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• Team-based learning and nurse education: a systematic review
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• http://orcid.org/0000-0002-7933-5182 Michael J Tatterton ,
• Megan J Fisher
• School of Nursing and Healthcare Leadership , University of Bradford , Bradford , UK
• Correspondence to Dr Michael J Tatterton, School of Nursing and Healthcare Leadership, University of Bradford, Bradford, UK; m.tatterton{at}bradford.ac.uk

https://doi.org/10.1136/ebnurs-2022-103595

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• nursing education research

Background and purpose

This is a summary of Alberti, Motta, Ferri and Bonetti (2021).

Team-based learning (TBL) is an active, student-centred method of teaching, used with increasing frequency in nurse education. Students work in small teams, using their knowledge and interaction with peers to resolve problems and pass tests.

Although several studies have explored the effectiveness of using TBL in preregistration heath professional education, this is the first systematic review to evaluate the methodology and …

Twitter @MJTatterton, @MeganJFisher91

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

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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• Open access
• Published: 21 February 2015

Mentorship in nursing academia: a systematic review protocol

• Lorelli Nowell 1 ,
• Deborah E White 1 ,
• Kelly Mrklas 2 &
• Jill M Norris 1  

Systematic Reviews volume  4 , Article number:  16 ( 2015 ) Cite this article

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Mentorship is perceived as vital to attracting, training, and retaining nursing faculty members and to maintaining high-quality education programs. While there is emerging evidence to support the value of mentorship in academic medicine, the extant state of the evidence for mentorship in nursing academia has not been established. We describe a protocol for a mixed-methods systematic review to critically appraise the evidence for mentorship in nursing academia.

Studies examining the effectiveness of mentorship interventions with nursing faculty who teach in registered nursing education programs will be included. Mentee, mentor, and nursing education institutional outcomes will be explored. Quantitative, qualitative, and mixed method studies will be eligible for inclusion, without restrictions on publication status, year of publication, or language. We will search electronic databases (for example, MEDLINE, CINAHL, ERIC) and gray literature (for example, conference proceedings, key journals, relevant organizational websites) for relevant citations. Using pilot-tested screening and data extraction forms, two reviewers will independently review the studies in three steps: (1) abstract/title screening, (2) full-text screening of accepted studies, and (3) data extraction of accepted studies. Studies will be aggregated for meta-synthesis (qualitative) and meta-analysis (quantitative), should the data permit.

This study is the first systematic review of existing global evidence for mentorship in nursing academia. It will help identify key evidence gaps and inform the development and implementation of mentorship interventions. The mentorship outcomes that result from this review could be used to guide the practice of mentorship to increase positive outcomes for nursing faculty and the students they teach and ultimately effect improvements for the patients they care for. This review will also identify key considerations for future research on mentorship in nursing academia and the enhancement of nursing science.

Peer Review reports

One of the many challenges in nursing education today is the shortage of nursing faculty [ 1 ]. In a report focusing on human resources for health, the World Health Organization described a shortage of nurse faculty in the majority of its member states in 2006 [ 2 ]. The number of nurses in the workforce continues to decrease, as does the number of nursing faculty needed to teach new nurses to ensure quality health care delivery, to study health problems, to address patient issues, and to inform health policy. Nursing faculty shortages have not received the same attention as registered nursing (RN) shortages, but the problem is no less critical. The shortage of qualified nursing faculty is an issue of local, national, and international concern and is anticipated to worsen [ 3 ].

Nurses are the largest health-care professional group, comprising approximately 51% of all health-care providers globally, ranging from the lowest (47%) in Europe to the highest (71%) in Southeast Asia [ 2 ]. Diminished nursing faculty directly impacts the ability to admit and graduate adequate numbers of students for the nursing workforce [ 3 - 5 ], which further impedes resolution of workforce shortages. This is of concern because nurses spend more direct time with patients than any other health-care professionals and play a critical role in health outcomes [ 6 - 8 ]. The shortage of qualified RNs has been shown to decrease quality of health-care delivery [ 6 - 9 ]. Growing nurse faculty shortages are a threat to patient outcomes [ 10 , 11 ].

The nursing faculty shortage has implications for nursing research and its influence, particularly at a time when health system transformation is of paramount importance globally [ 12 ]. Generation, dissemination, and application of evidence is essential to maintain and expand any discipline [ 13 ], and the recognition of nursing as a profession and academic discipline is greatly dependent on evidence-based practice, with nursing knowledge imparted through education and advanced through scholarship [ 14 ]. According to Wood et al . [ 15 ], as energy is focused on stemming the shortage of nurses for the health-care system, the capability to build critical research capacity may be lost. Deliberate attention must be given to scholarship in order for the nursing discipline to advance and keep pace with parallel advancements in medical and related subspecialties, to advance evidence-based practice, and to inform effective, sustainable health care. The absence of an academic nursing presence from front-line care, administration, research, and policy arenas is of long-term detriment to patient outcomes and the nursing profession. The expansion of nursing science has shown to be instrumental in the provision of better patient care and improved health [ 16 ]. There are not currently enough master’s- and doctorally trained nurses to meet increasing research and leadership demand [ 16 , 11 ].

In 2004, Wood, Giovanetti, and Ross-Kerr [ 15 ] acknowledged that the number of doctoral students would not sufficiently meet the needs of nursing schools across Canada. Five years later, the Canadian Nurses Association (CNA) and Canadian Association of Schools of Nursing (CASN) reported a need for 3,673 nurses with master’s degrees and 650 nurses with doctoral degrees to meet existing school of nursing faculty vacancies [ 11 ]. The CNA and CASN continue to warn of an imminent shortage of qualified faculty if current entry-to-practice enrolments are maintained [ 4 ]. Diminished enrollees and graduates in doctoral nursing programs have also been acknowledged in the USA. In 2004, the American Association of Colleges of Nursing (ACCN) reported that insufficient number of faculty resulted in over 75,000 qualified applicants being refused entrance into baccalaureate, master’s, and doctoral nursing programs [ 17 ]. Although insufficient statistics are currently available from Australia, New Zealand, and the United Kingdom, the Council of Deans of Nursing and Midwifery of Australia and New Zealand have warned that an academic nursing workforce shortage is imminent [ 18 ].

The shortage of graduate students, faculty, and researchers persists in the nursing discipline. There is an urgent need to advance evidence-based nursing practice and skills focused on increasing population health, more efficient and effective health services and systems, and returning value on public investments. Nursing faculty shortage will hinder the ability to educate future nurses, erode the potential for research to advance clinical practice, and result in the loss of nursing leadership needed to advance the profession [ 19 ].

Causes of the nursing faculty shortage

According to IOM [ 16 ], the root causes of this inability to meet undergraduate nursing educational needs were partly due to nursing faculty shortages, inadequate workforce planning, and decreasing educational capacity to meet market demand. The following key influences have been cited: (a) salary disparities, (b) aging academic workforce, (c) changing faculty workload demands and role expectations, (d) career opportunities in clinical and private sectors, (e) diminished student numbers preparing for faculty positions, and (f) inadequate institutional funding for additional faculty positions.

Nursing faculty are one of the most poorly compensated categories in the nursing profession [ 16 ]. According to Kowalski and Kelley [ 20 ], equivalent clinical careers paid 25 to 50% more than academic careers, with the cost of acquiring faculty degrees increasingly prohibitive. Large discrepancies between faculty and non-academic salaries persist and negatively impact enrolment and retention [ 21 ].

