nursing education research articles

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• Volume 26 - 2021
• Number 1: January 2021

Crisis in Competency: A Defining Moment in Nursing Education

Dr. Kavanagh is Associate Chief Nurse for Education and Professional Development, The Cleveland Clinic Foundation in Cleveland, Ohio. She leads the integration, standardization, and advancement of nursing education and professional development for the more than 30,000 caregivers in the Cleveland Clinic Nursing Institute. A former medical-surgical faculty member, Dr. Kavanagh's research addresses quantifying and mitigating the preparation-to-practice gap. In 2013, Kavanagh developed and launched Cleveland Clinic’s first New Graduate Registered Nurse (NGRN) competency-based residency program. The residency program, accredited with distinction by the American Nurse Credentialing Center, is designed to 'meet the learner where they are' and has received national attention as an exemplar in supporting transition-to-practice.

Dr. Sharpnack Is Dean and Strawbridge Professor, The Breen School of Nursing and Health Professions of Ursuline College in Cleveland, Ohio. She has held leadership roles in academia and service for over 40 years. She has extensively published and presented at national and international conferences regarding creative academic strategies for clinical education and transition to practice. A Masters TeamSTEPPS ® Trainer, she serves as a member of the Advisory Board for the American Hospital Association. She is an immediate three term Past-President of the Ohio Board of Nursing and is currently the Board Supervisory Member and Chair of the Nursing Education Advisory Committee.

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Advancing the mission of nursing education for a future we cannot yet fully conceive is a daunting task. The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and infinite possibilities to improve patient care, safety, and outcomes. New data suggest a continuing decline in the initial preparedness of new nurses at a time when preparation is most needed. We must adapt and embrace pedagogies relevant to a new generation of learners. In this article, we first describe the digital disruption informed by innovation moving at warp speed, catalyzing necessary and long overdue change not only in healthcare, but in how education is conceptualized and delivered. Leading and promoting the paradigm shift needed for this change is not discretionary as nurse educators strive to enhance the competency of new registered nurses . Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap, such as competency-based education. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses for successful collaborative artificial intelligence-infused, clinical practice.

Key Words: nursing education- future of education, preparation-to-practice gap, transition to practice, Performance Based Development System (PBDS), entry-level competency

This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role... The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and perhaps infinite possibilities to improve patient care, safety, and outcomes. The exponential rate of progress in Artificial Intelligence (AI) and machine learning, along with advances in genetics, genomics, and dramatic enhancements in wearable and implanted sensors, are pressurizing and shifting tectonic plates in every industry ( Marx & Padmanabhan, 2021 ). In healthcare, the changes are massive and, in many instances, long overdue. Reforms include the move from volume to value; from process to a focus on quality and outcomes; from episodic to life cycle care; and from acute care to population health. This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role in patient safety, advocacy, education, and leadership, regardless of the setting and focus of care.

In this article, we first describe the digital disruption informed by innovation, and the paradigm shift needed for change, particularly to address the continued decline in initial competency of new registered nurses. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses.

Digital Disruption

The worlds of big data, discovery, and innovation are moving at warp speed... The worlds of big data, discovery, and innovation are moving at warp speed, catalyzing necessary and long overdue changes. Changes are happening not only in healthcare, but in how education is conceptualized and delivered, creating opportunities to live and learn in a whole new way ( Carroll, 2021 ; Remtula, 2019 ; Thomas & Rogers, 2020 ; Weston, 2020 ). Klaus Schwab ( 2017 ), Executive Director of the World Economic Forum, has named this epoch of AI, digitization, and biotechnological advances as "The Fourth Industrial Revolution." Schwab ( 2018 ) admonishes that many of our current education systems are already disconnected from the needed competencies to thrive in today's workforce and that the rate of technological innovation and change threatens to widen the gap between education and the demands of practice if we do not respond.

Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task... Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task, but leading and promoting change is not discretionary. To understand digital disruption, the impact on patient care, and the implications for education, we need only look at the worldwide evolution of care delivery already enabled by technology and supported by AI. Digital tools have become ubiquitous and invaluable partners in care; from sensors providing critical patient data, to the Internet of Things (IoT) connecting devices and sensors, to entire hospitals without patients, where interprofessional healthcare teams remotely monitor and care for individuals with complex health challenges in their homes ( Allen, 2018 ). These advances provide a glimpse at the present-day, seemingly futuristic, and evolving skills and competencies necessary to harness technology and enhance the quality of care.

Although healthcare has been relatively slow to integrate robotics, that is rapidly changing. With an aging population, an aging workforce, and a global nursing shortage, the use of robots to perform routine tasks has captured the interest and financial backing of the Japanese government, who generously support technology research that might decrease the high demand for nurses ( Carroll, 2021 ). It is estimated that by 2025 there will be 1.5 billion commercial and industrial robots and that by 2030 industrial robots will replace 50 to 70% of existing jobs ( King, 2016 ).

What an exciting and engaging way to prepare the next generation of nurses! While robots will never replace the registered nurse, they can already support care, follow algorithms, suggest plans of action supported by AI, and perform routine tasks. The Duke University schools of nursing and engineering have previously revealed that Rethink Robotics' Baxter robot could accomplish more than twenty simulated nursing tasks ( Carroll, 2021 ). In The Future is Faster Than You Think, Diamandis and Kotler ( 2020 ) remind us that emerging technology can not only promote optimal patient care, but allows us as educators to create an infinite range of immersive, multi-sensory, experiential teaching-learning environments. What an exciting and engaging way to prepare the next generation of nurses!

The Paradigm Shift

Densen ( 2011 ) accurately predicted that by 2020, medical knowledge would double every 73 days. Today, awash in accelerated knowledge creation and sweeping innovation, professionals in the healthcare and higher education find themselves facing isomer-like challenges to provide value, positive outcomes, access, and affordability for their consumers--or become obsolete ( Kavanagh, 2019 ). This opportunity necessitates a paradigm shift in education that moves us from cohort-based teaching and learning to personalized adaptive learning (AL), focused not on time but competency. The Landscape of Change paradigm shift can be visualized in the Figure 1 .

Figure 1. Landscape of Change

Preparing future nurses as knowledge workers is the required and essential pivot...

Adaptive learning (AL) platforms deliver customized instruction to students based on past knowledge and adjust delivery of content based on distinct preferences and variances in knowledge acquisition ( Hinkle, Jones, & Saccomano, 2020 ; Sharma, Doherty, & Dong, 2017 ). Preparing future nurses as knowledge workers is the required and essential pivot, supported by technology and underpinned by AI. The burgeoning world of AI is positive, disruptive innovation and creates the ability for educators to envision and design individualized AL experiences that will accelerate the pace of learning and potentially, knowledge use ( Hinkle, Jones, & Saccomano, 2020 ; Samadbeik et al., 2018 ).

Strategies such as spaced learning, bridging, and chunking of information are excellent examples of evidence-based tactics to decrease cognitive load and promote memory and learning ( Kelter, Steward & Zamis, 2019 ). Yet, despite the substantial evidence that brain-based, active learning in educational design leads to students engaged in deeper thinking and learning, the move to consistently apply cognitive neuroscience to education remains in the nascent phase of adoption ( Carr & O'Mahony, 2019 ; Deslauriers, McCarty, Miller, Callaghan, & Kestin, 2019 ; Pilcher, 2017 ; Remtula, 2019 ). The thought that these innovative technologies will guide educational transformation assumes that educators will accept and use the evidence, and these technologies, to engage learners.

Research findings have indicated that educators do not quickly accept new technologies. Research findings have indicated that educators do not quickly accept new technologies. Even when they do, they are used to support prevailing teaching practices, rather than to develop new pedagogies ( Grainger, Liu, & Geertshuis, 2020 ). In just a few short years, the digital revolution fueled by AI will be commonplace; but will we be ready? The time is now to embrace digital disruption, including immersive learning technologies that can transform education.

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies enable users to interact with and control virtually displayed components within virtual and physical environments ( Carroll, 2021 ; Remtula, 2019 ; Weinstein, Madan & Sumeracki, 2018 ). These rich, immersive technologies will continue to evolve as powerful and essential tools in clinical education. This shift requires a holistic view of education and pedagogies that empower both students and faculty as life-long learners. Education scholar Dennis Shirley ( 2017 ), author of The New Imperatives of Educational Change , reminds us of the power of the present moment. There is cause for hope and optimism, but past success does not entitle us to future success; we must plan for success and move quickly.

Declining Initial Competency of New Registered Nurses

Jim Collins ( 2001 ), famed author of Good to Great , cautions that if success is ones' goal, one must first ask, what are the brutal facts - not what are our opinions, but what are the facts? If we do not confront the facts, they will surely rise-up and confront us. While we continue to appreciate the many in-roads and tangible signs of excellence in the evolution of teaching and learning, from flipped classrooms to simulation and standardized patients; from monologue to dialogue and Socratic method; to makerspaces and virtual learning, there remains substantive work yet to be considered ( Forneris, 2020 ).

...practice is evolving faster than education can respond As educators, we must address the brutal facts of failing to prepare graduates as residency-ready and confront the issue that the academic, or preparation-to-practice gap, is increasing despite current efforts. While we continue to explore and research how best to prepare nurses for practice, Ironside ( 2008 ) conceded long ago that practice is evolving faster than education can respond. Our current educational model, developed in the 19th century, is obsolete ( Gidley, 2016 ). Gidley ( 2016 ) argued that we are unable to solve tomorrow's problems with yesterday's thinking.

We suggest that tomorrow's problems are already here. Transforming nursing education to meet the technologically savvy, digital native students of today requires embracing the capacity of technology to transform education ( Clark, Glazer, Edwards, & Pryse, 2017 ). We must shift to a post-formal pedagogy to prepare students for the higher-order thinking and knowledge work required for today's clinical practice ( Forneris & Fey, 2018 ).

New data suggest that we are continuing to lose ground in the preparedness of New Graduate Registered Nurses (NGRNs) at a time when it is needed most. Initial competency of NGRNs is declining at an alarming rate, slightly exacerbated by the impact of the COVID-19 pandemic as many traditional in-person clinical and classroom experiences have been adapted or abbreviated. In her seminal work, del Bueno ( 2005 ) shared aggregate national data on initial NGRN competency for all hospitals utilizing Performance Based Development System (PBDS), an assessment del Bueno designed to identify growth opportunities in critical thinking and provide insight into the thought processes of the NGRN. Del Bueno ( 2005 ) reported that 35% of NGRNs assessed as safe or in the acceptable range. Kavanagh and Szweda ( 2017 ) documented a decline in initial competency with assessments of more than 5,000 NGRNs from 2011-2015, from more than 140 nursing programs in 21 states, with 23% scoring in the acceptable range for a novice new nurse. Current aggregate assessment data utilizing the same PBDS assessment collected between 2016-2020 on more than 5000 NGRNs indicate that 14% of them demonstrated entry-level competencies or readiness for residency , and 2020 YTD graduate data (n=1222) from 200 unique schools of nursing display an even more disturbing decline, with only 9% of NGRNs in the acceptable competency range for a novice nurse.

A decade of PBDS assessments...reveals an alarming year-over-year decline in initial competency A decade of PBDS assessments representing more than 10,000 NGRNs reveals an alarming year-over-year decline in initial competency. PBDS assessments are administered post-hire but prior to orientation to ensure that results are indicative of the time before patient care initiation and that orientation and residency are not cofounding variables in the assessment results. Although the assessment is only one data point, it captures a snapshot of NGRN initial competency after graduation and, in most instances, post successful completion of the NCLEX.

The PBDS assessment is a valid and reliable tool ( del Bueno, 2001 ). The tool has not changed over time, other than updating clinical scenarios to reflect modern equipment and technology. The subjects in data collection from 2016-2020 included 60% holding a BSN; 35% an ADN; 1% a diploma; and 1% were MSN graduates. Consistent with earlier findings from del Bueno ( 2005 ) and Kavanagh and Szweda ( 2017 ), there was no difference in assessment ratings regardless of the type of nursing program. Site-specific aggregated PBDS assessment data is depicted in the Table . Aggregate data (2016-2020) indicated 14% of NGRNs assessing in the acceptable range; 29% failing to recognize urgency or a change in a patient's status; and 57% demonstrated opportunities for growth in the management of patient problems, including selecting the proper nursing interventions, communication of relevant data to the Licensed Independent Professional (LIP) and rationale for nursing actions.

...there was no difference in assessment ratings regardless of the type of nursing program The 2020 aggregate PBDS data includes an n of 1222, with less than 10% assessing in the acceptable range. When further subdivided to isolate the April/May 2020 graduates who experienced the impact of limited clinical experiences (sample size of 626), 7% assessed in the acceptable range for a novice nurse and 40% assessed in the lowest domain, failing to recognize urgency or a change in a patient's condition. In sum, evidence supports a continued decline in the competency of HGRNs.

Table 1. Site-Specific PBDS Assessment Data

Leveraging the Tipping-Point

The crisis in initial competency of NGRNs must not become a portent of patient safety challenges and NGRN success. In a day when we can transplant a face, a heart, or a uterus, we can certainly design and create processes and grow cultures where patients come first and safety always is a living breathing testament to our great profession's commitment to patients and nurses alike. Whether one's primary role is in academe or practice, five critical sub-narratives demand our reflection and re-evaluation. These sub-narratives include an acceptance of the chasm between academe and practice and the resultant challenge deemed inherent and inevitable in transition-to-practice (TTP); accountability for success and what NGRN residency-readiness requires; speed of learning, education transformation, and moving innovations to scale; the impact of digital disruption, and finally, the divide and inequality in education.

We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. In this, the International Year of the Nurse and Midwife ( WHO, 2020 ), the challenges before us are vast and complex. However, we argue that these challenges are ours to embrace. This is our moment, our time! As nurse leaders, we have the power to either build excitement and anticipation about change, about ongoing and much-needed education transformation, or potentially contribute to stress, anxiety, and even disengagement. We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. Most academic programs moved from in-person to virtual learning, from in-person clinical to virtual simulations mapped to the curricula within just a few days! Technology was readily incorporated and enhanced remote student classroom experiences introduced as the new normal in instructional design. Agility by fire, and yet we prevailed!

Despite each of these successes, the COVID-19 pandemic added to the chasm in NGRN preparedness. While no one can predict the longitudinal consequences of the pandemic with certainty, there is no question that healthcare and education responded in a profound and remarkably swift way. The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes ( Berwick, 2020 ), particularly in higher education. The success of an agile and thoughtful response in a time of crisis, albeit not perfect, brings honor to us all and hope for the future.

The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes... Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Nursing education reform is indebted to the iconic work of Dr. Patricia Benner, whose contributions from the Carnegie Foundation Preparation for the Professions research fueled the celerity of education reform ( Benner, Sutphen, Leonard, & Day, 2010 ). In the past few years, we have seen increasing attention addressing the development of critical thinking, clinical judgment, and clinical reasoning in our pre-licensure nursing students. Significant trends in higher education that foster higher-order thinking include moving from structured, cohort-based education to a personalized, individualized, adaptive learning approach, such as smart book technology and virtual on-screen simulation like NovEx, that adapts information to the learner's progression ( Santos, 2013 ; Hooper-Kyriakidis, Ahrens, & Benner, 2017 ; Benner, 2020 ).

Another major trend gaining traction is the severing of time, measured in credit hours, from learning and competency. In a traditional academic environment, programs of study are delineated by credit hours that equate to time spent either in class or online. The credit hour, initially conceived a century ago by the Carnegie Foundation to describe educators eligible for pensions, grew into an easily understood and adopted method to track academic progression, financial aid, and faculty workload. However, no evidence exists that the credit hour and time spent in class or online equates with learning ( Laitinen, 2012 ; Kirst & Stevens, 2015 ; Robinson, 2018 ). The 2015 Carnegie Foundation report on the 'Carnegie Unit,' concluded that although flawed, the credit hour remains a necessary model. Laitinen ( 2012 ) urged that the credit hour is negatively impacting our nation's workforce and that, as the cost of education soars, federal policy needs to shift from paying for and valuing time to paying for and valuing learning.

Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Competency-based education (CBE) is gaining momentum buoyed by the 2013 Department of Education Experimental Sites program success, which allowed select institutions to grant credit through competency-based assessments ( Cunningham, Key & Capron, 2016 ; Silva, White & Thomas, 2015 ). Although CBE and direct assessment are in the earliest phase of development, the transition from time-based to competency-based assessment is a movement whose time has come ( Johnson, 2017 ; Josiah Macy Jr. Foundation, 2017 ; Robinson, 2018 ). To date, the United States Department of Education has granted approval for almost 200 universities to offer some form of CBE, and the Higher Learning Commission has embraced CBE as the future of academic preparation ( Nodine, 2016 ; Silva et al. 2015 ).

The magnitude and significance of Benner's ( 2010 ) call for radical transformation and her innovative work to elucidate the current science of teaching and learning has been compared to Abraham Flexner's report ( 1910 ) on medical edition. Benner's findings spurred leaders from national nursing organizations to examine the current state of academia and initiate much needed change efforts. The National League for Nursing's (NLN) strategic educational resources, the National Council of State Boards of Nursing's (NCSBN) work to design a psychometrically sound and legally defensible Next Generation NCLEX ( Dickinson, Haerling & Lasater, 2019 ) to assess higher-order thinking better and thus, preparedness for practice of new graduates, and more recently, the American Association of Colleges of Nursing's (AACN) call for reformation of nursing education are substantial attempts to mitigate the NGRN competency gap.

Competency-based education is gaining momentum... The AACN Vision for Academic Nursing ( 2019 ) white paper addresses fundamental academic failings. It proposes an action plan to meet the needs of a dynamic, global society and a diverse patient population ( AACN, 2019 ). The report identifies several trends and changes that inform nursing education. These include a changing higher education climate; competency-based education; learners who hail from diverse backgrounds and generations; advances in neuroscience that have resulted in the development and adoption of innovative educational technologies; a rapidly evolving healthcare system with a shifting workforce; an aging faculty; and the ongoing evolution of regulatory bodies ( AACN, 2019 ). The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. Strengthening academic-practice partnerships, accelerating diversity and inclusion through holistic admission policies, improved faculty development through a greater understanding of the neuroscience of learning, efficient use of resources, and competency-based education and assessment are central to these recommendations.

The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. While the recommendations are intended to be realized as a compendium, it will take time to fully engage the academic community in these initiatives. Innovative thinking and approaches to preparing the nursing workforce of tomorrow are critical if nursing education is to meet the public demands for graduates to be able to know and do the work of nursing ( AACN, 2020 ). The Essentials: Core Competencies for Professional Nursing Education, the framework proposed to supersede the current BSN, MSN, and DNP Essentials documents, is informed by the lived experiences of nursing practice where there is a fusion of knowledge and action ( AACN, 2020 ).

The foundational elements of the new recommendations are built upon nursing as a discipline, the underpinning of a liberal arts education, and competency-based education principles. While considering the vital preparation for a residency-ready graduate, additional elements have shaped the proposed essentials document. These include diversity equity and inclusion, spheres of care, academic partnerships, systems-based practice, technology and informatics, consumerism, and career-long learning ( AACN, 2020 ). The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Scaffolding and measuring these competencies will require nurse educators to foster higher-order thinking. Common competencies for NGRNs will demonstrate the effectiveness of educational programs and assure the public of a graduate's capability.

The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Advances in teaching-learning technologies and strategies, shifting learning styles of students, and the push for outcome-based education all point to the necessity of competency-based education ( AACN, 2020 ). Public demand for accountability in the health professions is propelling the shift toward CBE ( Englander et al., 2013 ). Nevertheless, there exists no common taxonomy for domains of competence for health professions. Methods to best measure competency in nursing education need further exploration and a design that will challenge students and prepare them for practice. Rigorous quantitative and qualitative research must be conducted to determine the reliability and validity of CBE ( Gravina, 2017 ).

Public demand for accountability in the health professions is propelling the shift toward CBE Bridging the gap between CBE, practice, and implementation of knowledge, skills, and attitudes, has been explored by implementing Entrustable Professional Acts (EPAs) in medical education ( Wagner, Dolansky, & Englander, 2018 . Entrustable Professional Acts are units of professional practice, defined as tasks or responsibilities, to be entrusted to the unsupervised execution by a trainee once they have attained a specific competence. They are not an alternative for competencies but a way to translate competencies into clinical practice ( Cate, 2016 ). Similar to the revised Healthcare Quality Competency Framework that guides academic institutions to reduce variability in quality competencies and supports workforce readiness and effectiveness in healthcare quality ( NAHQ, 2020 ), sequencing domains of competence of increasing difficulty, risk, or sophistication can serve as a practical approach to integrate competencies in nursing.

They are not an alternative for competencies but a way to translate competencies into clinical practice Competency-based education will require novel approaches to enhance nursing education using technology. Integrating technology into nursing curricula improves efficiency and enhances student experiences, accomplished primarily through active learning and interactive learning designs ( Luo &Yang, 2018 ). The development of augmented, mixed, and virtual reality simulation offers an opportunity for focused application-based learning ( Fertleman et al., 2017 ). Foronda and colleagues ( 2017 ) argued that using these realities may influence the length of the learning curve, reduce practice time, and enhance learning outcomes ( Foronda et al., 2017 ). Augmented or mixed reality tools such as Microsoft HoloLens ® , and virtual simulations such as vSims ® created through a partnership with Laerdal ® , Wolters Kluwer Health ® , and the NLN have already been integrated into nursing programs to augment existing teaching-learning practices.

