 91 , 92 , 93 ]. As a consequence, employees may perceive strong social influence and peer pressure, which may increase their self-efficacy and self-regulated behaviors [ 94 ]. These interventions seem to foster social identification, social comparison, and socialization mechanisms by increasing individuals’ adherence to BCIs in the workplace [ 91 , 92 , 93 ].

In addition, at the organizational level, employees’ behaviors are often influenced by organizational policies promoting PA in the workplace [ 87 ]. Moreover, the broader context plays a role in shaping the individuals’ behaviors. For instance, Davis [ 21 ] reported that behavioral modeling is only effective if individuals see other active people in their social context. Other scholars have shown that a lack of perceived security (crimes, sexual harassment, incivility) may reduce people’s willingness to carry out outdoor PA [ 95 ].

Our scoping review indicates that in the context of school BCIs, in line with other findings [ 96 , 97 ], children may also benefit from systemic interventions by reducing their screen time usage through school policies and receiving individual training sessions to enable them to reduce their SB while also engaging with their parents (interpersonal and social influence) through role modeling. However, more attention is needed to develop systemic BCIs based on multiple-level interventions, such as individual coaching, mentoring, interpersonal social support, and altering the physical and cultural environment [ 98 ].

Our scoping review, in line with [ 82 , 94 , 99 ] and [ 100 ], has shown the usefulness of SCT in explaining how the training and empowerment of individuals enhance their self-efficacy, self-regulation, their perceived benefits, and risk and control volition, which may prove appropriate in the context of PA and SB interventions.

Our scoping review demonstrated, in line with previous systematic reviews [ 101 ], that using a combination of multiple behavioral change techniques is associated with an increased overall effect of the intervention and the adoption of desired behavioral outcomes. Techniques include, for instance, social support, goal setting, and self-monitoring, in line with other studies [ 102 , 103 ].

Figure  2 shows a tentative integrative framework that incorporates three levels of interventions (environmental, interpersonal, and intrapersonal) and may be useful for helping program designers to build theory informed BCIs on the basis of a multilayered theoretical model. For instance, at the intrapersonal level, one might use the HBM combined with the TTM and SDT. However, at the interpersonal level, program designers might use SCT and behavioral choice theory. At the environmental level, one can use environmental theories such as social influence strategies ( see Fig.  2 ).

Integrative framework of theories and constructs for effective BCT interventions

These constructs serve as mechanisms of action at the individual and interpersonal levels. This finding aligns with the results regarding the contribution of SCT and its constructs in predicting and adopting active behavior.

Study limitations and research gaps

In our review, we identified a lack of comprehensive reporting by scholars of key theoretical constructs underlying the design of BCI. We may have missed other relevant literature, as we had to make some trade-offs between comprehensiveness, depth of analysis and feasibility (Arksey, 2005). However, we performed a systematic, comprehensive search of four databases, including Google Scholar, to identify contextually rich gray literature. In addition, two reviewers screened the titles and abstracts, and extracted the data. Our findings also suggest that many theory-informed interventions do not use theoretical constructs appropriately; however, a call for improving the reporting and quality of intervention fidelity is needed while promoting the use of standardized tools such as Michie’s taxonomy of BCIs [ 40 ] and BCTs [ 104 ].

Our scoping review included only experimental studies that lacked sufficient descriptions of the role of context in shaping the characteristics of interventions and their mechanisms of action. Thus, more attention should be paid to promoting evaluation using context-sensitive methods and approaching theory-based evaluation, realistic evaluation [ 105 ], qualitative comparative analysis [ 106 ], and contribution analysis [ 107 ]. Further research is needed to unpack the black box of behavioral theories -informed interventions by unraveling what works for whom and in what context.

Further studies are also needed to examine the role of individual and digital interventions, which we insufficiently explored in our review. More rigorous systematic and meta-analyses are needed to complement the results of this descriptive, explorative scoping review and to provide evidence of the effectiveness of Theory -informed BCI [ 85 ].

Our review offers an innovative approach to systematically categorize behavioral theories interventions using a set of appropriate behavioral theories taxonomies, tools, and techniques, and provides working examples of how these taxonomies can be applied to assess the theory use and the described characteristics of BCT theory-informed interventions. Our study suggests an integrative framework to help program designers develop interventions while implying that specific behavioral theories and BCTs can be used at every level of intervention (the individual, interpersonal and environmental, policy and global levels). In sum, the congruence between behavioral theories, the implementation settings, and the characteristics of the targeted subpopulations needs to be considered when designing behavioral theories interventions to reduce PIA and SB. One size does not fit all. We also recommend, in line with (Noar et al., 2008), that behavioral change practitioners select theories and techniques based on their congruence with participants’characteristics and the nature of the context.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Behavior Change theory based Intervention

Behavior Change Intervention Ontology

Behavior Change Techniques

Health behavior, health context, exclusion, models and theories

Control group

Health Action Process Approach

Health Belief Model

Information Motivation Behavior

Intervention Group

Joanna Briggs Institute

Multi-site Randomized Control Trial

Non-Communicable Diseases

Physical Activity

Physical Inactivity

Protection Motivation Theory

Quasi-Experimental Study

Randomized Control Trial

• Sedentary behavior

Social Cognitive Theory

Self Determination Theory

Social Ecological Model

Self-Efficacy Theory

Social influence Strategy

Theory of Planned Behavior

Transtheoretical Model of Change

First version

World Health Organisation

Web of Sciences

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Houda El Kirat, Asmae Khattabi & Zakaria Belrhiti

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H. E. K: PhD candidate, conceptualization, screening, data extraction, formal analysis, writing–original draft preparation, visualization. Z.B, ORCID: 0000–0002-0115-682X; PhD supervisor, contributed to the conceptualization, building of the search strategy, title and abstract screening, methodological support, revisions of different drafts and supervision. SV B, ORCID: 0000–0003-2074–0359 critically revised the final version of the manuscript. A K, PhD supervisor, critically revised the latest version of the manuscript.

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Literature review of complementary and alternative therapies: using text mining and analysis of trends in nursing research

• Jihye Nam   ORCID: orcid.org/0000-0002-5534-2660 1 ,
• Hyejin Lee   ORCID: orcid.org/0000-0002-8501-0560 1 ,
• Seunghyeon Lee   ORCID: orcid.org/0009-0005-6411-364X 1 &
• Hyojung Park   ORCID: orcid.org/0000-0002-7804-0593 1  

BMC Nursing volume  23 , Article number:  526 ( 2024 ) Cite this article

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This study aimed to review the literature on complementary and alternative therapies, utilizing text mining and trend analysis in nursing research. As CAM becomes increasingly prevalent in healthcare settings, a comprehensive understanding of the current research landscape is essential to guide evidence-based practice, inform clinical decision-making, and ultimately enhance patient outcomes.

This study aimed to identify CAM-related literature published from 2018 to 2023. Using the search terms 'complementary therap*', 'complementary medicine', 'alternative therap*', and 'alternative medicine', we performed a comprehensive search in eight databases, including EMBASE, Cochrane Central, PubMed Central, Korea Education and Research Information Service (RISS), Web of Science, KMbase, KISS, and CINAHL. From the text network and topic modeling analysis of 66,490 documents, 15 topics were identified. These topics were classified into two nursing-related topics through an academic classification process involving three doctors with doctoral degrees, three nurses, and three pharmacists. Based on the classified topics, research trends were comparatively analyzed by re-searching the database for 12 nursing and 22 non-nursing literature.

This study found that in nursing literature, yoga is used to improve mental symptoms such as stress and anxiety. In non-nursing literature, most of the experimental studies on complementary and alternative therapies were conducted in a randomized manner, confirming that a variety of physiological and objective indicators were used. Additionally, it was discovered that there were differences in the diversity of research subjects and research design methods for the same intervention method. Therefore, future research should focus on broadening the scope of subjects and measurement tools in nursing studies. Additionally, such studies should be conducted with randomization and generalizability in the experimental design in mind.

This study employed text network analysis and text mining to identify domestic and international CAM research trends. Our novel approach combined big data-derived keywords with a systematic classification method, proposing a new methodological strategy for trend analysis. Future nursing research should focus on broadening the scope of subjects, diversifying measurement tools, and emphasizing randomization and generalizability in experimental designs.

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The World Health Organization (WHO) defines complementary and alternative medicine (CAM) as healthcare practices outside a country's traditional or conventional medicine [ 1 ]. According to the National Center for Complementary and Integrative Health (NCCIH), CAM encompasses nutritional approaches (e.g., herbs), psychological methods (e.g., mindfulness), physical therapies (e.g., massage), integrated mind–body practices (e.g., yoga or auricular acupressure), and modalities that combine psychology and nutrition [ 2 ]. This definition suggests CAM may facilitate holistic nursing by addressing both psychological and physical aspects [ 3 ]. Consequently, substantial CAM research is conducted in nursing internationally [ 4 , 5 ], spanning areas like pain, depression, anxiety, chronic disease symptoms, sleep disturbances, and vomiting [ 4 , 5 , 6 ]. Classification systems exist, with the Korean Nursing Association (2023) delineating 12 CAM subcategories [ 6 ] and NCCIH outlining 76 therapies across major categories like nutrition, body, and psychotherapies [ 4 , 5 , 6 , 7 ]. The multitude of CAM types has prompted trend identification research, including reviews on Chinese medicine for allergic rhinitis, aromatherapy, auricular acupressure, and CAM for COVID-19 [ 6 , 8 ]. However, many previous studies have significant limitations in comprehensively identifying overall research trends in CAM. First, they tend to focus narrowly on specific diseases or treatments, lacking a broader perspective on the field as a whole [ 6 , 8 ]. Second, the use of search queries containing keywords from a specific discipline or arbitrarily selected by researchers introduces bias and hinders the identification of overarching trends [ 9 , 10 ]. These limitations highlight the need for a more systematic and data-driven approach to analyzing CAM research trends [ 11 , 12 , 13 ]. A previous study [ 14 , 15 ] suggested the use of text mining technique as an approach for literature review [ 16 ]. To date, the analysis on research trend in nursing has been conducted more than five years after publication or has only been conducted with partial analyses through literature reviews and text mining [ 17 , 18 , 19 ].

The overarching goal was to extract keywords identifying domestic and international CAM research trends using text network analysis and analyze these trends within the nursing field. Specific objectives were: 1) Identify frequency, degree centrality, closeness centrality, and betweenness centrality for keywords appearing in domestic and international CAM studies; 2) Identify key themes within these studies; 3) Discern nursing keywords among sub-topic groups; 4) Analyze and compare nursing and other disciplinary literature based on findings; and 5) Analyze the trend of CAM in nursing based on extracted nursing keywords.

Study design and methodological framework

This study employs a novel methodological framework that combines text mining techniques with expert validation to identify and analyze CAM research trends in a comprehensive and data-driven manner. The framework consists of the following key steps.

Data collection: A comprehensive search of multiple databases is conducted to collect a broad range of CAM-related literature across various disciplines.

Text preprocessing involves several techniques to prepare the data for analysis. These include natural language processing, stopword removal, and synonym standardization.

Keyword extraction and network analysis: Text mining techniques, including term frequency-inverse document frequency (TF-IDF) and centrality analysis, are applied to extract key topics and analyze their relationships within the literature.

Topic modeling: Latent Dirichlet Allocation (LDA) is used to identify latent topics within the literature and visualize their proportions and relationships.

Expert validation: An expert panel of physicians, nurses, and pharmacists is consulted to validate the relevance and credibility of the identified topics and classify them into respective academic fields.

Focused literature analysis: Based on the expert-validated nursing-related topics, a focused re-search and analysis of the literature are conducted to identify trends specific to nursing research on CAM.

This multi-step framework allows for a more comprehensive and less biased exploration of CAM research trends by leveraging text mining techniques to process large volumes of literature, identify key topics, and uncover patterns that may not be apparent through traditional review methods [ 14 , 15 , 16 ]. The integration of expert validation ensures the relevance and credibility of the findings, while the focused analysis of nursing literature provides insights specific to the nursing discipline within the broader context of CAM research. The process of selecting studies for our analysis is illustrated in Fig.  1 , which provides a clear visual representation of the key steps involved, from the initial database search to the final classification of studies into nursing and other disciplines. This multi-step approach, combined with the visual aid, enhances the clarity and transparency of our methodology, allowing readers to better understand and contextualize the subsequent data analysis steps.

Flow diagram for literature selection process

Literature selection

This study focused on complementary and alternative medicine studies conducted in the fields of medicine, public health, and nursing in Korea and abroad. After specifying the research title and abstract as the search scope to extract the literature and build a database, the literature related to nursing was classified based on the topics derived through text network analysis and then, the literature that met the selection criteria was secondarily extracted and analyzed through the abstract screening. The three researchers checked the consistency of the study selection process and if there was any discrepancy, the final decision was made through consensus among the researchers.

