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Systematic review as a research method in post-graduate nursing education

2016, Health SA Gesondheid

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Systematic review as a research method in post-graduate nursing education

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In South Africa, there appears to be poor understanding about using a systematic review as an acceptable research method in post-graduate nursing education. The lack of understanding may result in research supervisors being unable to guide post-graduate students, such as masters and doctoral students, in using the systematic review methodology in the completion of an academic qualification. Furthermore, they might not be able to assist post-graduate students in completing their studies, or conducting studies, in particular systematic reviews, which are of high quality. Valuable opportunities can thus be missed that might add to the body of knowledge to inform and improve research, education, and clinical practice. This article may set the field for an informed debate on systematic reviews as a useful and acceptable research method to be used by post-graduate nursing students in South Africa. We conclude that a systematic review could be a useful and acceptable method for research in post-graduate nursing education. However, the method's benefits and disadvantages should be considered before a post-graduate student embarks on such a journey.

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Systematic review as a research method in postgraduate nursing education, wilma ten ham-baloyi, portia jordan.

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How to Write a Systematic Review: A Narrative Review

Ali hasanpour dehkordi.

Social Determinants of Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

Elaheh Mazaheri

1 Health Information Technology Research Center, Student Research Committee, Department of Medical Library and Information Sciences, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran

Hanan A. Ibrahim

2 Department of International Relations, College of Law, Bayan University, Erbil, Kurdistan, Iraq

Sahar Dalvand

3 MSc in Biostatistics, Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran

Reza Ghanei Gheshlagh

4 Spiritual Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

In recent years, published systematic reviews in the world and in Iran have been increasing. These studies are an important resource to answer evidence-based clinical questions and assist health policy-makers and students who want to identify evidence gaps in published research. Systematic review studies, with or without meta-analysis, synthesize all available evidence from studies focused on the same research question. In this study, the steps for a systematic review such as research question design and identification, the search for qualified published studies, the extraction and synthesis of information that pertain to the research question, and interpretation of the results are presented in details. This will be helpful to all interested researchers.

A systematic review, as its name suggests, is a systematic way of collecting, evaluating, integrating, and presenting findings from several studies on a specific question or topic.[ 1 ] A systematic review is a research that, by identifying and combining evidence, is tailored to and answers the research question, based on an assessment of all relevant studies.[ 2 , 3 ] To identify assess and interpret available research, identify effective and ineffective health-care interventions, provide integrated documentation to help decision-making, and identify the gap between studies is one of the most important reasons for conducting systematic review studies.[ 4 ]

In the review studies, the latest scientific information about a particular topic is criticized. In these studies, the terms of review, systematic review, and meta-analysis are used instead. A systematic review is done in one of two methods, quantitative (meta-analysis) and qualitative. In a meta-analysis, the results of two or more studies for the evaluation of say health interventions are combined to measure the effect of treatment, while in the qualitative method, the findings of other studies are combined without using statistical methods.[ 5 ]

Since 1999, various guidelines, including the QUORUM, the MOOSE, the STROBE, the CONSORT, and the QUADAS, have been introduced for reporting meta-analyses. But recently the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement has gained widespread popularity.[ 6 , 7 , 8 , 9 ] The systematic review process based on the PRISMA statement includes four steps of how to formulate research questions, define the eligibility criteria, identify all relevant studies, extract and synthesize data, and deduce and present results (answers to research questions).[ 2 ]

Systematic Review Protocol

Systematic reviews start with a protocol. The protocol is a researcher road map that outlines the goals, methodology, and outcomes of the research. Many journals advise writers to use the PRISMA statement to write the protocol.[ 10 ] The PRISMA checklist includes 27 items related to the content of a systematic review and meta-analysis and includes abstracts, methods, results, discussions, and financial resources.[ 11 ] PRISMA helps writers improve their systematic review and meta-analysis report. Reviewers and editors of medical journals acknowledge that while PRISMA may not be used as a tool to assess the methodological quality, it does help them to publish a better study article [ Figure 1 ].[ 12 ]

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Object name is IJPVM-12-27-g001.jpg

Screening process and articles selection according to the PRISMA guidelines

The main step in designing the protocol is to define the main objectives of the study and provide some background information. Before starting a systematic review, it is important to assess that your study is not a duplicate; therefore, in search of published research, it is necessary to review PREOSPERO and the Cochrane Database of Systematic. Sometimes it is better to search, in four databases, related systematic reviews that have already been published (PubMed, Web of Sciences, Scopus, Cochrane), published systematic review protocols (PubMed, Web of Sciences, Scopus, Cochrane), systematic review protocols that have already been registered but have not been published (PROSPERO, Cochrane), and finally related published articles (PubMed, Web of Sciences, Scopus, Cochrane). The goal is to reduce duplicate research and keep up-to-date systematic reviews.[ 13 ]