AI is being used to create virtual patients (VP) scenarios that improve interactions with patients, the interprofessional team, and nursing colleagues. These scenarios enhance self-efficacy and confidence in effective communication skills. Academe must support the technological and digital transformation to foster student success, improve the TTP outcomes, and provide foundational and advanced faculty development that fosters the adoption of a new educational paradigm.

...the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. Finally, the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. The Joint Commission ( 2017 ) has cited communication failures among interdisciplinary team members as the most common root cause of sentinel events and pronounces the inability to communicate and work effectively in teams as a significant threat to patient safety. Foundational competencies commonly understood by all professionals will support appropriate role expectations and predictable outcomes and, arguably, improved teamwork and collaboration.

The 2010 Institute of Medicine report argued that entry-level nurses must be able to efficiently transition from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings ( IOM, 2010 ). Ten years have elapsed without discernable change in our outcomes, based upon quantifiable outcomes of preparedness for practice or residency. Given the COVID-19 pandemic, one could contend that we lost ground. Despite advances in technology, in practice, and accessibility, nursing education struggles to own the outcomes of the graduate nurse.

We have an unprecedented opportunity to become architects to advance nursing education in a digital age! The initiatives proposed by AACN may provide an opportunity to re-examine our efforts. Nurse educators must mobilize to prepare future nurses for successful, collaborative, AI-infused, clinical practice. The call for transformation is more robust because of the pace of change and obvious gaps that can no longer be tolerated. We must adapt and embrace pedagogies relevant to a new generation of learners and a new world order replete with quantum leaps in technology, addressing each student as a unique learner ( Hopkins et al. 2018 ; Presti & Sanko, 2019 ). Risling ( 2017 ) warns that the evolving technological advances will necessitate responses and navigational shifts, unlike any that we have ever negotiated. The time is now. We have an unprecedented opportunity to become architects to advance nursing education in a digital age!

Ludvik reminds us that the requisite demonstration of whether learning can be applied in "real-life" contexts requires collaboration with the professionals who will either hire the students or admit them into ongoing professional or academic degree programs ( 2018 , p. 13). Whether our primary role is practice or academe, we are called to evolve from the perspective that an educator's job is just one part of the whole, to the belief that the job is a system. Practice and academe must work together as a system supporting student success and that of the eventual NGRN, a collaborative belief long held but infrequently realized. Almost five decades ago, Myrtle Aydelotte ( 1972 ), founding Dean and Professor at the University of Iowa College of Nursing, shared: "What is needed is a reexamination of nursing leadership and a new thrust forward. Nursing leadership must reorient itself and restructure itself in such a way that nursing education and practice are inseparable, are symbolic, and are united in purpose" ( 1972 , p.23). That defining moment is now.

Joan M. Kavanagh, PhD, MSN, RN, NEA-BC, FAAN Email: [email protected]

Patricia A. Sharpnack DNP, RN, CNE, NEA-BC, ANEF, FAAN Email: [email protected]

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January 31, 2021

DOI : 10.3912/OJIN.Vol26No01Man02

https://doi.org/10.3912/OJIN.Vol26No01Man02

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Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review

• Bente Hamre Larsen 1 ,
• Dagrunn Nåden Dyrstad 2 ,
• Helle K. Falkenberg 3 , 4 ,
• Peter Dieckmann 2 , 5 , 6 &
• Marianne Storm 1 , 7 , 8  

BMC Medical Education volume  24 , Article number:  1019 ( 2024 ) Cite this article

Metrics details

Interprofessional assessment and management of health needs for older adults living at home can help prioritize community service resources and enhance health, yet there is a shortage of professionals with the necessary competencies. Therefore, support and training for healthcare professionals in community settings to assess older adults’ health with the aim of for health promotion are needed.

To identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home.

A systematic literature search of the Cinahl, Medline, Academic Search Ultimate, Scopus, Embase, and British Nursing Index databases was performed. We considered studies focusing on the training of healthcare professionals in assessing a single or multiple health needs of older adults aged 65 and above living at home. We considered studies published between 1990 – and March 2024. The review evaluated qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. A quality appraisal was conducted via the Mixed Methods Appraisal Tool (MMAT).

Twenty-three studies focused on training healthcare professionals to assess health needs and plan care for older adults living at home were included. The majority of the included studies combined teacher-driven pedagogical approaches consisting of educational sessions, written materials or e-learning, and more participant-engaging pedagogical approaches such as knowledge exchange or various forms of interactive learning. Healthcare professionals were trained to detect and manage single and multiple health needs, and some studies additionally incorporated interprofessional collaboration. Healthcare professionals were satisfied with the training content and it increased their confidence and competencies in health needs assessment and care planning for older adults. Moreover, some studies have reported that training interventions foster the implementation of new and effective ways of working and lead to positive outcomes for older adults.

Healthcare professionals were satisfied with a combination of participant-engaging and teacher-driven pedagogical approaches used to train them in assessing health needs and planning care for older adults living at home. Such training can lead to enhanced assessment skills and facilitate improvements in practice and health promotion for older adults. Future research is recommended on interprofessional simulation training for conducting structured and comprehensive health needs assessments of older adults living at home, as well as on the implementation of such assessments and health-promoting interventions.

Peer Review reports

Introduction

The globally growing and diverse aging population will impact the sustainability of healthcare systems and the independent living of older adults. To support the health needs of older adults, the World Health Organization (WHO) underscores the necessity of effectively training the healthcare workforce [ 1 , 2 ]. However, the complexity of health needs in older adults, coupled with an increased risk of frailty and adverse health outcomes, challenges the provision of tailored care [ 3 ]. Healthcare professionals in homecare settings are well-positioned to assess the health needs of home-living older adults [ 4 , 5 ] and facilitate the interprofessional management of these needs within the community [ 5 ].

Health needs assessment should offer a comprehensive understanding of individuals’ physical, mental, and social health needs, and address the constantly changing needs with increasing age. The assessments aim to identify those who can benefit from healthcare services, such as health education, disease prevention, treatment, and rehabilitation [ 6 ]. The assessment can help set service priorities and allocate service resources effectively, guide clinical decision-making [ 7 ] and design targeted, health promoting interventions [ 4 , 7 , 8 , 9 ] to prevent or delay frailty [ 10 ], enhance overall outcomes for those with complex health needs [ 11 ] and enable them to remain at home for as long as possible [ 12 ]. Given its importance, the task of health needs assessment, is becoming increasingly crucial in homecare settings [ 13 ]. However, there is a scarcity of adequately trained professionals proficient in conducting interprofessional health needs assessments [ 4 , 5 , 9 , 14 , 15 ], including depression [ 16 ], cognitive function [ 17 ], social needs [ 18 ], sensory function (i.e. hearing and vision) [ 19 ], geriatric healthcare [ 20 , 21 ], and multidimensional frailty [ 22 , 23 ]. Frailty, as a dynamic state, affects an individual who experiences losses in one or more domains of human functioning (physical, mental, social) that are caused by the influence of a range of variables, and which increase the risk of adverse outcomes [ 24 ].

A comprehensive understanding of how to train healthcare professionals in health needs assessment of the physical, mental, and social health needs of older adults living at home is crucial. This review understands training as “planned and systematic activities designed to promote the acquisition of the knowledge, skills, and attitudes” [ 25 , p77]. Training can take place as “on-the-job training,” with practicing tasks with a mentor or receiving feedback, or through “off-the-job training,” in a classroom setting with lectures, discussions, and exercises [ 26 ]. It is essential to consistently update and expand knowledge and skills throughout healthcare professionals’ careers [ 27 ]. Mentorship and support are highly valued as pedagogical approaches [ 28 ]. Another approach is implementing interprofessional team-based training [ 29 ] focused on health needs assessment for older adults, which can be complemented by practical, supervised training with a mentor in real-world settings [ 9 ]. Interprofessional simulation training can support healthcare professionals developing communication and collaborative skills and improving patient outcomes [ 2 ]. Additionally, opportunities to share and exchange experiences and new learning with peers and seniors, along with tailored, role-focused teaching, are effective approaches training strategies in community healthcare [ 30 ]. Practical training through simulation, case studies, and role-playing influences skill development by creating experiences that promote individual understanding and learning [ 31 ] and it is based on Vygotsky’s sociocultural learning theory [ 32 ]. Tailored simulation training in use of systematic assessment tools enhanced nurses’ competencies to assess and treat complex symptoms among older adults in long-term care facilities [ 33 ].

Therefore, this scoping review aimed to identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home. Three research questions guided the review: (1) what pedagogical approaches are used when training healthcare professionals to assess the health needs of older adults living at home, (2) what is the content and foci in the health needs assessment training provided in the studies, and (3) what are the outcomes of training reported by healthcare professionals and older adults living at home?

Scoping review design

This study followed the Joanna Briggs Institute (JBI) methodology [ 34 ] for conducting and reporting scoping reviews built on Arksey and O’Malley’s framework [ 35 ]: (1) Define and align the objectives (2) develop and align the inclusion criteria with the objectives (3) describe the planned approach to evidence searching, selection, data extraction, and presentation of the evidence (4) search for the evidence (5) select the evidence (6) extract the evidence (7) analyze the evidence (8) present the results (9) summarize the evidence in relation to the purpose of the review, draw conclusions and note the implications of the findings [ 36 ]. In addition, the PRISMA-ScR [ 37 ] was used as a checklist to report the scoping review data charting, data synthesis and presentation of the data (Additional file 1).

Selection of studies

To be eligible for inclusion in the review, the study had to focus on the training of healthcare professionals in assessing physical, mental and social health needs [ 24 ], specifically assessing frailty, physical function, depression, cognition, social health, and sensory function of older adults aged 65 and above living at home [ 38 ]. Healthcare professionals from diverse fields were included, whether engaging in one-to-one interactions where individual healthcare professionals work directly with patients or working collaboratively in interprofessional teams of members from different professional backgrounds [ 29 ]. The review included qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. The inclusion and exclusion criteria are specified in Table  1 below.

Search strategy

The authors and an experienced research librarian collaboratively developed the search strategy and search terms. The search strategy followed the recommendation of JBI [ 34 ]. In June 2022, a limited search of PubMed and CINAHL was conducted to identify relevant articles. To develop a more comprehensive search strategy, we subsequently analyzed the titles and abstracts of the retrieved papers, as well as the index terms used to describe the articles. A systematic literature search was performed on October 6, 2022, in the CINAHL (EBSCO), MEDLINE (EBSCO), Academic Search Ultimate (EBSCO), Scopus (Elsevier), Embase (OVID) and British Nursing Index (ProQuest) databases. The updated search was conducted on the 7th of March 2024. The search terms employed in the different databases to represent training healthcare professionals to assess health needs in older adults living at home are described in Table  2 . We considered studies published between 1990 – and March 2024. Ultimately, the reference lists of all included studies were reviewed to identify any additional studies aligned with the scoping review’s aim.

Identification and selection of studies

The search yielded a total of 2266 records. The study selection process is illustrated in Fig.  1 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [ 39 ]. The search results were uploaded into the citation management system EndNote, where duplicates were removed. A total of 1722 records remained for screening. We used the web application Rayyan [ 40 ] to screen studies for inclusion or exclusion. The screening involved all the authors working in pairs, independently assessing eligibility on the basis of the inclusion and exclusion criteria. Discrepancies were resolved through discussions until consensus by all authors in arranged meetings.

All the records were independently screened by the authors (BHL, DND, HKF, PD and MS), and 1452 records were excluded. Two hundred seventy abstracts were reviewed in blinded pairs, leading to the exclusion of 212 records. Next, the full texts of 58 studies were read. This process resulted in the exclusion of 38 studies whose reasons are provided in the flow chart. The remaining 20 studies were included in this review (Fig.  1 ).

The primary reason for exclusion was the lack of content related to training in health needs assessment  ( n  = 13) or incorrect populations ( n  = 12). Eight studies were excluded because they focused on training for medical or bachelor’s degree students. Additionally, four publications were not peer-reviewed studies ( n  = 4).

BHL and MS independently screened the reference lists from the 20 included studies to identify additional eligible studies. After all the blinded titles were read, 28 titles of records were identified for abstract review. Following this, 22 titles were excluded, leaving 6 abstracts included in the full-text examination. The full-text reading further excluded four studies because they did not focus on training in health needs assessment. Finally, two studies [ 41 , 42 ] were added to this scoping review, resulting in a total of 22 included studies.

An updated search was conducted on the 7th of March 2024, including publications from 2022 to 2024, following the procedure above. After removing duplicates, 173 titles and abstracts were screened for eligibility. The full texts of nine articles were read. Six studies were excluded because they did not include training for healthcare professionals. One had incorrect population, and the others were in a language other than English. This led to the inclusion of one new study [ 43 ], bringing the total number of included studies for the scoping review to 23.

Search results, study selection and inclusion process [ 39 ]

Extraction and analysis of the data

In line with the updated JBI methodological guidelines for scoping reviews [ 34 ], we extracted and coded descriptive details from the 23 included records. The extraction table covered the publication year, country of origin, study purpose, research design, study population, context/setting, training intervention content and assessment tools, pedagogical approaches and training duration, and outcomes for healthcare professionals and older adults. A test was conducted to ensure that the coauthors were aligned in their understanding of what type of data to extract for the table. Feedback from the test guided essential refinements to the extraction table before the authors collaborated to extract and organize pertinent information. We applied a basic thematic analysis to code the data and identify, analyze, and interpret patterns, ultimately deriving themes that addressed our research questions [ 44 , 45 ]. The analysis utilized NVivo 12 Pro software [ 46 ].

Quality appraisal

We performed a quality evaluation of the included studies via the Mixed Methods Appraisal Tool (MMAT) in blinded pairs. This tool is designed for a structured and standardized evaluation of methodological quality and risk of bias in systematic reviews that include qualitative, quantitative, and mixed methods studies [ 47 ]. Although quality evaluation is optional in a scoping review, it can provide valuable insights [ 48 ] and enhance the interpretability of the included studies [ 49 ].

All studies were evaluated according to five quality criteria specific to each research design (qualitative, quantitative descriptive, nonrandomized, randomized, and mixed methods studies). Each criterion received a response score of either “Yes,” indicating that the study met the quality criteria, or “No,” indicating that it did not meet the quality criteria or that it was unclear (see Table  4 ). It is discouraged to calculate an overall score. Any disagreements in scoring were resolved through discussion. The quality scores were not used to exclude articles from the review; instead, they were reported and discussed [ 49 ].

In accordance with the JBI scoping review guidance [ 44 ], the extracted data are presented in a table format (Tables  3 and 5 ) and a narrative summary is provided to respond to the three research questions. Table  3 provides a description of the study characteristics, while Table  5 outlines overarching categories along with relevant extracted information [ 44 ].

Characteristics of the included studies

Table  3 shows that the 23 studies were published between 1990- and 2023. Eight studies were conducted in the United States [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 ], three in Canada [ 55 , 56 , 57 ], three in Australia [ 58 , 59 , 60 ], three in the United Kingdom [ 41 , 61 , 62 ], and one each in Ireland [ 63 ], Italy [ 64 ], Brazil [ 65 ], France [ 66 ], Singapore [ 67 ], and Belgium [ 68 ].

Ten studies meticulously examined training interventions tailored for primary nurses [ 43 , 50 , 51 , 54 , 55 , 60 , 61 , 63 , 66 , 68 ], one study specifically targeted the training of community health workers [ 65 ] and another presented an educational session tailored for case managers and agency supervisors [ 42 ]. The remaining studies indicated that training was provided to interprofessional teams or various distinct professions, such as nurses, physical therapists, occupational therapists, general practitioners, social workers and psychologists [ 16 , 41 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 67 ]. The study participants were in home healthcare or primary/community care [ 16 , 41 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 68 ], community and social services [ 42 , 64 ], mental health care [ 61 ], eldercare centers/daycare [ 67 ], residential settings [ 58 , 59 , 64 ], hospitals [ 53 , 56 ], rehabilitation [ 56 ] and acute care [ 61 ].

Quality evaluation results

The quality appraisal procedure revealed variations in the quality of the 23 included studies. The detailed quality evaluation results for each study are presented in Table  4 , and an overview of the methodological quality criteria is presented in Additional file 3.

Each study was evaluated on five criteria appropriate to its study design category. Overall, only one study, which was a mixed methods study, met al.l five quality criteria in the MMAT [ 62 ]. Additionally, one mixed methods study met four criteria [ 61 ], and another met three criteria [ 65 ]. The most common criterion that mixed methods studies failed to meet was 5.2: whether the different components of the study were effectively integrated to answer the research question. Among the quantitative randomized studies, one study met four quality criteria [ 50 ], whereas the other was of low quality, meeting only one criterion [ 59 ]. None of these studies met the quality criterion for proper randomization. In the quantitative nonrandomized studies, six met four criteria [ 41 , 55 , 56 , 58 , 64 , 68 ], one met three [ 63 ], and one met only one criterion [ 16 ], indicating low quality. All studies met the criterion regarding whether the intervention was administered as intended. The most common criteria they failed to meet were 3.3: whether there were complete data and 3.4: whether confounders were accounted for in the study design and analysis. Among the descriptive studies, seven met four criteria [ 42 , 43 , 54 , 57 , 60 , 66 , 67 ], one met three criteria [ 53 ], and two met only one criterion [ 51 , 52 ], demonstrating low quality.

The majority of these studies met the criterion regarding whether the measurements were appropriate. However, the criterion most studies did not meet (only one out of ten) was whether the risk of nonresponse bias was low. Notably, no qualitative methods studies were included in our scoping review.

Training interventions in assessment of older adults living at home

The next section presents a narrative overview of three major themes related to the three research questions. The themes concerned the training provided for healthcare professionals in assessing the physical, mental, and social health needs of older adults living at home: pedagogical approaches, content and foci of health needs assessment training for healthcare professionals and outcomes and evaluation of health needs assessment training for healthcare professionals and older adults living at home. The findings are summarized in Table  5 [ 44 ].

Pedagogical approaches

The included studies employed diverse pedagogical approaches to train healthcare professionals in assessing the health needs of older adults living at home. The spectrum of pedagogical approaches observed in the studies was categorized into teacher-driven and participant-engaging pedagogical approaches. Twenty-one studies [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ] combined teacher-driven and participant-engaging pedagogical approaches, reflecting a multifaceted training strategy. Mayall et al. [ 41 ] opted for a more singular pedagogical approach, exclusively relying on lecture-based education, whereas the training method used in the Piau et al. [ 66 ] study remained unspecified. The training interventions varied in duration, from one-hour sessions [ 68 ] to an ongoing training program spanning 21 months [ 57 ]. In two studies, the specific duration of the training interventions was not specified [ 53 , 57 ]. The most common duration for training was 4–8 h [ 16 , 43 , 50 , 52 , 54 , 56 , 58 , 59 , 62 , 67 ].

Teacher-driven pedagogical approaches

Almost all studies utilized teacher-driven pedagogical approaches, including educational sessions, written materials or e-learning [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. Educational sessions were evident in 14 studies [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 65 ], providing healthcare professionals with information about relevant topics through lectures [ 16 , 41 , 42 , 51 , 62 , 64 , 65 ], slides [ 16 , 64 ] and instructions [ 50 , 52 , 53 ], as well as demonstrations of the use of assessment tools [ 41 , 42 , 51 , 56 , 58 , 59 ]. Additionally, Abbasi et al. [ 57 ] and Quijano et al. [ 42 ] offered ongoing sessions during the post training implementation period.

Written materials were provided to the participants in nine studies [ 16 , 42 , 50 , 52 , 54 , 58 , 59 , 63 , 64 ]. This included training manuals containing examples and case studies [ 58 , 59 ], written documents about the training pack and the assessment forms [ 63 ], course textbooks and instruction manuals [ 64 ], educational materials including the program manual and articles [ 42 ], a CD-ROM (a data-disc for computer) containing written educational material [ 52 ] and toolkits derived from the educational material [ 16 , 50 , 54 ]. Brown et al. [ 54 ] reported that toolkits included key intervention components for seamless application of learned concepts [ 54 ]. Furthermore, some described follow-up emails to provide participants with information post training [ 50 , 54 ].

E-learning as a preplaying online module or videoclip appeared in nine studies [ 16 , 42 , 43 , 50 , 53 , 54 , 61 , 64 , 68 ]. Naughton et al. [ 61 ] delivered prerecorded lectures [ 61 ], Landi et al. [ 64 ] used video recordings presenting real cases to test participants’ assessments- and decision-making skills, and Quinlan and Ryer [ 43 ] offered online modules on aging epidemiology, fall risk factors, and age-friendly health systems [ 43 ]. Participants watched video recordings portraying late-life depression [ 42 , 53 , 54 ], and patient interactions illustrating approaches to depression assessment [ 50 , 54 , 68 ] via standardized questions and follow-up questions [ 16 ]. Professional actors were used in three studies [ 16 , 53 , 68 ].

Participant-engaging pedagogical approaches

The majority of the included studies utilized participant-engaging pedagogical approaches involving knowledge exchange or various forms of interactive learning [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ].

Sixteen studies employed various forms of knowledge exchange such as discussion, questioning and coaching, between training participants and teachers [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. Peer-to-peer learning and dialog facilitated the exchange of knowledge and insights [ 65 ], which enriched the overall learning experience [ 61 ]. The participants were included in discussions following lectures [ 55 ], after watching scripted videos [ 53 ], and during patient case reviews [ 56 , 67 ]. Additionally, three studies included both discussions and allowed participants questions [ 52 , 54 , 68 ]. Discussions allowed participants to delve into case management techniques [ 51 ], explore experiences related to assessing the health of older adults [ 54 , 60 , 64 ] and solve problems and discuss alternative strategies regarding depression screening [ 54 ]. A few studies have provided ongoing coaching in the post training phase to support healthcare professionals in applying newly acquired skills [ 42 , 55 , 57 ]. This included three months of feedback and support [ 42 ], mentorship for skill integration [ 57 ], and a six-month collaborative approach between resource staff and case managers involving home visits and clinical consultations [ 55 ].