While nursing faculty members are within the same demographic era that has partly influenced the current lack of RNs, academic nursing is further impacted by more rapid aging out of employment than clinical nursing due to later career stream entry [ 22 ]. Nursing faculty tend to be older than clinical nurses given advanced degree requirements to teach [ 16 ]. This does not lend itself to lengthy employment in an academic setting. Resignation and retirements are projected to reduce the current nursing faculty greatly over the next decade [ 14 ]. As aging faculty contributes to attrition, it is important that the next generation of nursing faculty be identified early, encouraged, nurtured, and welcomed into academia [ 23 ]. Faculty mentorship is suggested as a way to successfully foster a collegial, caring environment; these supportive relationships are positive strategies that help to retain RNs in faculty positions [ 24 ].

The number of master’s- and doctoral-prepared advanced practice nurses choosing academia has decreased throughout the years [ 21 ]. Recent statistics indicate that nurses graduating from master’s and doctoral programs are not choosing an academic career path [ 25 ]. Increased opportunities outside academia for PhD-trained nurses further contribute to the shortage of nursing faculty [ 26 ].

Even if adequate enrolment were not a problem, both US and Canadian nursing programs have lacked the funds to create new teaching positions [ 22 ]. Canadian nursing schools have identified the lack of sustainable funding to create full-time positions as a major challenge, limiting their ability to recruit new faculty [ 4 ].

Nursing faculty shortage is the result of multiple, systemic problems emerging over decades. With such staggering nursing faculty workforce statistics, recruitment and retention of new nursing faculty are critical strategies. Mentorship has been identified by the National League for Nursing [ 27 ] as one way to address the nursing faculty shortage by encouraging RNs to begin and remain in nursing faculty roles.

Evidence for mentorship

The evidence base for mentorship interventions has evolved in business, medicine, and education literature. Research on mentorship in nursing is a recent development. Most mentorship studies conducted to date are observational or qualitative, and the conclusions are not conclusive. Systematic reviews on mentorship in corporate settings have reported increased job satisfaction and perceived increases in career advancement opportunities for those that received mentorship, compared to those who did not [ 28 ]. A systematic review of mentorship in academic medicine reported that mentorship has a significant influence on personal development, career guidance, career choice, and research productivity, recruitment, and retention [ 29 ]. Within the education literature, similar reviews have identified mentorship as improving the socialization, orientation, and career outcomes of faculty [ 30 ]. Evidence of mentorship in nursing academia has not yet been synthesized.

Nursing education institutions that have established mentoring programs reported positive outcomes for nursing faculty such as improved morale, higher career satisfaction, increased self-confidence, increased professional development, increased publication, obtaining more grants, and quicker promotion [ 31 , 32 ]. Organizations have reported benefits from mentoring including developing future leaders from within the institution through nurturing commitment, retention, and teamwork [ 33 , 34 ]. While the nursing literature contains numerous references to the importance of mentoring, mentorship in nursing academia is not an established standard practice.

Given the potential importance of mentoring in nursing academia, a systematic review is needed to identify and describe how mentoring interventions in the field of nursing academia were developed, implemented, and evaluated. These data will help determine whether there is a sufficient range of methodologically rigorous evidence to support the development of mentorship interventions in nursing academia. This systematic review may also contribute a gap analysis and guide the objectives and designs of future mentorship interventions in nursing academia.

The systematic review question is: What is the nature and strength of the evidence for mentorship in nursing academia? The main objective of this mixed-methods systematic review is to evaluate the quantitative and qualitative literature that addresses mentorship in nursing academia. Findings that are relevant to the mentee, mentor, and nursing education institution will be included. Findings that address outcomes, including but not limited to knowledge, skills, attitudes, career progression, recruitment, retention, and costs, will be reported.

Methods/design

This mixed-methods systematic review protocol is based on the PRISMA [ 35 ] and ENTREQ [ 36 ] reporting guidelines. The design follows the Joanna Briggs Institute (JBI) [ 37 ] approach for conducting systematic reviews of both quantitative and qualitative research. The synthesis of quantitative and the qualitative evidence will be conducted independently prior to a final mixed methods synthesis (that is, segregated). The findings will be presented in a way that preserves the context of their production by anchoring the findings to sample information, source of information, information about time, comparative reference points, information about the magnitudes and significance, and study-specific conceptions of phenomena [ 38 ]. This will be facilitated by JBI-SUMARI software (v 5.0; Joanna Briggs Institute, Adelaide, SA, Australia) and analytical modules, including the Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI), Qualitative Assessment and Review Instrument (JBI-QARI), and Mixed Methods Assessment and Review Instrument (JBI-MMARI) [ 39 ]. This protocol has not been registered with PROSPERO, as protocols for systematic reviews of studies not related to health conditions and health-related outcomes are not currently eligible for registration.

Eligibility criteria

The question of relevance is: What is the nature and strength of the evidence for mentorship in nursing academia?

Participants

Studies will be included if they involve RNs teaching in RN education programs. This will include nursing instructors, nursing faculty, nursing researchers, and nursing academics. Studies involving undergraduate nursing students, staff nurses, nursing educators who teach in licensed nursing programs, and/or nursing assistant programs will be excluded. In studies where it is unclear that participants meet our inclusion criteria, we will contact the corresponding study author for verification. We will exclude studies where verification of inclusion criteria is not possible.

Interventions

Studies that explore formal and informal mentorship interventions including, but not limited to, dyadic mentoring, peer mentoring, online mentoring, and tele-mentoring will be included.

Informed by other medical, education, and business studies, this review will report on the outcomes of measures that are relevant to the mentee, mentor, and nursing education institutions. Similar to other published non-nursing meta-analyses on mentorship [ 40 , 41 ], variables that are conceptually similar will be combined. Table  1 lists the six broad categories of outcomes that will be examined. Within each category, we list the specific outcomes that will be examined and example of how these outcomes are measured. Some of the outcomes listed are applicable to mentors, mentees, and nursing education institutions. We will include new variables if reported.

The review will include quantitative, qualitative, and mixed method studies that report on mentorship on nursing academia without restriction by study design, publication status, year of publication, or language.

Information sources and search strategy

Prior to commencing the study search, a preliminary search of existing systematic reviews will be made through Database of Abstracts and Reviews (DARE), MEDLINE, and PROSPERO to identify studies relevant to this review. Electronic searches will include MEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO databases from their inception to present, and the search strategy will be updated within 90 days of final publication, without limitation on study design, publication year, status, or language. A search to identify gray literature (non-peer-reviewed works) will be undertaken by scanning ProQuest Dissertations and Theses, Index to Theses, and mentorship conference proceedings. Experts in the field and corresponding authors of key studies will be contacted to gather further information on gray literature. The authors will undertake a bibliographic search of all eligible studies to identify and retrieve other relevant studies for the review.

The search strategy was designed with the assistance of an experienced nursing librarian to focus on maximum sensitivity and to be as extensive as possible to identify all possible eligible studies and then refined according to the inclusion and exclusion criteria. Several consecutive searches were performed and the results were combined to design the final search strategy. The provisional search strategy for MEDLINE is outlined in Table  2 and will be modified according to the indexing systems of the other databases. All references will be exported to EndNote citation management software, where duplicated records will be verified, recorded, and removed.

Study selection

The selection of studies will occur in two phases. The first phase will involve screening of titles and abstracts by two reviewers, independently using a structured data entry form. To minimize the risk of bias, data screening forms will be pilot tested by reviewers on the first 50 studies to ensure consistency and reliability. A Kappa [ 42 ] of greater than 0.6 will be used to quantify inter-investigator agreement. Disagreements will be resolved to consensus through discussion and passed to a third investigator for final resolution if the issue cannot be resolved. Studies identified as potentially relevant will be passed to the next screening level.