Research questions

Writing a research question is the first step in systematic review that summarizes the main goal of the study.[ 14 ] The research question determines which types of studies should be included in the analysis (quantitative, qualitative, methodic mix, review overviews, or other studies). Sometimes a research question may be broken down into several more detailed questions.[ 15 ] The vague questions (such as: is walking helpful?) makes the researcher fail to be well focused on the collected studies or analyze them appropriately.[ 16 ] On the other hand, if the research question is rigid and restrictive (e.g., walking for 43 min and 3 times a week is better than walking for 38 min and 4 times a week?), there may not be enough studies in this area to answer this question and hence the generalizability of the findings to other populations will be reduced.[ 16 , 17 ] A good question in systematic review should include components that are PICOS style which include population (P), intervention (I), comparison (C), outcome (O), and setting (S).[ 18 ] Regarding the purpose of the study, control in clinical trials or pre-poststudies can replace C.[ 19 ]

Search and identify eligible texts

After clarifying the research question and before searching the databases, it is necessary to specify searching methods, articles screening, studies eligibility check, check of the references in eligible studies, data extraction, and data analysis. This helps researchers ensure that potential biases in the selection of potential studies are minimized.[ 14 , 17 ] It should also look at details such as which published and unpublished literature have been searched, how they were searched, by which mechanism they were searched, and what are the inclusion and exclusion criteria.[ 4 ] First, all studies are searched and collected according to predefined keywords; then the title, abstract, and the entire text are screened for relevance by the authors.[ 13 ] By screening articles based on their titles, researchers can quickly decide on whether to retain or remove an article. If more information is needed, the abstracts of the articles will also be reviewed. In the next step, the full text of the articles will be reviewed to identify the relevant articles, and the reason for the removal of excluded articles is reported.[ 20 ] Finally, it is recommended that the process of searching, selecting, and screening articles be reported as a flowchart.[ 21 ] By increasing research, finding up-to-date and relevant information has become more difficult.[ 22 ]

Currently, there is no specific guideline as to which databases should be searched, which database is the best, and how many should be searched; but overall, it is advisable to search broadly. Because no database covers all health topics, it is recommended to use several databases to search.[ 23 ] According to the A MeaSurement Tool to Assess Systematic Reviews scale (AMSTAR) at least two databases should be searched in systematic and meta-analysis, although more comprehensive and accurate results can be obtained by increasing the number of searched databases.[ 24 ] The type of database to be searched depends on the systematic review question. For example, in a clinical trial study, it is recommended that Cochrane, multi-regional clinical trial (mRCTs), and International Clinical Trials Registry Platform be searched.[ 25 ]

For example, MEDLINE, a product of the National Library of Medicine in the United States of America, focuses on peer-reviewed articles in biomedical and health issues, while Embase covers the broad field of pharmacology and summaries of conferences. CINAHL is a great resource for nursing and health research and PsycINFO is a great database for psychology, psychiatry, counseling, addiction, and behavioral problems. Also, national and regional databases can be used to search related articles.[ 26 , 27 ] In addition, the search for conferences and gray literature helps to resolve the file-drawn problem (negative studies that may not be published yet).[ 26 ] If a systematic review is carried out on articles in a particular country or region, the databases in that region or country should also be investigated. For example, Iranian researchers can use national databases such as Scientific Information Database and MagIran. Comprehensive search to identify the maximum number of existing studies leads to a minimization of the selection bias. In the search process, the available databases should be used as much as possible, since many databases are overlapping.[ 17 ] Searching 12 databases (PubMed, Scopus, Web of Science, EMBASE, GHL, VHL, Cochrane, Google Scholar, Clinical trials.gov, mRCTs, POPLINE, and SIGLE) covers all articles published in the field of medicine and health.[ 25 ] Some have suggested that references management software be used to search for more easy identification and removal of duplicate articles from several different databases.[ 20 ] At least one search strategy is presented in the article.[ 21 ]

Quality assessment

The methodological quality assessment of articles is a key step in systematic review that helps identify systemic errors (bias) in results and interpretations. In systematic review studies, unlike other review studies, qualitative assessment or risk of bias is required. There are currently several tools available to review the quality of the articles. The overall score of these tools may not provide sufficient information on the strengths and weaknesses of the studies.[ 28 ] At least two reviewers should independently evaluate the quality of the articles, and if there is any objection, the third author should be asked to examine the article or the two researchers agree on the discussion. Some believe that the study of the quality of studies should be done by removing the name of the journal, title, authors, and institutions in a Blinded fashion.[ 29 ]

There are several ways for quality assessment, such as Sack's quality assessment (1988),[ 30 ] overview quality assessment questionnaire (1991),[ 31 ] CASP (Critical Appraisal Skills Program),[ 32 ] and AMSTAR (2007),[ 33 ] Besides, CASP,[ 34 ] the National Institute for Health and Care Excellence,[ 35 ] and the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information checklists.[ 30 , 36 ] However, it is worth mentioning that there is no single tool for assessing the quality of all types of reviews, but each is more applicable to some types of reviews. Often, the STROBE tool is used to check the quality of articles. It reviews the title and abstract (item 1), introduction (items 2 and 3), implementation method (items 4–12), findings (items 13–17), discussion (Items 18–21), and funding (item 22). Eighteen items are used to review all articles, but four items (6, 12, 14, and 15) apply in certain situations.[ 9 ] The quality of interventional articles is often evaluated by the JADAD tool, which consists of three sections of randomization (2 scores), blinding (2 scores), and patient count (1 scores).[ 29 ]