Interactive training was employed in fifteen studies through skills training, role-playing, simulations, and hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ]. Skill training allows nurses to practice patient interviews and assessments and receive instructor feedback [ 54 ]. The participants practiced by assessing their colleagues’ health and responding to assessment [ 16 , 51 ], with faculty staff offering assistance, encouragement, and feedback throughout [ 51 ]. Landi et al. [ 64 ] provided practice exercises followed by presentations, and Quinlan and Ryer [ 43 ] provided a virtual training session in motivational interviewing technique and assessment. Roleplay as a teaching strategy was used to address practical aspects of administering depression screening [ 50 , 52 , 60 ], and Butler and Quayle [ 63 ] incorporated case scenarios, roleplay, and practical skills training for assessing depression in older adults [ 63 ]. Simulation training was used to immerse participants in the experience of living with sight and hearing impairments performing everyday tasks such as filling out forms or managing medications using sight impairment spectacles. Training was followed by a debriefing session [ 62 ]. Hands-on training in the assessment of older adults’ health in real-world settings was conducted in ten studies [ 42 , 51 , 54 , 55 , 57 , 58 , 59 , 60 , 64 , 65 ]. Healthcare professionals gained clinical experience through assessments of home dwelling older adults [ 55 , 58 , 59 , 60 , 64 , 65 ] and through participation in a rotational preceptorship for community health nurses. This enabled them to practice newly acquired assessment skills and collaborate in a real-life setting [ 51 ]. Additionally, two other studies emphasized practical training in communication with other professionals in real-world settings [ 58 , 59 ], while Brown et al. [ 54 ] encouraged participants to practice assessments in a real-world setting between educational sessions.

Content and foci of health needs assessment training for health care professionals

All the included studies offered insights into the content and foci of health neesd assessment training interventions for healthcare professionals. The studies were divided into those aimed at training healthcare professionals to understand and assess either single or multiple physical, mental, and social health needs in older adults living at home. Additionally, some training sessions focused on interprofessional collaboration.

Single health need assessment training

The focus of twelve studies involved enhancing the skills of healthcare professionals in assessing, planning and conducting interventions for a specific, single health need in older adults, with each addressing either the assessment of mental or physical health [ 16 , 41 , 43 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 63 , 68 ]. Two of these studies [ 43 , 62 ] focused solely on physical health factor training. Smith et al. [ 62 ] emphasized training in assessing and detecting sight and hearing impairments without specifying whether any assessment tools were used [ 62 ]. Quinlan and Ryer [ 43 ] provided fall risk assessment training, which included the use of assessment tools to evaluate the physical function of older adults and to assess their home environments. The other ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused on training to assess depression in older adults living at home. The training encompassed understanding and detecting the condition, and all of them included the use of assessment tools. Van Daele et al. [ 68 ] included skills such as actively listening to patients and motivating them to seek expert assistance when needed. Delaney et al. [ 16 ] incorporated skills in asking follow-up questions, and Mellor et al. [ 59 ] offered training in appropriate communication with older adults to identify masked, early signs of depression.

Multiple health needs assessment training

Eleven studies [ 42 , 50 , 51 , 55 , 56 , 57 , 61 , 64 , 65 , 66 , 67 ] described training interventions for healthcare professionals aimed at assessing, planning, and conducting interventions for multiple health needs in older adults living at home. The training content ranged from learning to performing a holistic health assessment of older adults encompassing physical, mental, cognitive, and social factors [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] to a more nuanced assessment of two or three of these factors [ 50 , 65 , 67 ]. All studies described the use of assessment tools or checklists. A holistic assessment and understanding of older adults’ health context and needs enables interventions to be tailored to their health and care needs, priorities, and levels of frailty [ 57 ]. Within the realm of holistic assessment, only two of these studies addressed alcohol and medication usage [ 55 , 56 ], whereas two other studies focused on evaluating sensory status [ 57 , 66 ]. For studies with more nuanced assessment training, three studies [ 42 , 50 , 67 ] primarily tailored their training to focus on depression assessment and intervention in older adults, but Quijano et al. [ 42 ] also included training in assessing general physical health status, social function, and cognitive function. Sin et al. [ 67 ] included dementia assessment and Bruce et al. [ 50 ] addressed factors that commonly complicate depression in homecare patients, such as health conditions, disability in activities of daily living, and cognitive function. The training included how to ask follow-up questions and observe nonverbal language [ 50 ]. Neto et al. [ 65 ] provided training for healthcare professionals in rural areas to screen for geriatric risk factors such as caregiver overburden, general health, social health, risk of falling, or difficulties in activities of daily living.

Interprofessional collaboration and communication skills in health needs assessment training

Beyond the focus on training for assessing the health needs of older adults, sixteen studies [ 42 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 , 68 ] have incorporated training elements to increase interprofessional collaboration and communication skills among healthcare professionals. Health needs assessment training for interprofessional teams was evident in eight of the included studies [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Two studies [ 58 , 59 ] outlined an advanced session to teach skills for interacting with other healthcare providers, including general practitioners and mental health specialists, whereas Couser et al. [ 51 ] stressed the importance of effectively communicating the assessment results to physicians and other healthcare providers. Training in writing referrals was emphasized in ten studies [ 42 , 50 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 68 ]. In addition, Stolee et al. [ 55 ] trained healthcare professionals in writing reports and making recommendations to the referring case manager. Only two studies [ 61 , 65 ] included collaboration with family in their training programs. Naughton et al. [ 61 ] designed training programs to support healthcare professionals in navigating the complexities of collaboration with multidisciplinary teams, older adults, and their families. They also developed a network among nurses to facilitate the exchange of expertise, experience, and innovative ideas [ 61 ]. Neto et al. [ 65 ] aimed to increase the capacity of care workers to effectively collaborate with family caregivers and social services for dependent older adults in rural areas. Stolee et al. [ 55 ] provided training for case managers to extend this knowledge to their teams and strengthen connections with specialized geriatric services. Similarly, Abbasi et al. [ 57 ] emphasized team-based care delivery training, with active and holistic discussions among patients, caregivers, and interprofessional teams. Diverse skill sets within teams can effectively meet the holistic care needs of patients. In parallel, Piau et al. [ 66 ] focused on training nurses to collaborate with general practitioners to develop comprehensive care plans. Landi et al. [ 64 ] trained case managers who collaborated in supervised teams to assess older adults and present care plans. They watched videos of simulated team discussions to enhance their understanding of the assessment process and teamwork [ 64 ].

Evaluation and outcomes of health needs assessment training for healthcare professionals and older adults

All of the studies provided insight into the experiences or outcomes of healthcare professionals participating in the training interventions. This included their satisfaction and experiences with health needs assessment training, improved confidence and competencies in health assessment and care planning and shifts in work practices. Additionally, some studies have reported outcomes for older adults following health needs assessment training, such as appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. The evaluation of these outcomes relied to a small extent on models or frameworks, with only three studies incorporating them [ 43 , 61 , 62 ]. Smith et al. [ 62 ] utilized Kirkpatrick’s four-level training evaluation model to assess the relevance and impact of educational intervention. Naughton et al. [ 61 ] adopted Alvarez et al.’s (2004) framework of an integral model of training evaluation and effectiveness. Quinlan and Ryer [ 43 ] presented their findings following the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework.

Healthcare professionals’ satisfaction and experiences with assessment training

Ten studies provided insights into healthcare professionals’ experiences with participating in training interventions [ 16 , 41 , 43 , 54 , 55 , 56 , 60 , 61 , 62 , 65 ], where most of the participants expressed satisfaction with both the content and format of the courses. The participants in Brymer, Cormack and Spezowka [ 56 ] expressed a high level of satisfaction with the presenter’s content, pacing, and format, and in Mayall et al. [ 41 ], the training met the participants’ needs and expectations. The participants in Naughton et al. [ 61 ] particularly valued the peer-to-peer learning aspect, whereas Smith et al. [ 62 ] emphasized the effectiveness of simulations. Neto et al. [ 65 ] rated classroom sessions and supervised home visits very positively and found them useful. Furthermore, participants in four of the studies [ 16 , 60 , 61 , 65 ] offered suggestions to enhance the number of educational sessions. They suggested allocating more time for training [ 16 , 65 ], a greater focus on skills training [ 60 , 61 ], additional training in managing complex and technically challenging issues [ 65 ] and incorporating more time for case studies and discussions [ 16 ].

Improved confidence and competence in health assessment and care planning

Improvements in assessment competencies following training interventions among healthcare professionals were reported in nineteen studies [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Among these, nine studies explicitly reported increased confidence among healthcare professionals in assessing older adults’ health needs [ 16 , 41 , 54 , 55 , 58 , 59 , 63 , 67 , 68 ]. The health need sassessment and use of assessment tools or checklists led to the identification of health needs. Quinlan and Ryer [ 43 ] noted that without screening in a fall prevention program, the identification of fall risk among older adults would be missed. Piau et al. [ 66 ] noted that a high proportion of assessments effectively identified frailty and suggested interventions and referrals. One comment was that they “were previously skirting around the problem, now asked about mental health directly” [ 61 , p. 33]. Naughton et al. [ 61 ] reported that performing a comprehensive geriatric assessment helped when raising issues with general practitioners because they were talking about their language. Nunn, Annells and Sims [ 60 ] acknowledged the use of Geriatric Depression Screening (GDS) tool raised awareness of depression. A total of 62.5% felt that the GDS helped identify depression that might otherwise be overlooked, but some questioned its universal usefulness [ 60 ]. Abbasi et al. [ 57 ] reported that having an evaluation framework helped healthcare professionals guide meaningful measures [ 57 ]. Conversely, some participants also expressed that they relied more on observation than direct questions when assessing depression [ 54 ]. According to Landi et al. [ 64 ], careful assessments is deemed essential for effective care planning, and Stolee et al. [ 55 ] emphasize the critical role of assessment training in identifying health needs and equitably distributing community service resources. Two studies reported one year of retention of knowledge and skills without the inclusion of a refresher course [ 54 , 62 ].

Twenty studies documented a better understanding of appropriate interventions and referrals [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. According to Delaney et al. [ 16 ], 50% of the participants noted that a key aspect they learned was understanding the significance of the assessment results and the corresponding interventions [ 16 ]. The participants in the study by Neto et al. [ 65 ] demonstrated significantly improved capacity in responding to the health and care needs of older adults. The participant reported increased confidence in making referrals and consulting resources [ 51 ], increased knowledge about managing depression, making referrals, and accessing available local services [ 41 ] and enhanced self-efficacy in providing care for older adults [ 16 , 58 ]. Nunn, Annells and Sims [ 60 ] reported that 50% of participants felt prepared to address older adults’ depression after training. Smith et al. [ 62 ] observed increased referral practices and improved ability to advise patients about sensory services, whereas Mellor et al. [ 59 ] noted a slight increase over time in specialist referrals, and senior staff reported increased confidence in interacting with health specialists.

Shift in healthcare professionals’ work practices after assessment training

The training intervention resulted in either a change or potential for change in work practices in ten studies [ 16 , 42 , 43 , 52 , 53 , 55 , 57 , 62 , 63 , 64 ]. Butler and Quayle [ 63 ] reported that prior to receiving training, nurses did not utilize any formal assessment measures to screen for depression in older adults. However, following training, some nurses continue to use screening measures for depression in their clinical practice [ 63 ]. Similarly, case managers in Stolee et al. [ 55 ] stated that the major change in their assessment practice was greater consistency in the use of assessment tools. Smith et al. [ 62 ] reported a shift in practice toward incorporating more detailed information about patients’ impairments and implementing supportive strategies, and in Marcus et al. [ 53 ], communication of depression screening results to patients, physicians, or mental health specialists became a standard protocol.

Landi et al. [ 64 ] reported that training was proven feasible and may be implemented on a broader scale, and Luptak et al. [ 52 ] outlined an implementation period of the ADAPT—Assuring Depression Assessment and Proactive Treatment protocol for depression care in rural healthcare—with the potential to achieve the outlined goals in various clinical settings [ 52 ]. Delaney et al. [ 16 ] reported that project participants were interested in implementing the program in their homecare setting and developed a train-the-trainer model. Abbasi et al. [ 57 ] provided results and experiences regarding the Seniors Community Hub (SCH) through the ADKAR (awareness, desire, knowledge, ability, reinforcement) evaluation framework to assist others interested in implementing a similar integrated care model [ 57 ]. Quinlan and Ryer [ 43 ] stated that fall assessment practices are currently implemented and continuous; similarly, Quijano et al. [ 42 ] reported that depression interventions continue to be offered by participating agency offices. On the other hand, Butler and Quayle [ 63 ] noted the challenge of implementing assessment tools due to competing demands such as holidays, working part-time or being too busy, and Sin et al. [ 67 ] outlined one participant with difficulties in applying new knowledge owing to manpower shortages and constraints in time and space.

Outcomes for older adults following the health needs assessment training

Seven studies [ 42 , 43 , 50 , 53 , 57 , 66 , 68 ] detailed outcomes for older adults following health needs assessment training for healthcare professionals. These outcomes included appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. Bruce et al. [ 50 ] highlighted that depressed older adults in the intervention group were more likely to receive appropriate referrals for mental health evaluation [ 50 ], aligning with findings where a minimal intervention significantly increased the detection of depression and further referrals to general practitioners [ 68 ]. The findings in two studies demonstrated that patients were referred to tailored resources designed to address their identified problems [ 53 , 57 ]. Furthermore, Quijano et al. [ 42 ] revealed that older adults’ awareness of seeking help and the significance of physical activity for maintaining health improved. Quinlan and Ryer [ 43 ] stated that after providing care plans to 83 older adults, most implemented fall prevention strategies during a two-week follow-up call with 29 older adults, with only one fall reported. Piau et al. [ 66 ] identified the main causes of frailty and reported effective intervention recommendations and referrals [ 66 ]. Most physicians in Stolee et al. [ 55 ] reported better general function for older adults due to comprehensive geriatric assessment. Findings in two studies [ 42 , 57 ] documented reductions in depression severity at the follow-up assessment due to appropriate referrals and interventions [ 42 , 57 ], and significantly more older adults felt better and experienced pain reduction, followed by increased activity [ 42 ]. Additionally, Abbasi et al. [ 57 ] reported a slight improvement in health-related quality of life, including mobility, usual activities, pain/discomfort, and anxiety and depression, suggesting enhanced function [ 57 ].

This scoping review provides insights into training interventions for healthcare professionals assessing the physical, mental, and social health needs of older adults living at home. The analysis of 23 studies revealed that nearly all training interventions used a multifaceted training strategy combining teacher-driven and participant-engaging pedagogical approaches to teach healthcare professionals theoretical and practical knowledge. Health needs assessment training focuses on the skills needed to conduct single or multiple health needs assessments in older adults. Interprofessional collaboration was an essential part of most training interventions. Multiple studies noted that participants were satisfied with the training content and had increased confidence and competencies in health needs assessment and care planning. Studies have also reported a shift in work practices for health care professionals and some included results have shown improved health outcomes for older adults.

Our study revealed that most of the included studies blended the use of teacher-driven and participant-engaging pedagogical approaches [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. These approaches provide participants with confidence and competencies in health needs assessment [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Skilled healthcare professionals are crucial in facilitating the implementation of health assessments for older adults [ 69 ]. Lectures can be highly effective for learning, especially when they stimulate thinking and active engagement. Their effectiveness depends on the lecturer’s skill and can be improved by incorporating learner feedback, performance results, self-reflection, and peer feedback [ 70 ]. Another way to improve lecture quality is by including interactive elements such as practical skill training, following John Dewey’s “learning by doing” philosophy [ 32 ]. In our review, we identified fifteen studies that utilized participant-engaging approaches such as skills training, role-playing, simulations, hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ], and sixteen studies employed discussion, questioning and coaching [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. The integration of teacher-driven sessions, interactive training, and knowledge exchange resembles simulation training, which typically includes briefing, simulation exercises, and debriefing phases. These phases allow participants to reflect, enhance their learning, and deepen their educational experience [ 71 ]. Debriefing is a valuable tool for reflecting on and discussing experiences in training and real-world settings. This helps individuals and teams identify strengths, areas for improvement, and lessons learned, thereby enhancing learning and future performance [ 72 ]. However, effective debriefing relies on facilitators with strong skills to maximize learning outcomes [ 73 ].

The WHO advocates interprofessional simulation training to enhance healthcare professionals’ competencies and improve patient outcomes [ 2 ]. Even if several studies combined teacher-driven approaches, interactive training and knowledge exchange, our review included only one study utilizing simulation training [ 62 ]. Health needs assessment training for interprofessional teams was evident in eight of the studies included in our review [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Such training has been proven to provide valuable insights into the health of older adults, leading to improved care delivery [ 74 , 75 ], improved patient outcomes [ 76 ] and reduced hospitalization [ 74 ]. It can improve conflict management skills and team functioning [ 76 ] and play a critical role in equitably distributing community service resources [ 55 ]. Interprofessional simulation training is an engaging method for training clinical skills, procedures, teamwork, and communication in a safe, realistic environment [ 77 ]. It promotes critical thinking, reflection [ 78 ], and effective learning [ 79 ] enhancing the application of knowledge in clinical practice [ 80 ]. The use of participant engaging pedagogical approaches aligns with the sociocultural view of training, which emphasizes active engagement and collaboration in the learning process. It enables knowledge exchange and reflection, and participants can integrate their experiences with new information, internalize it, and construct new knowledge [ 32 , 81 ]. Practical training such as simulations, can push participants out of their comfort zones, foster collaborative learning and enrich the educational experience [ 82 ]. However, to achieve optimal learning, it is crucial to balance skill development with an appropriate level of challenge as learners acquire new concepts. At the same time, temporary support from more experienced learners should be available. This balance is known as the zone of proximal development, which represents the space between a learner’s current skill level and their potential skill level with guidance. Tasks within this zone promote growth [ 83 ].

Our review reports a distinction in training content with a focus on assessing single versus multiple health needs in older adults. Ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused solely on assessing depression. There is a strong correlation between late-life depression and reduced quality of life, as well as comorbidities such as physical illness, disability [ 58 , 84 ] and physical frailty [ 85 , 86 ]. However, single health need assessment training may inadvertently lead to the overlooking of broader health needs among older adults. A multiple health assessment of older adults is recommended [ 7 ], as it can serve as the foundation for developing holistic interventions to enhance overall health [ 10 , 12 , 87 , 88 , 89 ], promote health [ 90 ], foster positive health behaviors [ 91 ], and reduce frailty [ 92 , 93 ]. Our review included eight studies [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] providing training in physical, cognitive, mental, and social health needs assessment, alongside care planning on the basis of these assessments. Research indicates that both healthcare professionals and frail older adults participating in an interdisciplinary care approach were satisfied with the improved structure of care and appreciated the emphasis on health promotion [ 94 ]. On the other hand, a comprehensive health needs assessment is a multifaceted and complex intervention, with uncertainties surrounding its effectiveness and underlying mechanisms [ 95 ]. Some research findings indicate that there is no conclusive evidence that it reduces disability, prevents functional decline [ 96 ], impacts mortality, or supports independent living in older adults [ 97 ]. These results underscore the complexity and challenges in conducting and implementing comprehensive health needs assessments and tailoring interventions to promote health in older adults.

Our review revealed that almost all [ 16 , 41 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 66 , 67 , 68 ] health needs assessment training programs included the use of assessment tools or checklists, leading to the identification of health needs. Only one of these studies reported that participants relied more on observation than on direct questioning when assessing depression [ 54 ]. Additionally, another study found that healthcare professionals using assessment tools felt that this approach led to asking overly personal and intrusive questions without first establishing trust or explaining the purpose of the assessment [ 98 ]. On the other hand, some older adults reported that using assessment tools made it difficult to discuss issues outside the predefined domains of the comprehensive health needs assessment [ 99 ]. Research indicates that current assessment practices heavily rely on professional judgment and intuition, and healthcare professionals in community settings often lack adequate knowledge and training regarding the health needs assessment of older adults [ 22 , 100 ]. This can be seen as problematic because these professionals are ideally positioned to assess older adults early in their health trajectories [ 105 ]. Proper assessment in these settings can facilitate the early recognition of functional decline [ 101 , 102 ] and vulnerability, enable timely intervention to mitigate frailty’s adverse effects [ 105 ], and support effective care planning [ 64 ]. Even if several healthcare professionals have endorsed the integration of frailty assessment tools into primary care [ 22 ], they need a simple, efficient assessment tool [ 105 ] that empowers them to identify older adults’ health needs [ 9 , 88 , 103 , 104 ]. This is particularly critical due to the essential role that assessments play in equitably distributing community service resources [ 105 ]. As such, this review underscores the importance of educating healthcare professionals in community care to effectively assess the physical, mental, and social health needs of older adults. Furthermore, understanding the learning process of healthcare professionals [ 78 ], evaluating the effects of training [ 106 ], and establishing evidence-based standards for skills training are crucial for high-quality teaching [ 107 ]. Additionally, further research is necessary to assess the feasibility, effectiveness, and acceptability of interprofessional interventions targeting multiple health needs aimed at health promotion [ 90 ] and experiences using comprehensive health assessment tools [ 108 ].