In phase two, the same two reviewers will independently review full-text versions of all potentially relevant studies. To minimize the risk of bias, both reviewers will be trained on the use of the eligibility form prior to beginning the review. Eligibility forms will be pilot tested by the reviewers on the first ten identified full texts to ensure consistency and reliability between the reviewers. A Kappa [ 42 ] of greater than 0.6 will be used to quantify inter-investigator agreement, and disagreements will be resolved by discussion. Unresolved disagreements will be referred to a third investigator for review and resolution.

Data collection process and data items

Once a final set of included studies is established, data will be extracted independently by two researchers according to the inclusion and exclusion criteria using two standardized data extraction instruments: one specific to quantitative studies (JBI-MAStARI) and one specific to qualitative studies (JBI-QARI). To minimize the risk of bias, reviewers will be trained on both data extraction forms prior to extracting data. The data extraction forms will be pilot tested by the reviewers on the first ten included studies to ensure consistency and reliability between the reviewers. Disagreements will be resolved by discussion. In the absence of consensus, disagreements will be referred to a third investigator for review and resolution. Table  3 shows data categories that will be extracted from all the studies selected.

Studies that have been published in duplicate will be retained and assessed in full text; the most comprehensive study will be included. Following independent data extraction, co-reviewers will meet to resolve any discrepancies and obtain consensus. Any unresolved disagreement between the two reviewers will be solved by referral to a third researcher.

Assessment of methodological quality/risk of bias in individual studies

Each included study will be assessed for methodological quality by two independent reviewers. Quantitative studies will be assessed using the appropriate JBI-MAStARI critical appraisal tool for controlled trial/pseudo-randomized trial, comparable cohort/case control studies, or descriptive/case series studies. All qualitative studies, regardless of study design, will be assessed using JBI-QARI critical appraisal tool. Responses to these quality appraisal questions are:

‘Yes’ (the criteria have been established through the report description or have been confirmed by the primary author)

‘No’ (the criteria have not been applied appropriately)

‘Unclear’ (the criteria are not clearly identified in the report and it was not possible to acquire clarification from the author)

‘Not Applicable’

When both reviewers have completed the assessment process, the primary reviewer will compare the two sets of appraisals. Any discordant response will be first discussed by the first two reviewers and referred to a third reviewer if a resolution cannot be reached. All non-English literature identified in the search will be screened and reviewed by one interpreter. Studies that meet the inclusion criteria will be extracted by the same interpreter.

Synthesis of included studies

Mentorship studies are known to be heterogeneous; if possible, the quantitative data will be pooled for meta-analysis using JBI-MAStARI and we will use a random-effects model (odds ratios for categorical data, mean differences for continuous data, 95% confidence intervals). Meta-aggregation will be used to synthesize qualitative date using JBI-QARI, if possible. This process will involve assembling the findings based on study quality, categorizing findings based on similar meanings, and producing a set of synthesized findings. If there is a lack of available studies and statistical or textual pooling is not achievable in the single method syntheses, findings will be reported in narrative form. JBI-MMARI will be used to aggregate the single-method syntheses. Using a Bayesian approach, the quantitative findings will then be converted to qualitative themes and subsequently pooled with the qualitative synthesis in tabular form. This approach was used by Crandell and colleagues [ 43 ], whereby similar variables will be grouped together into themes and then data will be coded for each variable. These data will be entered into a data matrix with included studies in rows and single themes (or variables) in the columns. If a study does not address a variable, that cell will be left blank. An overarching synthesis will be created for each theme (based on the variables included in that theme). Utilizing both quantitative and qualitative data to develop themes and coding all data into a compatible format allows for a meta-aggregative analysis where equality between qualitative and quantitative data is achieved. Finally, all themes will be aggregated to generate a set of recommendations for mentorship in practice and mentorship research.

Ethical considerations

Systematic reviews should not ignore ethical considerations [ 44 ]. An ethical assessment will be conducted for all included studies in this systematic review, and an assessment of ethics approval for all gray literature will be confirmed. The ethical characteristics will be collected and summarized in the discussion of the systematic review findings.

Validity and reliability

In order to ensure decisions are not biased, a systematic review team has been established to conduct this systematic review. The team includes a knowledge expert with a research focus on mentorship, systematic review methodologists, and a nursing research librarian. All team members will participate in regularly scheduled meetings to discuss project progress and findings. To minimize the risk of error, reviewers will be trained on the use of all selection, appraisal, and extraction forms prior to beginning the review. The forms will be pilot tested by the reviewers to ensure consistency and reliability between the reviewers.

This systematic review protocol considers both quantitative and qualitative studies. Mixed methods reviews are still evolving and consistent methods have not been validated. In response to these concerns, the development process of this systematic review is illustrated in Figure  1 . The methodology used has been adapted from JBI [ 37 ] and other mixed methods systematic reviews [ 45 ]. The robust method of this systematic review protocol enables critical appraisal and synthesis of the cumulate global evidence on the topic, while preserving the integrity of findings from different study designs and providing precise results with rich contextual data.

Systematic review development. JBI, Joanna Briggs Institute; JBI-MAStARI, Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument; JBI-QARI, Joanna Briggs Institute Qualitative Assessment and Review Instrument.

The current lack of knowledge synthesis is a major limitation of the current state of evidence on mentorship strategies aimed at addressing the nursing faculty shortage. Although a number of mentorship outcomes (increased recruitment, retention, promotion, job satisfaction, occupation commitment, career progression, skills development, self-efficacy, publications, grants, and decreased administrative costs) have been identified in medicine, business, and education literature, presently, the outcomes of mentorship in academic nursing remain unclear. The absence of a systematic review that identifies, critically appraises, and synthesizes the current evidence for mentorship interventions presents a dilemma for policy makers. Failing to provide a consensus understanding of appropriate mentorship approaches and positive mentorship outcomes has left policy makers with limited guidance regarding which alternatives to consider when designing mentorship strategies to alleviate the nursing faculty shortage [ 46 ]. We have planned this review to address this current knowledge gap.

The findings of this systematic review may have implications for policy, practice, and research. The results of this systematic review will provide a comprehensive examination of the evidence for mentorship in nursing academia and highlight gaps where future research on mentorship remains to be conducted. Given the significant resources required to fund mentorship innovations, understanding the benefits and shortcomings of various strategies may ensure that scarce resources are devoted to the most efficient and effective strategies. The result from this review could be used to guide administrators and policy makers to most effectively implement mentorship innovations aimed at addressing the nursing faculty shortage.

Limitations

Due to the complexities and diversity of mentorship interventions and limited availability of quantitative studies, the extent to which clear conclusions can be drawn about the usefulness of mentorship may be limited. However, this review will provide clarity on the existing evidence for mentorship in nursing academia and identify areas for future research.

Abbreviations

American Association of Colleges of Nursing

Canadian Nurses Association

Canadian Association of Schools of Nursing

Joanna Briggs Institute

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument

Joanna Briggs Institute Mixed Methods Assessment and Review Instrument

Joanna Briggs Institute Qualitative Assessment and Review Instrument

Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information

Registered nurse

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Acknowledgements

The authors express their gratitude to the excellent assistance of Dr. Alix Hayden, librarian at the University of Calgary, for assisting in developing the database searches. LN is supported by a University of Calgary Graduate Student entrance scholarship.

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Lorelli Nowell, Deborah E White & Jill M Norris

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LN conceived the study. LN, DW, KM, and JN developed the study design and drafted and edited the protocol manuscript. LN created the proposed search strategy in consultation with a nursing librarian. All authors read and approved the final manuscript.

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LN is a doctoral student and nursing instructor at University of Calgary Faculty of Nursing. DW is associate dean (research) and associate professor at University of Calgary Faculty of Nursing. KM is a PhD trainee in the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary. JN is a scientific writer at University of Calgary Faculty of Nursing.