Data extraction

At this stage, the researchers extract the necessary information in the selected articles. Elamin believes that reviewing the titles and abstracts and data extraction is a key step in the review process, which is often carried out by two of the research team independently, and ultimately, the results are compared.[ 37 ] This step aimed to prevent selection bias and it is recommended that the chance of agreement between the two researchers (Kappa coefficient) be reported at the end.[ 26 ] Although data collection forms may differ in systematic reviews, they all have information such as first author, year of publication, sample size, target community, region, and outcome. The purpose of data synthesis is to collect the findings of eligible studies, evaluate the strengths of the findings of the studies, and summarize the results. In data synthesis, we can use different analysis frameworks such as meta-ethnography, meta-analysis, or thematic synthesis.[ 38 ] Finally, after quality assessment, data analysis is conducted. The first step in this section is to provide a descriptive evaluation of each study and present the findings in a tabular form. Reviewing this table can determine how to combine and analyze various studies.[ 28 ] The data synthesis approach depends on the nature of the research question and the nature of the initial research studies.[ 39 ] After reviewing the bias and the abstract of the data, it is decided that the synthesis is carried out quantitatively or qualitatively. In case of conceptual heterogeneity (systematic differences in the study design, population, and interventions), the generalizability of the findings will be reduced and the study will not be meta-analysis. The meta-analysis study allows the estimation of the effect size, which is reported as the odds ratio, relative risk, hazard ratio, prevalence, correlation, sensitivity, specificity, and incidence with a confidence interval.[ 26 ]

Estimation of the effect size in systematic review and meta-analysis studies varies according to the type of studies entered into the analysis. Unlike the mean, prevalence, or incidence index, in odds ratio, relative risk, and hazard ratio, it is necessary to combine logarithm and logarithmic standard error of these statistics [ Table 1 ].

Effect size in systematic review and meta-analysis

OR=Odds ratio; RR=Relative risk; RCT= Randomized controlled trial; PPV: positive predictive value; NPV: negative predictive value; PLR: positive likelihood ratio; NLR: negative likelihood ratio; DOR: diagnostic odds ratio

Interpreting and presenting results (answers to research questions)

A systematic review ends with the interpretation of results. At this stage, the results of the study are summarized and the conclusions are presented to improve clinical and therapeutic decision-making. A systematic review with or without meta-analysis provides the best evidence available in the hierarchy of evidence-based practice.[ 14 ] Using meta-analysis can provide explicit conclusions. Conceptually, meta-analysis is used to combine the results of two or more studies that are similar to the specific intervention and the similar outcomes. In meta-analysis, instead of the simple average of the results of various studies, the weighted average of studies is reported, meaning studies with larger sample sizes account for more weight. To combine the results of various studies, we can use two models of fixed and random effects. In the fixed-effect model, it is assumed that the parameters studied are constant in all studies, and in the random-effect model, the measured parameter is assumed to be distributed between the studies and each study has measured some of it. This model offers a more conservative estimate.[ 40 ]

Three types of homogeneity tests can be used: (1) forest plot, (2) Cochrane's Q test (Chi-squared), and (3) Higgins I 2 statistics. In the forest plot, more overlap between confidence intervals indicates more homogeneity. In the Q statistic, when the P value is less than 0.1, it indicates heterogeneity exists and a random-effect model should be used.[ 41 ] Various tests such as the I 2 index are used to determine heterogeneity, values between 0 and 100; the values below 25%, between 25% and 50%, and above 75% indicate low, moderate, and high levels of heterogeneity, respectively.[ 26 , 42 ] The results of the meta-analyzing study are presented graphically using the forest plot, which shows the statistical weight of each study with a 95% confidence interval and a standard error of the mean.[ 40 ]

The importance of meta-analyses and systematic reviews in providing evidence useful in making clinical and policy decisions is ever-increasing. Nevertheless, they are prone to publication bias that occurs when positive or significant results are preferred for publication.[ 43 ] Song maintains that studies reporting a certain direction of results or powerful correlations may be more likely to be published than the studies which do not.[ 44 ] In addition, when searching for meta-analyses, gray literature (e.g., dissertations, conference abstracts, or book chapters) and unpublished studies may be missed. Moreover, meta-analyses only based on published studies may exaggerate the estimates of effect sizes; as a result, patients may be exposed to harmful or ineffective treatment methods.[ 44 , 45 ] However, there are some tests that can help in detecting negative expected results that are not included in a review due to publication bias.[ 46 ] In addition, publication bias can be reduced through searching for data that are not published.