Methodological considerations

This review included studies employing various methods to obtain comprehensive insights into training healthcare professionals in assessing the health needs of older adults living at home [ 47 ]. We utilized a validated mixed-methods appraisal tool to assess the quality of the included studies [ 47 , 49 ]. We did not include reporting on screening questions regarding the clarity of the research question or whether the collected data addressed the research questions, as our review focused exclusively on empirical studies. Additionally, we chose not to calculate an overall score from the ratings of each criterion, as this practice is discouraged. We provide an overview of each study’s quality by presenting the ratings of each criterion [ 49 ]. Our findings revealed that only one study met all the quality criteria, fifteen studies met four criteria, three studies met three criteria, and four studies met only one criterion. High-quality studies employ rigorous and robust methods, leading to reliable and valid findings [ 109 ]. While most studies met 3–4 quality criteria, they provide a relatively strong evidence base and offer valuable insights, although some concerns remain. Several studies did not meet the quality criteria for nonresponse bias or complete outcome data. It is crucial to describe and evaluate a low response rate for its potential impact, as this can limit the generalizability of findings [ 110 ]. Many studies also failed to account for confounders in their design and analysis. Confounding factors may bias results by distorting the interpretation of findings [ 49 ], masking actual associations or creating false associations, potentially leading to incorrect conclusions [ 111 ]. The randomization of study subjects and rigorous statistical analyses can mitigate the impact of confounding variables [ 112 ]. Nonetheless, conducting a quality assessment increases awareness of these biases and limitations, thereby enhancing our confidence in the study findings.

Strengths and limitations

Our scoping review has several limitations. Initially, our search strategy involved the use of six databases and various relevant search terms related to training healthcare professionals in assessing the health needs of older adults. We excluded gray literature to focus on mapping existing published research and identifying any research gaps. The search was conducted by an experienced librarian. Despite our efforts to comprehensively map the research literature, we may have overlooked some studies. Second, our exclusion criteria, which encompassed, for example, general practitioners, students, and institutional settings, restricted the scope of the study. Additionally, we focused on health needs assessment, excluding studies that assessed the environment, an important factor in enabling older adults to stay at home as long as possible. However, based on the findings and limitations of the included studies, we believe our review provides valuable insights into the research context. These findings can inform future research, practice, policymaking, and the development of training programs for healthcare professionals in community settings to assess older adults’ health needs.

Healthcare professionals require training in assessing physical, mental, and social health needs in older adults living at home to ensure tailored interventions that enhance their health and independence. Our study revealed that healthcare professionals were satisfied with the combination of participant-engaging and teacher-driven pedagogical approaches when training in physical, mental, and social health needs assessment. Such training is beneficial and strengthens healthcare professionals’ confidence and competency in assessment and care planning for older adults living at home. Additionally, some studies reported that following health needs assessment training, there was a shift in work practices and improved health outcomes for older adults. We suggest that health needs assessment training programs are valuable for improving health and care for older adults living at home and contribute to increased sustainability in healthcare.

Furthermore, we propose additional research on interprofessional simulation training for the structured assessment of multiple health needs in older adults, ensuring comprehensive coverage of all significant health issues in these assessments. We also recommend research on the implementation of such assessments and health promoting interventions.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors express gratitude to librarian Kari Hølland, Division of Research, Stavanger University Library for performing the systematic literature searches.

This article stems from the research project “More good days at home - Advancing health promoting practices in municipal healthcare services for older recipients of homecare” (HEIME), specifically related to Work Package 3, “Simulation and training for health needs assessment in home-living older adults”. HEIME is funded by the Research Council of Norway (grant 320622), University of Southeastern-Norway, University of Stavanger, Stavanger, Horten, Porsgrunn and Nome municipality (2021–2025). Dr. Grethe Eilertsen is the project director. Drs. Siri Tønnessen, Anette Hansen and Professor Marianne Storm are the principal researchers and work package leaders.

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Dagrunn Nåden Dyrstad & Peter Dieckmann

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Helle K. Falkenberg

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All authors (BHL, DND, HKF, PD and MS) contributed to the design and development of the study, research questions, and literature search. BHL conducted the literature search in collaboration with MS and research librarian. All authors participated in the screening and quality assessment processes. Data analysis and manuscript writing and preparation was led by BHL in collaboration with MS. All authors were involved in reading, commenting and reviewing the text, and approving the final manuscript.

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Larsen, B.H., Dyrstad, D.N., Falkenberg, H.K. et al. Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review. BMC Med Educ 24 , 1019 (2024). https://doi.org/10.1186/s12909-024-06014-9

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Advancing sustainable healthcare: a concept analysis of eco-conscious nursing practices

• Marwa Mamdouh Shaban 1 ,
• Majed Awad Alanazi 2 ,
• Huda Hamdy Mohammed 3 ,
• Fatma Gomaa Mohamed Amer 4 ,
• Hla Hosny Elsayed 1 ,
• Mohammed ElSayed Zaky 1 ,
• Osama Elsayed Mohammed Ramadan 1 ,
• Mohamed Ezzelregal Abdelgawad 5 &
• Mostafa Shaban 2  

BMC Nursing volume  23 , Article number:  660 ( 2024 ) Cite this article

Metrics details

As the healthcare sector grapples with its environmental footprint, the concept of Eco-conscious Nursing emerges as a pivotal framework for integrating sustainability into nursing practice. This study aims to clarify and operationalize Eco-conscious Nursing, examining its attributes, antecedents, consequences, and providing operational definitions to guide future research and practice.

Utilizing a systematic literature review across PubMed, Google Scholar, and CINAHL Ultimate, this study identifies and analyzes existing theories, frameworks, and practices related to eco-conscious nursing. Through conceptual analysis, key attributes, antecedents, and consequences of Eco-conscious Nursing are delineated, leading to the formulation of comprehensive operational definitions.

The study reveals Eco-conscious Nursing as a multifaceted concept characterized by environmental stewardship, sustainable healthcare practices, and a commitment to reducing the ecological impact of nursing care. Operational definitions highlight the role of education, awareness, and institutional support as antecedents, with improved environmental health and sustainable healthcare outcomes as key consequences.

Eco-conscious Nursing represents a crucial ethos for the nursing profession, emphasizing the necessity of sustainable practices within healthcare. The operational definitions provided serve as a foundation for embedding eco-conscious principles into nursing, addressing the urgent need for sustainability in healthcare settings. Future research should focus on the empirical application of these definitions and explore the economic and cross-cultural dimensions of eco-conscious nursing.

Peer Review reports

Introduction

In the realm of healthcare, the burgeoning emphasis on sustainability has sparked a transformative movement towards environmentally conscious practices [ 1 , 2 , 3 ]. This shift recognizes the substantial environmental footprint left by healthcare operations, from extensive waste generation to significant energy consumption and greenhouse gas emissions [ 4 ]. As stewards of health, the healthcare sector is reevaluating its impact on the planet, aiming to reconcile the delivery of exceptional care with the imperative to preserve environmental integrity for future generations [ 5 ]. This holistic approach to healthcare not only addresses immediate health needs but also acknowledges the long-term implications of environmental health on overall well-being [ 6 ]. The intersection of healthcare and environmental stewardship underscores the urgent need for practices that ensure the health of the patient does not come at the expense of the planet’s health [ 7 , 8 ].

Nurses, who form the backbone of healthcare services worldwide, are pivotal to this paradigm shift [ 9 ]. Historically, nursing has been intricately linked with environmental health, drawing from foundational principles laid down by pioneers like Florence Nightingale, who underscored the importance of sanitation, fresh air, and clean water [ 10 ]. Today, the nursing profession is expanding its scope to include environmental sustainability as a core component of healthcare delivery [ 11 ]. Nurses are increasingly recognized as essential agents of change, capable of influencing sustainable practices within healthcare settings [ 12 ]. Their close proximity to patients and integral role in healthcare operations positions them uniquely to advocate for and implement eco-friendly practices, embedding sustainability into the very fabric of healthcare [ 13 ].

However, the integration of eco-conscious principles into nursing practice is not without its challenges. Barriers such as a lack of awareness, insufficient training in sustainable practices, and entrenched systemic obstacles often hinder progress [ 14 ]. Despite these challenges, the transition towards eco-conscious nursing practices presents a myriad of opportunities for enhancing both environmental and patient outcomes [ 14 ]. For instance, effective waste management and energy-efficient practices not only mitigate environmental harm but also have the potential to reduce hospital-acquired infections and lower healthcare costs, illustrating the dual benefits of eco-conscious nursing [ 15 ].

The concept of eco-conscious nursing has emerged as a vital response to these challenges and opportunities, signifying a commitment to the principles of sustainability within the nursing profession [ 16 ]. This nascent concept, which seeks to harmonize nursing care with environmental stewardship, is still in the process of being defined and operationalized [ 14 ]. The aim is to develop a clear and actionable framework that nurses can adopt, ensuring that their work contributes positively to the health of the planet. By refining and embracing the concept of eco-conscious nursing, the profession can make significant strides towards a more sustainable and ethically responsible practice.

In support of this movement, notable nursing theorists have emphasized the importance of environmental considerations. Fawcett (2022) and Fawcett (2024) have articulated the evolution of nursing’s metaparadigm to include environmental and cultural components, highlighting the growing recognition of environmental health within the profession. Additionally, blogs on nursology.net provide valuable insights into nursing’s engagement with climate change and sustainability issues [ 17 , 18 ]​.

The positions of major health organizations further underscore the urgency of this transition. The World Health Organization (WHO), the International Labour Organization (ILO), and the International Council of Nurses (ICN) have all published reports emphasizing the critical nature of addressing climate change and its impacts on health [ 19 ]. Recent international conferences on climate change, such as COP 28 in 2023, have highlighted the global health emergency posed by environmental degradation and called for immediate and sustained action​ [ 20 ].

The journey toward fully integrating eco-conscious principles within nursing practices necessitates a collaborative effort that spans beyond individual nurses to encompass healthcare institutions, educational bodies, and policy frameworks [ 21 ]. This collaborative approach involves the creation and adoption of policies that support sustainable practices, the development of nursing curricula that include environmental health, and the establishment of healthcare infrastructure that prioritizes sustainability [ 22 ]. Educational initiatives are particularly crucial, as they equip future nurses with the knowledge and skills needed to implement eco-conscious practices effectively [ 23 ]. Moreover, research plays a vital role in this transition, offering evidence-based strategies to mitigate the environmental impact of healthcare operations [ 24 ]. Through a concerted effort across these domains, the nursing profession can lead by example, demonstrating how healthcare can contribute to environmental sustainability without compromising the quality of patient care [ 25 ].

The movement towards eco-conscious nursing is a critical step in the evolution of healthcare, reflecting a growing recognition of the interconnectedness of human and environmental health [ 26 ]. By integrating sustainable practices into nursing, the healthcare sector can significantly reduce its environmental footprint, setting a precedent for responsible and ethical care delivery [ 27 ]. This shift not only aligns with global health priorities, such as the United Nations Sustainable Development Goals but also empowers nurses to take a proactive role in shaping a healthier and more sustainable future. As this concept continues to evolve, it will undoubtedly pave the way for innovative practices that ensure the well-being of patients and the planet alike [ 28 ].

Methodology

This concept analysis of eco-conscious nursing employed Rodgers’ evolutionary method, a well-established framework in nursing research that facilitates the clarification and operationalization of complex concepts [ 29 ]. The following steps were taken to ensure a comprehensive and systematic approach:

Theoretical Framework:

The conceptual analysis was guided by Rodgers’ evolutionary method, which views concepts as dynamic and context-dependent, evolving over time based on the interplay of various factors. This method involves identifying the attributes, antecedents, and consequences of a concept through systematic literature review and analysis.

Literature Search Strategy:

A comprehensive literature search was conducted across multiple databases, including PubMed, Google Scholar, and CINAHL Ultimate. The search incorporated a mix of specific Medical Subject Headings (MeSH) and keywords pertinent to the intersection of environmental sustainability and nursing practice. The chosen MeSH terms included ‘Environmental Health,’ ‘Sustainability,’ ‘Healthcare Waste,’ ‘Energy Conservation,’ ‘Nursing Care,’ ‘Nursing Practice,’ ‘Green Healthcare,’ and ‘Eco-friendly Practices.‘

The search strategy was structured using Boolean operators to broaden the scope: ((((((((Environmental Health) OR (Sustainability)) OR (Healthcare Waste)) OR (Energy Conservation)) OR (Nursing Care)) OR (Nursing Practice)) OR (Green Healthcare)) OR (Eco-friendly Practices)) AND (Nursing).

Selection Criteria:

A comprehensive search across multiple databases, including PubMed, Google Scholar, and CINAHL Ultimate, identified 2301 records. After removing 815 duplicates, 1486 records were screened, resulting in the exclusion of 1201 irrelevant records. From the remaining, 285 reports were sought for retrieval, but 126 could not be accessed. Of the 159 reports assessed for eligibility, 131 were excluded due to various reasons, such as not meeting the inclusion criteria or irrelevance. Ultimately, 28 studies were included in the qualitative synthesis and analysis, providing the necessary data to support the concept analysis of eco-conscious nursing, following the PRIMSA flow diagram, the selection was shown in Fig.  1 .

Inclusion criteria were: peer-reviewed articles, publications in English, and studies directly related to eco-conscious nursing practices. Exclusion criteria included non-peer-reviewed articles, publications in languages other than English, and studies not directly addressing eco-conscious nursing.

Analysis Process:

The final selection of articles underwent an in-depth review to distill data pertinent to eco-conscious nursing practices, focusing on identifying the attributes, antecedents, and consequences of the concept. Abstracts and full texts were scrutinized where necessary to ensure a thorough understanding and synthesis of the prevailing knowledge landscape.

Key themes were identified, including the integration of sustainability into nursing education and practice, the role of nurses in promoting environmental health, and the challenges and opportunities inherent in shifting towards more sustainable healthcare practices.

Quality Criteria:

The quality of selected publications was assessed based on their methodological rigor, relevance to the concept of eco-conscious nursing, and contribution to understanding the attributes, antecedents, and consequences of the concept. Publications were included if they provided substantial empirical evidence, theoretical insights, or practical examples of eco-conscious nursing practices.

Temporal Scope:

The review included publications from the past two decades to capture the evolution of eco-conscious nursing and its current state in the context of contemporary healthcare practices. This temporal scope ensured the inclusion of both foundational studies and recent advancements in the field.

PRISMA Flow Diagram of the Literature Search Process

Uses of the concept

The concept of “Eco-conscious Nursing” plays a pivotal role in a variety of contexts within healthcare, emphasizing the integration of environmental sustainability principles into nursing practice. As healthcare systems globally grapple with their environmental impact, eco-conscious nursing emerges as a vital strategy aimed at reducing waste, conserving resources, and promoting a sustainable approach to patient care and facility operations [ 30 ]. This concept, broadly defined, encompasses practices that seek to minimize the environmental footprint of healthcare activities, advocating for environmentally responsible decision-making in clinical settings [ 31 , 32 ]. This concept, broadly defined, encompasses practices that seek to minimize the environmental footprint of healthcare activities, advocating for environmentally responsible decision-making in clinical settings.

In clinical practice, the scope of eco-conscious nursing encompasses a diverse range of activities aimed at promoting environmental sustainability within healthcare settings. This involves the adoption of energy-saving measures such as the utilization of energy-efficient lighting and heating, ventilation, and air conditioning (HVAC) systems, which significantly reduce the carbon footprint of healthcare facilities [ 33 ]. Additionally, eco-conscious nursing advocates for the reduction of medical waste through strategies such as recycling programs, the proper segregation of waste, and the use of biodegradable products wherever possible [ 34 ]. The push towards the use of sustainable materials and resources further underscores the profession’s commitment to minimizing environmental harm. This includes advocating for the procurement of sustainably sourced medical supplies and the integration of eco-friendly products into daily nursing practice [ 24 , 32 ]. These practices highlight the defining attribute of sustainability integration, reflecting the profession’s commitment to minimizing environmental harm.

These eco-conscious practices extend beyond the immediate benefits of environmental conservation, offering profound implications for patient care and staff wellbeing [ 35 ]. The implementation of green practices within clinical settings has been shown to enhance the healing environment, contributing to faster patient recovery times and improved mental health outcomes [ 36 ]. The presence of natural elements and increased access to outdoor spaces can significantly reduce stress levels among patients and staff alike, fostering a more positive and restorative hospital experience [ 37 ]. Moreover, by reducing exposure to harmful chemicals and pollutants through the adoption of non-toxic cleaning agents and sustainable materials, eco-conscious nursing also contributes to a safer, healthier workplace [ 38 ]. This holistic approach not only benefits the environment but also promotes a culture of health and wellbeing within healthcare institutions, demonstrating that sustainable practices in nursing can lead to improved health outcomes and enhanced staff satisfaction [ 39 ]. This advocacy aspect underscores the defining attribute of environmental advocacy, highlighting nurses’ roles as proactive agents of change within and beyond healthcare settings.

Beyond the immediate healthcare environment, eco-conscious nursing plays a crucial role in public health and community engagement. Nurses, leveraging their trusted position in society, are uniquely positioned to advocate for environmental health, educating patients and communities about the health impacts of pollution, climate change, and other environmental hazards [ 40 ]. This role includes participating in policy advocacy, pushing for regulations and policies that support environmental sustainability in healthcare and the wider community [ 41 ].

Educational initiatives represent a pivotal aspect of eco-conscious nursing, offering a foundational approach for embedding sustainability within the core of nursing education [ 42 ]. By integrating principles of environmental stewardship into nursing curricula, educational institutions are preparing future nurses to not only excel in clinical competencies but also to actively engage in eco-friendly practices across various aspects of their professional roles [ 43 ]. This integration encompasses a broad spectrum of activities, from employing sustainable materials and waste reduction techniques in clinical settings to advocating for policies that promote environmental health and sustainability [ 22 ]. This educational paradigm shift encourages a holistic view of health that includes the well-being of the planet, ensuring that upcoming nurses are well-prepared to address the challenges of modern healthcare through a sustainability lens [ 44 ]. Such an approach not only reinforces the importance of environmental considerations in nursing practice but also positions nurses as key players in leading the transition towards more sustainable healthcare practices globally [ 45 ]. This strategic incorporation of sustainability into nursing education underscores the profession’s commitment to fostering a culture of environmental responsibility, ultimately contributing to the development of healthcare professionals who are not just healthcare providers but also guardians of the environment [ 16 ]. This reflects the defining attribute of professional development and education, emphasizing continuous learning and the dissemination of sustainable practices.

The concept of eco-conscious nursing extends significantly into the realm of research, serving as a foundational framework that underscores the intricate connections between health and the environment [ 46 ]. This research domain is crucial for uncovering innovative and sustainable practices within healthcare, aiming not only to mitigate the sector’s environmental footprint but also to enhance patient care through more holistic and environmentally mindful approaches [ 47 ]. Scholars and practitioners alike delve into the study of eco-conscious interventions, ranging from waste reduction and energy efficiency in healthcare facilities to the promotion of green prescribing and the utilization of sustainable medical supplies [ 48 ]. Moreover, research in eco-conscious nursing contributes to a broader understanding of how health professionals can act as pivotal agents of change, advocating for policies and practices that protect the environment while promoting public health and wellbeing [ 49 ]. Through this lens, eco-conscious nursing research is not just about identifying and implementing green practices but also about reimagining the role of healthcare in fostering a sustainable future [ 50 ]. This aligns with the defining attribute of collaboration and leadership, where nurses work alongside other professionals to develop and implement sustainable healthcare solutions.

Eco-conscious nursing, therefore, is not merely about adopting green practices but represents a comprehensive approach to healthcare that prioritizes environmental stewardship as essential to health and wellbeing [ 51 ]. Its applications span the spectrum of nursing activities, from direct patient care to community engagement, education, and research, highlighting the profession’s integral role in advancing sustainable healthcare solutions [ 52 ].

The defining attributes of eco-conscious nursing—sustainability integration, environmental advocacy, holistic patient care, professional development and education, and collaboration and leadership—are inherently linked to the uses of the concept in various healthcare contexts. These attributes collectively frame eco-conscious nursing as a proactive and engaged approach to nursing, seeking to mitigate environmental harm while promoting a sustainable and healthy future for individuals and communities alike.

Defining attributes

Defining attributes are essential characteristics that frequently emerge in the literature and are consistently present when a concept manifests [ 53 , 54 ]. This section aims to identify and elaborate on the critical attributes that define “Eco-conscious Nursing,” underscoring the inherent qualities necessary for this concept’s realization within the nursing and broader healthcare context. Eco-conscious nursing, as illuminated through extensive literature review and conceptual analysis, is characterized by a set of attributes that collectively distinguish it from traditional nursing practices, emphasizing a deliberate focus on sustainability and environmental health.

Sustainability Integration : This attribute involves incorporating sustainability principles into all aspects of nursing care. Eco-conscious nurses actively seek to minimize environmental impact through practices such as waste reduction, energy conservation, and sustainable resource management. This integration requires a conscious effort to balance patient care excellence with environmental stewardship [ 55 ].

Environmental Advocacy : Eco-conscious nurses serve as advocates for environmental health within healthcare settings and the wider community. This attribute encompasses raising awareness about environmental determinants of health, advocating for policies that support sustainable healthcare environments, and engaging in community outreach to promote public understanding of environmental health issues [ 56 ].

Holistic Patient Care : This attribute reflects a commitment to a comprehensive approach to patient care that includes environmental factors affecting health. Eco-conscious nurses develop care plans considering the physical, psychological, social, and environmental aspects of patient well-being, recognizing the interconnection between human health and the environment [ 57 ].