The selection criteria for the literature were: (1) domestic and foreign studies published within the last five years (January 2018 to September 2023) that conducted studies on complementary and alternative medicine; and

The exclusion criteria for the literature were grey literatures, dissertations, and studies for which original texts are not available.

Data collection strategies

In this study, the database was selected by referring to the COSI (Core, Standard, Ideal) [ 20 ] model presented by the National Library of Medicine for literature search. EMBASE, Cochrane Central, and PubMed Central were selected as the core databases.

On the other hand, the standard databases selected were the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Korean database services such as the Research Information Sharing Service (RISS), KMbase, and Korean studies Information Service System (KISS). These Korean databases were included to ensure a comprehensive coverage of potentially relevant studies published in South Korea, as they index a wide range of domestic and international journals, conference proceedings, and dissertations across various disciplines, including those related to CAM. However, it is important to note that the inclusion of these Korean databases does not limit the scope of our study to Korean literature only, as the majority of our analysis focuses on studies published in English and indexed in the core and standard international databases.

In addition, the Web of Science was selected to include a wider range of literature for the ideal database, and the period of literature search focused on the last five years, from 1 January 2018 to 15 September 2023. to capture the most recent trends in CAM research following the last comprehensive analysis of CAM research trends conducted in 2018 by Sung et al. [ 19 ]. This time frame was chosen to provide an updated and comprehensive analysis of CAM research trends, building upon the findings of previous studies and identifying new patterns and areas of focus that have emerged in recent years, given the rapid evolution of CAM research and the increasing integration of CAM into mainstream healthcare.

The data collection procedure was limited for both domestic and foreign studies. In case of foreign studies, ‘English’ was limited as the search language, ‘abstract and title’ were identified as the field, ‘article’ was set as the document form, and the keywords were ‘complementary therap*,’ ‘complementary medicine,’ ‘alternative therap*,’ and ‘alternative medicine.’ For the Korean studies, ‘Korean’ was limited as the search language, ‘abstract and title’ were identified as the field, ‘article’ was set as the document form, and the search keywords used were ‘보완대체,’ ‘대체요법,’ and ‘대체의학.’ In searching for the secondary literature, studies in the field of nursing were presented to a group of nine experts including physicians, nurses, and pharmacists with a master's degree or higher, and then the relevant areas were classified to extract the keywords. These keywords were then used in the text mining search. Topic words, the majority of which were classified as nursing, were re-searched in the collected database. The literature selection and classification process were carried out independently by three researchers and promoted through discussions between the researchers.

Data analysis process

Data extraction.

A comprehensive literature search was conducted across eight databases: CINAHL, Cochrane, EMBASE, KISS, Kmbase, PubMed, RISS, and Web of Science. This extensive search yielded a total of 77,062 studies. To ensure the integrity and non-redundancy of our dataset, we employed a rigorous two-step deduplication process. First, we utilized the 'Find Duplicates' function in EndNote software for initial automatic deduplication. This function systematically identifies and groups potential duplicate records based on shared metadata such as title, authors, year, and DOI. Through this automated process, 12,107 duplicate records were identified and removed.

Following the automated process, we conducted a manual review to identify and remove any remaining duplicates that the software might have missed. This careful manual screening allowed us to catch subtle duplicates that automated systems might overlook, such as those with slight variations in titles or author names. Through this manual review, an additional 465 duplicate records were identified and removed. In total, our rigorous two-step deduplication process resulted in the removal of 12,572 duplicate records. Of these, 12,107 were removed through automated deduplication and 465 through manual review. After deduplication, 64,490 unique studies were retained for further analysis. These studies were systematically organized by title and subjected to a thorough text preprocessing phase. During this phase, unstructured words were sorted and cleaned using the social networking program Netminer 4.3.3 and text editor Notepad + + (version 8.5.8).

Also, stopwords such as pronouns, adverbs, and numbers were deleted through natural language processing, while exception list, defined words, and thesaurus were registered. The exception list and thesaurus were selected by the three researchers, and if they failed to reach a unanimous agreement, the keywords were refined through consultation and the abstracts and preambles were reviewed again to examine the context in which the words were used. In case of the exception list, literature search keywords or stopwords such as pronouns, adverbs, numbers, and special symbols were considered, while ‘complementary,’ ‘medicine,’ ‘alternative,’ ‘therapeutic,’ ‘therapy,’ ‘therap,’ ‘therapies,’ ‘the,’ ‘a,’ ‘and,’ ‘of,’ ‘for,’ ‘in,’ ‘to,’ and ‘among’ were excluded. Special symbols like ‘’,:'"()&-?# <  >  + "",‘ were excluded as well. As for defined words, ‘cells → cell,’ ‘effects → effect,’ ‘staphylococcus aureus → staphylococcus,’ ‘aureus → staphylococcus,’ ‘characteristics → characterization,’ ‘efficacy → effect,’ ‘rat → mice,’ ‘radio → radiation,’ ‘systems → system,’ ‘agents → agent,’ ‘activity → activation,’ ‘carcinoma → cancer,’ ‘cases → case,’ ‘mouse → mice,’ ‘practices → practice,’ ‘radio sensitization → radiation,’ ‘years → year,’ ‘α → alpha,’ and ‘β → beta’ were selected, and data sorting for synonyms was performed. As a result of the analysis, a database consisting of 464,625 words was constructed.

Data analysis

In this study, text mining and topic modeling analysis were employed using textom and RStudio (4.3) to identify keywords related to CAM. Word analysis, TF-IDF, and degree centrality analysis were performed through text mining, with results presented via visualization. TF-IDF determines if a keyword holds actual significance within a document, as words with high TF and TF-IDF values appear frequently and are more likely keywords or important terms [ 21 , 22 ]. Following previous studies [ 22 , 23 ], the minimum word length was set to two, with the top 20 words extracted per topic. Text network analysis created word networks expressing co-occurrence frequency as links [ 24 ]. To gauge word occurrence frequency, words were converted to word-word one-mode, and degree centrality analysis identified highly influential network words. The results of these analyses, including frequency, TF-IDF, degree centrality, closeness centrality, and betweenness centrality of core keywords, can be found in Table 1 .

This study utilized Latent Dirichlet Allocation (LDA) for topic modeling, a statistical method that estimates the probability distribution of topics within documents based on the Document Term Matrix (DTM). Following established practices in the literature, we set the Markov Chain Monte Carlo (MCMC) parameters to alpha = 1.44, beta = 0.001, and iterations = 1,000 [ 25 ]. To determine the optimal number of topics, we iteratively tested configurations ranging from 1 to 20 topics. Through a combination of silhouette clustering analysis and researcher consensus, we identified that a 15-topic model best represented the research trends in our corpus.

LDA visualization indicated that larger topic sizes represented greater proportions within the analyzed studies [ 25 ]. We confirmed that the ideal number of topics, where topics do not overlap and have distinct boundaries, is 15, as shown in Fig.  2 . To validate the relevance and credibility of the topic modeling results, we consulted an expert panel consisting of physicians, nurses, and pharmacists with master's or doctoral degrees. The panel members were asked to classify the 15 derived topics into their respective academic fields. Based on the survey results, two topics (Topics 4 and 7) were identified as nursing-related, with the majority of the expert panel categorizing them as such.

LDA topic modeling visualization

Using the words from these two nursing-related topics, a keyword search was conducted within the database to identify the final set of literature containing these terms. The selected literature was then classified as either nursing-related or non-nursing-related based on the following criteria: (1) the study was published by a nursing school or department, (2) the authors were nurses or nursing researchers, (3) the authors were hospital-affiliated nurses, or (4) the study was published in a nursing journal. The classification process was carried out independently by three authors, and the final categorization was determined through a verification process among them.

Literature review

After the three researchers re-searched the database built based on the sub-words of the extracted topics, a total of 35 articles were selected, including 13 nursing-related literatures and 22 other discipline-related literatures. The sub-words used for the re-search were derived from Topic 4 and Topic 7 in Table 2  and were classified using the PICO (Population, Intervention, Comparison, Outcome) framework. The population-related sub-words included 'patient,' 'students,' and 'nursing.' The intervention-related sub-words were 'yoga,' 'treatment,' 'radiation,' 'acupuncture,' 'education,' and 'cam.' The comparison-related sub-word was 'placebo,' and the outcome-related sub-words included 'anxiety,' 'depression,' 'symptoms,' 'knowledge,' 'attitudes,' and 'perceptions.' These PICO-classified sub-words were used to conduct the database re-search.

In order to examine the research trends in nursing and other related fields, general characteristics (author, country of publication, year of publication) and research characteristics (research design model, statistical method, research subject, intervention method, outcome variable, measurement instruments) were identified, presented, and compared. Meanwhile, the three researchers independently prepared a characteristic table to ensure the accuracy of the extracted contents and if there was any discrepancy, one data was selected through the discussion process until a consensus was reached and a characteristic table was constructed.

To assess the quality of the selected studies, we employed the Mixed Methods Appraisal Tool (MMAT), a concise tool designed to evaluate various study designs, including qualitative, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies [ 26 ]. This comprehensive tool allowed us to systematically evaluate the methodological rigor of our diverse selection of studies. Each study was evaluated against five MMAT criteria specific to its design, focusing on aspects such as research question appropriateness, data collection methods, and result interpretation. Our assessment revealed varying levels of methodological quality. Among nursing studies (A1-A12), 25% were high quality (5/5 criteria met), 58.3% moderate quality (4/5 criteria), and 16.7% low quality (3/5 criteria). Importantly, all included studies met at least 3 out of the 5 MMAT criteria, indicating an overall moderate to high quality across the selected literature. This suggests that the studies included in our analysis provide a reliable foundation for drawing conclusions. Studies that did not meet all criteria were carefully reviewed, and their potential limitations were considered when interpreting their findings. The MMAT provided a useful overview of study quality and was deemed suitable for assessing methodological rigor while maintaining the feasibility of our analysis. This approach ensured a balanced and nuanced interpretation of the evidence in the field of complementary and alternative medicine. The detailed results of this quality assessment can be found in Tables 3  and 4 .

Data collection and ethical considerations

Since the data used in this study did not contain information that can identify individuals, the study was conducted after obtaining an IRB approval (IRB No: ewha-202311–0008-01) from the Institutional Review Board of Ewha Womans University.

Analysis of word frequency and centrality

The frequency and percentage of the top 20 words related to complementary and alternative medicine are shown in Table 1 . The frequency and percentage of the top 20 words related to complementary and alternative medicine are shown in Table 1 . The table presents the top 20 keywords ranked by frequency, TF-IDF, degree centrality, closeness centrality, and betweenness centrality. The frequency column indicates the number of times each keyword appears in the analyzed documents, while the TF-IDF column represents the importance of each keyword within the entire document set. Degree centrality, closeness centrality, and betweenness centrality are network analysis measures that indicate the importance and influence of each keyword within the text network. The words with the highest frequency included ‘cell’ (7,653 times), ‘patient’ (6,910 times), ‘treatment’ (6,851 times), ‘cancer’ (6,722 times), ‘study’ (6,295 times), and ‘effect’ (6,203 times). The words with the highest values of TF-IDF, in order, were ‘cell,’ ‘effect,’ ‘cancer,’ ‘patient,’ ‘treatment,’ and ‘study.’ As a result of centrality analysis, the top six common words, in order, were ‘effect,’ ‘treatment,’ ‘study,’ ‘analysis,’ ‘disease,’ and ‘approach.’ Except for common words, the words with the highest values in the centrality analysis, in order, were ‘model,’ ‘patient,’ ‘activation,’ and ‘use.’ The words with the highest values for closeness centrality were ‘factor,’ ‘model,’ ‘patient,’ and ‘activation,’ while the words with the highest values for betweenness centrality were ‘factor,’ ‘model,’ ‘type,’ and ‘activation.’

Results of the topic modeling

The LDA visualization provides insights into the relative importance and distinctiveness of identified topics. In this visualization, the size of each topic circle is proportional to its prevalence within the analyzed corpus, with larger circles indicating topics that are more frequently discussed across the literature. Interestingly, we observed that some topics, despite being represented by smaller circles, were positioned at considerable distances from other topics. This spatial separation suggests that these topics, while perhaps less prevalent, possess high discriminant validity and represent distinct thematic areas within the field of complementary and alternative medicine research. This interpretation is consistent with established principles in topic modeling, where spatial relationships in visualizations can indicate semantic distinctiveness. An expert panel of 9 individuals (3 doctors, 3 nurses, and 3 pharmacists), each holding a master's or doctoral degree, conducted a survey to classify the topics based on the keywords. The topic that received the most votes from the panel was designated as the representative field for that topic. Based on the resulting values of the topic modeling, 20 sub-words for each topic were presented and provided in Table 2 , Topics 1–3, 5–6, and 9–15 were classified as Medicine, Topics 4 and 7 as Nursing, and Topics 8 and 10 as Pharmacology.