Systematic reviews and meta-analyses have certain advantages; some of the most important ones are as follows: examining differences in the findings of different studies, summarizing results from various studies, increased accuracy of estimating effects, increased statistical power, overcoming problems related to small sample sizes, resolving controversies from disagreeing studies, increased generalizability of results, determining the possible need for new studies, overcoming the limitations of narrative reviews, and making new hypotheses for further research.[ 47 , 48 ]

Despite the importance of systematic reviews, the author may face numerous problems in searching, screening, and synthesizing data during this process. A systematic review requires extensive access to databases and journals that can be costly for nonacademic researchers.[ 13 ] Also, in reviewing the inclusion and exclusion criteria, the inevitable mindsets of browsers may be involved and the criteria are interpreted differently from each other.[ 49 ] Lee refers to some disadvantages of these studies, the most significant ones are as follows: a research field cannot be summarized by one number, publication bias, heterogeneity, combining unrelated things, being vulnerable to subjectivity, failing to account for all confounders, comparing variables that are not comparable, just focusing on main effects, and possible inconsistency with results of randomized trials.[ 47 ] Different types of programs are available to perform meta-analysis. Some of the most commonly used statistical programs are general statistical packages, including SAS, SPSS, R, and Stata. Using flexible commands in these programs, meta-analyses can be easily run and the results can be readily plotted out. However, these statistical programs are often expensive. An alternative to using statistical packages is to use programs designed for meta-analysis, including Metawin, RevMan, and Comprehensive Meta-analysis. However, these programs may have limitations, including that they can accept few data formats and do not provide much opportunity to set the graphical display of findings. Another alternative is to use Microsoft Excel. Although it is not a free software, it is usually found in many computers.[ 20 , 50 ]

A systematic review study is a powerful and valuable tool for answering research questions, generating new hypotheses, and identifying areas where there is a lack of tangible knowledge. A systematic review study provides an excellent opportunity for researchers to improve critical assessment and evidence synthesis skills.

Authors' contributions

All authors contributed equally to this work.

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Conflicts of interest.

There are no conflicts of interest.

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Health SA Gesondheid (Online)

On-line version issn 2071-9736 print version issn 1025-9848, health sa gesondheid (online) vol.21 n.1 cape town 2016, http://dx.doi.org/10.1016/j.hsag.2015.08.002 .

Systematic review as a research method in post-graduate nursing education

Wilma ten Ham-Baloyi * ; Portia Jordan

Nelson Mandela Metropolitan University, Department of Nursing Science, Port Elizabeth, South Africa

Keywords: Critical interpretive synthesis, Methodology, Post-graduate nursing education, Research, Systematic review

1. Introduction

A 'systematic review' refers to a literature review associated with a clearly formulated research question that uses systematic explicit methods to identify, select, and critically appraise relevant research from previously published studies related to the question at hand (The Cochrane Collaboration, 2005). The systematic review process employs literature review methods to select only those studies that meet specific criteria which reasonably confirm the rigour of the 'evidence' produced by a previously published study. The primary characteristic of a systematic review is that it uses a rigorous set of criteria by which to appraise the reliability and validity of previously published research.

Systematic reviews are increasingly being used as a preferred research method for the education of post-graduate nursing students (Bettany-Saltikov, 2012; Sambunjak & Puljak, 2010) as these reviews provide a mechanism for identifying the most robust evidence-based research from among the range of research studies being published (Lam & Kennedy, 2005). As a result, a systematic review plays an increasingly important role in formulating evidence-based nursing practice by including only the highest quality evidence for the development of best-practice guidelines, and to better direct nursing practice (Dixon-Woods et al., 2006; Scott et al., 2007).

A strong international community of discourse currently exists regarding the use of systematic reviews as a research method for master nursing students and this method is increasingly being used as an acceptable method for clinical doctorate students owing to its evidence-based nature, and its results being relevant for clinical practice (Kung et al., 2010). Publishing a systematic review or conducting a high-quality integrative literature review as part of a doctoral is, however, not yet accepted (Olsson, Ringnér, & Borglin, 2014; Sambunjak & Puljak, 2010) as the doctoral degree holds expectation of knowledge discovery, but not necessarily synthesis and application of knowledge.