Professional Development and Education : Eco-conscious nurses are committed to continuous learning and professional development related to environmental health and sustainability in healthcare. This attribute includes pursuing education and training opportunities that enhance the ability to incorporate eco-conscious principles into nursing practice and disseminating knowledge about sustainable practices to peers, patients, and the community [ 58 , 59 ].

Collaboration and Leadership Eco-conscious nursing necessitates collaborative efforts across disciplines and the assumption of leadership roles in initiating and guiding sustainability efforts within healthcare settings. Nurses with this attribute work alongside healthcare professionals, environmental experts, and organizational leaders to develop and implement strategies that reduce the environmental footprint of healthcare operations. [ 60 ].

These defining attributes of eco-conscious nursing—sustainability integration, environmental advocacy, holistic patient care, professional development and education, and collaboration and leadership—collectively frame a nursing practice that is attuned to the environmental impacts of healthcare. They underscore a proactive and engaged approach to nursing that seeks not only to mitigate harm but also to promote a sustainable and healthy future for individuals and communities alike. Through the embodiment of these attributes, eco-conscious nurses play a pivotal role in steering the healthcare sector towards more sustainable and environmentally responsible practices.

Pioneering interventions in other countries

Several countries have spearheaded innovative interventions in eco-conscious nursing, setting exemplary standards for integrating sustainability into healthcare. In Sweden, healthcare facilities have widely adopted energy-efficient lighting and HVAC systems, significantly reducing their carbon footprint. The Swedish approach also includes comprehensive recycling programs and the use of biodegradable medical supplies, showcasing a holistic commitment to environmental sustainability [ 61 ]. Similarly, in Australia, hospitals have embraced green building designs that maximize natural light and ventilation, thus cutting down on energy consumption. Initiatives like “Green Health Partnerships” in Australia further promote sustainable practices by educating healthcare professionals and encouraging eco-friendly behaviors within hospitals [ 62 ].

In the Netherlands, healthcare institutions have made substantial progress through the implementation of green procurement policies, ensuring that medical supplies and equipment are sustainably sourced [ 63 ]. Dutch hospitals also lead in innovative waste management practices, which include the safe disposal and recycling of medical waste. These interventions not only mitigate environmental harm but also foster a culture of sustainability within healthcare settings, positioning these countries as pioneers in eco-conscious nursing [ 64 ].

Concrete research lines

Future research should delve into the impact of eco-conscious nursing on patient outcomes. This includes investigating how sustainable practices influence recovery times, mental health, and overall well-being of patients. Such studies can provide empirical evidence on the benefits of integrating eco-friendly practices in nursing, potentially leading to improved patient care and satisfaction. Another crucial research line involves exploring the economic benefits of sustainable healthcare practices [ 65 ]. By analyzing cost savings from reduced energy consumption, efficient waste management, and sustainable procurement, researchers can make a compelling case for the financial viability of eco-conscious nursing.

Additionally, cross-cultural adaptation of eco-conscious nursing practices warrants further investigation. Research should focus on how these practices can be tailored to different cultural contexts to ensure their effectiveness and cultural sensitivity [ 66 ]. This can help in developing universally applicable guidelines that respect cultural differences while promoting sustainability. Lastly, the role of policy in advancing eco-conscious nursing practices should be explored. Evaluating existing policies and developing new frameworks can provide insights into the best practices for integrating sustainability into healthcare governance. This includes assessing the impact of policy-driven initiatives on the adoption of eco-conscious practices in various healthcare settings.

Antecedents and consequences

The exploration of antecedents and consequences is crucial for a comprehensive understanding of “Eco-conscious Nursing,” as it illuminates the factors that foster its emergence and the outcomes that follow its implementation. This analysis aids in delineating the underlying conditions conducive to eco-conscious nursing practices and their subsequent impacts on healthcare and environmental sustainability [ 67 ].

Antecedents of eco-conscious

Nursing Antecedents to eco-conscious nursing are the pre-existing conditions or factors that must be present for the concept to manifest within the healthcare setting. These foundational elements provide the necessary groundwork for the development and recognition of eco-conscious nursing practices [ 68 ].

Environmental Awareness and Education : A foundational awareness of environmental issues and a solid educational background in sustainable practices are critical antecedents. Nurses informed about the environmental impact of healthcare operations are better equipped to initiate and participate in sustainable practices [ 69 ].

Institutional Policies and Support : Healthcare institutions that prioritize environmental sustainability and support eco-conscious initiatives create a conducive environment for these practices. This support may include providing resources for sustainability projects, implementing green policies, and fostering a culture that values environmental stewardship [ 65 ].

Interdisciplinary Collaboration : Collaboration across disciplines is essential for integrating eco-conscious practices into nursing. The synergy between nursing, environmental science, and other healthcare disciplines enhances the development and implementation of sustainable healthcare solutions [ 70 ].

Consequences of eco-conscious nursing

The consequences of eco-conscious nursing refer to the outcomes or effects that arise from the application of sustainability principles within the nursing profession [ 53 ]. These effects underscore the impact of eco-conscious nursing on healthcare quality, environmental sustainability, and societal well-being.

Improved Environmental Health Outcomes : Eco-conscious nursing practices can lead to significant improvements in environmental health. By reducing waste, minimizing the use of harmful substances, and conserving resources, nursing practices can directly contribute to reducing the ecological footprint of healthcare facilities [ 71 ].

Enhanced Patient and Community Well-being : Sustainable healthcare practices not only have a positive impact on the environment but also on patient and community health. For example, reducing the use of toxic materials in healthcare settings can decrease exposure to harmful chemicals, benefiting both patients and healthcare workers [ 72 ].

Economic Efficiency : Implementing eco-conscious practices can result in economic benefits for healthcare institutions. Efficient resource use and waste reduction can lead to cost savings, while sustainable investments can improve long-term financial stability [ 15 ].

Specific intervention programs , their economic impacts , and potential challenges and strengths faced by professionals.

Specific Intervention Programs : Examples of specific intervention programs include the adoption of energy-saving measures such as the utilization of energy-efficient lighting and HVAC systems, which significantly reduce the carbon footprint of healthcare facilities. Another example is the implementation of comprehensive waste management programs that emphasize recycling, proper segregation of waste, and the use of biodegradable products.

Economic Impacts : The economic impacts of these interventions can be substantial. Energy-efficient practices and sustainable waste management can lead to significant cost savings for healthcare facilities. These savings can be reinvested into further sustainability initiatives or other areas of patient care, creating a positive feedback loop that promotes continuous improvement.

Challenges and Strengths : Challenges in implementing these programs often include a lack of awareness, insufficient training in sustainable practices, and entrenched systemic obstacles. However, strengths such as strong institutional support, interdisciplinary collaboration, and ongoing professional development can help overcome these challenges.

These antecedents and consequences collectively frame eco-conscious nursing as a pivotal element in advancing sustainable healthcare. By understanding the conditions that facilitate eco-conscious nursing and recognizing its beneficial outcomes, healthcare professionals and institutions can better integrate these practices into their operations. This integration not only aligns with global sustainability goals but also promotes a holistic approach to health that encompasses both human and environmental well-being.

Empirical referents

Defining empirical referents for the concept of “Eco-conscious Nursing” entails identifying measurable indicators or observable phenomena that embody this concept [ 73 ]. Empirical referents are crucial for operationalizing “Eco-conscious Nursing,” offering a tangible means to evaluate its manifestation and efficacy within healthcare settings [ 74 ]. By delineating these referents, researchers and practitioners can objectively measure and assess the presence, implementation, and impact of eco-conscious practices in nursing, facilitating a clearer understanding and fostering the integration of these practices into routine nursing care. The empirical referents for Eco-conscious Nursing might include:

Sustainable Waste Management practices:

Description : Sustainable waste management practices include the adoption and effectiveness of waste reduction strategies within healthcare facilities. This can be measured by reductions in medical waste production, increases in recycling rates, and the proper segregation and disposal of hazardous materials.

Relation to Eco-Conscious Nursing : These practices are integral to eco-conscious nursing as they reflect a commitment to minimizing the environmental impact of healthcare operations. Nurses play a crucial role in implementing and advocating for sustainable waste management practices, ensuring that clinical waste is handled in an environmentally responsible manner.

Energy Efficiency measures:

Description : Energy efficiency measures refer to the incorporation of strategies and technologies that reduce energy consumption in healthcare settings. This can include the use of energy-efficient lighting, heating, ventilation, and air conditioning (HVAC) systems, as well as the adoption of renewable energy sources.

Relation to Eco-Conscious Nursing : Energy efficiency is a core component of eco-conscious nursing. Nurses contribute to energy-saving efforts by adopting practices that reduce energy use and by promoting the use of energy-efficient technologies. This not only reduces the environmental footprint of healthcare facilities but also demonstrates the nursing profession’s commitment to sustainability.

Water Conservation efforts:

Description : Water conservation efforts involve implementing methods to reduce water usage in healthcare operations. This can be assessed by measuring reductions in water consumption, employing water-saving technologies, and promoting water conservation practices among staff and patients.

Relation to Eco-Conscious Nursing : Water conservation is another key aspect of eco-conscious nursing. Nurses can lead initiatives to conserve water in clinical settings, thereby reducing the overall environmental impact and supporting broader sustainability goals.

Green procurement policies:

Description : Green procurement policies refer to the adoption of purchasing practices that prioritize eco-friendly products and services. This includes the use of biodegradable disposables, non-toxic cleaning supplies, and sustainably sourced materials.

Relation to Eco-Conscious Nursing : Green procurement is essential for eco-conscious nursing as it ensures that the materials and products used in patient care are environmentally sustainable. Nurses can advocate for and implement green procurement policies to promote sustainability within their healthcare institutions.

Nurse-led sustainability initiatives:

Description : The degree to which nurses lead and participate in sustainability initiatives can be an empirical referent. This involvement can be measured by the number and scope of nurse-driven projects aimed at enhancing environmental sustainability, such as educational programs, policy development for reducing carbon footprints, and advocacy for sustainable healthcare practices.

Relation to Eco-Conscious Nursing : Nurse-led initiatives are a direct manifestation of eco-conscious nursing. These projects reflect the proactive role of nurses in promoting environmental health and sustainability, showcasing their leadership and commitment to integrating eco-conscious principles into healthcare practice.

Our analysis suggests that two concepts - sustainable waste management and energy efficiency - are particularly pivotal. These areas not only underscore the practical application of eco-conscious nursing but also highlight its potential to significantly reduce the environmental impact of healthcare operations. Emphasizing these empirical referents enhances the visibility and viability of eco-conscious nursing practices, encouraging their widespread adoption and leading to improved environmental outcomes as well as enhanced patient care and nursing satisfaction.

A model case exemplifies a scenario that fully encapsulates all the defining attributes of the concept being analyzed [ 53 ]. It serves as an ideal example, illustrating how the concept of eco-conscious nursing can manifest in a real-world setting. In this instance, we will construct a model case to showcase a scenario that encompasses the defining attributes of eco-conscious nursing:

Jasmine represents an exemplary figure in the nursing field, embodying the principles of eco-conscious nursing within a large healthcare facility. Her journey in nursing has been marked by a steadfast commitment to integrating environmental sustainability into healthcare practices. Jasmine has pursued additional certifications in environmental health and sustainability, showcasing her dedication to eco-conscious principles. As a leader in her facility, she has spearheaded initiatives aimed at reducing waste, conserving energy, and promoting sustainable resource use in patient care practices.

In her role, Jasmine exercises a significant level of professional autonomy and authority, allowing her to implement innovative eco-friendly practices. She has been instrumental in transitioning her department to the use of biodegradable materials and ensuring the adoption of energy-efficient medical devices. Her efforts have not only reduced the environmental impact of her facility but also served as a cost-saving measure, showcasing the dual benefits of eco-conscious nursing practices.

Jasmine’s influence extends beyond her immediate responsibilities. She is an active member of the hospital’s sustainability committee, where she collaborates with other healthcare professionals to develop hospital-wide policies that enhance environmental sustainability. Her contributions are highly valued, and she plays a critical role in decision-making processes related to sustainability initiatives. Through her leadership, Jasmine has fostered a culture of eco-consciousness within her team, encouraging continuous education on environmental health issues and sustainable practices.

Moreover, Jasmine leverages her access to resources and information to stay abreast of the latest developments in sustainable healthcare. She regularly attends workshops and seminars on environmental sustainability and shares this knowledge with her colleagues, enhancing their capacity to contribute to eco-friendly initiatives. Her commitment to professional development in the realm of eco-conscious nursing is evident in her advocacy for incorporating sustainability principles into nursing curricula and continuing education programs.

As a respected figure in her healthcare facility and the broader nursing community, Jasmine has garnered recognition for her pioneering work in eco-conscious nursing. She serves as a role model and mentor to aspiring nurses interested in sustainability, exemplifying how dedication to eco-conscious principles can lead to meaningful changes in healthcare practices. Her case embodies the essence of eco-conscious nursing, illustrating the profound impact that nurses can have on promoting environmental sustainability in healthcare settings. Jasmine’s story is a testament to the power of nursing professionals to effect change, not only in patient care but also in leading the way towards a more sustainable future in healthcare.

Borderline case

Borderline cases exemplify scenarios that demonstrate some, but not all, attributes of eco-conscious nursing practices [ 75 ]. These instances help refine and delineate the concept by showcasing examples that are on the fringe or exhibit only partial aspects of eco-consciousness in nursing. The following outlines a borderline case:

Max is a nurse in a suburban community hospital striving to incorporate eco-conscious practices into his daily routines. While he lacks the authority to implement wide-scale environmental policies or access to a broad array of eco-friendly supplies, he demonstrates a commitment to sustainability within his scope of influence. Max advocates for reducing single-use plastic usage in his department by encouraging the use of reusable alternatives where possible and consistently educates his patients and colleagues about the environmental impacts of healthcare waste. However, the hospital’s limited budget for sustainability initiatives and the absence of a formal eco-conscious framework hinder his ability to fully integrate comprehensive green practices into patient care and departmental operations.

In this borderline case, Max exhibits key attributes of eco-conscious nursing, such as a commitment to sustainability and proactive engagement in eco-friendly practices. However, he encounters significant constraints, including limited institutional support and resources, which curtail the full expression of eco-conscious nursing as defined by broader, systemic changes and adoption of sustainability measures. Despite these challenges, Max’s efforts to incorporate environmental considerations into his nursing practice underscore the nuanced manifestations of eco-conscious nursing. His case illustrates that while individual actions are valuable, the realization of eco-conscious nursing on a larger scale requires structural support and resources.

This borderline scenario emphasizes the complexity of eco-conscious nursing, showcasing how nurses can embody the spirit of sustainability even when systemic barriers exist. It highlights the need for healthcare institutions to provide support and resources that enable nurses like Max to fully engage in eco-conscious practices. Examining cases like Max’s broadens our understanding of eco-conscious nursing, acknowledging the spectrum of its application and the varied contexts in which it can occur. It also points to the importance of institutional policies and support in facilitating the transition towards more sustainable healthcare practices.

Contrary case

A contrary case for the concept of eco-conscious nursing illustrates a scenario that starkly contrasts with the core attributes of eco-conscious practices in nursing [ 73 ]. Such a case helps delineate the concept’s boundaries and clarifies what it does not encompass. For instance, consider the situation of Maya, a nurse working in a healthcare setting that places minimal emphasis on environmental sustainability. Despite awareness of the environmental impact of healthcare waste and energy use, the facility where Maya works lacks recycling programs, continues to use single-use disposable materials extensively, and has no initiatives in place to reduce energy consumption. Maya herself does not prioritize or engage in sustainable practices, either due to a lack of knowledge, interest, or support from her workplace. She rarely considers the environmental impact of her actions or the healthcare services provided, focusing solely on immediate patient care needs without regard to long-term environmental consequences.

In this contrary case, Maya’s disengagement from eco-conscious practices and her workplace’s indifference to sustainability starkly oppose the defining characteristics of eco-conscious nursing. The absence of initiative to minimize environmental impact, along with a lack of policies supporting sustainability, reflects a complete negation of eco-conscious principles. Furthermore, Maya’s lack of involvement in and advocacy for sustainable practices contrasts sharply with the proactive and committed stance integral to eco-conscious nursing. This scenario underscores the absence of awareness, motivation, and institutional support as key barriers to embedding eco-consciousness in nursing practice.

Examining Maya’s case sheds light on the importance of individual and organizational commitment to environmental sustainability in healthcare. It highlights how the absence of eco-conscious principles in nursing can lead to missed opportunities for reducing healthcare’s environmental footprint and promoting a healthier planet. Moreover, this case serves as a reminder of the need for education, policy development, and leadership in fostering eco-conscious nursing practices. By understanding what eco-conscious nursing is not, through the lens of this contrary case, the distinct and essential features of the concept become more pronounced, guiding efforts to integrate sustainability more deeply into the nursing profession and healthcare at large.

This study endeavors to unravel the concept of “Eco-conscious Nursing,” by delineating its key attributes, antecedents, and consequences. Our primary goal is to establish an operational definition that is both pertinent and resonant across the myriad settings where eco-conscious nursing finds relevance. Through a detailed analysis, we aim to uncover the nuanced layers of eco-conscious nursing and its broad implications within the healthcare landscape. Central to our discussion is the recognition of eco-conscious nursing as a fluid and evolving construct, shaped by factors such as environmental awareness, sustainable healthcare practices, and the integration of green principles into nursing care. This adaptability underscores the necessity for a sophisticated grasp of the concept, encouraging its integration into academic debates and practical healthcare applications alike. The proposed operational definitions are crafted with contextual versatility in mind, presenting adaptable insights for both scholarly and practical environments.

In our quest to define “Eco-conscious Nursing” through its attributes, antecedents, and consequences, it’s vital to formulate a precise operational definition. This definition encapsulates the core characteristics, precursors, and impacts of eco-conscious nursing, enhancing the concept’s clarity and application.

Comprehensive operational definition of Eco-conscious Nursing Eco-conscious Nursing is identified as a professional ethos within healthcare, characterized by a commitment to environmental sustainability and the application of eco-friendly practices in nursing care. This ethos empowers nurses with the knowledge and practices necessary for minimizing environmental impact, fostering a culture of sustainability within healthcare settings. Antecedents include a foundational understanding of environmental health and sustainability principles, while consequences manifest as enhanced patient and community health outcomes, alongside reduced ecological footprints of healthcare practices.

Given the intricate and multi-faceted nature of “Eco-conscious Nursing,” we have expanded the operational definition to encapsulate critical components that imbue the concept with its significance and applicability in both academic and operational spheres. We identified two crucial dimensions: environmental stewardship, as reflected in the stewardship-centric operational definition, and sustainable practice, highlighted in the practice-focused operational definition. Thus, in addition to the comprehensive definition, we present two more operational definitions tailored to the specific scope and context of eco-conscious nursing’s application.

Stewardship-centric operational definition Eco-conscious Nursing represents a professional stance wherein nurses champion environmental stewardship, advocating for and implementing sustainable practices within healthcare. It involves the authority to influence healthcare policies and practices towards sustainability, autonomy in integrating eco-friendly practices, and gaining respect for such initiatives. Antecedents are rooted in a strong educational foundation in environmental health, leading to outcomes that significantly improve the sustainability of healthcare services and patient care through efficient resource use and sustainable practices.

Practice-focused operational definition Eco-conscious Nursing signifies a professional approach characterized by the practical implementation of sustainable healthcare practices. It grants nurses the autonomy to apply eco-friendly practices, access to sustainable resources, and the authority to influence patient care and operational policies. Founded on a robust educational background in sustainability and environmental health, its consequences include heightened professional satisfaction and an uplifted standard of care that aligns with environmental sustainability goals. This definition emphasizes the importance of practical, sustainable actions and decision-making in nursing, marking a shift towards more environmentally responsible healthcare practices.

These operational definitions reflect the depth and breadth of eco-conscious nursing, emphasizing its pivotal role in advancing sustainable healthcare practices. They serve not only as a conceptual framework for further academic exploration but also as a practical guide for integrating sustainability into nursing practice, ultimately leading to a healthcare system that is both ethically responsible and environmentally sustainable.

Future implications

The exploration and conceptual analysis of “Eco-conscious Nursing” set forth in this study open several avenues for future research, practice development, and policy formulation, each holding significant potential to advance the integration of sustainability within the nursing profession and the broader healthcare sector. The implications of this study extend into various dimensions, including educational curricula, clinical practice, healthcare policy, and global health initiatives, underlining the pivotal role of nursing in spearheading sustainable healthcare solutions.

Educational curricula

Integrating eco-conscious principles into nursing education is essential for preparing future nurses to engage in sustainable practices. Nursing programs should incorporate environmental sustainability as a core competency, equipping students with the knowledge and skills to implement eco-friendly practices in their professional roles. This shift in educational focus will ensure that upcoming nurses are well-prepared to lead the transition toward more sustainable healthcare systems.

Clinical practice

The practical applications of eco-conscious nursing in various healthcare settings highlight a roadmap for integrating sustainable practices into daily nursing care. Future research should explore innovative strategies for reducing waste, conserving energy, and promoting eco-friendly patient care practices. Developing best practice guidelines based on the findings of this study can facilitate the widespread adoption of eco-conscious practices, enhancing the environmental sustainability of healthcare operations.