The process of selecting studies for our analysis is illustrated in Fig.  2 . To determine the optimal number of topics for our analysis, we conducted Latent Dirichlet Allocation (LDA) visualization. As Greene et al. [ 25 ] suggest, larger topic sizes in LDA visualization indicate a greater proportion of that topic within the analyzed studies. We tested topic numbers ranging from 1 to 20, seeking a configuration where topics were visually distinct and non-overlapping. This approach aligns with Liu et al. [ 24 ], who note that topics with high discriminant validity appear as small but clearly separated clusters. After careful visual analysis, we determined that 15 topics provided the most coherent and distinct groupings, as shown in Fig.  2 . This visualization demonstrates the independence and non-overlapping nature of our identified topics, supporting the robustness of our topic modeling approach. Based on the resulting values of the topic modeling, 20 sub-words for each topic were presented and provided in Table 2 . The expert panel's classification suggested that Topics 4 and 7 had relevance to nursing research. However, upon closer examination of the keywords included in these topics, it became apparent that they also encompassed literature from other medical disciplines. While the expert panel's classification indicated these topics were nursing-related, the presence of medical terminology suggested a broader interdisciplinary scope. This highlighted the limitations in identifying nursing-specific research using the current topic modeling approach. To address this issue and clarify the nursing-specific research within these topics, a further refinement of the literature search was conducted using the PICO framework. The keywords from Topics 4 and 7 were used to formulate a focused research question and search strategy. This targeted approach yielded a final selection of 12 nursing-specific articles and 22 articles from other disciplines. By employing the PICO framework and leveraging the keywords from the identified nursing-related topics, it was possible to isolate the nursing research within the broader interdisciplinary landscape.

The words included in topic 4 were the following: ‘trial,’ ‘effect,’ ‘yoga,’ ‘treatment,’ ‘radiation,’ ‘phage,’ ‘protocol,’ ‘anxiety,’ ‘dose,’ ‘zinc,’ ‘symptoms,’ ‘depression,’ ‘placebo,’ ‘acupuncture,’ ‘feasibility,’ ‘training,’ ‘insights,’ ‘toxicity,’ ‘mri,’ and ‘emergency.’ The words included in the topic 7 were: ‘role,’ ‘survey,’ ‘practice,’ ‘evidence,’ ‘failure,’ ‘utilization,’ ‘heart,’ ‘students,’ ‘cam,’ education,’ ‘healthcare,’ ‘valve,’ ‘knowledge,’ ‘communication,’ ‘narrative,’ ‘practitioners,’ ‘attitudes,’ ‘nursing,’ ‘perceptions,’ and ‘pseudomonas.’

The characteristics of the 12 studies included in the literature review analysis are shown in Table 3 .

Of the 12 final literature selections in nursing, there were four randomized controlled trials [A2] [A4] [A7] [A8], three non-randomized comparative trials [A3] [A5] [A6], four descriptive survey studies [A1] [A9] [A10] [A11], and one qualitative study [A12]. Regarding the country of the study’s publication, there were five studies from the United States, three from the United Kingdom, two from Germany and Turkey, and one from Australia. As for the statistical techniques that appeared with high frequency, 10 studies, which were [A1] [A2] [A3] [A4] [A5] [A7] [A8] [A9] [A10] [A11,] used independent t-test, and it was used in most studies. On the other hand, χ2 test was used in seven studies [A3] [A4] [A7] [A8] [A9] [A10] [A11] and one-way analysis of variance was used in four studies [A1] [A9] [A10] [A11]. Regarding the studies that were conducted targeting patients, there was one study conducted on cancer patients [A5], one study on women with post-traumatic stress disorder caused by a car accident [A8], one study on hypertension patients [A7], and one study on breast cancer patients undergoing chemoradiotherapy [A4]. There were seven studies conducted on medical staffs [A1] [A3] [A6] [A9] [A10] [A11] [A12] and one study conducted on nursing students [A2]. Among the interventional therapies used in clinical trials, the most common one was yoga, which was identified in three studies. Specifically, there was one study that used yoga therapy for chemotherapy patients [A5], laughter yoga for nursing students [A2], and yoga therapy for women with post-traumatic disorder [A8]. There were also studies conducted on virtual cancer education program [A6], education on complementary and alternative medicine [A3], auricular acupressure for hypertensive patients [A7], and music therapy for those with breast cancer [A4]. In the studies conducted among medical professionals and nursing students, knowledge [A1] [A3] [A6] [A9] [A10] [A11], attitudes [A1] [A3] [A10] [A11], and usage surveys [A1] [A11] were identified as measurement variables, whereas depression [A8], pain [A7], quality of life [A7], and anxiety [A8] [A4] were identified as the measurement variables in the studies conducted on patients.

Other disciplines

The detailed characteristics of these studies, including the study design, sample, intervention, statistical methods, and outcome measures, are presented in Table 4 .

Of the 22 final literature selections in other disciplines, there were 20 randomized controlled trials [B1] [B2] [B3] [B5] [B6] [B7] [B8] [B9] [B10] [B11] [B12] [B13] [B14] [B15] [B16] [B17] [B18] [B20] [B21] [B22], one pre- and post-hoc comparative study [B4], and one scoping review [B19]. The detailed characteristics of these studies, including the study design, sample, intervention, statistical methods, and outcome measures, are presented in Table 4 . Regarding the country of the study's publication, there were seven studies from the United States of America and the United Kingdom, three studies from China, two studies from the Netherlands, and one study each from Germany, India, and Hong Kong. As for the statistical techniques that appeared with high frequency, there were 10 studies that used independent t-test [B2] [B3] [B5] [B6] [B8] [B11] [B13] [B15] [B18] and one-way ANOVA [B3] [B6] [B7] [B9] [B11] [B14] [B18] [B21] [B20] [B22], while seven studies used repeated measures ANOVA [B2] [B4] [B10] [B11] [B15] [B20] [B22]. All studies for the literature review were conducted on patients. The most common intervention used was auricular acupressure, which was applied on patients with Parkinson’s disease [B11], poststroke depression [B6] [B14], insomnia and depression [B20] [B21], carpal tunnel syndrome [B7], soldiers with PTSD [B19], migraine [B15], pelvic organ prolapse [B8], and gallbladder stones [B22]. The second most common intervention used was yoga therapy, and the subjects were those with active arthritis [B18], generalized anxiety disorder [B17], hemodialysis [B4], and hypertension [B2]. Other subjects and interventions shown in the studies were the following: irritable bladder syndrome patients treated with cinnamon patch [B13]; depression patients treated with bouldering psychotherapy [B12]; dementia patients treated with aromatherapy [B10]; insomnia patients treated with Tai-chi and meridian pressure [B9]; Crohn’s disease patients treated with moxibustion [B3]; HIV patients treated with green tea [B5]; and peripheral arterial disease patients treated with laser acupuncture [B1]. On the other hand, the following were identified as the measurement variables for yoga intervention: level of depression, arthritis stage, anxiety level, quality of life, treatment response rate, sleep, and autonomic function [B2] [B4] [B16] [B17] [B18]. Measurement variables for auricular acupressure included level of depression, sleep quality, level of pain, physical and psychological symptoms, severity of depressive symptoms pelvic organ prolapse, and gastrointestinal symptoms [B3] [B6] [B7] [B8] [B11] [B14] [B15] [B19] [B20] [B21] [B22].

In the study conducted using cinnamon patches, the overactive bladder symptom scores and residual urine volume after urination were identified [B13]. In the study which used green tea, the level of depression was assessed while measuring the severity of depressive symptoms through bouldering [B12]. In the study that used aromatherapy, the behavior, psychology, daily living ability, and cognitive function of the patients with dementia were also assessed [B10].

The present study employed text mining techniques to analyze the literature on CAM published over the past five years and identify trends in nursing research. The text network analysis revealed keywords with high TF-IDF and degree centrality, such as 'cell', 'patient', 'treatment', 'cancer', 'study', and 'effect', suggesting a strong focus on cellular mechanisms, patient-centered approaches, and treatment effects, particularly in the context of cancer [ 22 , 23 ]. The high centrality of these keywords indicates their importance and influence within the broader network of CAM research [ 24 , 25 ]. The topic modeling approach identified 15 major topics, providing a comprehensive overview of the key areas of focus in recent CAM research. This data-driven method offers a more nuanced understanding of research trends compared to previous studies that relied on arbitrary searches or focused on narrow populations or interventions [ 27 , 28 , 29 , 30 , 31 ]. By employing this systematic approach, the present study captures the breadth and diversity of CAM research, overcoming the limitations of previous nursing studies.

An expert panel of 9 individuals (3 doctors, 3 nurses, and 3 pharmacists), each holding a master's or doctoral degree, conducted a survey to classify topics based on keywords. According to the expert classification results shown in Table 2 , Topics 1–3, 5–6, and 9–15 were classified as Medicine, Topics 4 and 7 as Nursing, and Topics 8 and 10 as Pharmacology. While Topics 4 and 7 were found to be nursing-related, closer examination revealed the presence of literature from other medical disciplines within these topics. To address this issue and clarify the nursing-specific research, a further refinement of the literature search was conducted using the PICO framework. The keywords from Topics 4 and 7 were used to formulate a focused research question and search strategy, yielding a final selection of 34 articles, with 12 nursing-specific articles and 22 articles from other disciplines. Analyzing trends in nursing and interdisciplinary studies within the context of the existing literature provides a more comprehensive understanding of CAM research trends. From a nursing perspective, the identification of topics related to patient care, such as symptom management, quality of life, and patient education, highlights the potential for CAM interventions to improve patient outcomes and experiences. The prominence of keywords such as 'patient', 'treatment', and 'effect' highlights the need for evidence-based practice and the need for rigorous studies to evaluate the efficacy and safety of CAM interventions in nursing care. Furthermore, the expert panel's validation of Topics 4 and 7 as relevant to nursing research emphasizes the relevance of these areas within the nursing discipline. Topic 4, which includes keywords such as 'trial', 'effect', 'yoga', 'anxiety', and 'depression', suggests a focus on the psychological benefits of CAM interventions, particularly in the context of clinical trials. This aligns with the growing recognition of the importance of holistic, patient-centered care in nursing practice [ 3 , 4 ]. Topic 7, which includes keywords such as 'practice', 'evidence', 'education', 'knowledge', and 'attitudes', highlights the importance of evidence-based practice and the need for nurse education and training in CAM. As CAM interventions become increasingly popular among patients, it is crucial for nurses to have the knowledge and skills needed to provide safe and effective care [ 5 , 6 ]. The insights gained from this study highlight the potential of text mining and topic modeling techniques for investigating research trends in various fields [ 11 , 12 , 13 ]. By leveraging these methods, researchers can systematically analyze large volumes of literature, identify key areas of focus, and uncover patterns and trends that may not be apparent through traditional review methods [ 14 , 15 ]. This approach can lead to a more comprehensive understanding of the current state of research and inform future directions for investigation.

In conclusion, the present study demonstrates the value of text mining and topic modeling techniques in analyzing research trends, particularly in the field of CAM [ 9 , 10 ]. The systematic approach employed in this study allowed for a more comprehensive and data-driven exploration of the research landscape, overcoming the limitations of previous studies and providing valuable insights into the trends in nursing research on CAM. The findings of this study have significant implications for nursing practice, highlighting the need for evidence-based approaches, patient-centered care, and the integration of CAM interventions into nursing education and training. Future studies should consider adopting similar methodological approaches to investigate research trends in other fields, as this can lead to a more complete understanding of the current state of research and inform future directions for investigation.

The trends analysis of nursing and interdisciplinary studies on CAM revealed notable differences in research design, subject characteristics, intervention types, and assessment methods. Nursing studies exhibited a more balanced distribution of research designs, including randomized controlled trials [A2, A4, A7, A8], non-randomized comparative trials [A3, A5, A6], descriptive survey studies [A1, A9-A11], and a qualitative study [A12]. In contrast, other disciplines predominantly utilized experimental designs, with 95.2% of the studies being randomized controlled trials [B1-B3, B5-B18, B20-B22]. This disparity suggests that nursing research on CAM should expand its focus on experimental studies to enhance the evidence base and align with the methodological approaches of other disciplines.