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Nowell, L., White, D.E., Mrklas, K. et al. Mentorship in nursing academia: a systematic review protocol. Syst Rev 4 , 16 (2015). https://doi.org/10.1186/s13643-015-0007-5

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Organisational factors associated with healthcare workforce development, recruitment, and retention in the United Kingdom: a systematic review

• Erkan Alkan 1 ,
• Noreen Cushen-Brewster 2 &
• Philip Anyanwu 1 , 3  

BMC Nursing volume  23 , Article number:  604 ( 2024 ) Cite this article

Metrics details

To synthesise evidence regarding organisational practice environment factors affecting healthcare workforce development, recruitment, and retention in the UK.

Methods/data sources

A systematic search of PubMed, Web of Science, EMBASE, and PsycINFO yielded ten relevant studies published between 2018 and 2023 and conducted in the UK (the last search was conducted in March 2023). Adhering to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent reviewers conducted screening, sifting, and data extraction, applying the quality assessment tool for risk of bias.

Results highlight key factors associated with staff intention to leave/turnover/retention: workplace challenges, aggression, moral distress, on-the-job embeddedness, leadership involvement, organisational support, and flexible shift patterns. Notably, aggression from colleagues, including clinical staff but not interdisciplinary personnel, has a more detrimental impact on staff intention to leave than aggression from patients.

The complex and context-dependent impacts of these organisational factors on the UK healthcare workforce underscore the need for tailored interventions. The review acknowledges limitations, including bias from excluding qualitative studies, a small pool of included studies, and nurse overrepresentation.

Summary statement

Securement and retainment issues affect different aspects of health and care services. Moreover, healthcare workforce shortages persist in the UK.

Our findings on the importance of workplace challenges and aggression, moral distress, on-the-job-embeddedness, leadership, flexible shift pattern, and organisational support in staff retention are important to addressing the current UK healthcare workforce crisis.

The findings of this review are important to healthcare commissioners, policymakers, and stakeholders, offering valuable insights for dealing with factors contributing to shortages in the healthcare workforce and enhancing staff satisfaction and retention.

Peer Review reports

What does this paper contribute to the wider global clinical community?

Contributes to the evidence on the role of organisational practice environment factors in healthcare workforce development and retention.

Introduction

Healthcare workforce development, recruitment, and retention are critical for providing quality services and achieving and sustaining global strategies, such as Universal Health Coverage (UHC), by ensuring a sufficient, well-trained, and stable workforce [ 1 , 2 , 3 ]. Effective healthcare workforce development involves continuous training and skill diversification, enhancing service quality. Recruitment strategies that address geographic disparities and offer incentives can improve accessibility and equity in healthcare. Retention efforts focused on job satisfaction, work-life balance, and ongoing professional development reduce turnover and ensure a motivated and capable workforce. Together, these elements can ensure that healthcare services are comprehensive, accessible, and of high quality, supporting the goals of UHC.

Countries at all income levels face challenges in the education, deployment, retention and performance of their healthcare workforce [ 4 ]. By 2030, a global shortage of 10 million health workers is estimated [ 4 , 5 ]. Recent events have impacted the healthcare workforce challenges. For example, around 100,000 nursing personnel in the United Kingdom (UK) initiated a two-day strike on December 15th 2022, protesting the government’s firm position on wage requests [ 6 ]. In addition to this industrial action, the health workforce has been influenced by the challenges posed by the COVID-19 pandemic. A recent review highlighted that nurses caring for COVID-19 patients, or those who had experienced COVID-19 infection themselves or within their team, exhibited an increased tendency to consider leaving their positions [ 7 ]. By the end of the first quarter of 2024, there were 31,294 vacancies within the Registered Nursing staff group in NHS England [ 8 ]. A similar staffing issue is seen among other healthcare professionals, including allied health professionals (AHPs) (paramedics, physiotherapists, occupational therapists, and dieticians, among others) [ 9 , 10 ]. During the pandemic, not only nurses but also other healthcare workers experienced detrimental effects related to the pandemic. A recent scoping review found that doctors, dentists, radiologic technologists, and other healthcare workers face heightened workload pressures, including more intensive patient care, additional non-routine tasks, increased documentation, greater demands and skill requirements, more overtime and extended work hours, and higher patient-to-nurse ratios [ 11 ].

Securement and retainment issues affect different aspects of health and care services. A high turnover and shortage of doctors, nurses and Allied Health Professionals (AHPs) indicate retention issues and impact care quality, patient outcomes, and the cost of healthcare delivery [ 12 , 13 , 14 , 15 ]. Addressing these issues requires an extensive understanding of their drivers.

Studies have identified several factors influencing healthcare workforce recruitment and retention, including organisational culture, professional development opportunities, staff level and mix, compensation and benefits, work-life balance, geographical location, support, transformational leadership, leadership, well-being, job satisfaction, technology and equipment [ 16 , 17 , 18 , 19 ]. A recent systematic review identified professional development opportunities and pay as important factors in NHS workers’ job satisfaction and retention [ 16 ]. Healthcare workers are often attracted to NHS organisations that offer competitive salaries and comprehensive benefits packages.

The relationship between recruitment/retention/turnover intention and contextual/organisational factors extends beyond the UK. In Europe, the economic climate and cost-of-living crisis in mid-2022 impacted pay, attrition rates and the attractiveness of working in healthcare [ 20 ]. A systematic review of the prevalence of intention to leave and determinants of retention among nurses and physicians in European and non-European countries reported job satisfaction, career development and work-life balance as the main determinants of job retention [ 21 ]. A recent qualitative study adopting co-creation workshops and Delphi sessions with healthcare professionals from Belgium, the Netherlands, Italy, and Poland reported professional and personal support, education, financial incentives, and regulatory measures as key to addressing staff retention in healthcare [ 22 ]. A study in China reported a reduction in turnover intention with an increase in staff salary level and job satisfaction, with factors such as conflicts with colleagues increasing turnover intention among nurses [ 23 ]. A global perspective, as presented in a systematic review, emphasises that turnover intention in nurses is influenced by organisational factors such as nursing home and staffing characteristics, resident characteristics, and job satisfaction [ 24 ].

Within the United Kingdom (UK) healthcare economy, there is inconsistency in reports on the impact of the organisational practice environment on healthcare workforce securement and retainment. As the evidence in this area keeps evolving with changes and events such as increased cost of living [ 25 ], there is a need to integrate information on what is known on this subject to support policies and practices toward healthcare workforce improvement.

This systematic review aims to advance an understanding of organisational practice environment factors affecting healthcare workforce development, recruitment, and retention in the UK by synthesising existing evidence in this area.

Methods/methodology

Guidelines and study registration.

This systematic review (without a meta-analysis) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 26 ]. The protocol was registered with PROSPERO, the International Prospective Register of Systematic Reviews (registration number: CRD42023412559).

Inclusion and/or exclusion criteria

Inclusion criteria were studies conducted in the UK, published in the English language in the last five years (2018 to 2023), peer-reviewed research articles, employed quantitative research designs (e.g., cross-sectional and longitudinal), and recruited nurses and/or various allied health professionals working in all healthcare settings as the study sample. To include nurses and allied health professionals working on a diverse range of roles, there was no restriction based on their roles. Papers published in English in the last five years (2018 to 2023), adopted a quantitative design (including mixed methods paper with the intention to extract only the quantitative results), and were conducted in the UK were selected. The primary predictor or independent variable of interest was indicators related to the organisational practice environment, and the primary outcomes were recruitment, retention, intention to leave/stay, and turnover. The eligibility criteria are further presented in Table  1 .