Healthcare policy

The conceptual analysis presented here lays a foundation for advocating policy changes at institutional, national, and international levels. Policymakers should consider the operational definitions and frameworks proposed in this study to craft legislation and regulations that support sustainable healthcare practices. Policies that incentivize eco-friendly initiatives and embed environmental stewardship into healthcare governance will be crucial for promoting eco-conscious nursing.

Global health initiatives

The study’s findings align with global health priorities such as the United Nations Sustainable Development Goals (SDGs). Leveraging the concept of eco-conscious nursing to address global health challenges emphasizes the role of nurses in implementing sustainable health interventions. Collaborative international research and cross-sector partnerships can further elucidate the global impact of eco-conscious nursing practices, contributing to a healthier planet and populations.

Innovation and leadership

The future of eco-conscious nursing requires innovation in practice and leadership in sustainability initiatives. Nurses equipped with the insights from this study are poised to take leadership roles in sustainability efforts within healthcare settings. Future research should focus on identifying and overcoming barriers to implementing eco-conscious practices, developing leadership programs for nurses in environmental health, and fostering a culture of innovation that encourages sustainable healthcare solutions.

In conclusion, the implications of this study are far-reaching, offering a blueprint for integrating eco-conscious principles into the nursing profession and healthcare at large. By advancing education, practice, policy, and global health initiatives focused on sustainability, the nursing profession can significantly contribute to the creation of a more sustainable and health-focused future.

Limitations

This study, while pioneering in its effort to elucidate the concept of Eco-conscious Nursing, encounters several limitations that merit consideration. First and foremost, the scope of literature reviewed may not encompass all existing material pertinent to eco-conscious nursing practices. Despite a rigorous and systematic approach to the literature search, the possibility remains that certain relevant studies, particularly those published in languages other than English or in less accessible journals, were not included. This limitation could potentially narrow the breadth of perspectives and evidence integrated into our analysis.

Furthermore, the conceptual analysis method, while robust in its ability to dissect and clarify complex concepts, relies heavily on the subjective interpretation of the researchers. This subjectivity may influence the selection of attributes, antecedents, and consequences deemed significant to the operational definitions of eco-conscious nursing. Although efforts were made to mitigate bias through methodical analysis and peer consultation, inherent subjectivity cannot be entirely eliminated.

This concept analysis of Eco-conscious Nursing provides a foundational understanding of integrating environmental sustainability principles into nursing practice. By delineating key attributes, antecedents, and consequences, this study underscores the critical role of nurses in promoting sustainable healthcare practices. Eco-conscious nursing is characterized by sustainability integration, environmental advocacy, holistic patient care, professional development, and collaboration. These attributes collectively frame a nursing practice that addresses the environmental impacts of healthcare, positioning nurses as essential agents of change.

Global health priorities and SDGs

The findings resonate with global health priorities, particularly the United Nations Sustainable Development Goals (SDGs). Eco-conscious nursing aligns with SDG 3 (Good Health and Well-being), SDG 6 (Clean Water and Sanitation), SDG 7 (Affordable and Clean Energy), SDG 12 (Responsible Consumption and Production), and SDG 13 (Climate Action). By promoting environmentally sustainable practices, nurses contribute to better health outcomes, responsible resource management, and climate change mitigation.

Future directions

This study lays the groundwork for future research on the empirical application of eco-conscious nursing practices, exploring their economic and cross-cultural dimensions. Developing best practice guidelines and policy frameworks will facilitate the widespread adoption of eco-conscious nursing, ensuring sustainability becomes integral to healthcare delivery.

In conclusion, integrating eco-conscious principles into nursing aligns with global sustainability goals and empowers nurses to lead towards a more sustainable and ethically responsible healthcare system. As the concept of eco-conscious nursing evolves, it holds the potential to significantly impact the healthcare sector and the broader global community, fostering a healthier and more sustainable future for all.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Appreciation is given to all faculty members of the Department of Rheumatology and Rehabilitation, School of Medicine, Qasr Al-Ainy, Cairo University for their help to conduct this research., and special thanks to Dr.Reem Hamdy: Professor of Immunology, Rheumatology, and Rehabilitation, Qasr Al-Ainy Faculty of Medicine, for her valuable guidance and support.

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Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Faculty of Nursing, Cairo University, Cairo, Egypt

Marwa Mamdouh Shaban, Hla Hosny Elsayed, Mohammed ElSayed Zaky & Osama Elsayed Mohammed Ramadan

College of Nursing, Jouf University, Sakaka, Saudi Arabia

Majed Awad Alanazi & Mostafa Shaban

PhD Candidate- Faculty of Nursing- Cairo University, Cairo, Egypt

Huda Hamdy Mohammed

Faculty of Nursing, Ain Shams University, Cairo, Egypt

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MS conceptualized the study and led the methodology, design, and manuscript drafting and revisions. MAA and HHM contributed to literature search and analysis, with MAA also assisting in conceptual framework development. FGMA focused on reviewing literature related to sustainable healthcare practices. HHE, MEZ, OEMR, and MMA were instrumental in data collection, analysis, and drafting relevant sections of the manuscript. MMS coordinated the research activities, contributed to the manuscript drafting, and provided critical revisions. All authors read and approved the final manuscript, ensuring the integrity and accuracy of the work presented.

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Shaban, M.M., Alanazi, M.A., Mohammed, H.H. et al. Advancing sustainable healthcare: a concept analysis of eco-conscious nursing practices. BMC Nurs 23 , 660 (2024). https://doi.org/10.1186/s12912-024-02197-0

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Use of Creative Drama to Facilitate the Questioning of Sexual Expression by Nursing Students: A Qualitative Study

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• Published: 18 September 2024

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• Elanur Uludağ   ORCID: orcid.org/0000-0001-5448-5427 1 ,
• Özlem Albayrak   ORCID: orcid.org/0000-0002-9167-307X 2 &
• Mağfiret Kaşıkçı   ORCID: orcid.org/0000-0001-5136-462X 3  

To prepare future nurses in their providing of holistic care to patients, creative drama activities involving hands-on learning and experiential exercises are important in developing requisite skills. The aim of this study is to determine the effectiveness of education based on creative drama among nursing students, specifically in relation to facilitating discussions as to the expression of sexuality—an important aspect of patient care. A qualitative descriptive research design was employed in this study, therein utilizing semi-structured interviews as the data collection method. The dataset is comprised of field notes from interviews conducted with 16 students. Thematic analysis was employed to analyze the data and MAXQDA analysis software was used for data organization purposes. Five themes and twenty-one codes were identified. The themes which emerged from the data are; (1) the difficulties faced in questioning expressions of sexuality, (2) the factors which affect sexual care, (3) the feelings experienced by student nurses when taking patient histories, (4) the inclusion of creative drama in nursing education and (5) the perceptions held among student nurses towards the creative drama method. The 21 codes which emerged included cultural and social structures, the perception of sexuality as a private matter, gender discrimination, societal knowledge gaps, age-related concerns, patient hesitation, personal comfort when discussing sexuality, the encountering of negative reactions from patients, the ability to communicate comfortably, the comprehensive fulfilment of the caregiving role and the students' feelings of shame or boredom. Providing education as to the expression of sexuality, accompanied by creative drama activities, shall enable students to address and explore this challenging area and to provide holistic care.

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Acknowledgements

We would like to thank all of the nursing students who participated in this study.

To complete the present study, no financial support was received from any institution or organization.

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Department of Nursing, Erzurum Technical University Faculty of Health Sciences, Erzurum, Turkey

Elanur Uludağ

Department of Nursing, Recep Tayyip Erdoğan University Faculty of Health Sciences, Rıze, Turkey

Özlem Albayrak

Department of Nursing, Ataturk University Faculty of Nursing, Erzurum, Turkey

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Uludağ, E., Albayrak, Ö. & Kaşıkçı, M. Use of Creative Drama to Facilitate the Questioning of Sexual Expression by Nursing Students: A Qualitative Study. Sex Disabil (2024). https://doi.org/10.1007/s11195-024-09871-w

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DOI : https://doi.org/10.1007/s11195-024-09871-w

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The use of bibliometrics in nursing science: Topics, data sources and contributions to research and practice

Affiliations.

• 1 Departament de Ciències Bàsiques, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain.
• 2 Departament d'Infermeria, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain.
• 3 Facultat d'Informació i Mitjans Audiovisuals, Universitat de Barcelona, Barcelona, Spain.
• PMID: 39279488
• PMCID: PMC11403276
• DOI: 10.1002/nop2.70036

Aim: To describe the use of bibliometrics in nursing and assess their contribution to research and practice.

Design: A content analysis was conducted of topics, data sources and applications of bibliometrics in nursing research articles.

Methods: The study universe included 129 bibliometric articles on nursing retrieved from Scopus. A content analysis was performed to identify the purposes and topics of the articles, the sources employed to collect the data, the time frames covered, the amounts of records surveyed, and the features of the nursing literature analysed in bibliometric papers.

Results: Nursing bibliometric research revolves around six key areas: global descriptions of the nursing literature, literature on specific nursing research topics, nursing education, nursing profession, nursing research using a certain framework or method, and nursing literature published in a country or region. Studies rely on three types of sources to retrieve the surveyed literature: bibliographic databases, sets of disciplinary journals and samples of documents. Bibliometrics can be employed to advance nursing research (identification of research gaps, establishment of research agendas, assessment of methodological approaches, etc.) and practice (identification of professional competences, categorisation of professional tasks, recognition of educational improvements, etc.), suggesting new avenues for researchers who aim to conduct further bibliometric research in the field. Further research is needed to assess the coverage of the nursing literature by new bibliographic data sources and to explore unaddressed topics such as gender imbalance in authorship.

Keywords: bibliographic databases; bibliometrics; citation analysis; citation indexes; nursing; scholarly journals; scholarly literature.

© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.

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Topics of nursing bibliometric research.

Types of analyses in nursing…

Types of analyses in nursing bibliometric research.

• Alcalá‐Albert, G. J. , & Parra‐González, M. E. (2021). Bibliometric analysis of scientific production on nursing research in the web of science. Educational Sciences, 11(9), 455. 10.3390/educsci11090455 - DOI
• Alfonzo, P. M. , Sakraida, T. J. , & Hastings‐Tolsma, M. (2014). Bibliometrics: Visualizing the impact of nursing research. Online Journal of Nursing Informatics, 18(1), 18–33. https://ojni.org/archive.html .
• Borrego, Á. , Ardanuy, J. , & Arguimbau, L. (2023). Crossref as a bibliographic discovery tool in the arts and humanities. Quantitative Science Studies, 4(1), 91–104. 10.1162/qss_a_00240 - DOI
• Borrego, Á. , & Mezquita, B. (2023). Data for "the use of bibliometrics in nursing research: Topics, data sources and applications" [data set]. Zenodo. 10.5281/zenodo.7928599 - DOI
• Cant, R. , Ryan, C. , & Kardong‐Edgren, S. (2022). Virtual simulation studies in nursing education: A bibliometric analysis of the top 100 cited studies. Nurse Education Today, 114, 105385. 10.1016/j.nedt.2022.105385 - DOI - PubMed
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Oral healthcare beliefs among home care services personnel; a cross-sectional study in south-eastern Norway

• Hero Ibrahim Hassan 1 , 2 ,
• V. E. Ansteinsson 1 , 2 ,
• E. T. Dalbak 3 ,
• R. Skudutyte-Rysstad 2 ,
• R. Hellesø 1 ,
• I. Mdala 2 , 4 &
• E. A. Sz. Hovden 2  

BMC Health Services Research volume  24 , Article number:  1090 ( 2024 ) Cite this article

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There is little knowledge about home care services personnel competencies and beliefs concerning oral healthcare for home-dwelling, dependent older adults. This study aims to map oral healthcare beliefs among home care services personnel, and have the following question: How do the education level, years of work experience and training in oral health have impact on home care services personnel oral healthcare beliefs?

A cross-sectional study among home care services personnel working with older people receiving home care services was conducted across four municipalities in south-eastern Norway. The questionnaire consisted of background information (gender, education level, years of work experience, training in oral healthcare, employment status) and the nursing Dental Coping Beliefs scale. Ethics approval for this study was obtained from the Norwegian Centre for Research Data.

Two hundred and sixty-two homecare services personnel responded to the questionnaire, 16.5% males and 83.5% females; 40.5% had had training in oral healthcare. Home care services personnel believed that gum diseases and cavities can be prevented by dental flossing (61.4%) and toothbrushing (98.4%). 59% disagreed that preventing sickness and medicines from destroying teeth is impossible. However, the majority of the home care services personnel were uncertain about how oral mucosal disorders can be treated. Having more than three years of higher education was positively associated with being in higher quartiles of oral healthcare beliefs, and external locus of control, and having training in oral healthcare was positively associated with being in the lower quartiles of internal locus of control and self-efficacy dimensions. Males were more likely to be in the lower quartile of oral healthcare beliefs, which wasn’t positive.

In the population studied, the home care services personnel beliefs about oral healthcare improved with an increasing level of education and having had training in oral healthcare. This suggests that home care services personnel need more education and training in oral healthcare.

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Globally, including in Norway, the population of care-dependent older adults with complex health needs is increasing [ 1 ], and healthcare services are enduring change as a result of demographic changes and changing health needs [ 2 ]. In the coming decades, the demand for health services, such as home care services (HCS), is expected to increase, necessitating an expansion of home care employees’ responsibilities [ 3 ]. Norway like many other countries faces challenges with access to qualified healthcare personnel [ 4 ]. A larger need for qualified personnel in home care services and difficulties in recruiting qualified personnel, HCS has had to use unskilled personnel [ 4 , 5 , 6 ]. In 2020 a proportion of unskilled personnel working in HCS in Norway was almost 19% [ 6 ]. In Norway, the responsibility for providing HCS is delegated to the municipalities [ 7 , 8 ] and is mainly publicly funded. The users of HCS differ in terms of age, diseases, and conditions. All individuals with special assistance need arising from illnesses or disabilities can apply for HCS in the municipality in which they are living or have temporary residency [ 8 , 9 ]. In 2020, nearly 200,000 people were receiving help from HCS in Norway, 59% of whom were adults above the age of 67 years [ 10 ]. Care of older people in Norway is regulated by general legislation [ 9 , 11 ], and many care-dependent older adults are not institutionalized, but rather, they live with supervision at home with assistance from HCS. Home care services personnel (HCS personnel) in Norway offer a range of services, such as somatic and psychiatric care, assistance in daily living, and user-controlled personal assistance, to mention some [ 9 , 12 ]. HCS personnel are also responsible for different tasks such as wound care, administering medication, and daily personal hygiene, including oral healthcare [ 9 , 12 ]. There are several professions with different levels of education working in Norwegian HCS such as registered nurses, social workers, assistant nurses, and those without any formal education [ 6 ]. Among the elderly people still living at home, there are many who are dependent on help for the basic necessities of life.

Today, there is a high proportion of older adult who keep their teeth for life [ 13 , 14 ]. Many of these adults are care-dependent and need help from HCS to manage personal hygiene, including taking care of the oral hygiene [ 9 , 11 ]. Due to impairments in general health such as reduced muscle strength, coordination, or cognitive impairment, these individuals will possibly present some challenges in maintaining daily oral hygiene [ 15 ]. According to the World Health Organization, oral health is a key indicator of overall health, well-being, and quality of life, and most oral diseases share modifiable risk factors with the leading noncommunicable diseases such as: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes. Adequate oral function and absence of oral diseases are necessary to maintain good oral health [ 16 ].

In a study among care-dependent older people in Sweden, Holmen et al. [ 17 ] found that there was a higher proportion of care-dependent elderly that had dental treatment needs compared with healthy older adults. An increasing number of dentate care-dependent elderly with complex needs required HCS personnel with a broader knowledge of oral healthcare [ 18 ]. The public dental health service (PDS) in Norway has an outreach responsibility towards home dwelling elderly receiving service from home care service. According to Norwegian law the DPS are obliged to provide the nursing staff with information which enables them to perform oral healthcare on the elderly [ 19 ]. An interdisciplinary approach and collaboration between these two health services is necessary in order to ensure that employees have sufficient oral health knowledge and that the elderly receive the assistance to which they are entitled [ 20 ]. HCS personnel who are younger and have less work experience have been demonstrated to require more training in oral health to properly assist the dependent elderly with oral health [ 21 ]. Despite positive attitudes toward oral health, earlier studies have revealed a lack of knowledge among HCS personnel working with the elderly [ 22 , 23 ]. Knowledge about oral health of the care-dependent older person, and more focus on oral healthcare education has been noted to be necessary to practice better oral healthcare [ 24 ]. Moreover, in a systematic review, the barriers and facilitators for providing oral healthcare for care-dependent older adults were assessed from different stakeholders’ perspectives, and a lack of knowledge was identified as one of the main barriers to the provision of good oral healthcare [ 25 ].

There is little knowledge about home care services personnels’ oral healthcare beliefs in Norway. Therefore, this study aimed to map the oral healthcare beliefs among home care services personnel in Norway, and has the following question: How does the education level, years of work experience and training in oral health have impact on home care services personnel oral healthcare beliefs?.

Study population

The present study was a cross-sectional study among HCS personnel working with elderly in four municipalities in south-eastern Norway. A total of 893 HCS personnel representing different geographical areas were invited to participate. Both permanent and temporary employees, as well as part-time and full-time employees, were invited to participate.

The questionnaire and description of background variables

The questionnaire consisted of two parts, background information about the HCS personnel and the nursing Dental Coping Beliefs scale (nDCBS) [ 26 ]. Background information about the HCS personnel included gender, education level, years of work experience, and employment status. Employment status was defined as 100% position when working full time per year, whereas 0–50% and 51-99.9% as working part time per year. Education level was recorded in the following categories: no higher education (without any formal nursing education), student (nurse student or assistant nurse student), assistant nurse, social worker, or registered nurse (three years’ tertiary education), and master’s degree or higher. Work experience was categorized as < 5 years, 5–10 years, 11 − 2 0 years, 21–30 years, and > 30 years. Training in oral healthcare was assessed by the question “I received training in how I can help users with their oral healthcare,” with response alternatives (yes/no). The term users in this question refers to all users of HCS. If respondents answered “yes” to receiving training, an additional question about “where did you receive the training in oral healthcare?” was asked.

Nursing Dental Coping Beliefs scale (nDCBS)

The nDCBS was used to assess oral healthcare beliefs among HCS personnel working with older people in HCS. The DCBS was developed in the United States [ 27 , 28 ] and was built on three behavioral psychology models: the Cognitive Behavioral model, Locus of Control, and Self-efficacy. A modified scale was later developed in 2005, which reduced the number of items to 28, and it is called the nursing DCBS [ 26 ].

The nDCBS we used consists of four dimensions: oral healthcare beliefs (OHCB), external locus of control (EL), internal locus of control (IL), and self-efficacy (SE). Seven items comprised each dimension. The responses were recorded with a five-point Likert scale, from 1 (“strongly agree”) to 5 (“strongly disagree”). For each dimension, it was possible to have a minimum sum score of 7 points and a maximum sum score of 35 points.

The Norwegian version of the nDCBS used in this study was first tested in 2020 in a pilot study conducted in Eastern Norway [ 29 ]. We followed the guidelines for translation of the questionnaire from Swedish to Norwegian using two independent translators with Norwegian as their first language [ 30 ]. The two translations were then compared and retranslated back to Swedish by two other translators with Swedish as their first language. After a minor linguistic adjustment, that questionnaire was used in this study.

Nettskjema, a software developed and operated by the University of Oslo, was used for designing the electronic questionnaire for data collection. The questionnaire was distributed by leaders of HCS in the four municipalities, who forwarded an Internet link to all employees. One reminder was sent to all leaders of HCS in the respective municipalities after two weeks. Because of a low response rate to the electronic questionnaire, additional data collection was conducted using paper questionnaires distributed at HCS staff meetings. The purpose of the survey was explained to the participants verbally and in writing, but they didn’t get explanation of each question. Participation was voluntary, and written consent was obtained before the questionnaire was completed. The responses were anonymous.

Statistical methods

Descriptive statistics in the form of frequency and percentage distributions were used to describe categorical variables. Education level was trichotomized into “no higher education” (unskilled / without any formal education), “< 3 years of higher education” (assistant nurse and students), and “≥ 3 years of higher education” (social worker, registered nurse, master’s degree or higher). The employment state was trichotomized into 0–50%, 51–99.9% and 100%. Years of work experience were trichotomized into < 5 years, 5–10 years, and ≥ 11 years of work experience.

The items in the nDCBS were grouped into four dimensions: Oral health care beliefs, External locus of control, Internal locus of control, and Self-efficacy, each with seven items. Sums of scores were obtained for each dimension, where high sum scores for the Oral health care beliefs and External locus of control dimensions indicated positive oral healthcare beliefs; for dimensions Internal locus of control and Self-efficacy, positive oral healthcare beliefs were indicated by low sum scores. The sums of scores were then divided into quartiles, with Q3 and Q4 representing high sum scores (positive beliefs for external locus of control and Oral healthcare beliefs), and Q1and Q2 representing low sum scores (positive beliefs for internal locus of control and Self-efficacy dimensions).

Proportions (%) with 95% confidence intervals (CI) were used to describe the distribution of participants’ background variables in each quartile. Differences across the quartiles were established from tests for trends of proportions in statistics software R.

The quartiles have a natural ordering, hence we tried to fit an ordered logistic regression to identify factors associated with being in different quartiles of each construct. However, the assumption of proportionality between the quartiles was violated for some independent variables. Therefore, we fitted generalized partial ordered logistic regression models using the Stata user command gologit2 (Stata Corp LLC version 17, College Station, Texas, USA). We obtained three equal proportional odds ratio (OR) estimates for variables that satisfied the proportionality assumption, whereas different OR estimates were obtained for variables that violated the proportionality assumption.