The subject characteristics of nursing studies differed significantly from those of other disciplines, with nursing research primarily focusing on healthcare professionals and students [A1, A3, A6, A9-A12], while other disciplines exclusively studied patient populations [B1-B22]. This highlights the need for nursing research to diversify its study subjects and investigate the effects of CAM interventions on patients and healthcare providers [ 28 , 29 ], as well as broader community and general health populations [ 3 , 6 ]. By expanding its scope, nursing research can provide valuable insights into the effectiveness and applicability of CAM interventions in promoting health and well-being across diverse settings and populations [ 4 , 5 , 7 , 8 ]. Nurses, as frontline healthcare providers, are uniquely positioned to bridge the gap between healthcare settings and the community, engaging with patients and community members to assess their health needs and provide evidence-based recommendations for CAM interventions [ 1 , 2 ]. This expanded focus, coupled with interdisciplinary collaboration and knowledge exchange [ 9 , 10 ], can lead to the development of innovative, culturally sensitive, and evidence-based CAM interventions that address the complex health needs of individuals and communities alike.

A closer examination of the intervention types in nursing studies reveals that although they focused on a relatively limited range of CAM modalities, such as yoga [A2, A5, A8] and auricular acupressure [A7], these interventions demonstrated promising potential for managing various symptoms and conditions. For instance, yoga was found to be effective in reducing psychological symptoms and cortisol levels in college students [A2], alleviating chemotherapy-related symptoms in cancer patients [A5], and improving post-traumatic stress disorder among traffic accident survivors [A8]. Similarly, auricular acupressure was shown to help decrease angina symptoms in hypertensive patients [A7]. These research findings suggest that even though the scope of CAM interventions in nursing research may be limited, they can provide significant benefits to diverse patient populations [ 2 , 4 , 22 ]. In contrast, the wide array of CAM interventions investigated in other disciplines, such as aromatherapy for dementia [B10], green tea for depression in HIV patients [B5], laser acupuncture for peripheral arterial disease [B1], cinnamon patch for irritable bladder syndrome [B13], bouldering psychotherapy for depression [B12], Tai-chi and meridian pressure for insomnia [B9], and moxibustion for Crohn's disease [B3], demonstrates the potential for nursing research to explore and apply new therapies. The safety, efficacy, and potential of these diverse CAM modalities, as evidenced in other disciplines [ 23 , 24 ], should encourage nursing researchers to investigate their applicability in patient care. By conducting rigorous studies on the safety and efficacy of various CAM interventions, nursing research can provide valuable evidence to support the integration of complementary therapies into nursing practice [ 2 , 4 , 22 ]. Moreover, this trends analysis emphasizes the importance of studying CAM interventions for chronic disease management. With the increasing prevalence of chronic conditions [ 1 , 9 , 10 ], nursing research can play a pivotal role in evaluating the effectiveness of CAM for managing these diseases. Studies on yoga for hypertension [B2] and arthritis [B18], auricular acupressure for insomnia and depression [B20, B21], and moxibustion for Crohn's disease [B3] demonstrate the potential of CAM in improving patient outcomes and quality of life. As nurses have more direct and prolonged contact with patients compared to other healthcare professionals, they are well-positioned to assess the effectiveness of CAM interventions in both clinical and community settings [ 3 , 5 ]. By conducting well-designed studies on the safety and efficacy of various CAM modalities, nursing research can provide the necessary evidence to support the integration of complementary therapies into chronic disease management plans, ultimately enhancing patient care and outcomes across diverse settings. Leveraging their unique role in patient care and conducting rigorous studies on the safety and efficacy of various CAM interventions, particularly for chronic disease management, can enable nursing research to make significant contributions to the integration of complementary therapies into nursing practice. This approach has the potential to not only improve patient outcomes and experiences but also strengthen the evidence base for CAM in healthcare, fostering interdisciplinary collaboration in CAM research and advancing the field of nursing.

The analysis of assessment methods revealed that nursing studies heavily relied on self-developed measurement instruments (58.3%) [A3, A5, A6, A9-A12], while other disciplines predominantly used previously validated tools [B1-B22]. Furthermore, nursing studies rarely incorporated physiological indicators (8.3%) [A2], in contrast to the more frequent use of such measures in other disciplines (36.3%) [B1-B22]. These findings underscore the importance of utilizing validated assessment tools and physiological indicators in nursing research to enhance the reliability and validity of study results [ 31 ]. By incorporating these objective measures, nursing research can more clearly identify significant factors and strengthen the level of evidence, ultimately improving the credibility and applicability of the results.

The trends analysis of statistical techniques revealed a higher prevalence of independent t-tests in nursing research (83.3%) [A1-A5, A7-A11], while other disciplines showed a more balanced use of various techniques, including one-way ANOVA (45.5%) [B3, B6, B7, B9, B11, B14, B18, B20-B22] and repeated measures ANOVA (31.8%) [B2, B4, B10, B11, B15, B20, B22]. This difference can be attributed to the nature of the dependent variables assessed in each field, with nursing studies primarily focusing on single assessments of knowledge, attitudes, education, beliefs, and symptoms [A1, A3-A11], whereas other disciplines frequently employed repeated measures of pain, depression, response rate, serum levels, and neurological outcomes [B2-B4, B6-B8, B10, B11, B14-B22]. These findings underscore the importance of aligning the choice of statistical techniques with the nature of the outcome measures to ensure the validity and reliability of the research findings.

In conclusion, the trends analysis of nursing and interdisciplinary studies on CAM highlights the need for nursing research to expand its focus on experimental designs, diversify study subjects, explore various CAM interventions, utilize validated assessment tools and physiological indicators, and employ robust statistical techniques. By addressing these methodological considerations, nursing research can strengthen the evidence base for CAM interventions, facilitate their integration into nursing practice, and contribute to interdisciplinary dialogue in the field of CAM research [ 11 , 12 , 13 ]. As CAM use becomes increasingly prevalent among patients, particularly those with chronic conditions [ 1 , 9 , 10 ], nursing research has a crucial role to play in investigating the safety and efficacy of various CAM modalities [ 2 , 4 , 22 ]. This approach not only has the potential to improve patient outcomes and experiences but also enables nursing research to make valuable contributions to interdisciplinary collaboration in the field of CAM [ 3 , 5 ]. By embracing the diversity of CAM interventions and fostering interdisciplinary interactions, nursing research can broaden its scope, enhance the efficiency of patient-focused care, and move closer to providing truly holistic care that addresses the multifaceted needs of patients. Also, the integration of CAM into nursing practice, supported by robust research evidence, has the power to transform healthcare delivery and improve the lives of patients, particularly those with chronic conditions who stand to benefit greatly from a more comprehensive and individualized approach to care.

The trends analysis of nursing and interdisciplinary studies on CAM highlights the potential for nursing research to draw inspiration from the diverse CAM interventions studied in other disciplines and adapt them for nursing practice. For example, the use of aromatherapy for dementia [B10], green tea for depression in HIV patients [B5], and cinnamon patch for irritable bladder syndrome [B13] could be explored in nursing research to assess their feasibility and effectiveness in nursing care settings. By learning from the experiences of other disciplines and adapting promising CAM interventions for nursing practice, researchers can expand the scope of nursing research on CAM and contribute to the development of innovative, evidence-based complementary therapies for various patient populations. Given the current trends in nursing research on CAM, it is essential for future studies to consider the research directions and methodologies employed in other disciplines to guide the advancement of nursing science in this field. In summary, this trends analysis emphasizes the need for nursing research to embrace a more diverse and rigorous approach to CAM research, drawing inspiration from the methodologies and interventions studied in other disciplines. By expanding the focus on experimental designs, diversifying study subjects, exploring novel CAM interventions, utilizing validated assessment tools and physiological indicators, nursing research can strengthen the evidence base for CAM interventions, facilitate their integration into nursing practice.

Limitations

This study aimed to identify research trends in CAM through text network analysis and to analyze nursing research trends based on the findings. The use of text mining and big data analysis allowed for a more comprehensive and less biased approach to data collection and processing compared to arbitrary search strategies. However, there were still limitations in defining each field intuitively due to the diverse and wide-ranging areas of CAM used in different disciplines. Future studies should focus on analyzing overall topics across various fields as well as keyword extraction through text mining to gain a more holistic understanding of CAM research trends. Another limitation of this study is that the search languages were restricted to Korean and English. This may have excluded relevant studies published in other languages and might limit the generalizability of the findings. As CAM is rooted in diverse cultures and traditions worldwide, it is important to include studies conducted in various languages for a comprehensive understanding. Future research should incorporate more languages to provide a global perspective on CAM research trends.

Despite these limitations, this study offers a novel methodological strategy for trend analysis by combining keywords extracted using big data rather than relying on researchers' arbitrary settings. The keyword-based classification and literature analysis provide a new approach to identifying research trends and directions. The trends analysis between nursing literature and other disciplines revealed differences in subject selection, study design, statistical techniques, and measurement of dependent variables, highlighting the need for nursing research to broaden the range of subjects and measurement tools while considering randomization and generalization in experimental designs. Furthermore, this study emphasizes the importance of using design techniques that facilitate the sharing of research results beyond the nursing community.

Conclusions

This study significantly advances CAM research in nursing by providing a comprehensive, data-driven overview of research trends. We have identified key areas for improvement, such as the need for more randomized controlled trials and broader subject diversity, and have proposed innovative methodological strategies. Our findings underscore the importance of interdisciplinary collaboration and the adoption of diverse, rigorous research approaches. By addressing these gaps, nursing research in CAM can be strengthened, ultimately enhancing the integration of evidence-based CAM practices in nursing care and improving patient outcomes.

Availability of data and materials

The data and materials of this study are available from the corresponding author upon reasonable request.

Abbreviations

Complementary and Alternative Medicine

World Health Organization

National Center for Complementary and Integrative Health

Research Information Sharing Service

Korean studies Information Service System

Cumulative Index to Nursing and Allied Health Literature

Term Frequency-Inverse Document Frequency

Latent Dirichlet Allocation

Markov Chain Monte Carlo

Document Term Matrix

Mixed Methods Appraisal Tool

Institutional Review Board

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This study was supported by the National Research Foundation of Korea (NRF-2022R1F1A1071533)

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Study design: JN, HP, and HL; Data collection and Data analysis : JN and HL ;Study supervision: HP; Manuscript writing: JN, HL, and SL Critical revisions for important intellectual content: HP. All authors reviewed and approved the final manuscript.

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Nam, J., Lee, H., Lee, S. et al. Literature review of complementary and alternative therapies: using text mining and analysis of trends in nursing research. BMC Nurs 23 , 526 (2024). https://doi.org/10.1186/s12912-024-02172-9

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Motivational interviewing (MI) is a person-centred approach focused on empowering and motivating individuals for behavioural change. Medical students can utilize MI in patient education to engage with patients’ chronic health ailments and maladaptive behaviours. A current scoping review was conducted to 1) determine the types of MI (conventional, adapted, brief and group MI) education programs in medical schools, delivery modalities and teaching methods used; 2) classify educational outcomes on the basis of Kirkpatrick’s hierarchy; and 3) determine the key elements of MI education via the FRAMES (feedback, responsibility, advice, menu of options, empathy, self-efficacy) model.

This scoping review was conducted via the framework outlined by Arksey and O’Malley. Two online databases, CINAHL and MEDLINE Complete, were searched to identify MI interventions in medical education. Further articles were selected from bibliography lists and the Google Scholar search engine.

From an initial yield of 2019 articles, 19 articles were included. First, there appears to be a bimodal distribution of most articles published between the two time periods of 2004--2008 and 2019--2023. Second, all the studies included in this review did not use conventional MI but instead utilized a variety of MI adaptation techniques. Third, most studies used face-to-face training in MI, whereas only one study used online delivery. Fourth, most studies have used a variety of interactive experiences to teach MI. Next, all studies reported outcomes at Kirkpatrick’s Level 2, but only 4 studies reported outcomes at Kirkpatrick’s Level 3. According to the FRAMES model, all studies ( n =19; 100%) reported the elements of responsibility and advice. The element that was reported the least was self-efficacy ( n = 12; 63.1%).

Our findings suggest that motivational interviewing can be taught effectively in medical schools via adaptations to MI and a variety of teaching approaches. However, there is a need for further research investigating standardized MI training across medical schools, the adequate dose for training in MI and the implementation of reflective practices. Future studies may benefit from exploring and better understanding the relationship between MI and self-efficacy in their MI interventions.

Peer Review reports

Motivational interviewing (MI) is a person-centred approach that focuses on empowering and motivating individuals for behavioural change [ 1 ]. Undoubtedly, the empathetic approach of MI in clinical settings fosters a supportive environment that encourages discussion of the benefits of enhanced self-care [ 2 ]. In this context, MI practitioners utilize a set of essential skills encapsulated by the acronym “OARS”, which stands for O = open-ended questions, A = affirmations, R = reflections and S = summaries to promote active listening [ 3 ]. MI was developed primarily for the treatment of addiction disorders but has since progressed to include other physical and mental ailments as well [ 4 ]. In a study on MI interventions in alcoholism, Miller & Sanchez [ 68 ] identified six common motivational elements that should be covered, represented by the acronym “FRAMES”, where F = feedback (e.g., personalized feedback on the impacts of alcoholism on the client’s own experiences, as opposed to providing generic information); R = responsibility (e.g., empowering clients to make their own choices and take responsibility for their change process); A = advice (e.g., effectively given in a nondirective and noncoercive manner); M = menu (e.g., offering a variety of choices on transition methods and plans); E = empathy (e.g., rendering empathic, reassuring and reflective listening); and S = self-efficacy (e.g., supporting clients to succeed in a specified goal). This review used the FRAMES model to determine the key elements of MI education. FRAMES was a predecessor to MI and was initially designed to address drinking problems [ 5 ]; however, it is also used in other health issues, such as decreasing stroke risk [ 6 ], substance use screening and brief intervention [ 7 ]. The FRAMES model offers a structure that can be used to improve the delivery of MI by ensuring that key elements of MI are present in educational interventions.