Globally, ensuring high quality of post-graduate nursing education is the priority of many organisations. For example, one of the aims of the International Network for Doctoral Education in Nursing (INGEN) is to enhance doctoral education by promoting networking between doctoral educators to address issues of shared interest globally (The Johns Hopkins University School of Nursing, 2015, and the Sigma Theta Tau International has a centre for excellence in nursing education, including post-graduate nursing education (Sigma Theta Tau International, 2015). In South Africa, clear post-graduate requirements exist, and the need to generate an increased number of masters and doctorates as well as postgraduate research supervision, increases. The Academy of Science in South Africa (ASSAF) concurs in stating that a quality PhD should enhance the student's systematic understanding of the field of study as well as the research methods associated with the field, have made a contribution through original research, and should be able to critically analyse, evaluate and synthesise complex ideas (ASSAF, 2010). This is in line with the National Qualification Framework (NQF)'s level descriptors for Masters (NQF level 9) and PhD (NQF level 10), which outlines the abilities of problem solving, in-depth knowledge about the topic researched, and the research method (South African Qualifications Authority, 2012). A systematic review could be a good research method to be used for post-graduate education because it not only enhances problem solving by using critical and analytical thinking and acquiring in-depth knowledge of a variety of research methods, but it can provide opportunities for networking by contacting different authors of publications nationally and globally (Sambunjak & Puljak, 2010). A systematic review is a cost-effective research method which does not require a lengthy ethical approval process, and may generate more high-quality masters and doctoral graduates who will fulfil the need for postgraduate education and supervision (Academy of Science in South Africa, 2010). However, in South Africa there is little understanding of the systematic review process and its scientific rigour as a research method in post-graduate nursing education. There exists only a limited research community of nurse educators who share a common understanding of systematic review methods, who can act as post-graduate research supervisors and mentors (Boland, Cherry, & Dickson, 2008). Because of this limited availability, missed opportunities prevail for adding to the body of evidence-based nursing science and practice, including the development of robust nursing practice clinical guidelines to inform clinical practice, which is fundamentally based on a systematic review (Hemington & Brereton, 2009).

As a result of the relative newness of the systematic review process in post-graduate nursing education in South Africa, there exists a paucity of information and clear understandable guidelines to produce a rigorous systematic review. This article aims to provide a clear roadmap for conducting a systematic review, as well as discussing its potential and limitations for use by post-graduate nursing students. 'Post-graduate nursing students' in this context refers to masters and doctoral students who conduct research at an academic institution towards obtaining an academic qualification. Cognisance is taken of a clinical doctorate, but in South Africa, obtaining clinical doctorates is not general practice.

2. Nursing research methods

Nursing research dates as far back as the 1850s when Florence Nightingale identified problems in nursing practice and began to produce a systematic collection of data to address these problems (Cantelon, 2010; Moule & Goodman, 2009).

In traditional nursing research, which is grouped among other social science research disciplines, opinions and beliefs about phenomena are referred to as 'statements'. Each statement holds a knowledge claim which is linked to a specific reality (Mouton & Marais, 1990). When critically examining these statements, one could question the objective basis on which they were made (Hancock, 2002; Mouton & Marais, 1990). Different approaches have been used to validate the truth in such statements, for example, personal preferences and feelings, authoritative position, and casual observation (Burns & Grove, 2013; Mouton & Marais, 1990:5-6). However validation is attempted, these methods remain subjective, and subject to change based on idiosyncratic factors. As a result, the need has arisen for more rigorous research methods defined as "process[es] that involve obtaining scientific knowledge by means of various objective methods and procedures" (Welman, Kruger, & Mitchell, 2012).

In nursing research, qualitative research methods have long been used as the preferred model for social and behavioural science enquiry (Lincoln & Guba, 1985). According to Holloway and Fulbrook (2001), qualitative research is the preferred research method for nurses and midwives because it is a 'human-centred'" and holistic approach that is consistent with the philosophical underpinnings of the nursing profession. In the past twenty years, practice and evidence-based clinical decision-making has become a central tenet that guides clinical practice in healthcare institutions and frames the design of health services research (Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000:1).

The concept of evidence-based practice has increased the awareness to use various pieces of evidence and/or research, other than only using qualitative or quantitative research paradigms. Researchers are increasingly using evidence from previously conducted studies to inform their own research question (the 'why' of the statement). Evidence can be ranked according to the hierarchy of evidence ( Fig. 1 ), where different types of evidence are recognised. Systematic reviews and meta analyses in studies using randomised controlled trials (RCTs) are considered superior in the hierarchy of evidence-based research, while qualitative case studies and expert opinions occupy the lowest rung on this hierarchical ladder (Evans, 2003; Frymark et al., 2009).

It should be noted that an RCT deemed to have strong internal validity (established a statistically significant causal link between intervention and outcome) may have weak external validity (its applicability across settings and populations) when compared to descriptive studies (Evans, 2003; Melnyk, 2004). Inherent in this rating hierarchy is the belief that systematic literature reviews produce the highest level of evidence (LoBiondo & Haber, 2010). The preference to include the so-called high ranking types of studies on the hierarchy of evidence in systematic reviews is evident. Systematic reviews increasingly include a component of meta-analysis, which refers to using statistical techniques to synthesise the data from included studies into a "quantitative estimate" or "summary effect size" (Petticrew & Roberts, 2006). However, this is only applicable when quantitative studies are included in the review. When including qualitative studies, a qualitative approach to synthesise the extracted data may be more applicable (Thomas & Harden, 2007).

While the conduct of original research is essential for producing new data, insights, and evidence, the protocols associated with the systematic review process informs the researcher about what is known, how the evidence was produced, and how it may vary across studies based on study populations and contextual factors (Kitchenham, 2004).

Considering the historical background to nursing research, the hierarchy of evidence and the need for the inclusion of high-quality research to inform education, research and practice, a paradigm shift is required to use a diversity of research paradigms, including systematic reviews. An increased awareness of the systematic reviews to inform education, research and practice is evident among researchers.