Exclusion criteria were studies conducted outside the UK, non-English-language publications, published before 2018, non-peer-reviewed sources (e.g., theses, literature reviews, editorials), non-quantitative research designs (e.g., qualitative and case studies), and other groups not falling under the specified allied health professions (such as pharmacists, clinicians, students and patients). Additionally, outcomes related to the quality of care and mental well-being were outside the scope of this review.

Search methods

We used the Population Intervention, Comparison and Outcome (PICO) framework (without the optional ‘comparison’ element as this was not relevant to our research question) to guide the search [ 27 , 28 ].

Population (P): Healthcare workforce (nurses and allied health professionals) in the United Kingdom.

Intervention (I): Organisational practice environment factors.

Outcome (O): Workforce development, recruitment, and retention.

Information sources

PubMed, Web of Science, EMBASE, and PsycINFO were searched for relevant articles; the last search was conducted in March 2023. An example of a database search strategy is provided in Appendix 1 (see Appendix 1, Additional File 1). The reference lists of the selected publications were also searched for eligible papers.

Study selection

All potential records generated from the search of databases were collated and uploaded into Endnote© Version X8. Duplicates were identified and removed using the Endnote functions. Two reviewers (PA and EA) screened titles and abstracts to assess each record according to the inclusion criteria. Screening of titles and abstracts resulted in the exclusion of papers ineligible based on population (e.g., first-year students, patients), design (review papers), and relevance of title and abstract. Studies retained after title and abstract screening were reviewed in full-text sifting by three researchers (NC, PA, and EA). Any disagreements that occurred among reviewers were resolved through discussion.

Data extraction

Two reviewers (EA and PA) independently performed data extraction. They used a data extraction form to extract information on the study design, participants’ characteristics, indicators of organisational practice environment factors reported, and study outcomes (Table  2 ).

Quality appraisal

The National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tool [ 39 ] for observational cohort and cross-sectional studies was used to assess the quality of the included studies for risk of bias (Table  3 ). The tool comprises 15 questions that thoroughly examine various aspects of the studies, such as their aims, sample size, design, outcome and independent measures, confounding variables, and inclusion/exclusion criteria. Two reviewers (EA and PA) independently assessed each question by assigning a rating of ‘yes’ for a low risk of bias, ‘no’ for a high risk of bias, ‘Not Reported’ when no supporting information was available, and ‘NA’ if the criteria were not applicable. Any discrepancies in the quality ratings between reviewers were resolved through discussions and consensus with the third reviewer. To ensure the validity and reliability of the review’s conclusions, studies rated as ‘poor’ will be removed as their results may be unreliable.

Data synthesis

Given the methods of analyses and outcomes reported in the included studies, a narrative synthesis, compared to a meta-analysis, was a better fit for synthesising the results. The narrative synthesis followed the methodologies proposed by the Cochrane Consumers and Communication Review Group’s Data Synthesis and Analysis document [ 40 ] and the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews by the UK Economic and Social Research Council Methods Programme [ 41 ]. The results were integrated based on the reported organisational practice environment factors.

Results/findings

All potential records ( n =4216) generated from the search of databases were collated and uploaded into Endnote© Version X8. Duplicates ( n =1043) were identified and removed using the Endnote functions, leaving 3173 records. Screening of titles and abstracts resulted in the exclusion of 3001 papers. The full texts of the remaining 111 papers were screened, resulting in the exclusion of 101 papers due to inclusion criteria, study design and location. The remaining 10 papers (32–41) were included in the review (see Fig.  1 for the PRISMA flowchart showing the selection process). No additional papers were identified through the reference lists of the included studies.

Prisma diagram showing the selection of articles for review

Characteristics of the included studies

A summary table of the characteristics of the included studies is provided in Table  2 . Most of the studies recruited participants working in hospital settings, with two studies conducted in a care home/community nursing setting [ 33 , 37 ]. While our primary focus was on nursing and allied health professionals with no restriction based on role, it is important to highlight that the studies included in our review featured a range of distinct roles within these staff groups. These encompassed clinical and non-clinical roles, frontline clinical staff, and managerial positions. To further elucidate the composition of the study samples, we have detailed the specific staff groups investigated in each study within Table  2 . All the studies incorporated a quantitative component, with two adopting a mixed methods approach [ 31 , 35 ]. Nearly all the studies were cross-sectional; only one had a longitudinal design [ 33 ]. The sample sizes varied across the studies, ranging from 116 to 36,850 participants, with most studies reporting nurses as their participants. The analyses employed in the included studies were varied, with correlation and regression analyses commonly reported. Multiple tools were used to assess outcomes (see Appendix 2, Additional File 1 for a description of the indicators reported and how they were measured in each study). Authors employed various measurements in their studies to capture specific dimensions of interest. For example, when investigating intention to leave, some studies used single-item questions such as “Are you considering leaving your job?” [ 29 , 37 ] or multi-item Likert scale-based questions to gauge the degree of intention to leave [ 30 , 34 ]. Actual turnover was assessed through self-report measures, where care home managers, for example, reported the number of staff left over a given period [ 33 ]. Retention was measured using questionnaires that examined factors influencing retirement age and timing [ 31 ] or was calculated using organisational workforce data [ 36 ].

Quality assessment

Overall, the quality ratings varied across studies, with most studies rated as fair or good. The specific quality ratings for each study are provided in Table  3 . Six of the ten papers were rated as good, while four were rated as fair. All studies clearly stated their research aim/question. The study population was also clearly specified and defined in all studies. The participation rate of eligible persons was below 50% in most studies, except for two studies where this information was not reported. All study subjects were selected or recruited from the same or similar populations, and the timeframe was considered sufficient to observe associations between exposure and outcome. Most studies did not provide sample size justification or power calculation; only four studies reported this information [ 29 , 31 , 35 , 37 ]. Potential confounding variables were measured and adjusted for in most studies except for four [ 29 , 36 , 37 , 38 ].

Organisational practice environment factors

The associations between organisational environmental factors and healthcare staff intention to leave/actual turnover/retention is summarised in Table  4 .

Working conditions (workload, burnout, and job stress)

Four of the included studies [ 29 , 33 , 34 , 37 ] investigated associations between workplace challenges (job stress, burnout and working conditions) and staff turnover or intention to leave. The study reporting burnout (defined by the WHO as “ a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed ” [ 42 ]) found no association with staff turnover [ 33 ]. One study reported a positive association between job stress (that is, the mental situation individuals may experience when they are confronted with job demands and pressures that do not align with their skills and capabilities [ 43 ]), and nurses’ intention to leave [ 34 ]. Two studies reported the effect of working conditions on intention to leave [ 29 , 37 ], with one focusing on staff experience working in COVID-19 high-risk areas [ 29 ]. The COVID-19-focused study found no difference in turnover intention between those working in higher- or lower-risk areas. Another study found that staff intention to leave significantly decreased with improvements in working conditions (0.49 (0.34–0.70), p  < 0.001) [ 37 ].

Workplace aggression

Workplace aggression, in this context, refers to encountering actions that pose potential harm, are actively avoided by the target, and take place during the target’s work duties [ 44 ]. Only one study investigated the impact of workplace aggression on staff intention to leave. The study by Cheng et al. found that experiencing aggression from either patients or colleagues had a damaging effect on staff intention to leave, with the impact of aggression from colleagues twice that from patients [ 30 ].

Moral distress

The results of the two studies that reported on moral distress were consistent. Colville et al. found that moral distress (resulting from situations when someone is aware of the correct course of action but institutional constraints create significant obstacles to following through with the right decision) predicts staff intention to leave and turnover [ 32 ]. Similarly, Witton et al. reported that moral distress was negatively correlated with intent to stay; nurses who stated they had high rates of moral distress were more likely to consider leaving their current employer [ 38 ].