Mechanisms of motivational interviewing

Frey et al. [ 8 ] developed mechanisms of the motivational interviewing (MMI) framework and described the mechanisms of fidelity of practice in MI, including a technical component, a relational component and MI-inconsistent practices [ 8 ]. The technical component consists of the interviewer’s ability to evaluate the participant’s language relating to a specific behaviour change target and then build a conversation that evokes change talk. The relational component includes respect for the participant’s self-determination, appropriate empathy, and equal partnership. Non-MI consistent behaviours include confrontation, offering unsolicited advice, and persuasion. Additionally, it is important to identify and understand the mechanisms of change so that MI users and researchers can focus on these mechanisms during training, which can lead to improved outcomes and fidelity [ 8 ].

Types of motivational interviewing

MI can be categorized into four types: conventional, adaptive, brief, and group. Conventional MI is an evidence-based approach and directive form of interviewing developed by Miller & Rollnick [ 9 ]. Throughout the course of MI, four important tasks occur: engaging (building mutual relationships), focusing (setting goals), evoking (developing clients’ motivations for change) and planning (negotiating change) [ 9 ]. In this review, the term conventional MI is defined as an approach that utilizes MI-consistent tasks and behaviours in multiple sessions that target an identified population of clients.

Adapted MI consists of culturally sensitive MI and digitally supported interventions that can be used as adjunct interventions to the primary behavioural program [ 10 ]. This review defines the term adapted MI to include any adaptations made to adapt MI culturally to the setting or delivered by technology through various types of technologies and content (e.g., computers, smartphones, applications, videos and audio). Additionally, it also includes adaptations made to structured curricula, such as using role plays or real patient interactions to facilitate the learning of MI.

Brief MI is a type of MI with varying lengths, ranging from 5--90 minutes in duration, emphasizing the lack of an accepted definition of brief MI [ 10 ]. This review defines the term brief MI as an MI that provides brief consultations centred on typically fewer sessions (e.g., 1--2 sessions) than conventional MI (e.g., 3--4 sessions or more).

Group MI can be defined as groups of clients that apply the MI spirit, processes and methods to increase motivation for change and promote beneficial collaboration among participants and practitioners in a shared location to encourage change [ 11 ]. This review defines the term group MI as MI that is adapted for group format and is MI consistent (e.g., applying MI principles, spirit and techniques in its delivery).

Additionally, MI can be used in patient education to help patients better handle their chronic health conditions and maladaptive behaviours. Therefore, behavioural change is vital in the recovery course of different mental and physical disorders, as a change to a healthier lifestyle has been shown to result in a significant decrease in chronic disease risk [ 12 ]. More than 120 studies have demonstrated the efficacy of MI in addressing a wide range of problematic behaviours, such as substance abuse and risky behaviour, as well as promoting healthy behaviours [ 13 ]. There is specific evidence regarding the effectiveness of MI across different health behaviours (substance abuse, risky behaviours and promoting health behaviours), according to the types of MI: conventional, adaptive, brief and group. For conventional MI, research has shown effectiveness in treating substance abuse [ 14 ], reducing risky behaviours in human immunodeficiency virus (HIV)-positive men [ 15 ] and promoting physical activity in older adults [ 16 ]. Adaptive MI has demonstrated its effectiveness in reducing alcohol problems in women [ 17 ], reducing risky sexual behaviours and psychological symptoms in HIV-positive older adults [ 18 ] and promoting self-management to reduce BMI and improve lifestyle adherence with a computer assistant [ 19 ]. Brief MI has been effective in reduction in alcohol misuse in college students with attention deficit hyperactivity disorder (ADHD) [ 20 ] and improvement in the engagement of physical activity in patients with low physical activity levels [ 21 ]. Research has revealed that group MI is effective in treating drug use among women [ 22 ], reducing risky sexual behaviour among adolescents [ 23 ] and improving self-efficacy and oral health behaviours among pregnant women [ 24 ].

Unhealthy lifestyle-linked behaviours characterize common preventable risk factors that lead to the majority of noncommunicable diseases and their associated mortality and morbidity [ 25 ]. MI provides an approach for healthcare providers to assist patients in investigating and resolving their ambivalence toward changing unhealthy lifestyle behaviour [ 27 ]. Studies have reported the effectiveness of teaching MI to medical students [ 4 , 26 , 28 , 29 , 30 ]. Therefore, considering the prevalence and widespread application of MI in health care settings, this underscores the importance of MI being taught in the initial stages of medical education.

In a recent systematic review, Kaltman and Tankersley [ 31 ] reviewed MI curricula in undergraduate medical education (UME) and revealed important findings. Their research findings suggest that generally being involved in an MI curriculum can be linked to enhanced MI-related knowledge and skills in the short term. Additionally, they noted that 1) the MI curricula were heterogeneous in nature; 2) the curricula were different in terms of timing, duration and number of sessions; 3) the curricula employed in studies were multiple pedagogies; and 4) the quality of the evaluations and research evidence varied. However, this review by Kaltman and Tankersley [ 31 ] was limited to reporting only on MI-specific outcomes such as knowledge, skills, attitudes towards, and self-efficacy in implementing MI. Kaltman and Tankersley [ 31 ] systematic review did not stratify and explore in detail studies on the types of MI (conventional, adaptive, brief, or group). Furthermore, the systematic review did not investigate the key elements of MI education as described by the FRAMES model. The scoping review aimed to bridge the knowledge gap on types of MI (conventional, adapted, brief, group MI) and key elements of MI education covered via the FRAMES model. Specifically, the objectives of this study were to 1) determine the types of MI education programs in medical schools, the delivery modalities, and the teaching methods used; 2) classify educational outcomes on the basis of Kirkpatrick’s hierarchy [ 32 ]; and 3) determine the key elements of MI education covered via the FRAMES model.

This study adopted the methodological 5-step framework of Arksey and O’Malley for this scoping review. The five steps are as follows: 1) define our research objectives; 2) identify relevant studies; 3) identify studies based on our selection criteria; 4) chart and analyse the data; and 5) collate, summarize, and disseminate the results.

Eligibility criteria

Relevant peer-reviewed articles on MI studies conducted in medical education settings, published in academic journals only, in the English language, with no time limit imposed on the publication period, were identified. Studies involving nonmedical students as well as grey literature, such as conference proceedings, technical reports, videos, and informal communications, were excluded. Studies in languages other than English were also excluded. The search strategy was guided by the methodology of Aromataris and Riitano [ 33 ]. The Boolean operators and keywords used in this search strategy were ("medical education" OR "medical teaching*" OR "medical graduate*" OR "medical postgraduate*” OR “medical student*”) AND ("motivational interview*" OR "motivational enhanc*" OR "motivational chang*" OR "motivational behavior”) AND ("psycholog*" OR "health*"). The search utilized databases from the Medical Literature Analysis and Retrieval System Online (MEDLINE Complete) and Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete) databases via the EBSCOHost database search query, covering all study designs (i.e., quantitative, qualitative, and mixed studies). The protocol was developed a priori before the search process was conducted, including establishing the objectives and eligibility criteria for determining the studies selected. The reference lists of the selected studies were further checked for additional sources, including traditional and systematic reviews. Articles that met the eligibility criteria were selected through a consensus among the authors and were charted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) guidelines [ 34 ]. The first author conducted the searches and screened the articles using the search strategy and the inclusion and exclusion criteria stated above. This process resulted in the identification of 59 articles. The decision process resulted in 19 studies for inclusion in this review based on the inclusion and exclusion criteria. The data were extracted and charted by the first author. Notably, the following data were extracted: 1) the study characteristics of the identified articles (publication year, country of origin, type of MI, and medical student phase) and 2) a detailed description of the key findings of the articles (i.e., author, year, objectives, participants, delivery, duration, teaching methods, assessments, and educational outcomes based on Kirkpatrick’s hierarchy). Proforma was developed by all the authors and used to extract and chart the data. The study characteristics are then charted in Table 1 , and detailed descriptions of the key findings of the articles are charted in Table 2 . The other authors assisted in identifying specific data elements to be charted onto Tables 1 and 2 . All the authors contributed to analysing the charted data to ensure the consistency and accuracy of the analysis. The outcomes of educational intervention were classified under the four levels of Kirkpatrick’s hierarchy. Studies classified as Level 3 consists of simulations and observations of behaviours in activities (e.g., roleplay, standardized patients, real patients) after a learning activity such as a workshop. Although Level 3 is usually linked to students applying what they have acquired in training to job settings, our classification extends to controlled settings simulating real-life applications. The most recent search of MEDLINE Complete, CINAHL Complete and Google Scholar was carried out in October 2023.

From an initial pool of 2,019 articles, after removing duplicates and screening for relevance, 19 articles were included in this review. The detailed selection process is illustrated in the PRISMA flow diagram in Fig. 1 .

Prism flow diagram

Characteristics of the identified articles

The study characteristics, country of origin, and phase of study are presented in Table 1 . The detailed descriptions of the key findings of these articles (i.e., author, year, objectives, participants, delivery, duration, teaching methods, assessments, and educational outcomes based on Kirkpatrick’s hierarchy) are provided in Table 2 . Most of the studies were published between 2004–2008 and 2019–2023, with each period accounting for 31.5% of the total articles. The majority of MI studies originated from the US (57.8%).

Types and characteristics of MI

With respect to the first research objective, none of the 19 studies in this scoping review conducted conventional MI. Rather, most studies in this scoping review used adapted MI ( n =8; 42.1%) [ 4 , 36 , 38 , 42 , 44 , 46 , 47 , 49 ], followed by group MI ( n =7; 36.8%) [ 26 , 29 , 35 , 40 , 45 , 48 , 39 ] and brief MI ( n =4; 21%) [ 37 , 41 , 43 , 50 ].

Adapted motivational interviewing was utilized in 8 studies. This approach includes any adaptations utilized to adjust MI culturally to the situation or facilitated by technology via different types of content and technologies (e.g., computers, smartphones, applications, videos and audio). Additionally, it also includes adaptations made to structured curricula, such as using role plays via standardized patients or real patient interactions to facilitate the learning of MI. Adapted MI was reported in 8 studies. Specifically, 5 studies [ 36 , 38 , 42 , 44 , 47 ] adapted their curricula to teach MI via role playing standardized patients or real patients. Additionally, 3 studies [ 4 , 46 , 49 ] utilized technological adaptations and blended learning (face-to-face and online) to teach motivational interviewing.

In group MI, this approach consists of MI that is adapted for group format and is MI consistent (e.g., applying MI principles, spirit and techniques in its delivery). Group MI was carried out in 7 studies. Two studies [ 26 , 45 ] used training workshops to teach and practice MI in smaller groups. The remaining 5 studies [ 29 , 35 , 39 , 40 , 48 ] used a small group format to teach MI skills consisting of lectures, roleplay, a case-based curriculum and demonstrations.

Brief MI provides brief consultations centred on typically shorter number sessions (e.g., 1--2 sessions) than conventional MI (e.g., 3--4 sessions or more). A brief MI was conducted in 4 studies. Two studies [ 41 , 51 ] delivered a single session of MI training within two hours. Another study [ 50 ] conducted four (10–15 minute) sessions teaching MI, with a total of less than 1 hour of training. Opheim et al. [ 43 ] conducted a four-hour workshop on MI, which is a relatively brief training intervention.

More than half of the studies focused on clinical medical students ( n =10; 52.6%) [ 4 , 35 , 37 , 38 , 41 , 42 , 43 , 45 , 46 , 49 ], and the least studied was the combination of preclinical and clinical students ( n =2; 10.5%) [ 40 , 47 ]. There was a diverse number of participants, ranging from 17 to 339 students. The median number of participants in these studies was 93. The most common delivery mode identified was face-to-face learning ( n =15; 78.9%) [ 26 , 29 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 51 ], followed by blended learning ( n =3; 15.7%) [ 4 , 46 , 49 ], and the least common delivery mode was online learning ( n =1, 5.2%) [ 50 ]. The duration of intervention for brief MI ( n =4; 21.0%) [ 37 , 41 , 43 , 50 ] ranged from 10 minutes to 2 hours per session. The duration of adapted MI ( n =8; 42.1%) [ 4 , 36 , 38 , 42 , 44 , 46 , 47 , 49 ] and group MI ( n =7; 36.8%) [ 26 , 29 , 35 , 40 , 39 , 45 , 48 ] ranged from 3 hours to 12 hours. The teaching methods include workshops, lectures, videos, role plays, demonstrations, interviews, interactive exercises, small and large group activities, simulated patients, and online forums.