The adjusted generalized ordered logistic regression analyses were purposefully fitted to the data based on independent variables with P ≤ 0.20 in the unadjusted models. We also fitted models based on independent variables with P  < 0.05 from the univariate analyses and used the Bayesian information criterion (BIC) to select the best model. The BIC states that the model with the smallest BIC among nested models is considered a better fit. The analyses were performed using Stata SE version 17, and statistical software R-4.2.1. The statistical significance level was set at a = 0.05.

Characteristics of the study participants

Two hundred and sixty-two HCS personnel responded to the questionnaire (response rate, 29.3%). The majority were female (83.5%), and 9.2% were with no higher education, 44.8% were HCS personnel with ≥ 3 years of higher education. More than half (59.5%) stated that they did not receive any training in oral healthcare. Not all participants answered the questions about where they got training in oral healthcare, but most of them (42) who received training in oral healthcare stated that training was given under education; 30 HCS personnel stated that they received training from the HCS, and 26 from the Public Dental Services (PDS). There were 171 (65.2%) who had 10 years or less of work experience, and more than half of the participants were employed in 100% positions. All background characteristics are shown in Table  1 .

Nursing dental coping beliefs scale

Table  2 shows the frequency distribution of responses in different dimensions of the nDCBS, and the results from Cronbach’s alpha (0.6038–6438) for each dimension. The frequency distribution of participants in each quartile are represented in the appendix (Table S1 ). The results from adjusted ordered logistic regression, and the background variables that were significantly associated with being in higher quartiles, are presented in Table  3 .

• Oral healthcare beliefs

The Oral health care beliefs dimension says something about the person’s perceptions of preventive oral health behavior [ 31 ]. As shown in Table  2 , more than half of the HCS personnel were uncertain about the possibility of stopping gum disease when the disease had already started. Over 60% of respondents disagreed that patients would ask when oral healthcare assistance was needed, and a clear majority of HCS personnel disagreed that one should stop flossing and brushing if gums were bleeding. Most of the HCS personnel (93%) disagreed that visiting the dentist was only necessary when experiencing pain, and 61.5% disagreed that dentures were less troublesome than taking care of natural teeth. A larger proportion of HCS personnel did not agree that fluoride products were most suitable for children. As shown in Table  3 and Fig.  1 , having ≥ 3years of higher education, was associated with higher Oral health care beliefs scores and the odds of being in the higher quartile were 2.12 times higher among those group. Analysis from Table  3 showed also that when compared with males, females were 3.37 times more likely to score higher and be in the higher quartile of Oral healthcare beliefs.

External locus of control

The External locus of control dimension represents respondents’ beliefs in external factors as ones that affect prevention of oral health diseases (factors beyond one’s control) [ 32 ]. The majority of the HCS personnel did not agree that if both parents had bad teeth, brushing and flossing would not help. Furthermore, they did not agree that a dentist was the only one who could prevent cavities and gum diseases. More than half of the HCS personnel (59.4%) disagreed on the question “It is not possible to prevent sickness and medicines from destroying teeth”. As many as 72% of those who responded did not agree that one method of brushing was just as effective as any other, and the majority did not agree that teeth fell out as one got older. Sixty-seven (26%) HCS personnel were uncertain about the claim that tooth loss was a normal part of growing old. Results obtained from the generalized ordered logistic regression model showed that having higher education was associated with being in the higher quartiles of EL (result did not reach statistical significance) (Table  3 ). The model predicted a 21.1% chance of being in Q4 for those with higher education compared with 13% for those without any formal education (Fig.  1 ).

Internal locus of control

The Internal locus of control dimension represents respondents’ beliefs in the possibility of preventing oral health diseases by one’s own actions (controlling one’s own life) [ 32 ]. As shown in Table  2 , the majority of HCS personnel agreed that cavities and gum disease could be prevented. They also agreed that dental flossing and tooth brushing could help prevent cavities. The respondents agreed that the patients wanted help with oral care (69.5%). On the question of whether their patients ate better if they had a healthy and clean mouth, 88.8% agreed. 72% agreed that teeth could be preserved for a lifetime.

Not having training in oral healthcare significantly increased the likelihood of getting a higher score and being in a higher quartile of Internal locus of control by 1.89 times (Table  3 ). HCS personnel who were trained in oral health had 38.2% chance of being in Q1 of Internal locus of control compared with 24.7% who were not trained in oral health (Fig.  2 ).

Self-efficacy

Self-efficacy refers to a person’s belief in their own ability to cope with challenges and achieve success, or the respondents’ belief in their “ability to achieve goals” [ 33 ]. Most of the HCS personnel agreed that they expected fewer dental problems if respondents brushed and flossed correctly. They also agreed that they knew how to prevent oral candidiasis (77.2%). Less than half of respondents were uncertain about how different oral mucosal disorders could be treated, and almost two-thirds believed that they could successfully remove plaque to prevent cavities and gum diseases. The majority (79.2%) believed that more facts about dental disease could make them practice better oral health.

Not having higher education and not having training in oral healthcare significantly increased the likelihood of being in higher quartiles of Self-efficacy, which is not positive of this dimension (Table  3 ). Furthermore, 34.7% of those who were trained in oral health were more likely to be in Q1 compared with 24.3% in the untrained group (Fig.  2 ).

Predicted probabilities for each OHBC and EL quartile by level of education

Predicted IL and SE quartile probabilities by training in oral health

The present study mapped the oral healthcare beliefs among HCS personnel and identified several factors associated with their beliefs in oral health. To our knowledge, this is the first study on that topic to be published in Norway.

The current study found that most HCS personnel have positive beliefs about oralhealth and, how to prevent gum diseases, dental caries, and oral yeast infections. There were more uncertainties on whether sickness and medicine can destroy teeth, and how to treat oral mucosal disorders. Receiving oral healthcare training and a higher level of education seem to have a significant effect on HCS personnel being in the higher quartiles of External locus of control and Oral health care beliefs, and the lower quartiles of Self-efficacy, which means positive beliefs.

In our study, while HCS personnel, knew what was important to prevent oral diseases, there were still little knowledge about impact of age, diseases, and medication on oralhealth (External locus of control). The majority of HCS personnel seemed to have positive beliefs about gum disease and tooth cavities being preventable; similar results have been shown in an earlier study in Finland [ 24 ]. HCS personnel agreed that patients eat better if they have a healthy, clean mouth. Previous studies have shown that oral healthcare is an important aspect of patients’ comfort and maintenance of dietary intake [ 34 ]. HCS personnel in our study were aware that to prevent dental problems, good oral hygiene is important. HCS personnel with oral health training were more confident that what they did could prevent oral diseases. Despite knowing that certain actions, such as brushing your teeth, prevent cavities and gum diseases (Internal locus of control), they were unsure if they could remove plaque correctly (Self-efficacy). They felt that they could overestimate the effect of external factors on oral health ( External locus of control) and were unsure whether tooth loss is a normal part of aging, and that if both parents had bad teeth, brushing and flossing would not help which may be due to lack of knowledge or personal experience with dental disease [ 21 ] Our findings are in agreement with findings from other healthcare personnel studies [ 21 , 23 , 35 , 36 ].

Almost 41% of HCS personnel answered “agree” or “I don’t know” to the statement that “it is not possible to prevent sickness and medication from destroying teeth.” Edman & Wårdh [ 21 ] have argued in their study that this may be due to a lack of knowledge and wrong perceptions of oral diseases. Lack of knowledge about the treatment of different oral mucosal disorders and how to correctly remove plaque may prevent HCS personnel from helping the users with for instance teeth brushing. One possible explanation may be that the HCS personnel has not received sufficient instructions, practice, and support in tooth brushing for care-dependent older adults [ 37 ]. An increasing number of dentate care-dependent elderly with complex needs requires HCS personnel with a broader knowledge of oral healthcare [ 18 ]. At the same time, shortage of qualified HCS personnel has resulted in more unqualified personnel working in HCS with users who require a lot of expertise [ 38 ]. HCS personnel need knowledge about oral health to manage older people’s oral healthcare. The performance of oral healthcare is affected by oral health beliefs, which in turn, are affected by how much education the individual has about oral health [ 26 , 39 ]. HCS personnel believe that they need more training on oral diseases to give better help with oral healthcare to the elderly. In our study, having training in oral healthcare was associated with being in the lower quartiles of Internal locus of control and Self- efficacy, and those with oralhealth training had more confidence on their action will be important to prevent oral health diseases, these results are in line with results from other studies showing that HCS personnel need oral healthcare training [ 23 , 40 , 41 ] and more knowledge about oral diseases, as well as practice, to gain more confidence in how to prevent oral diseases [ 21 , 24 , 35 , 36 ]. Our study showed that having more education improved oral health beliefs and was associated with being in higher quartiles in the dimensions OHCB and External locus of control, and in the lower quartile of Internal locus of control. Some earlier studies show that more education does not necessarily lead to better oral healthcare behavior among HCS personnel [ 23 ]. Even so, knowledge can influence their beliefs about consequences and their abilities, which can influence their behavior [ 24 , 25 ]. However, previous studies have indicated that there is a gap between knowledge and practice in HCS personnel beliefs about the oral healthcare of the dependent elderly [ 42 ]. In the Oral health care beliefs dimension, being male was associated with being in the lower quartile; a study from Sweden supports our findings [ 21 ].

More than half of HCS personnel lack training in oral healthcare. This is not unique to Norway as studies from other countries have shown similar results [ 39 , 43 , 44 ]. This is despite oral health training being included in the curriculum of the education system, and the PDS having responsibility for collaborating with the municipality to provide training sessions or courses for employees of HCS once per year [ 9 , 45 ]. Among those who had training in oralhealth only 26 participants answered they have received training from PDS. Notably, HCS personnel do not always attend the training sessions. This could be because of a high workload or low priorities for oral health [ 40 ]. There are HCS personnel with different levels of education working in the HCS, our results showed that education level had a positive association with having positive oral health beliefs and the fact that one in five of HCS personnel in Norway are unskilled, the HCS and PDS must ensure that knowledge about oral health is implemented and the competence of HCS personnel is good enough to cope with the tasks they encounter in the working day. A study conducted by Mehl et al. [ 37 ] exploring the quality and quantity of oral healthcare in educational programs for auxiliary nurses in Norway concluded that the education program for oral health training was insufficient, and students did not have enough knowledge of oral healthcare to qualify them for future work in healthcare.

Years of work experience did not have an impact on oral healthcare-related beliefs, as no significant difference in any dimension was detected in our study. Previous studies have shown that working conditions, HCS personnel’ health perspectives, cultural differences [ 36 ], and personal experiences with oral diseases [ 21 ] all influence how HCS personnel approach the oral healthcare of older people.

It is important, regardless of educational level, that HCS personnel have the knowledge and confidence needed to help care-dependent elderly users of HCS. Educational institutions, municipalities, and the PDS are all responsible for ensuring and facilitating HCS personnel’ acquisition of the knowledge required to meet the challenges of an increasingly older population dependent on assistance to keep their teeth. Oral healthcare education is important, and it influences how HCS personnel practice oral healthcare for older people. More education and oral health training are required for HCS personnel so that they are able to provide the necessary oral healthcare for older HCS users.

Study limitations

Of the 893 HCS personnel working across four different municipalities that were included in the study, only about one-third responded to the survey. The low response rate might lead to bias because the beliefs of nonrespondents of the target population might differ from those of respondents. Therefore, the findings should be taken with care considering the implications for health services research. This is not unique to our study, as prior research has revealed response rates of 20–75% [ 21 , 22 , 34 ]. The low rate of participation can be explained by the fact that oral healthcare is not a high priority among HCS personnel [ 26 , 46 ]. This might be due to a lack of time allotted for this topic and busy schedules. Another explanation could be that the COVID-19 pandemic caused extraordinary conditions in the healthcare system, requiring more health personnel. As a result, participating in research projects was not a priority. In addition, two of the four municipalities that participated in the survey were in the process of reorganizing HCS during the data collection. In our study, we had low Cronbach’s alpha values (0.6038–0.6438). One of the possible explanations for low consistency could be the heterogeneous group of respondents, who had different levels of education. Edman & Wårdh [ 21 ] have also questioned whether low consistency could be because there are several different levels of education among the participants. Another limitation of this study is that a questionnaire was used, and the possibility of a socially complacent answer and the social desirability phenomenon must be taken into account. Theres also a possibility that the respondent didn’t know if the subject of the questions was for them or for an older adult. The strength of this study is, to the best of our knowledge, the first to investigate oral healthcare beliefs among HCS personnel in Norway, and we have used nursing dental Coping Belief Scale, and the result can be compared with previous studies.

Conclusions

The home care services personnel beliefs about oral healthcare improved with an increasing level of education and having had training in oral healthcare. This suggests that HCS personnel need more education and training in oral healthcare. Additional studies are needed to investigate more about the routines for providing good oral healthcare for elderly users of HCS in Norway.

Availability of data and materials

The dataset used in the current study is available from the corresponding author on reasonable request.

Abbreviations

Home care services

nursing Dental Coping Beliefs scale

Confidence intervals

Odds ratios

Bayesian information criterion

Proportional odds ratios

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Acknowledgements

The authors would like to thank all the HCS personnel who responded to the questionnaire, and the PDS, Innlandet County, Norway, for contributing to the implementation of the project. Thanks to Kristin Lund Forren for help collecting the data.

The study is a part of the Connecting Oral and home health care services (CORAL) project, which is funded by the Norwegian Research Council (301517).

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Department of Public Health Science, Faculty of Medicine, University of Oslo, Oslo, Norway

Hero Ibrahim Hassan, V. E. Ansteinsson & R. Hellesø

Oral Health Centre of Expertise in Eastern Norway, Oslo, Norway

Hero Ibrahim Hassan, V. E. Ansteinsson, R. Skudutyte-Rysstad, I. Mdala & E. A. Sz. Hovden

Faculty of Health Studies, VID Specialized University Oslo, Oslo, Norway

E. T. Dalbak

Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway

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Contributions

HIH EASH, and VEA collected data. HIH analyzed the data and wrote the manuscript. EASH, RH, and VEA contributed to study concept, design, methodology and drafting of the manuscript. RSR contributed to drafting of the manuscript. IM analyzed the data and contributed to draft the manuscript. ETD translated nDCBS into Norwegian and carried out a pilot study. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Hero Ibrahim Hassan .

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This study was a questionnaire study, Regional Ethic Committee (REC) south-east has concluded that the study does not require approval in accordance with the Health Research Act § 10 (case reference: 32692) because the manuscript does not report on or involve the use of any animal or human data or tissue; it only needs approval from the Norwegian Center for Research Data (Sikt, former NSD). Thet Norwegian Centre for Research Data reviewed the project and found it legally compliant regarding handling participants personal information (297462). The participants gave their written informed consent before completing the questionnaire. All methods were carried out in accordance with relevant guidelines and regulations.

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Hassan, H.I., Ansteinsson, V.E., Dalbak, E.T. et al. Oral healthcare beliefs among home care services personnel; a cross-sectional study in south-eastern Norway. BMC Health Serv Res 24 , 1090 (2024). https://doi.org/10.1186/s12913-024-11534-7

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Strategies for sustaining and enhancing nursing students’ engagement in academic and clinical settings: a narrative review

Mohammad reza ghasemi.

1 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran

Hossein Karimi Moonaghi

2 Department of Medical Education, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Abbas Heydari

Students’ engagement in academic-related learning activities is one of the important determinants of students’ success. Identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nurse educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students. The purpose of this review was to explore and summarize the strategies that nurse educators use to sustain and promote nursing students’ engagement in academic and clinical settings. A narrative literature review was conducted. CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus were searched. Of 1,185 retrieved articles, 32 teaching strategies were identified and extracted from the nursing literature. We used thematic analysis approach to organize these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), simulation-based strategies (two articles), research-based strategies (two articles), and miscellanea learning strategies (three articles). As a general comment, these strategies have the potential to promote nursing students’ engagement. Among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today’s advances in smart technologies. The collection presented in this review can be used as a starting point for future research to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. Nevertheless, due to the lack of experimental studies, the optimal strategies remain to be elucidated through future high-quality experimental study.

Introduction

One of the essential requirements of healthcare systems to meet the broad needs of patients is the employment of well-qualified nurses [ 1 ]. In this respect, one of the important responsibilities of nursing education systems is providing high-quality education to nursing students and preparing competent nurses so that they can provide patients with safe and high-quality care in the future [ 2 - 4 ]. As a step toward that end, nursing educators need to use new educational strategies to actively engage nursing students in learning activities in academic and clinical settings [ 5 , 6 ]. Previous studies have shown that increasing academic engagement of students could increase their desirable academic performance and success [ 7 ]. Recent evidence indicates that engagement in academic-related learning activities is one of the important determinants of students’ success in university [ 8 - 10 ]. As a result, identifying the best teaching strategies to sustain and promote nursing students’ engagement in academic and clinical settings has always been a challenge for nursing educators. Hence, it is essential to provide a set of strategies for maintaining and enhancing the academic engagement of nursing students.

In educational literature, the concepts of academic engagement, student engagement (SE), educational engagement, student involvement, and school engagement have often been used interchangeably [ 11 ]. In this study, the term ‘SE’ was used. The concept of SE has been extensively studied in educational literature as an important determinant of quality in academic education. Several definitions of this concept have been proposed; however, one of the most widespread definitions of SE is provided by the prolific author, Kuh [ 12 ]. Kuh [ 12 ] defined SE as “the time and effort students devote to activities that are empirically linked to desired outcomes of college and what institutions do to induce students to participate in these activities.” However, several authors argue that this concept is more than student involvement in school-related activities. It is rather a multidimensional concept, whose dimensions include behavioral, emotional, cognitive, and motivational [ 11 , 13 , 14 ]. SE, also, refers to the quality of the effort that learners spend on the targeted educational activities such as attending classrooms, studying, doing practical work, and engaging with professors or other students to reach the desired outcomes [ 15 ]. In the most recent definition of SE proposed by Kahu [ 13 ], the amount of time students spend on learning-related activities is considered as one of the main components of SE. In clinical disciplines such as nursing, many educational activities are accomplished in clinical settings. Hence, it is expected that the concept of SE in nursing education includes at least two concepts of “academic engagement” and “clinical engagement [ 16 ].” However, a search of the literature revealed small number of studies regarding clinical engagement, and this concept has recently become an important issue in nursing students’ education. In addition, most nursing researchers have not provided a unique definition for the concept of SE [ 11 , 16 ]. Recently, Bernard [ 14 ] using concept analysis, theoretically defined SE as “a dynamic process marked by a positive behavioral, cognitive, and affective state exhibited in the pursuit of deep learning.” This definition included the previously discussed dimensions and focused on deep learning; however, this definition lacks practical and measurable characteristics of SE, particularly time spent to engage with educational activities. Given the lack of an operational definition of SE in nursing education, based on the literature, we used the following working definition for conducting the current review. SE is “the investment of time, effort, and other relevant resources by both students and their institutions intended to optimize the student experience and enhance the learning outcomes and development of students, and the performance and reputation of the institution [ 11 ].”

In the last decade, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. The result of these efforts has led to the creation of new teaching strategies or modification of the techniques used by other disciplines. However, the lack of a study that reviews these strategies and techniques as a collection is felt. Previously, Crookes et al. [ 17 ] explored the strategies and techniques that nurse educators have employed to help nursing students to contextualize theory learned in the classroom to their practice. However, most of those techniques borrowed from other disciplines. Therefore, the ultimate purpose of this review was to explore and summarize the strategies that nursing educators use to sustain and promote nursing students’ engagement so that we can provide a set of these educational strategies to nursing educators and researchers. This review has been carried out as part of a nursing doctorate dissertation attempting to assess the lived experiences of nursing students on academic engagement activities.

The following question was used to guide this non-systematic narrative literature review: What strategies or techniques have nursing educators used to sustain and promote nursing students’ academic or clinical engagement? To answer this question, we reviewed the literature to identify the most significant studies and theoretical foundations regarding the academic and clinical engagement strategies used by nursing educators.

1. Sources of information and search strategy

The following databases were searched for peer-reviewed scholarly articles: CINAHL (nursing content), ProQuest, Medline, the Cochrane, Google Scholar, and Scopus. Two authors (G.M.R. and K.M.H.) with the assistance of one librarian searched the databases using predefined search strategies. They individually screened the titles and abstracts of retrieved studies against the inclusion criteria for choosing relevant articles. We used several combinations of the following search terms ‘engagement, nurse, student’ and their related concepts by using the Boolean operator, “AND”, to obtain any link between them. The scope of the search was limited to English-language written international articles and publication dates were limited from January 2000 to June 2019. To find additional articles, we manually examined the reference sections of the retrieved studies and relevant review.

2. Selection criteria

To keep the focus directly on nursing students, the inclusion criteria for selecting articles were as follows: The sample should be nursing students and the used strategies must be done by nursing educators. As well, we included original articles, reviews, innovative papers, discussion papers, learning projects, and theoretical frameworks. We excluded the dissertations and articles related to the other professions. Duplicate articles were also excluded. Given that we intended to provide a comprehensive set of educational strategies for sustaining and promoting nursing students’ engagement, we did not appraise the quality of included studies and did not remove any studies due to the low quality.