On-the-job embeddedness

One of the included studies considered job embeddedness (the degree of connection employees have to their jobs through a network of social relationships and factors [ 45 ]), with a negative association between this organisational practice environment factor and nurses’ intention to leave reported [ 34 ].

Involvement in leadership and management

Two studies reported the effect of staff involvement in leadership and management. Quek et al. found that higher levels of distributed leadership significantly predicted lower turnover intention [ 35 ]. Robinson et al. investigated the association between involvement in improvement (measured using three indicators: the ability to make suggestions to improve their work, involvement in decisions on changes that affect their work area, and ability to make improvements in their area of work) and the retention of nurses working across different types of NHS Trusts (Community, Specialist, Mental Health and Acute). Only two indicators of improvement (ability to make suggestions to improve their work and ability to make improvements in their area of work) were significantly correlated with RN retention, and this was seen in those working in mental health and acute NHS trusts [ 36 ]. For RNs in Mental Health NHS Trusts, retention was positively correlated with their ability to make suggestions to improve their work and their ability to make improvements in their area of work. However, in Acute NHS Trusts, a negative correlation was seen between RNs’ ability to make improvements in their area of work and their retention.

Support (wellbeing and management support)

Two studies reported on aspects of organisational support. The COVID-19-focused study by Blake et al. found no significant differences in turnover intentions between staff who accessed a supported wellness centre set up in UK hospitals to mitigate the psychological impact of the pandemic and those who did not [ 29 ]. The other study reported that support from managers reduced the odds of staff indicating an intention to leave [ 37 ].

Flexible shift patterns

With a focus on older nurses (over 55 years of age), Cleaver et al. examined the relationship between shift patterns and the odds of working beyond retirement. The odds of working beyond retirement are significantly higher if staff can reduce their working hours and choose when to work or have a fixed working pattern. However, other factors, such as cessing to work shifts, nights and weekends, were not significantly associated with the intention to work beyond retirement [ 31 ].

Our review synthesised quantitative evidence on the impact of organisational practice environment factors on healthcare workforce development and retention. The included studies reported the impact of working conditions, workplace aggression, moral distress, on-the-job embeddedness, leadership and management involvement opportunities, well-being and management support and flexible shift patterns on the intention to leave, actual staff turnover and retention among nurses and AHPs in the UK. Intention to leave was the most reported outcome (with studies investigating its association with all reported organisation practice environment factors, except flexible shift pattern), demonstrating its importance in workforce planning and strategies for targeted retention, continuity of care, and employee engagement.

Our findings suggest that the influence of organisational factors on securement and retention is complex and context-dependent. For instance, findings on the impact of workplace challenges on intention to leave and staff turnover were mixed; while some studies indicate that workplace challenges, such as job stress and working conditions, are associated with higher intention to leave, other studies showed no significant relationship. These mixed findings could be attributed to various factors, including differences in study methodologies, sample characteristics, organisational contexts, events and the specific nature of the workplace challenges examined. A recent systematic review reported increased intention to leave among nurses driven by disruptive events such as the COVID-19 pandemic, with approximately one-third of nurses having thoughts about leaving their job [ 46 ].

Our review finding that workplace aggression from colleagues has a more detrimental impact on staff retention than workplace aggression from patients suggests that the source of aggression plays a significant role in its effect on staff intention to leave. A similar finding on the impact of aggression and its source on retention and securement has been reported in other UK [ 47 ] and non-UK studies [ 48 , 49 , 50 ]. Workplace aggression from colleagues has been attributed to factors such as misunderstanding of job roles and responsibilities, emotional exhaustion and job stress [ 49 , 50 ]. When aggression originates from colleagues, who are expected to provide support and collaboration, it can have a more profound negative impact on individuals’ job satisfaction and overall well-being. Additionally, aggression from colleagues may erode social support networks, trust, teamwork, and on-the-job-embeddedness (the extent to which employees feel rooted in their work, have strong social connections, and perceive a good fit between themselves and their colleagues/job) [ 34 , 51 ]. Our finding on on-the-job embeddedness emphasises the significance of fostering among colleagues a sense of belonging, positive relationships, and alignment to enhance staff retention.

The impact of moral distress on staff intention to leave resonates with the persistent workforce issues worsened by recent industrial actions and the cost-of-living challenges. Organisational factors such as working in an understaffed environment and inadequate financial remuneration can constrain healthcare professionals from acting in accordance with their ethical principles [ 52 ]. For instance, the recent cost-of-living crisis in the UK might partly explain the increasing reports of moral distress among healthcare professionals as they struggle with financial challenges while providing care, impacting job satisfaction and intentions to leave.

The perspective of our review is limited by the inclusion of only quantitative studies. Excluding qualitative studies could limit our ability to capture the process, complexity, and context of organisational practice environment factors’ influence on healthcare workforce securement and retention. Compared to observational studies, randomised controlled trials could have provided stronger evidence for causal inference. The review has other limitations stemming from the strict inclusion criteria, focusing solely on the UK population, resulting in a small number of studies with an overrepresentation of nurses compared to allied health professionals. The observational nature of the included studies introduces potential bias from uncontrolled confounders. While emphasising nursing and allied health professionals, it is acknowledged that diverse staff groups have unique needs. Balancing evidence from general population studies with role-specific investigations is crucial for a comprehensive understanding of healthcare workforce issues and devising solutions. The variation in outcome measures in the included studies (see Appendix 2) poses a challenge, hindering direct comparisons and preventing a meaningful meta-analysis due to the lack of standardised measurement approaches. Our focus on peer-reviewed publications, excluding grey literature, could lead to overlooking relevant studies; however, this restriction was important in ensuring the inclusion of high-quality, rigorously peer-reviewed research papers, thereby enhancing the reliability and validity of our findings. Acknowledging these limitations is essential for interpreting the nuanced landscape of healthcare workforce development and retention issues.

Conclusions

Our findings have practical, policy and research implications. This review contributes to the evidence needed by healthcare commissioners and policymakers to address persistent workforce securement and retention issues in the UK. Our results underscore the need for tailored strategies focusing on key aspects, such as reducing workplace aggression from colleagues. The review evidence can inform policies and practices aimed at promoting work-life balance, offering career development opportunities, fostering a positive workplace culture, providing competitive compensation, and implementing flexible work arrangements to enhance healthcare workforce retention. Additionally, our findings highlight the need for further research to understand how different organisational practice environment factors interact with individual and external factors to influence the intention to leave specific healthcare settings. Nevertheless, it is crucial to highlight that the healthcare workforce in the UK is dynamic and continues to be influenced by ongoing events, such as industrial actions and cost-of-living challenges [ 6 , 25 ]. Future research should address these dynamics, with an emphasis on developing strategies to meet the evolving challenges faced by the healthcare workforce.

Based on our findings, to improve healthcare staff development, recruitment, and retention, we recommend prioritising proactive organisational policies and interventions co-developed with healthcare workers that aim to create supportive and empowering work environments.

Data availability

The dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Sustainable Development Goals

Universal health coverage

United Kingdom

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Acknowledgements

We would like to acknowledge Health Education England and the steering committee members (Dr Paul Driscoll-Evans, Mr Graham Seward, and Professor Lynne Wigens).

This study was funded by Health Education England (RD22061).