Classifying educational outcomes based on Kirkpatrick’s hierarchy

With respect to the second research objective (i.e., classifying educational outcomes on the basis of Kirkpatrick’s hierarchy [ 32 ]), all 19 studies [ 4 , 26 , 29 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ] were categorized at Kirkpatrick’s Level 2 (knowledge/skills/attitudes). This is followed by 16 out of 19 studies [ 4 , 26 , 29 , 35 , 36 , 39 , 40 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ] categorized at Kirkpatrick’s Level 1. Only 4 out of 19 studies [ 35 , 38 , 41 , 47 ] are categorized at Kirkpatrick’s Level 3 (Behaviour). One of the studies [ 38 ] compared the effectiveness of standardized patients versus role plays from colleagues and reported that both were equally effective for teaching basic MI skills among medical students. The students were evaluated in a simulated environment and demonstrated their MI skills in terms of student roleplay or standardized patients. The study reported that standardized patient role play is as effective as student role play in teaching basic MI skills. The sessions focused on demonstrating skills in a simulated setting, suggesting that the student’s behaviour (i.e., adherence to MI skills) was evaluated and improved via the educational intervention. In another study, Bell et al. [ 35 ] investigated the use of a curriculum to teach medical students the principles of MI to increase their knowledge, skills and confidence in counselling patients with the aim of health behaviour change. The research indicated that video-recorded interactions between students and patients enabled students to effectively apply MI skills to real-life patients. None of the studies included reported outcomes at Level 4 (results).

Key elements of the reported FRAMES model and assessment methods used

With respect to the third research objective, all 6 elements in the FRAMES model were covered in 9 out of 19 studies [ 4 , 29 , 35 , 36 , 39 , 40 , 44 , 45 , 51 ], 5 elements were identified in another 4 studies [ 26 , 41 , 48 , 49 ], and 4 elements were identified in 4 studies [ 42 , 43 , 46 , 47 ]. The most reported element in all 19 studies was responsibility and advice ( n =19; 100%), and the least reported element was self-efficacy in only 12 studies ( n =12; 63.1%) [ 4 , 29 , 35 , 36 , 39 , 40 , 41 , 44 , 45 , 46 , 48 , 51 ]. Figure 2 shows additional details on the important elements present in the MI interventions.

Important elements of MI interventions ( n  = 19) identified as “reported” via the FRAMES model

The primary assessment method used across the studies was the use of pre- and posttest surveys, which are used to measure knowledge ( n =10, 52.6%), skills ( n =5, 26.3%) and attitudes ( n =3, 15.8%) pertaining to MI. Moreover, the specific instruments employed for focused assessments were (1) MITI to measure fidelity of MI in 5 out of 19 studies ( n =5, 26.3%), (2) Video Assessment of Simulated Encounters (VASE-R) to measure MI skills in 2 out of 19 ( n =2, 10.5%) (3) Behaviour Change Counselling Index (BECCI) to measure practitioner’s skill and competence in delivering effective MI in 2 studies out of 19 ( n =2, 10.5%), (4) Objective Structured Clinical Examination (OSCE) to measure clinical competence in 2 studies out of 19 ( n =2, 10.5%), (5) Motivational Interviewing Knowledge and Attitudes Test (MIKAT) to measure the practitioner’s knowledge and attitude pertaining to MI in 1 study out of 19 ( n =1, 5.2%), (6) Motivational interviewing skill code (MISC) to measure adherence to MI in 1 study out of 19 ( n =1, 5.2%), (7) the Calgary-Cambridge Observation Guide (C-CG) to measure communication skills between practitioners and patients was used in 1 study out of 19 ( n =1, 5.2%), (8) Motivational interviewing confidence scale (MICS) to measure confidence in health behaviour change dialogues in 1 study out of 19 ( n =1, 5.2%) and (8) the Jefferson Scale of Physician Empathy (JSPE) to measure empathy in patient care among health practitioners in 1 study out of 19 ( n =1, 5.2%).

Our scoping review sheds light on the current trends and key findings to determine the types of MI education programs in medical schools, the delivery modalities and teaching methods used, classify educational outcomes on based on Kirkpatrick’s hierarchy [ 32 ] and determine the key elements of MI education covered via the FRAMES model. First, there appears to be a bimodal distribution of most articles published between the two time periods of 2004--2008 and 2019--2023. Second, all the studies included in this review did not use conventional MI but instead utilized a variety of MI adaptation techniques. Third, most studies used face-to-face training in MI, whereas only one study used online delivery. Fourth, most studies have used a variety of interactive experiences to teach MI. Next, all studies reported outcomes at Kirkpatrick’s Level 2, but only 4 studies reported outcomes at Kirkpatrick’s Level 3. Finally, the most covered elements of MI training in these studies were responsibility and advice ( n = 19; 100%), and the least covered element in MI training was self-efficacy ( n = 12; 63.1%) [ 4 , 29 , 35 , 36 , 39 , 40 , 41 , 44 , 45 , 46 , 48 , 51 ]. This review expands on the evidence of MI interventions among medical schools. The results of our findings generally suggest that MI can be effectively taught in medical schools. Furthermore, we have provided several recommendations for further research to improve the implementation of MI in medical schools.

There appears to be a bimodal distribution of published articles between the two time periods, i.e., between 2004 and 2008 and between 2019 and 2023. A decline in the number of articles published was observed between 2009 and 2019. This decline could be due to the shift in the applications of MI beyond treating addictive behaviours to include a broad range of other behavioural conditions [ 52 ], such as its expanded applications in school education [ 53 , 54 , 55 ], lifestyle coaching [ 56 , 57 , 58 ], probation and parole [ 59 , 60 ] and digital health care and telemedicine [ 61 , 62 ]. From 2019 onwards, however, there was an increasing trend in the number of published articles on MI training for medical students. This could be attributed to the MI Network of Trainers (MINT) making it mandatory to attend MI training during the COVID-19 pandemic to provide virtual training in 2020 and 2021 [ 52 ], which has facilitated remote participation.

Types of MI education programs in medical schools

All the studies included in this review did not use conventional MI but utilized a variety of MI adaptation techniques. Most studies [ 4 , 36 , 38 , 42 , 44 , 46 , 47 , 49 ] have used adapted MI to conduct their MI training, possibly because of the need to tailor MI programs to fit medical school curricula. Medical students have been linked to extensive academic responsibilities and clinical rotations [ 63 ], contributing to this adaptation of MI. In fact, the lack of harmonization of training methods among medical schools has led to challenges in understanding the optimal approach to teach MI among medical students [ 31 ]. Furthermore, there is no consensus on the standard dose of training in MI that is adequate or mandatory for learners to acquire sufficient skilfulness in the practice of MI [ 9 ]. Moreover, medical schools have time constraints and limited MI teaching opportunities because of their hectic medical curriculum schedules [ 41 ]. This may lead to a variety of adaptations of MI, as noted in this review. Future research can focus on addressing the lack of harmonization in MI training methods and emphasize building and employing standardized MI training with adequate dosing across medical schools.

Delivery modalities and teaching methods used

In the present review, the delivery modalities used to train medical students in MI varied across the studies. Most studies [ 26 , 29 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 51 ] have focused on delivering face-to-face training on MI to clinical medical students. This aligns with the current literature, which suggests that MI is a complex communication skill [ 57 ] and is reported to be taught more effectively in face-to-face sessions [ 64 ]. In this review, only one study [ 50 ] used a fully online approach to teach MI to medical students. A systemic study suggested that for an online MI intervention to be effective, it requires significant emphasis on fidelity and training procedures [ 65 ]. In a recent comparative study, Schaper et al. [ 66 ] reported similar effects of training MI among general practitioners in both online and face-to-face training in MI skills and spirit. Future studies could focus on the implementation of online versus face-to-face training for medical students with an emphasis on fidelity and training procedures for MI.

A large proportion of the studies in this review report the use of a variety of teaching approaches (e.g., workshops, role-play, standardized patients, and small and large group sessions) to teach MI. This aligns with Kolb’s experiential learning cycle [ 67 ], where the process of learning occurs when knowledge is formed via the transformation of experience. This model is guided by four phases of the learning process: concrete experience (having an experience), reflective observation (reflecting on an experience), abstract conceptualization (learning from the experience), and active experimentation (experimenting what you have learned). Medical students who are given the opportunity to engage in Kolb’s learning cycle [ 67 ] via interactive activities, reflection and simulated or real-life settings are likely to develop good MI skills. Future research should underpin educational theories into MI training by implementing structured reflective exercises in MI education.

Educational outcomes based on Kirkpatrick’s hierarchy

Our review shows that all studies reported outcomes at Kirkpatrick’s Level 2, suggesting that medical students have acquired the intended knowledge, skills, and attitudes. There are only 4 studies that reported outcomes at Kirkpatrick’s Level 3, which evaluates the degree to which the students apply their learning to simulated or real-world settings. The first 3 studies [ 38 , 41 , 47 ] showed their improvement in behaviour by showing their learned skills in realistic settings, which included observing students’ behaviour in standardized patients or real patients. The last study [ 35 ] revealed improvements in the MI skills of real patients in diverse settings, such as traditional health behaviour interventions, such as alcohol, tobacco and weight loss interventions. Future studies should include longitudinal evaluations of the effectiveness of MI skills.

Key elements of MI education covered via the FRAMES model

According to the FRAMES model [ 68 ], all included studies reported the elements of responsibility and advice ( n =19; 100%) in the training of MI. The element responsibility is the shared responsibility of the learner’s growth by the learner and teacher. This could be attributed to the move towards competency-based medical education, which emphasizes shared responsibility among students while incorporating student-centric learning techniques and formative assessment as a vital element of the learning process [ 69 ]. In other words, the high reporting of ‘responsibility’ and ‘advice’ suggest that the present MI training significantly emphasizes medical students taking ownership of their learning and decision-making processes (‘responsibility’). Moreover, from a patient education perspective, empowering patients to take ownership of their health [ 70 ] and effectively guiding patients toward positive behavioural changes through good advice in a nonconfrontational approach is a basic tenet of MI (‘advice’).

The least reported element found in training for MI in our included studies [ 4 , 29 , 35 , 36 , 39 , 40 , 41 , 44 , 45 , 46 , 48 , 51 ] was self-efficacy. This may be due to MI training focusing less on self-efficacy and instead emphasizing other elements, such as empathy, open-ended questioning and reflective listening. An educational theory that is linked to the element of self-efficacy is social cognitive theory. Social cognitive theory can be defined as a person’s belief in their ability to determine the behaviours required to reach their desired goals and their perceptions of their ability and skills to manage their environment [ 71 , 72 ]. Continued research into integrating social cognitive theory into MI training could assist practitioners in comprehending the role and importance of self-efficacy in behaviour change and reflective practice. The lower reporting of ‘self-efficacy’ might also indicate a potential gap in MI training. Self-efficacy is essential because it relates to the practitioner’s confidence in their ability to effectively implement MI techniques and facilitate behaviour change in patients. Addressing this gap in future research could lead to more competent and confident practitioners who are better equipped to address challenging patient interactions and support positive health outcomes. Future studies can also utilize FRAMES to guide research design and interventions and investigate which aspects of FRAMES in the training of MI are most effective within the limited time frame of medical curricula.

Limitations

This scoping review is subject to several limitations. We included only English-language studies in which medical students were the target participants. We did not include articles that are categorized as grey literature or other forms of nonpeer review articles, which might have resulted in biased outcomes. Most of the studies focused on evaluating learner knowledge and skills in MI, which might have limited the practical applications of MI to real patients. The first author conducted the search and screening of the articles. This may lead to selection bias and reduce the reliability of the study selection process. The protocol for this review was developed before the search was initiated but was not registered or published online, which increases the risk of selective reporting. The database search was limited to MEDLINE Complete and CINAHL Complete, which were accessed via EBSCOhost and the search engine Google Scholar. Although a comprehensive search was conducted, other databases that were relevant to the review, such as the PsycINFO and ERIC databases, were not included, potentially resulting in missing relevant articles. Kirkpatrick’s hierarchy was utilized to assess educational outcomes in this review. This approach may neglect other core aspects of educational interventions. Furthermore, although we have extensively searched various countries, most of the studies reported are from the USA ( n =11; 57.8%) or Germany ( n =4; 21.0%). A lack of diversity among studies in other regions may lead to biased outcomes.