Of 1,185 retrieved articles, 32 articles have met the selection criteria. Fig. 1 shows the process of study selection for inclusion in review.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Nursing researchers have explored and applied several strategies/techniques for sustaining and promoting nursing students’ engagement. Given the heterogeneity of the educational methods, we used a thematic analysis approach to collate, summarize, and map the literature to identify themes across the retrieved studies based on the similarities of concepts and teaching techniques that educators had used. The second author reviewed each paper and data was coded to describe the main teaching methods. Similar codes were grouped together into categories to organize the main teaching strategies/techniques. New categories were developed or modified as analysis continued. At the end of analysis, we organized these strategies into five main categories as follows: technology-based strategies (15 articles), collaborative strategies (10 articles), active learning strategies (three articles), simulation-based strategies (two articles), and research-based strategies (two articles). It should be noted that there are some similarities between and within categories. Table 1 summarizes the students’ engagement strategies. Regarding the methodology of retrieved studies, five were innovative, 10 were discussion paper, six were quasi- experimental, five were descriptive, and six were qualitative studies.

Summary of Students’ Engagement Strategies

1. Technology-based strategies

There is growing evidence that shows the value of technology for engaging students in academic learning activities [ 18 ]. We found 15 articles discussing the importance of using online and offline technologies in promoting nursing students’ engagement.

1) Online technologies

a. Kahoot in the classroom: Kahoot is a free web-based technology that incorporates a quizzing program to increase the participation of learners during the lecture. As well, it can be used as a mean for formative assessment of students. It is believed that the learners’ attention is reduced in the first minutes after the beginning of the lecture and educators need to alter the situation and engage the learners to regain their attention [ 19 ]. The underlying assumption of Kahoot method is that an interesting program could increase students’ participation during the lecture. Barnes [ 20 ] introduced this technique as an innovative tool for nurse educators for engaging students during the lecture. However, the effectiveness of Kahoot to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

b. Online teaching techniques: Along with advances in technology and the Internet, many traditional teaching methods have been transformed into interactive web-based educational methods [ 21 ]. In recent years, web-based courses provide many opportunities for actively engaging nursing students in learning activities [ 22 - 24 ]. Nursing education experts believe that online forum courses can bridge the gap between theory and practice in nursing discipline as well as it can facilitate the process of nursing students’ engagement [ 17 ].

c. Asynchronous discussion boards: These boards enable multiple learners to engage in discussion with each other. All discussions of the learners are collected on a board and the members contribute their comments by responding to the initial discussion question or by responding to each other. It is believed that asynchronous discussion boards, by use of the Web and other Internet technologies, encourage deeper learning and help students to be more engaged in learning activities related to analysis, synthesis, decision-making, and the use of knowledge [ 25 ]. In nursing education, Dickson [ 26 ], proposed the basic structure of asynchronous discussion boards for enhancing the engagement of nurse students. The foundation of the technology is that educators can enhance students’ engagement by posting a series of questions on the discussion board and then encourage those students to reflect and respond actively to those questions. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Posting videos on YouTube: Johnston et al. [ 27 ] incorporated a collection of YouTube videos into the bioscience course to support nursing students’ engagement. The total number of views, comments, and subscriptions from students were collected directly from the Biological Sciences YouTube channel over four semesters. The videos are highly successful; with more than 300,000 views, 1.5 million minutes of viewing and more than 5,000 international subscribers during the study. More than 90% agreed that watching videos increased their engagement time in learning. Authors concluded that posting educational videos on YouTube can significantly engage students in learning activities and enrich the student experience and performance [ 27 ].

e. Virtual Community: Giddens et al. [ 28 ] designed and implemented an intervention called “the neighborhood virtual community (VC)” to assist first-semester baccalaureate nursing students (n=350 participants) in learning complex, health-related content. They described VC as an online teaching application presenting an imaginary community with multiple interconnecting character stories. VC included households’ and health care nurses’ characters. Students should follow the character stories each week during the semester by logging on to the Website. Using a two-group quasi-experimental study, they found that engagement in learning activities were significantly higher in the experimental group than those of the control group (analysis of variance, F=2.40, p<0.05). In addition, a significantly positive relationship (r=0.416, p<0.001) between the frequency of VC use and perceived benefits among students was found [ 29 ]. In another study, using VC in nursing education leading to the improvement of students learning through emotional connectedness to families and engagement of characters into learning activities [ 30 ].

2) Offline technologies

a. Response systems (clickers): Response systems are a set of software and hardware that educators have used to attract learners’ attention and increase their engagement during the class lecture. By asking questions in the classroom, the educator encourages the students to respond to these questions through a technology-based response pad called “clickers”. Using this system, students can get instant feedback from the educator regarding the asked questions. In this way, clickers actively engage students during the lecture. Recently, several nursing schools across the world used this technology [ 31 - 34 ]. Filer [ 35 ] in a pilot quasi-experimental study with 90 nursing students assessed the impact of an audience response system (clickers) on students’ engagement and participation in the classroom. The control group responded verbally, while the intervention group responded anonymously using the clickers to questions posed during the lecture. The author found that students in the intervention group reported a greater level of motivation (p<0.001); were more comfortable in the classroom (p=0.00); and expressed a higher level of participation (p<0.001) than students in the control group. In addition, almost all students indicated the clickers were easy to use and they would like to use it in future classes [ 35 ]. In another quasi-experimental study, Revell and McCurry [ 36 ] compared the effectiveness of a personal response system with didactic presentations. These interventions were incorporated within two undergraduate courses, nursing research (n=33) and junior medical-surgical nursing (n=116). The efficacy of each intervention was evaluated by multiple-choice, true-false, and quiz questions. Authors found that using a personal response system could significantly increase faculty-student participation and enhance active learning (p<0.001) compared with the lecture [ 36 ]. In a study with 47 first-year nursing students, Fifer [ 33 ] evaluated the perceptions of first-year nursing students regarding the use of student response system technology. A 14-item Likert scale survey was used to collect students’ perceptions. More than 80% of the student had a positive perception regarding the strengths of this technology for increasing SE. Many students expressed that this method maintained their focus during the lecture [ 33 ]. Berry [ 32 ] incorporated clickers to enhance student interaction and learning in a didactic pediatric nursing course. Exam grades and level of participation were monitored and exam scores and final scores were compared between two groups of ‘with clickers’ (n=65) and ‘without clickers’ (n=61). Student t-tests demonstrated that one of the three-course exams and final course grades were significantly higher for the students who used clickers (mean±standard deviation, 93.33±1.99 versus 95.03±1.64; p<0.001). Satisfaction feedback also supported the use of clickers as a tool to engage students and enhance learning outcomes [ 32 ].

b. Barcode scanning: Quick response (QR) code is a specific two-dimensional code that are used to encode and decode information such as text, Uniform Resource Locator links, Short Message Service messages with a mobile device that is equipped with a camera and QR reader software. QR codes can be integrated with learning activities such as linking a specific topic to information on the Internet, reviewing information, or evaluating classroom assignments. As an interactive technology-based approach, many health care systems incorporate barcode scanning or QR codes into nursing students’ clinical rotations to ensure patient safety. In addition, many educators incorporate this approach into the classroom activities to enhance students’ engagement. In this regard, Aul and Johnston [ 37 ] explored the experiences of undergraduate nursing students during the oncology course. The authors created barcodes consisted of one review question using a web-based, QR code generator tool. The authors printed the barcodes on an index card and then the cards were strategically taped throughout the classroom and the hallways outside of the classroom. Sixty-seven students were instructed to circulate around the room to scan the codes with their smartphones to find a range of oncology review questions. Afterward, the students should present and discuss the answer to the scanned questions. The authors found that barcode scanning is an attractive method for increasing SE and performance of nursing students. At present, the efficacy of barcode scanning to increase the engagement of nurse students is under research and currently, there is no experimental research that examined the effectiveness of this method.

2. Collaborative strategies

Collaborative learning is defined as a set of instructional methods to encourage students to work together to achieve a common learning goal. It involves mutual intellectual works by students themselves or students and educators. In this approach, students themselves are responsible for group governance and education output [ 38 ]. We found 10 articles discussing the importance of using collaborative strategies in promoting nursing students’ engagement.

1) Team-based strategies

a. Team-based learning: Team-based learning (TBL) is a shared learning and teaching approach, which is frequently used by health sciences educators in their preclinical and clinical programs to foster self-directed learning [ 39 ]. In nursing education, Dearnley et al. [ 40 ] reviewed the outcomes of TBL in nursing education programs to explore the experiences of nursing students regarding the TBL. They discussed that there is a great body of evidence, which supports TBL, as collaborative teaching and learning strategy, for sustaining and enhancing students’ engagement [ 40 ]. In an exploratory, descriptive study, Oldland et al. [ 41 ] explored the perceptions of nursing students regarding the role of TBL in shaping their professional clinical behaviors. Authors found that TBL can maximize students’ participation in the learning activities, develop active and deep learning, and raise teamwork performance, which in turn can enhance the students’ engagement in both academic and clinical settings [ 41 ].

b. Interdisciplinary partnership: Many schools across the world have been implementing partnership projects between students and the school’s staff in order to increase students’ engagement in academic learning activities. Bramble et al. [ 42 ] implemented a participatory action research to develop a “3-month mentorship partnership intervention” between nursing students and a group of academics as a mentor. They found that interdisciplinary partnership could increase students’ academic engagement and success; however, the acquisition of mutual trust and security were the main issues for developing mentorship capacity [ 42 ].

c. Collaborative testing: Quizzing has become a popular method of assessing learning and retention of knowledge as well as a mean of engaging students. In collaborative testing, students work together in small groups to complete quizzes before they select their final answer. Therefore, an important aspect of collaborative testing is the peer interaction, education, and collaboration during discussing each question. In nursing, Burgess and Medina-Smuck [ 43 ] used a collaborative testing approach using quizzes during maternal-infant course in the undergraduate nursing program. During this course, four multiple-choice quizzes were electronically administered. The outcomes were perception and attitude of students regarding collaborative testing strategy. Seventy-eight percent of students described this method as helpful and enjoyable in supporting their learning of the course material. Authors concluded that this strategy provided a structured method to enhance students learning and retention of course contents [ 43 ]. At present, no experimental research has evaluated the effectiveness of this technology in terms of SE.

d. Faculty-student interaction: D’Souza et al. [ 44 ] highlighted and summarized the important roles of nursing educators to promote nursing students’ engagement in the clinical environment. The suggested that to increase students’ academic engagement, nursing educators should: (1) involve students in teaching strategies, (2) balance student’s clinical activities with clinical assignments, (3) provide wide range of clinical activities, (4) appreciate the individual difference, (5) provide them with multidimensional resources, (6) group students for reflective activities, (7) create an atmosphere to enable students to learn, and (8) continuously supervise their activities. Authors found that when students and faculty actively share learning opportunities with each other, students are motivated to be more engaged in the new clinical learning environment.

e. Crossword puzzles solving: Raines [ 45 ] incorporated two models of crossword puzzles, as a cooperative learning activity, into nursing courses to promote students’ engagement and their critical thinking. Students worked in two phases of individually and in a small group. In the first model, which was designed for simple courses, students should solve the clues and in the second one, they should construct the content for the crossword puzzle (advanced courses). This process forces the students to actively engage and share their thinking and reasoning process with each other. The author found that these methods can actively engage students, promote their decision-making process, and help them to solve the problems [ 45 ].

2) Service-based strategies

Service-based learning involves learning that takes place outside the classroom in a structured way between the learner and a service, and seeks to achieve common goals. It is a kind of partnership that bridges academic and community needs. This type of learning is mostly done in the community, but it can also be used in clinical settings [ 46 ]. It is believed that service-based learning is one of the most effective strategies for students’ engagement because it has the potential to positively engage learners into the real-life situations and encourage the learner to be an active learner [ 46 , 47 ]. In this regard, Hart [ 46 ] provided a three-step framework, called “ABCs of service-learning,” that indicated the process of establishing and evaluating a service–learning project. The main components of this project are taken from the nursing process. In this project, A stands for “assessment and evaluation of community and educational needs,” B stands for “be flexible and engaging,” and C stands for “collaboration and celebration.” The authors claimed that service-learning project has the distinctive potential for engaging students because it can capture the learners’ attention, develop their partnerships and collaboration [ 46 ].

3) Peer-based strategies

Peer assessment (PA) refers to a process whereby students evaluate the learning or task performance of their peers and conversely, their learning are evaluated by their peers [ 48 ]. Although a few studies have focused on PA as a strategy for enhancing students’ engagement in academic learning, some nursing authors agree that PA can actively engage nursing students in their learning activities by enhancing the confidence of students in judging about their own work/performance. In addition, PA can encourage them to reread their own assignment in light of their peers’ feedback [ 49 , 50 ].

3. Simulation-based techniques

This category includes two strategies of “Simulation with Manikins and Tag” team simulation.

1) Simulation with manikins

Manikins have been long used in nursing education since they can provide safe and repeatable conditions for practicing. In this regard, Power et al. [ 51 ] simulated five separate case studies during ten teaching weeks. They aimed to explore student perspectives (n=9) of the use of vignettes to increase engagement with manikins. Authors through thematic analysis and group discussion found that manikins are an effective procedure for increasing SE. Authors believed that if the appropriate educational scenario is selected in this learning method, the instructors will be able to actively engage nursing students in the learning process and to promote their decision-making skills [ 51 ].

2) Tag team simulation

The word “tag team” refers to a combination of two or more people who have formed a team to meet similar goals. The tag team is a small group, so the participation of the members in that team is maximal and active. In nursing programs, simulations are regularly led in large groups, with few students playing an active role and most observing. In contrast, tag team simulation (TTS) as an innovative educational strategy emphasizes the active engagement of both participants and observers in the simulation scenario. This method is inspired by the principles of theater and allows learners, as actors, to take responsibility for the actions and outcomes in a real context. Levett-Jones et al. [ 52 ] provided a TTS with pain scenario for 444 second-year nursing students. Satisfaction with Simulation Experience Scale was used to evaluate the active engagement and satisfaction of observers and participants. The mean satisfaction score was not different between participants and observers (4.63 versus 4.56, p=0.16). This indicated that TTS is an effective approach for ensuring observers’ and participants’ active involvement during group-based simulations. Authors showed that TTS could promote the active engagement of learners and enhance their satisfaction with the simulation experience [ 52 ].

4. Research-based strategies: Q methodology

Q methodology is a mixed-method approach for conducting research that focuses on individuals’ preferences and subjective attitudes. Participants can express and share their viewpoints within the group [ 53 ]. In nursing, Judge et al. [ 54 ] incorporated Q methodology into a nursing education course about “substance abuse in school.” The basis for using this method was that if students’ attitudes and preferences are recognized and fulfilled, their participation and engagement in educational activities will be enhanced. The authors aimed to promote students’ engagement and enhance their learning of evidence-based practice. Nursing students (n=35) participated in a 2.5-hour session to create a mock Q study on their opinions about substance abuse education. The outcome was the overall opinions of students regarding the characteristic of Q methodology and the class format. At the end of the study, most students expressed favorable opinions. Authors found that Q methodology can provide a means to extract the participants’ opinion around a given topic and thus provide a way to keep students as active and engaged learners [ 54 ].

5. Miscellanea learning strategies

We found three articles discussing uncategorized learning strategies in promoting nursing students’ engagement.

1) Active learning

Undoubtedly, active learning is one of the key strategies for enhancing students’ engagement within the nursing educational programs. Active learning is a student-centered approach in which requires students to participate and cooperate in the teaching and learning process [ 55 ]. Many of the discussed educational strategies in the current review can be classified as an active learning strategy. In general, the available evidence about the effectiveness of active learning in nursing education shows that this cooperative educational strategy has a potential to promote nursing students’ engagement in the academic and clinical learning activities [ 9 , 55 ]. In contrast, some studies have shown that in the absence of active learning, academic engagement is not created. Popkess and McDaniel [ 9 ] examined the relationship between pre-college students’ inputs and academic engagement levels among baccalaureate students in nursing (n=1,000) and non-nursing professions (n=2,000). The National Survey of Student Engagement instrument was used to measure engagement on five subscales with a total of 41 items. Their findings showed that nursing students scored significantly higher (mean=58.71) on some aspects of academic engagement than other professions (mean=55.22 or 56.14). However, they were less engaged in active and collaborative learning than other majors [ 9 ].

2) Homework completion

Although many studies have shown that homework, as an active learning approach, can increase the academic performance of students, this learning activities has received little attention in nursing education [ 56 ]. Salamonson et al. [ 56 ] described the relationship between academic engagement (homework completion, lecture attendance) and academic performance in nursing students (n=126) who were enrolled in a pathophysiology subject. Students spent about 6 hours per week studying. The mean percentages of lecture attendance and homework completion were 67.5% and 48.9%, respectively. Authors found that active learning activities such as homework completion are one of the best way to engage students. As well, it is a strong positive predictor of academic performance and success for nursing students [ 56 ].

Engaging nursing students in academic environments and clinical settings is a challenging issue for nursing educators, worldwide. In recent years, many nurse researchers have investigated various educational strategies to explore and develop the best ways to increase nursing students’ academic engagement. Results of these efforts are the creation of new teaching strategies or modification of the techniques used by other disciplines. Accordingly, our main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we summarized the teaching strategies that nursing educators used to sustain or enhance the academic and clinical engagement of nursing students and eventually, we highlighted the gap for further research. We organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used: the main categories were technology-based strategies, collaborative strategies, simulation based strategies, research based strategies, and miscellanea learning strategies. Many of the training strategies had been created innovatively or derived from other disciplines such as management, technology, art, and theater. But the role of today technologies such as Internet in creating educational strategies was more prominent than the other [ 57 ]. Generally, in many of the strategies used, students’ academic engagement increased, but the main problem was that the tools used to measure the degree of engagement were mostly self-reported or subjective. In other words, due to the lack of experimental educational studies in nursing regarding the SE (only 6 quasi-experimental studies), we could not judge the strengths and weaknesses of the extracted strategies. Therefore, regarding the optimal strategy to sustain and promote nursing SE, further experimental study is needed. Moreover, given that the effectiveness of these techniques has been evaluated in the small number of studies, more experimental research is recommended.

Another important point is that educational strategies were mostly used in the classroom, and few were able to be transferred to clinical settings. Therefore, because more than half of nursing education takes place in clinical settings, the findings of these studies do not support the role of these strategies in increasing the academic engagement of nursing students in clinical education. In contrast, previous studies have shown that nursing students have greater motivation, both internally and externally, to learn clinical activities; therefore, they are more engaged in these activities [ 44 , 58 ]. However, there are limited studies on the clinical engagement of nursing students and there is a need for further research in this area. It is necessary that nursing instructors sustain and enhance the academic and clinical engagement of nursing students using innovative educational strategies in order to increase the level of students’ knowledge and abilities and improve the quality of clinical services provided.

Based on the results of this review, among the strategies discussed in this review, the use of technology, particularly the response system and online learning, was more common among nursing educators, which is in line with today advances in smart technologies. Students of new technologies’ era (‘digital native’ learners) are constantly engaged with the updated smart technologies [ 57 ]. In addition, online learning has witnessed a noticeable growth within healthcare education, nowadays [ 18 , 25 , 36 , 57 ]. Accordingly, if nursing educators want to maintain and enhance the students’ academic and clinical engagement, they should equip themselves more with innovative technologically-driven learning techniques.

Active learning was the foundation of most educational strategies used to enhance students’ academic engagement. In this regard, several studies in different fields of study have shown that any teaching method that can actively engage the student in learning process, can promote academic engagement and ultimately academic achievement of students [ 55 , 59 ]. Among the educational strategies reviewed in this study, strategies based on online technologies and simulation were more attractive to students and made their participation more active in the learning process. Accordingly, as a practical point of this study, if nursing teachers want to improve students’ academic engagement, they need to use attractive teaching methods that are based on the latest technologies of today world, such as smartphones and online discussion systems; however, at present little is known about the methods of promoting academic engagement in clinical activities.

1. Limitations and strengths

Our main limitation was that the number of experimental studies that accurately assessed the effectiveness of a particular teaching strategy on students’ engagement was limited. Some educators evaluated an innovative method in a limited group of nursing students without using a particular research plan and some others discussed the advantages and disadvantages of particular teaching strategies. These factors limited our conclusion about the effectiveness of a particular technique. Notwithstanding, the collection presented in this review can be used as a starting point for future research that to evaluate the effectiveness of an educational intervention on the academic engagement of nursing students. One of the strengths of our study is that we only considered the studies that were conducted in the field of nursing.

2. Conclusion and directions for future research

The main goal of this review study was to provide a set of useful tools for promoting nursing students’ academic engagement. In this review, we organized the teaching strategies into five categories based on the similarities of concepts and teaching techniques that educators had used. The main categories were technology-based strategies, collaborative strategies, simulation-based strategies, research-based strategies, and miscellanea learning strategies. Among these educational strategies, technologies- and simulation-based strategies were more attractive to students and made their participation more active in the learning process. At present, little is known about the methods of promoting academic engagement in clinical activities. Further experimental research is needed to confirm or disprove the effectiveness of the methods discussed in this paper. We did not find a unique strategy to enhance academic engagement in clinical education activities. One of the possible reasons for this is that learning in clinical settings particularly requires maximum engagement in clinical learning activities. It is recommended that future researchers design and test unique strategies for improving academic engagement in clinical settings.

Acknowledgments

This review was not funded by any companies, research grants, or funds.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

Study conception and design: MGH, HKM; data analysis and interpretation: MGH, HKM, AH; drafting the article or revising it critically for important intellectual content revisions for important intellectual content: MGH, HKM, AH; and final approval of the version to be published: MGH, HKM, AH.