3. Systematic reviews as research methodology

In order to understand systematic reviews as a research methodology, a definition, followed by the steps to follow when conducting a systematic review, is provided.

3.1. Defining a systematic review

A systematic review is defined as "[a] review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyse data from the studies that are included in the review. Statistical methods (meta-anal-ysis) may or may not be used to analyse and summarise the results of the included studies" (The Cochrane Collaboration, 2005).

According to Gough, Oliver, and Thomas (2012), a systematic review is a research method that is undertaken to review research literature, using systematic and rigorous methods. Systematic reviews are often referred to as 'original empirical research' because they review primary data, which can be either quantitative or qualitative (Aveyard & Sharp, 2011). Systematic reviews can be considered as the 'gold standard' for reviewing the extant literature on a specific topic as it synthesises the findings of previous research investigating the same or similar questions (Boland et al., 2008).

3.2. Systematic, traditional and expert reviews

According to Gough et al. (2012), systematic reviews employ explicit, rigorous, and accountable methods to inform new research questions. Reviewing research systematically involves three key activities: identifying and describing previously published relevant research; critically appraising the research methods, and bringing together the aggregated findings into a synthesis of research findings. Systematic reviews are more rigorous than a traditional literature review because they use a systematic approach to search, select, and appraise the produced evidence.

A traditional literature review often presents a summary of published research related to a topic of interest without a sorting based on the quality or rigour of the study design and methods identified. It summarises all published studies on the topic, and leaves it to the reviewer to determine the study's quality on a study-by-study basis. The traditional literature review uses often unsystematic and objective methods, and is not based on rigorous criteria and tools such as a systematic search strategy, algorithms to critically appraise identified articles, and systematic methods to analyse and synthesise the data, and therefore it is not possible to assess the quality or rigour of the methods of the included studies. A traditional review is therefore more prone to bias than a systematic review, including selection bias, when only studies which are published are selected, and language bias, when studies are selected based on their language of publication, such as English (Aveyard & Sharp, 2011; Gough et al., 2012).

There may be great insight and knowledge transferred in both a traditional review and a systematic review, but the lack of transparency about the traditional review process methods calls its findings into question. Expert reviews often lack: perspective and conceptual framework, inclusion criteria for evidence, nature of search for evidence, quality and relevant appraisal of the evidence, and method of synthesis of the evidence, methods which are typically considered when performing a systematic review (Evidence for Policy and Practice, 2010; Gough et al., 2012).

Traditional literature reviews are all too often restricted to literature already known to the authors, or literature that is found by conducting little more than cursory searches. This means that the same studies are frequently cited, and this introduces a persistent bias to literature reviews. Systematic reviews help reduce implicit researcher bias through the adoption of broad search strategies, predefined search strings, and uniform inclusion and exclusion criteria; systematic reviews effectively force researchers to search for studies beyond their own subject areas and networks (Mallett, Hagen-Zanker, Slater, & Duvendack, 2012).

The steps of the systematic review are discussed next.

3.3. Steps of the systematic review

Researchers differ on the number of steps taken when conducting a systematic review. However, the sequence of the steps is similar. Systematic reviews should be carried out prospectively and comprehensively, using an explicit algorithm that specifies the protocols that are guiding the research, for a well-defined research question or questions. The steps of systematic review are structured and well-defined and various frameworks, for instance the Cochrane Collaboration, Joanna Briggs Institute, can be used to guide the systematic review process. When conducting an integrative literature review, a structured framework, for instance one indicated by Whittemore and Knafl (2005) can be used to guide the process. The five steps of the systematic review are discussed below.

Step 1: Review question - The question(s) that are to guide the systematic review must be answerable and searchable and therefore should include the following variables: population of interest (P), intervention (I), comparative interventions (C) and the outcomes of interest (O) known as the PICO format (The Cochrane Collaboration, 2005). Alternatively, PICOT (to assess effect and timeframe) (Melnyk & Fineout-Overholt, 2005) or PICOC (to assess the context) can be used (The Cochrane Collaboration, 2005). The PICO, PICOT or PICOC methods help to specify the right question(s), which is a requirement for finding robust studies to produce valid and reliable results. Depending on the purpose of the review, the reviewer can either choose the PICO, PICOT or PICOC format. During the review question formulation process, these methods assists in identifying the subsequent search words for the literature review. Systematic reviews are often registered with systematic review research networks, for instance, the Cochrane Collaboration (medicine) or the Campbell Collaboration (education and law-related reviews) or the Joanna Briggs Institute. The aims of register reviews are to reduce bias of the review, to reduce duplication, to keep systematic reviews updated (The PLoS Medicine Editors, 2011) and to provide a library with all systematic reviews related to a specific profession. For the purpose of post-graduate nursing studies, registering of the systematic review with a network is optional (Mallett et al. 2012).