Based on our review, the findings suggest that motivational interviewing can be taught effectively in medical schools via adaptations of MI and a variety of teaching approaches. However, there is a need for further research investigating standardized MI training across medical schools, the adequate dose for training in MI and the implementation of reflective practices that are supported by educational learning theories. Furthermore, longitudinal studies can assess the effectiveness of MI. Future studies may benefit from exploring and better understanding the relationship between MI and self-efficacy in their MI interventions. The FRAMES model can be used to guide research and explore which aspects of FRAMES are optimally delivered within the limited time frame of medical curricula.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Attention-deficit/hyperactivity disorder

Behaviour Change Counselling Index

Brief motivational interviewing

Course Experience Questionnaire

Calgary-Cambridge Observation Guide

Cumulative Index of Nursing and Allied Health Literature

Feedback, Responsibility, Advice, Menu of Options, Empathy, Self-Efficacy

Human immunodeficiency virus

Helpful response questionnaire

Jefferson Scale of Physician Empathy

Large Group Activities

Learning Outcomes Questionnaire

Medical Literature Analysis and Retrieval System Online

• Motivational interviewing

Motivational Interviewing Confidence Scale

Motivational Interviewing Knowledge and Attitudes Test

Motivational interviewing network of trainers

Motivational interviewing skill code

Motivational interviewing treatment integrity

Mechanisms of Motivational Interview

O = open-ended questions, A = affirmations, R = reflections, and S = summaries to promote active listening

Objective Structured Clinical Examination

Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews guidelines

Small Group Activities

Simulated Patient

Tabacco Intervention Basic Skills

Theory of Planned Behaviour

Video Assessment of the Simulated Encounter

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Lei, L., Chew, K., Chai, C. et al. Evidence for motivational interviewing in educational settings among medical schools: a scoping review. BMC Med Educ 24 , 856 (2024). https://doi.org/10.1186/s12909-024-05845-w

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• Scoping review
• Motivational behaviour
• Motivational change
• Motivational enhancement
• Medical education
• Medical teaching

BMC Medical Education

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The impact of COVID-19 on health service utilization in sub-Saharan Africa—a scoping review

• Elliot Koranteng Tannor 1 , 2 , 3 , 7 ,
• John Amuasi 1 , 3 , 4 , 5 , 6 ,
• Reinhard Busse 3 , 7 ,
• Daniel Opoku 1 , 3 , 7 ,
• Emmanuel Ofori 8 ,
• Kwadwo Faka Gyan 9 ,
• Minas Aikins 9 ,
• Kojo Hutton-Mensah 9 ,
• Priscilla Opare-Addo 9 &
• Wilm Quentin 3 , 7 , 10  

BMC Global and Public Health volume  2 , Article number:  51 ( 2024 ) Cite this article

69 Accesses

Metrics details

Despite comparatively low rates of COVID-19 admissions and recorded deaths in sub-Saharan Africa (SSA), the pandemic still had significant impact on health service utilization (HSU). The aim of this scoping review is to synthesize the available evidence of HSU in SSA during the pandemic, focusing on types of studies, changes in HSU compared with the pre-pandemic period, and changes among specific patient groups.

The scoping review was guided by the methodological framework for conducting scoping reviews developed by Arksey and O’Malley. We identified relevant studies through a search of PubMed (MEDLINE), Embase, Scopus, and Web of Science. We then provided a general descriptive overview of the extracted data focusing on the types of studies, patient groups, and change in HSU.

We identified 262 studies reporting on HSU in 39 SSA countries. Studies were mainly quantitative (192; 73.3%), involving multiple centers (163; 62.2%), conducted in hospitals (205; 78.2%), and in urban settings (121; 46.2%). The median number of participants was 836.5 (IQR: 101.5–5897) involving 62.5% females. Most studies (92; 35.1%) focused on communicable diseases and mainly among outpatients (90; 34.2%). Maternal and child health studies formed the largest patient group (58; 22.1%) followed by people living with HIV (32; 12.2%). Change in HSU was reported in 249 (95.0%) studies with 221 (84.4%) studies reporting a decrease in HSU. The median decrease in HSU was 35.6% (IQR: 19.0–55.8) and median increase was 16.2% (IQR: 9.1–31.9). The patient group with the largest percentage decrease was cardiovascular diseases (68.0%; IQR: 16.7–71.1) and the lowest percentage decrease was in patients with infections (27.0%; IQR: 16.6–45.6).

Conclusions

A large body of literature is available on the effects of the pandemic on HSU in SSA. Most studies report decreases in HSU during the pandemic. However, patterns differ widely across disease categories, patient groups, and during different time periods of the pandemic.

Peer Review reports

The coronavirus disease 2019 (COVID-19) pandemic has had devastating effects on health systems globally and particularly in sub-Saharan Africa (SSA) [ 1 , 2 ]. The pandemic further aggravated the pre-existing weaknesses of health systems in the region, which were already strained due to poor health infrastructure and low density of skilled workforce [ 3 , 4 ]. Even though there have been comparatively low rates of COVID-19 hospitalizations and deaths reported in SSA [ 5 ], evidence points to the pandemic having significantly impacted health service utilization (HSU) in the region [ 6 ].

HSU has been defined as the process of seeking professional healthcare services, usually provided in the form of healthcare contacts, with the purpose of preventing or treating health problems [ 7 ]. Disruptions in HSU during the COVID-19 pandemic have been described at the global level, but the intensity of disruptions differed across countries depending on the level of income status (high-income versus low-income), the type of services provided (e.g., emergency care versus elective surgery), and the time period (2020 versus 2021) according to a World Health Organization (WHO) survey [ 8 ].

These disruptions also affected the management of chronic non-communicable diseases (NCDs) [ 9 ], which may have ultimately contributed to higher mortality in patients with NCDs who were infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [ 10 ]. It is therefore essential to better understand the impact of COVID-19 on HSU in SSA and among specific patient groups.

The Andersen behavioral model [ 11 ] has been extensively used as a framework for the analysis of HSU which includes both individual and contextual factors. Individual factors can be classified into predisposing characteristics, enabling factors, and need factors [ 12 , 13 ]. Predisposing characteristics include age, gender, marital status, and ethnicity. Enabling factors include educational status, income, employment status, household size, and health insurance. Need factors include disease severity, duration of illness, and the presence of acute illness. Contextual factors may have included prioritization of emergency services, introduction of COVID-19 services, and increase in staff workload [ 14 ].

Previous global reviews on changes in HSU during the pandemic have included very few studies from SSA [ 15 , 16 , 17 ]. However, several studies have become available relatively recently that report on changes in HSU during the pandemic in various sub-Saharan African countries [ 6 , 14 , 18 , 19 , 20 , 21 , 22 ]. Yet, a recent overview of the literature on the impact of the COVID-19 pandemic on HSU in SAA remains unavailable. We therefore aim to assess available evidence on HSU in SSA during the COVID-19 pandemic. More specifically, we focused on changes in HSU and changes in HSU among specific patient groups studied.

We conducted this scoping review guided by the methodological framework by Arksey and O’Malley for conducting scoping reviews [ 23 ]. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols extension for Scoping Reviews (PRISMA-ScR) checklist for reporting our findings [ 24 , 25 ] (Additional file: Table S 1 ). The study design and protocol has been published [ 26 ].

Information sources and search strategy

We conducted a comprehensive search of all peer-reviewed literature published between December 2019 and March 2023. We identified relevant studies through a search of PubMed (MEDLINE), Embase, Scopus, and Web of Science. Our search strategy was built on the basis of synonyms related to three key concepts: (1) “COVID-19 pandemic,” (2) “health service utilization” and related synonyms, and (3) “sub-Saharan Africa” as the population of interest. We employed the Boolean operators “AND” or “OR” to combine and refine terms as appropriate. We used truncations and field tags to improve the efficiency of the search. Given the complex nature of HSU, we used synonyms that capture various health services such as prescription, surgeries, ante-natal clinic or care, dental services, clinic, admissions, consultations, emergency visits, hospital visits, nursing services, endoscopy, scan, and imaging. The Medical Subject Headings (MeSH) term for sub-Saharan Africa and the list of all the 46 countries in SSA according to the United Nations (UN) were included in the search [ 26 ] (Additional file 2: Table S 2 ).

Eligibility criteria

We included studies that reported on HSU in SSA during the COVID-19 pandemic. The period of the COVID-19 pandemic was operationally defined from 11th March 2020 (when the WHO declared the pandemic) [ 27 ] to 31st March 2023. Two reviewers among a set of reviewers (KHM, POA, KFG, EO, and MA) independently screened each article for potential inclusion into the study. A third reviewer (EKT) was consulted in cases of disagreement for resolution. The review process involved first the screening of the title and abstract and second a detailed full text review for eligibility.

Each full text review was also done by two independent reviewers (KHM, POA, KFG, EO, MA), and any conflicts were resolved by a third reviewer (EKT) for eligibility for extraction. All reviews and extractions were done with the Covidence software [ 28 ]. Articles selected meet the following criteria:

Types of publications: original research studies on health service utilization

Types of studies: single and multi-center studies, quantitative, qualitative, and mixed methods

Population of studies: patients, health care providers, and healthcare managers

Intervention: any reported intervention of health service utilization

Comparator: pre-pandemic health service utilization if reported

Outcome: health service utilization, change in health service utilization, and patient reported outcomes

Language: English and French

Data collection: primary and secondary data

Location of study: sub-Saharan African countries, hospital based, community based, or online studies

Time: studies published between 1st December 2019 and 31st March 2023

The following were excluded:

Guidelines, letters to the editor, research protocols, abstracts, recommendations, and reviews (systematic, scoping, and literature)

Multi-center studies with one country outside sub-Saharan Africa

Research protocol papers, pre-prints, or conference abstracts

Articles with no clear quantitative or qualitative data on health service utilization

Data items and data extraction process

Results from the search were extracted from the Covidence software [ 28 ] and exported to Microsoft Excel for cleaning. We then followed the recommended data charting method proposed by Arksey and O’Malley [ 23 ] to extract the relevant details of included studies. Double extraction was used for a 10% sample of randomly selected studies for inclusion, and any conflicts were resolved by a third reviewer (EKT). Data was extracted under the following themes: (i) the characteristic of the study population, (ii) methods used for data collection, (iii) definition and measures of HSU and patient groups studied, and (iv) changes in HSU and reported changes in specific patient groups.

Collating, summarizing, and reporting of the results

All the extracted data were reviewed to ensure completeness and accuracy before analysis. For the quantitative studies, the median and interquartile ranges of studies reporting increases or decreases in HSU were analyzed. Analyses were performed (1) for all patients, (2) for the specific patient groups studied, and (3) for those studies that reported on changes in HSU. Being a scoping review, data was not pooled for further systematic meta-analysis.

Risk of bias assessment or quality appraisal

Risk of bias assessment or quality appraisal was not performed for the included studies following existing guidance for scoping reviews [ 23 ].

Characteristics of included studies

A total of 21,440 articles were identified from the databases and after removal of duplicates, 14,625 articles were available for title and abstract screening with 579 articles eligible for full text review. Data from 262 articles were extracted for analysis which were all in English (Fig.  1 ) (Additional file 3: Table S 3 ).

PRISMA study flow diagram

Table 1 summarizes study characteristics of included studies. Slightly less than half of all studies were published in 2022 (116; 44.3%). Almost half of all included studies had a study duration of less than a year (126; 49.0%) and the median study duration was 364.5 (IQR 89–730) days. Almost three-quarters (192; 73.3%) were quantitative studies, while 39 (14.9%) were qualitative. Over a half of all the quantitative studies were retrospective (117; 60.9%), while almost a third (64, 32.8%) were described as observational studies. There were two quasi-experimental studies and one randomized controlled trial in the included studies.

More than half of all studies (134; 51.2%) used secondary data from medical records, while more than one-third (101; 38.6%) used primary data collection. In the qualitative studies, individual interviews were used for data collection in more than three-quarters of all studies (55; 78.6%) and focus group discussions alone were used in 3 (4.3%) studies with the remainder of studies using both.

Figure  2 provides an overview of the distribution of included studies across countries in SSA. Studies were conducted in 39 countries in SSA (84.8% of all SSA countries)—including 21 (53.9%) low-income countries, 14 (35.9%) lower middle-income countries, and 4 (10.3%) upper middle-income countries. Almost all studies (245; 93.5%) were conducted in one country and only 17 studies (6.5%) included two or more countries. Almost one-fifth of studies were conducted in South Africa (49; 18.7%) and a similar number of studies were conducted in Ethiopia (48; 18.3%) (Fig.  2 ).

Number of studies on health service utilization during the COVID-19 pandemic in sub-Saharan Africa

More than three-quarters of all studies were hospital-based (205; 78.2%), with tertiary institutions accounting for almost one-third of all studies (82, 31.3%) (Table  1 ). Almost two-thirds of studies (163; 62.2%) were multi-center studies. Almost half of all studies were conducted exclusively in urban settings (121, 46.2%), while only 43 (16.4%) were conducted exclusively in rural areas.