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Alkan, E., Cushen-Brewster, N. & Anyanwu, P. Organisational factors associated with healthcare workforce development, recruitment, and retention in the United Kingdom: a systematic review. BMC Nurs 23 , 604 (2024). https://doi.org/10.1186/s12912-024-02216-0

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Defining mental health literacy: a systematic literature review and educational inspiration

• Shengnan Zeng , Richard Bailey , +1 author Xiaohui Chen
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A systematic review of the limitations and associated opportunities of chatgpt, deductive qualitative analysis: evaluating, expanding, and refining theory, conceptualising and measuring positive mental health literacy: a systematic literature review, mental health education integration into the school curriculum needs to be implemented, review: school-based mental health literacy interventions to promote help-seeking - a systematic review., public opinion towards mental health (the case of the vologda region), quantifying the global burden of mental disorders and their economic value, mental health literacy: it is now time to put knowledge into practice, clarifying the concept of mental health literacy: protocol for a scoping review, positive mental health literacy: a concept analysis, related papers.

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Effectiveness of serious games in nurse education: A systematic review

Affiliations.

• 1 Department of Nursing, Chung-Ang University, 84 Heukseok-ro, Bldg 106, Dongjak-gu, Seoul 06974, South Korea.
• 2 College of Nursing, Gyeongsang National University, 816-15 Jinju-daero, Jinju 52727, South Korea.
• 3 Department of Family Health Nursing, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, South Korea. Electronic address: [email protected].
• PMID: 34717098
• DOI: 10.1016/j.nedt.2021.105178

Objectives: To systematically summarize research employing serious games in nurse education, to examine their effectiveness, to provide recommendations and implementation strategies, and to suggest future directions for the development and application of serious games in nurse education.

Design: A systematic review.

Data sources: An online search of the CINAHL, Medline, PubMed, EMBASE, PsycINFO, SCOPUS, and Web of Science databases, and a manual search of the reference lists of selected studies or review articles published in English and Korean between 1990 and July 2020.

Review methods: This systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Articles that employed a serious game approach in nurse education were included. Two authors independently screened and reviewed the articles and assessed the methodological quality using the Cochrane risk-of-bias tools.

Results: A total of seven studies met the inclusion criteria: three randomized controlled trials and four quasi-experimental studies. Heterogeneity was found across all studies regarding the application of serious games, platforms, and gamification elements. Most of the studies evaluated the effectiveness of serious games using knowledge tests, while two studies evaluated skills performance. Two randomized controlled trials and two one group before and after studies reported that the use of serious games improved nursing students' and nurses' knowledge and performance.

Conclusions: This systematic review does not provide comprehensive insights into the effectiveness of serious games in nurse education. However, based on the evidence reviewed, we provide suggestions for developing and implementing serious games in nurse education to enhance students' knowledge and performance.

Keywords: Games; Gamification; Nurse education; Nurses; Nursing students; Serious games.

Copyright © 2021 Elsevier Ltd. All rights reserved.

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Determinants of clinical nurses’ patient safety competence: a systematic review protocol

Jong-hyuk park.

1 Seoul National University College of Nursing, Seoul, Republic of Korea

2 Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea

Hanseulgi Lee

Gihwan park, associated data, introduction.

Patient safety has become a fundamental element of healthcare quality. However, despite the ongoing efforts of various organisations, patient safety issues remain a problem in the healthcare system. Given the crucial role of nurses in the healthcare process, improving patient safety competence among clinical nurses is important. In order to promote patient safety competence, it is essential to identify and strengthen the relevant factors. This protocol is for a systematic review aiming to examine and categorise the factors influencing patient safety competence among clinical nurses.

Methods and analysis

This review protocol is based on the Joanna Briggs Institute (JBI) Methodology for Systematic Reviews of Effectiveness and Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Four electronic databases, including Ovid-MEDLINE, CINAHL, Cochrane Library and EMBASE, will be used for the systematic review. After consulting with a medical librarian, we designed our search terms to include subject heading terms and related terms in the titles and abstracts. Databases from January 2012 to August 2023 will be searched.

Two reviewers will independently conduct the search and extract data including the author(s), country, study design, sample size, clinical setting, clinical experience, tool used to measure patient safety competence and factors affecting patient safety competence. The quality of the included studies will be assessed using the JBI critical appraisal tool. Because heterogeneity of the results is anticipated, the data will be narratively synthesised and divided into two categories: individual and organisational factors.

Ethics and dissemination

Ethical review is not relevant to this study. The findings will be presented at professional conferences and published in peer-reviewed journals.

PROSPERO registration number

CRD42023422486.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The review protocol has been rigorously and systematically developed according to the Joanna Briggs Institute Methodology for Systematic Reviews of Effectiveness and Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol.
• This study will rigorously select relevant articles according to the Canadian Patient Safety Institute’s patient safety competence framework.
• The anticipated heterogeneity of contributing factors is expected to make it challenging to conduct a meta-analysis.
• This study will only include articles in English and exclude grey literature, which could result in potential publication bias.

Patient safety has become a global public health issue and a fundamental element of healthcare quality. 1 2 According to the WHO, patient safety is a framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur. 3

Despite its importance, patient safety issues continue to undermine the healthcare system. 4 5 Annually, an estimated 421 million patients worldwide are admitted to hospitals while approximately 42.7 million patient safety incidents occur within the healthcare system. 6 The impact of patient safety incidents during patient care is noteworthy on a global scale, leading to over 3 million deaths annually. 7 An estimated 237.3 million medication errors occur annually in England, 8 resulting in a financial burden of more than 750 million pounds. 9 Approximately 15% of healthcare expenditures are allocated to address the consequences of patient safety incidents. 6 This results in a considerable decrease in the global economy costing trillions of dollars annually. 6 7 However, it has been found that a significant portion (ranging from 25% to 50% or more) of these events are preventable within the healthcare system. 6 10 11

In all dimensions of the healthcare process, nurses are responsible for patient safety. 12 Nurses, who spend more time with patients than other healthcare professionals, play a vital role in identifying patient safety risks and ensuring high-quality care. 12 , 14 Through careful monitoring of patient conditions, quick identification of risks, and supervision of the healthcare process, they actively contribute to patient safety. 13 15 In addition, nursing activities such as medication administration, infection control and fall prevention have a direct impact on patient safety. 16 Therefore, maintaining high levels of patient safety competence among nurses is crucial for decreasing patient safety issues and enhancing the quality of patient care. 13 17

The Quality and Safety Education for Nurses project identified the fundamental elements of quality and safety competence in nursing, including patient-centred care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics. 18 These core principles improve evidence-based standards with a systemic perspective and enhance the quality of patient care. 19 In addition, the Canadian Patient Safety Institute (CPSI) outlines crucial aspects of patient safety competence, including the ability to recognise, respond to and disclose patient safety incidents, foster patient safety culture, promote effective teamwork and communication, ensure safety and manage risks, promote quality improvement and optimise both human and system factors. 20

The definition of patient safety competence encompasses the attitude, skills and knowledge that prevent unnecessary risk and harm to patients. 18 21 This competence helps prevent patient safety incidents and addresses latent problematic issues in the healthcare system. 13 22 A recent study revealed that patient safety competence can reduce preventable adverse events, including medication errors, surgical site infections, urinary tract infections and ventilator-associated pneumonia. 13

In addition to recognising the significance of the patient safety competence of nurses, there are many aspects of patient safety competence that require further investigation and understanding. 23 First, it is important to identify the factors relevant to patient safety competence and enforce the contributing factors. A study by Huh and Shin revealed that demographic factors such as age, education level, patient safety education and experience in patient safety activities are associated with patient safety competence. 16 However, prior studies have focused primarily on the individual attributes of patient safety competence and have not emphasised the organisational factors. 24 Patient safety is a complex process within the context of a system that requires collaborative efforts from both the individual and the organisation. 14 25

Although there are limited reviews of patient safety competence instruments, 26 27 there are currently no systematic reviews of the factors that contribute to the patient safety competence of clinical nurses. A previous review by Okuyama et al 26 conducted in 2011 explored patient safety competence across diverse healthcare professionals. However, the patient safety competence of clinical nurses may differ from other healthcare professionals. In addition, the most recent instruments of patient safety competence may not have been included in that review. Mortensen et al 27 published a scoping review of the instruments of patient safety competence in nursing. However, scoping reviews have methodological limitations that offer a general overview rather than a comprehensive in-depth analysis and they do not include a formal quality appraisal process. 28 Moreover, there is a lack of consensus on the definition of patient safety competence and its conceptual framework in that study.