Step 2: Searching the literature - This step involves the formulation of a search strategy, which includes inclusion and exclusion criteria, keywords, sources of evidence, the documentation of the search, and selection of the research reports to be included. Librarians can play a crucial role in many stages of a systematic review, especially when searching the literature. Their roles are multiple and involve applying their knowledge based on experience and training and their abilities to develop search strategies, including the choice of keywords and databases (McGowan & Sampson, 2005) but are not limited to organising of data and analysing of data to be included in the search (Harris, 2005). A librarian should therefore be involved to help with expanding the search, ensuring a comprehensive search which increases the robustness of the entire study (Kitchenham, 2004). The selection of relevant articles is based on two concepts: sensitivity and specificity. To ensure sensitivity, the total number of studies that meet the inclusion criteria of the search strategy should be recorded, although some will later be discarded owing to a lack of relevancy. To ensure specificity, non-relevant studies should be excluded in the next phase. The relevance of some studies can be determined from the title (and abstract if available) but in other cases the decision can only be made after the full text article has been reviewed. Throughout the search, all studies reviewed should be recorded (Centre for Evidence-Based Conservation, 2009; Centre for Review and Dissemination, 2009).

Step 3: Critical appraisal - The next step is an in-depth appraisal of the selected studies so that reported research not meeting the inclusion criteria, including the strength of the evidence, can be excluded from the final sample (Centre for Evidence-Based Conservation, 2009). A variety of critical appraisal instruments could be used to appraise the studies in a systematic review. However, a disadvantage of critical appraisal instruments is that there is not one single tool that can be fully applied to all studies (CRD, 2009). Tools that could be used for different types of studies can include the following: AMSTAR tool for the 'assessment of multiple systematic reviews' (Shea et al., 2007) the evaluation tool for quantitative research studies (Health Care Practice Research and Development Unit, 2005) the MAStARI critical appraisal tools for randomised control or pseudo-randomised trial (Johanna Briggs Institute, 2011), Critical appraisal instrument for qualitative research studies (CASP, 2006), the John Hopkins nursing evidence-based practice (JHNEBP) or the research evidence appraisal tool (Newhouse, Dearholt, Poe, Pugh, & White, 2007:210). As it is sometimes challenging to obtain information concerning the validity and reliability of most of the critical appraisal instruments, the decision regarding which critical appraisal instruments to use, was made based on the criterion that all instruments should fit the type of study used, as this strengthens its internal validity (Akobeng, 2005). The study appraisal criteria should be explicit and specified at the onset of the critical appraisal process, and ensure appropriateness for the research methods being reviewed (Centre for Reviews and Dissemination, 2009). An internally consistent review is achieved when two or more reviewers agree on the robustness of the study being reviewed, that is, when inter-rater reliability is high (Burns & Grove, 2013). The critical appraisal process should be done by the researcher and an independent reviewer, using the selected appraisal tools. Once the critical appraisal process is completed, consensus should be reached between the researcher and the reviewer. A decision, based on the appraisal results should then be reached on the inclusion or exclusion of the appraised studies.

Step 4: Data extraction - According to the CRD (2009:28), data extraction is "the process by which researchers obtain the necessary information about study findings from the included studies." Data extraction is the step in which all relevant findings meeting the selection criteria are aggregated to form the body of evidence regarding the research question(s) posed. Various data extraction tools, for instance the Joanna Briggs Institute tools, are available to perform the data extraction.

Step 5: Data synthesis - Data synthesis is the stage in the review process when studies meeting inclusion criteria are summarised to form the outcome of the systematic review (Centre for Reviews and Dissemination, 2009; Kitchenham, 2004). The aims of the data synthesis are to aggregate study findings for all studies meeting the inclusion criteria; assess the strength of the study findings using agreed upon, specified assessment criteria; and to summarise the results in a systematic, evidence-based literature review document (Academy of Nutrition and Dietetics, 2012; Centre for Reviews and Dissemination, 2009). Syntheses can use various analytic frameworks, namely meta-ethnography, meta-analysis, thematic synthesis, or framework synthesis. The method used will depend on the types of evidence collected and appraised during the process. Depending on the heterogeneity or homogenous nature of the data extracted, the syntheses can be concluded and presented either thematically or on a forest plot or scatter diagram.

4. Systematic reviews and their use in post-graduate nursing education

To answer whether a systematic review can be used in post-graduate nursing education, the question of whether and how systematic reviews will make a substantive contribution to the body of clinical nursing knowledge must be answered. Is a systematic review a legitimate form of research? A current debate involves claims that a systematic review is too large and complex to constitute an individual masters or PhD level study. The sceptics argue that a rigorous systematic review should be conducted by a research team (Louw & Keller, 2006). Furthermore it is debated that systematic reviews are not appropriate for qualitative studies. Another argument posits that systematic reviews should not be encouraged as they are not primary research, which involves conducting an original study including specifying a study design, collecting primary data, data analysis, and reporting findings. Finally, some academic naysayers argue that systematic reviews do not teach students the rigours of conducting a primary research project (Boland et al., 2008).