Table 2 provides an overview of participants and disease groups studied by the included articles. The number of study participants ranged from 10 in a qualitative study to 99,600,000 in a national database. Age of included participants ranged from 4 days to 73.4 years in studies providing information on the age range ( n  = 94). Mean age of participants was 33.3 years (SD 12.7). Almost two-thirds of all participants (62.5%) were females in studies with the gender reported ( n  = 126). More than one-third of studies focused on communicable diseases (92; 35.1%) and another third focused on non-communicable diseases (89, 34.0%). The most studied patient groups were maternal and child health (58; 22.1%), followed by people living with HIV (32; 12.2%). Two-fifths of studies (105; 40.1%) were focused on curative care and one-fifth (54; 20.6%) on preventive health services (Table  2 ).

Changes in health service utilization

There were 249 studies (95.0%) reporting change in HSU, either with quantitative data (167; 67.1%) (Additional file 4: Table S 4 ) or qualitative data (82; 32.9%). Most studies (221; 84.4%) reported a reduction of HSU during the pandemic, but some studies (25; 9.5%) reported an increase or no change (3; 1.2%) (Table  2 ).

Figure  3 provides more details on the 167 studies that reported a change with quantitative data available for analysis. The median percentage decrease in HSU reported in the 167 studies was 35.6% (IQR: 19.0–55.8). The largest number of studies was available for maternal and child health patients (29; 19.7%), followed by surgical patients (20; 13.6%), while relatively few studies were available for cardiovascular diseases (3; 2.0%) and sexual and reproductive health service utilization (3; 2.0%). The median reported percentage decrease was highest for cardiovascular conditions (68%, IQR: 16.7–71.1) and lowest for infections 27.0% (IQR: 16.6–45.6).

Forest plot showing changes in health service utilization as a result of the COVID-19 pandemic. PLWHIV, people living with human immunodeficiency virus; HSU, health service utilization; others include intensive care unit (ICU), blood donors, epilepsy, chronic obstructive pulmonary disease, elderly, dermatology, ophthalmology, people living with disability (PLWD), cancer, radiology, refugees; d, studies reporting decreases; i, studies reporting increases

The overall median percentage increase in HSU was 16.2% (IQR: 9.1–31.9) reported in 20 studies. The largest group of studies reporting increases in HSU was among PLWHIV (people living with human immunodeficiency virus) with 7 studies (35% of studies reporting increases). The largest percentage increase in HSU was in surgical cases (38.3%, IQR: 24.0–52.5) with the lowest in studies involving health care providers and managers (2.2%) (Fig.  3 ).

This is the largest scoping review focusing on HSU during the COVID-19 pandemic in SSA to our knowledge. We found 262 articles reporting on studies conducted in 39 countries. The vast majority of included studies were quantitative (> 85%), with almost all studies reporting a change in HSU. The overall median reduction was 35.6%.

Our review shows that the impact of the pandemic on HSU in SSA has been extensively studied. This is surprising because a previously published systematic review [ 17 ] which reported studies up to August 2020 did not include any studies from SSA. Potential reasons for this may be because research in SSA emerged later than in other regions of the world or that studies were excluded because of perceived larger risk of bias.

With regard to the available studies, almost two-fifths were done in South Africa and Ethiopia, which may likely be due to the availability of established structures or expertise to support HSU research in these countries. However, no studies are available from seven countries in SSA, namely the Central African Republic, Djibouti, Equatorial Guinea, Gabon, Guinea-Bissau, Mauritania, and Mauritius. This means that there is no information yet on HSU during the pandemic in these countries in SSA.

Furthermore, our findings show that considerable knowledge gaps remain about the impact of the pandemic outside of hospitals and urban centers. Over three-quarters of included studies were hospital-based and about half were performed exclusively in urban centers. While the impact of COVID-19 was probably larger in urban areas because of higher population density and seeding effects [ 5 ], the relative lack of evidence available from primary health care levels and rural areas does not permit the full picture of the impact of the pandemic on HSU in Africa to be fully appreciated.

Our results are similar to findings from another systematic review on HSU including 81 studies from 20 high- and upper middle-income countries (no countries from SSA), which reported a 37% median reduction in overall HSU [ 17 ]. Thus, our findings corroborate the growing body of literature demonstrating that the impact of the pandemic on health systems in SSA was substantial. For example, a multi-center study in 63,954 facilities from eight countries in SSA (Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone, and Somalia) reported a decrease in maternal health services with significant declines in institutional deliveries, antenatal, and postnatal care [ 29 ]. Another multi-center study including 18 low- and lower middle-income countries estimated that reduction in HSU was associated with additional increase of 24.3% and 27.6% in maternal and child mortality respectively in the second quarter of 2020 compared to the pre-pandemic period [ 30 ]. These reductions in HSU were projected to be associated with excess mortality of 110,686 (3.6%) deaths in children under 5 years and excess maternal mortality of 3276 (1.5%) in the multi-center study [ 30 ].

We found large reductions in HSU for several groups of patients, such as cardiovascular diseases (68.0%), emergency services (48.5%), and child health (43.1%), and this may have contributed to increased morbidity and mortality during the pandemic. In particular, patients with cardiovascular diseases were more at risk of COVID-19 infection and had increased mortality [ 10 ]. In fact, the disruptions in HSU for NCDs may have contributed to the higher excess mortality during the pandemic in low-income settings (135 per 100,000) than in high-income settings (68.08 per 100,000) [ 31 ].

The reduction in HSU that was reported in most studies has been the result of disruptions in health service provision during the pandemic [ 6 , 9 ]. According to Anderson’s behavioral model of HSU [ 11 ], individual and contextual factors can account for the reported changes in HSU [ 11 , 32 , 33 ]. Lockdown measures, lack of resources, shortage of personal protective equipment, fear of contagion, stigmatization, limitation of health service, reduction in effective health workforce due to COVID-19 infection, lower socio-economic status, and technological barriers are some reasons for reductions in HSU [ 15 , 34 , 35 , 36 ].

Interestingly, several studies reported increases in HSU during the pandemic. The reasons for these increases are multifaceted, including catching up with backlogs in surgical care during less acute phases of the pandemic [ 37 ], deterioration of acute conditions (e.g., typhoid perforations as a result of delays in HSU during the peak of the pandemic) [ 38 ], or expanded access through introduction of updated guidelines for PLWHIV in later phases of the pandemic [ 39 ].

Our review has several limitations. First, we included studies from four major databases (PubMed (MEDLINE), Embase, Scopus, and Web of Science) but we may have missed studies and reports that were not published in peer-reviewed journals. Potentially, the inclusion of gray literature would have expanded the available evidence though authors were generally satisfied with the outcome after searching the major databases. Second, we did not perform a risk of bias assessment or appraise quality of included studies. However, this is in line with guidance for conducting scoping reviews [ 23 , 40 , 41 ], where the purpose is to provide an overview of the available literature rather than to summarize results of this literature. Our indicative findings about decreases in health service utilization should therefore not be mistaken as evidence on the size of the effect for different patient groups. Further systematic reviews and meta-analyses will be needed to specifically investigate the effects of the pandemic on HSU for particular groups of patients. Third, we did not consult any relevant bodies or stakeholders for the scoping review which could have potentially improved the study. Fourth, we categorized studies into groups based on broad classifications as stated by original authors, which may have reduced consistency of the classification.

Our scoping review shows that a lot of research has been performed on HSU in SSA during the pandemic, but it also highlights several knowledge gaps, e.g., regarding certain countries, primary care levels, and rural areas. In addition, the impact of the pandemic seems to have been substantial for many groups of patients, as a lot of studies reported large decreases in HSU. The implications of these findings for researchers and policy-makers are that (1) efforts are needed to fill knowledge gaps about the effect of the pandemic in settings that have so far been underexplored, and this requires the establishment of structures and processes to ensure better data availability at the primary care level and in rural areas; (2) in order to safeguard service provision during future health crises, policy-makers should aim to strengthen resilience of health systems, addressing structural weaknesses, strengthening community-based service delivery models, and leveraging digital technologies; and (3) more research is needed to better understand the effects of the pandemic on HSU by (a) performing systematic reviews and meta-analyses of studies on particular groups of patients and (b) investigating the conditions that may enable health workers to provide health services during future health crises.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary files.

Abbreviations

The coronavirus disease 2019

• Sub-Saharan Africa
• Health service utilization

Human immunodeficiency virus

Non-communicable diseases

World Health Organization

Severe acute respiratory syndrome coronavirus 2

Joanna Briggs Institute

Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols extension for Scoping Reviews

Medical Subject Headings

Interquartile range

Standard deviation

People living with human immunodeficiency virus

Intensive care unit

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Acknowledgements

We would like to acknowledge the staff of the German-West African Center for Global Health and Pandemic Preparedness (G-WAC) at the Kwame Nkrumah University of Science and Technology and Jean Jacques Noubiap of the University of California, San Francisco for helping to refine the search strategy and the conducting the search.

This scoping review is part of research conducted by the German-West African Centre for Global Health and Pandemic Prevention, which is supported by the German Academic Exchange Service (DAAD) with funding provided by the German Federal Foreign Office.

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EKT, WQ, RB and DO conceived the study design. The first version of the manuscript was drafted by EKT and was revised by EKT, WQ, RB, DO and JA. Search strategy was developed by EKT and revised by JJ. EKT, POA, KHM, EO, KFG and AM performed the screening, study selection and extraction of data of the included studies. All conflicts were resolved by EKT. All authors revised and critically reviewed the manuscript and approved the final version before submission.

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44263_2024_83_moesm1_esm.pdf.

Additional file 1. Table S1 Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist

Additional file 2. Table S2 Key concepts, synonyms, and related terms to be used in the search strategy

Additional file 3. table s3 list of included studies, additional file 4. table s4 list of studies included in the quantitative analysis, rights and permissions.

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Tannor, E.K., Amuasi, J., Busse, R. et al. The impact of COVID-19 on health service utilization in sub-Saharan Africa—a scoping review. BMC Global Public Health 2 , 51 (2024). https://doi.org/10.1186/s44263-024-00083-0

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Critical thinking in nursing: Scoping review of the literature

Affiliations.

• 1 Hospital Vall d'Hebron, University School of Nursing, University of Barcelona, Barcelona, Spain.
• 2 University School of Nursing, University of Barcelona, Barcelona, Spain.
• 3 Sant Joan de Deu School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Rovira i Virigili University, Tarragona, Spain.
• 5 School of Nursing, Autonomous University of Barcelona, Barcelona, Spain.
• PMID: 24821020
• DOI: 10.1111/ijn.12347

This article seeks to analyse the current state of scientific knowledge concerning critical thinking in nursing. The methodology used consisted of a scoping review of the main scientific databases using an applied search strategy. A total of 1518 studies published from January 1999 to June 2013 were identified, of which 90 met the inclusion criteria. The main conclusion drawn is that critical thinking in nursing is experiencing a growing interest in the study of both its concepts and its dimensions, as well as in the development of training strategies to further its development among both students and professionals. Furthermore, the analysis reveals that critical thinking has been investigated principally in the university setting, independent of conceptual models, with a variety of instruments used for its measurement. We recommend (i) the investigation of critical thinking among working professionals, (ii) the designing of evaluative instruments linked to conceptual models and (iii) the identification of strategies to promote critical thinking in the context of providing nursing care.

Keywords: critical thinking; nurses; nursing; nursing education; systematic review.

© 2014 Wiley Publishing Asia Pty Ltd.

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Contributions of the communication and management of bad news in nursing to the readaptation process in palliative care: a scoping review.

1. Introduction

2. materials and methods, 2.1. selection criteria, 2.2. search strategy, 2.3. selection process and article eligibility criteria, 3.1. characteristics of included studies, contexts, and populations, 3.2. data presentation, 4. discussion, 4.1. intervenient factors in communication and management of bad news, 4.2. key points for improvement in the communication and management of bad news, 4.3. nursing-sensitive outcomes in the communication and management of bad news, 4.4. limitations and suggestions, 5. conclusions, author contributions, conflicts of interest.

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Moura, T.; Ramos, A.; Sá, E.; Pinho, L.; Fonseca, C. Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review. Appl. Sci. 2024 , 14 , 6806. https://doi.org/10.3390/app14156806

Moura T, Ramos A, Sá E, Pinho L, Fonseca C. Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review. Applied Sciences . 2024; 14(15):6806. https://doi.org/10.3390/app14156806

Moura, Teresa, Ana Ramos, Eunice Sá, Lara Pinho, and César Fonseca. 2024. "Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review" Applied Sciences 14, no. 15: 6806. https://doi.org/10.3390/app14156806

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