This protocol aims to provide guidance for a systematic review to identify the factors affecting the patient safety competence of clinical nurses. To foster a comprehensive understanding of patient safety competence, we will categorise those factors into two domains: individual and organisational. Moreover, this study will encompass research that has examined the core concept of patient safety competence based on the CPSI framework. This review would essentially provide a starting point for identifying the determinants of patient safety competence.

Study objectives

The purpose of this research is to examine the factors that influence the patient safety competence of clinical nurses. The specific research questions include (1) what is the definition of patient safety competence, (2) what instruments for assessing patient safety competence are examined in this research and (3) what factors affect the patient safety competence of clinical nurses?

Before conducting this review, we thoroughly searched the International Prospective Register of Systematic Reviews, which revealed no ongoing systematic reviews of the factors influencing the patient safety competence of clinical nurses. To conduct a systematically organised review, this protocol was developed based on the Joanna Briggs Institute (JBI) Methodology for Systematic Reviews of Effectiveness. The JBI checklist, an organised tool to promote and support evidence-based practice, provides a rigorous systematic review process. 29 Some elements were updated and modified from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. 30 We registered this systematic review with the International Prospective Register of Systematic Reviews (CRD42023422486). The systematic review started in August 2023 and included a preliminary search and pilot study selection process to screen the search results based on the eligibility criteria.

Search strategy (PICO) and data sources

This systematic review will explore the determinants of patient safety competence among clinical nurses (P-population). The study will examine the impact of various factors that either enhance or impair patient safety competence (I-indicator), comparing their effects on nurses exposed to these factors to those who are not exposed (C-comparison). The primary outcome to be measured will be the level of patient safety competence (O-outcome). According to the PICO statement guidelines, the search strategy was developed in consultation with a health sciences librarian. Four databases, including EMBASE, CINAHL, Ovid-Medline and Cochrane Library, will be explored from January 2012 to August 2023 ( online supplemental appendix A ). The reason for selecting this period is that the Medical Subject Headings for patient safety was introduced in 2012. The specific search strategy is presented ( table 1 ). In order to conduct a more thorough examination, we will use both backward and forward citation search methods.

This review will include studies involving clinical nurses directly engaged in providing patient care in hospitals. According to a previous study, clinical nurses consist of registered nurses or licensed practical/vocational nurses providing direct care to their patients in hospitals. 31 Therefore, this study aims to encompass a diverse group of clinical nurses, including medical, surgical and intensive care unit nurses. To minimise variations in competence attributed to distinct professional roles, articles exclusively focused on nurses not directly participating in independent front-line patient care, such as nursing students and nurse managers, will be excluded.

This study will explore multiple influencing factors that serve as indicators of patient safety competence. The JBI quality appraisal tools employ a rigorous assessment process to evaluate the validity and reliability of indicators. A diverse and heterogeneous range of tools is expected to be employed in the study.

This systematic review will allow for comparisons based on exposure to the indicators. Comparisons can be made between clinical nurses who have been exposed to specific factors and those who have not. Furthermore, the study enables comparisons across different hospital settings providing valuable insights into the variations in patient safety competence.

The primary outcome will be patient safety competence, which encompasses complex patient safety principles, including the CPSI’s patient safety competence. This competence includes the ability to recognise, respond to and disclose patient safety incidents; manage safety, risks and quality improvement; communicate effectively; foster teamwork; understand patient safety culture and optimise human and system factors. 20 The outcome measure will be rigorously evaluated for its validity and reliability.

Study design

The study will encompass original descriptive cross-sectional analyses, comparative research and mixed-method research. Only peer-reviewed articles on patient safety competence will be included, to ensure high-quality and reliable information. Grey literature will be excluded as it does not meet our criteria for being valid, rigorous and peer-reviewed.

Inclusion and exclusion criteria

All published studies examining factors related to the patient safety competence of clinical nurses directly involved in patient care in the hospital setting will be included. The measurement of patient safety competence among clinical nurses serves as the primary outcome in the included studies. According to the CPSI, 20 the competence should cover various attributes, including (1) patient safety culture; (2) teamwork; (3) communication; (4) safety, risk and quality improvement; (5) optimised human and system factors and (6) recognition, response and disclosure of patient safety incidents. The selected articles will be peer-reviewed, written in English and published from January 2012 to August 2023.

Articles exclusively focusing on nurses who are not directly engaged in front-line patient care, such as nurse managers, will be excluded. The review will not include studies in which the participants are individuals without official nursing licences, including nursing students and patients’ family members. Research exploring patient safety competence in populations other than nurses (eg, hospitalists and medical students) will also be excluded. Studies that focus exclusively on a single attribute, such as communication or medication competence, will be excluded. Additionally, to maintain methodological clarity with measurable indicators, qualitative studies will be excluded. Furthermore, review articles, theses and dissertations, conference abstracts, editorials, opinion articles and case studies will be excluded. Articles not available in full text will also be excluded.

Study selection

Using the Covidence platform, two independent reviewers will conduct the article screening process by evaluating the titles and abstracts and classifying them into the categories of relevant and irrelevant. Disagreements regarding irrelevant articles will be resolved through discussion between the two reviewers. Only articles classified as relevant during the initial screening will be selected for the subsequent step of full-text screening, which will also be conducted by the same two reviewers. During this stage, the reviewers will each compile their own list of relevant articles, which will then be compared. Any discrepancies will be resolved through discussion. For any unresolved discrepancies, a third reviewer will be consulted, and the final decision will be made by the entire team.

Data extraction

Two researchers will collect information independently based on the following criteria: the author(s), country, study design, sample size, clinical setting, clinical experience, instrument to measure patient safety competence and factors affecting patient safety competence. Any discrepancies between the results obtained by the two researchers will be resolved through discussion or with the involvement of a third reviewer.

Quality assessment

The JBI critical appraisal checklist will be used for a strict quality appraisal process. 32 The objective of the appraisal is to assess a study’s methodological quality and identify any potential bias in its design, conduct and analysis. 29 Two reviewers will independently evaluate the quality of every study included in the analysis. Any discrepancies between the reviewers regarding the risk of bias will be resolved through discussion, with the inclusion of a third reviewer when required. The results of the critical evaluation will be reported through narrative descriptions and a table. The outcomes of the quality appraisal will play a pivotal role in assessing the overall quality and reliability of the included studies. Since this review will encompass peer-reviewed articles, no study will be excluded solely based on its quality rating.

Data synthesis

Due to the expected diversity in research methods and outcome measures, the researchers will employ a narrative synthesis to incorporate the study findings, rather than conduct a meta-analysis. Recognising that individual and organisational factors are associated with patient safety competence, content analysis will be used to categorise the factors influencing clinical nurses’ patient safety competence into two groups: individual and organisational factors. Previous studies on nurses’ competence have examined both individual and organisational factors. 33 34

Patient and public involvement

This study will not include any patient involvement.

Ethical approval was not required for this review as it does not involve the collection of primary population data. The results will be presented at professional conferences and peer-reviewed open-access journals.

supplementary material

Online supplemental file 1.

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

Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2023-080038 ).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

• BMJ Open. 2024; 14(8): e080038.

Review Process File