On the other hand, it can be argued that a systematic review involves the collection, analysis and interpretation of data, although the data derive from secondary sources (Kitchenham, 2004). However, some do not agree with this argument as postgraduate students undertaking systematic reviews use a systematic approach which is similar to the process of primary research (Hemington & Brereton, 2009). This rigorous process is evident in the steps required by a systematic review previously discussed.

As in a primary research study, a systematic review requires that a clear research question be posed (Boland et al., 2008). As in primary research, the development of a rigorous proposal is a vital element of a systematic review. The systematic review proposal provides the plan by which the evidence-based review will be conducted and ensures the appropriate methodological rigour will be applied (Hemington & Brereton, 2009). It should also be noted that the review proposal is developed in addition to the research proposal that is formally submitted to the research supervisor and institutional structures when doing it for a formal qualification or postgraduate nursing research.

In primary research, data is collected from the target population once a sampling plan has been devised and approved. However, in a systematic review, data from some number of previously conducted studies that have met a rigorous set of selection criteria is "collected" and analysed with reference to the specified research question(s) posed by the student researcher (Hemington & Brereton, 2009; The Cochrane Collaboration, 2005).

A systematic review critically extracts and appraises data, which equates to data collection and analysis in primary research. In primary research, data synthesis, which is a comparable process to a systematic review, can employ either qualitative or quantitative data synthesis methods. In primary research, data is presented in the form of qualitative thematic statements or graphic presentation of quantitative data. In a systematic review, data is aggregated and presented as a meta-synthesis, meta-analysis, forest plots, or scatter diagrams, all of which are produced through a rigorous set of scientific protocols (Centre for Reviews and Dissemination, 2009; The Cochrane Collaboration, 2005).

Systematic reviews are regarded as a critical component of the development of evidence-based clinical practice; they support evidence-based practice based on clinical expertise and patient values (Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000). The current need arises to develop additional evidence-based protocols beyond RCTs and case-control studies in the context of clinical nursing practice. We suggest that systematic reviews be conducted in non-traditional ways that push beyond the Cochrane systematic process, which is heavily biased towards RCTs, to find new ways to provide a more rigorous assessment of qualitative research studies (Hemington & Brereton, 2009).

4.1. The debate continues:which side are you on?

Considering the different view presented, there is sufficient evidence to support systematic literature reviews as an approved research method in post-graduate nursing education and research, which will contribute to students' competencies in undertaking rigorous research in nursing (Olsson et al., 2014). At a masters degree level, students are expected to begin the process of engaging in critical thinking with regard to the research enterprise, including the ability to identify, conceptualise, design, and implement scientific enquiry that addresses complex and challenging clinical problems. On a PhD level, students are expected to make unique contributions to expanding the body of knowledge in clinical nursing in line with standards set by the National Qualifications Framework (NQF) of the South African Qualifications Authority (SAQA) (SAQA, 2012). At the graduate level, students are expected to engage in advanced meta-cognitive thought processes including abstract theorising, which only competencies in systematic reviews can offer (Khan, Kunz, Kleijnen, & Antes, 2003). With this in mind, let us consider the advantages and disadvantages of doing a systematic review at postgraduate level.

4.2. Advantages and disadvantages ofdoing a systematic review at postgraduate level

Although systematic reviews have become a major area of methodological development and have created interest in the academic arena, it is essential to consider the advantages and disadvantages in relation to postgraduate nursing research. A list of the advantages and disadvantages, gathered from anecdotal evidence and the researcher's experiences, are listed in Table 1 . Some of the advantages and disadvantages may be similar to those for master and PhD students conducting primary research, but these advantages and disadvantages are commonly observed by the researchers when students do systematic reviews.

Similar advantages and disadvantages have been noted in the literature. Advantages such as students learning to develop a well-defined review question was mentioned by Olsson et al. (2014) who indicated the advantages of using a systematic review to refine and enhance a research question. Development of critical appraisal skills was mentioned by Hemington and Brereton (2009) who noted that critical appraisal skills are not difficult to develop as they use common-sense thought processes. Researchers at King's College London found that systematic reviews provide a planning function in the interpretation of new research results (2014). Systematic reviews can identify where evidence is lacking on a certain topic and thus make recommendations for closing the knowledge gap.

Disadvantages such as time and capacity contraints were confirmed by Bhavsar and Waddington (2015) who indicated that conducting a systematic review is time-consuming, complex, and process-orientated. The inability to publish systematic reviews in preferred journals was confirmed by Olsson et al. (2014). They stated that a lack of published systematic reviews may be due to the general view that a systematic review is 'less worthy' research for PhD students than studies based on primary data collection methods. However, PhD students can benefit from conducting and publishing a systematic review as part of their doctoral studies, which can be incorporated as a phase within the doctoral studies. Conducting a systematic review, as part of the bigger study, can give PhD candidates the opportunity to engage in a variety of methodologies and content of primary studies. They will also learn to solve problems by using critical and analytical thinking, and this is considered as a well-sought-after skill required for future researchers (Sambunjak & Puljak, 2010). Furthermore, by using the results of the systematic review to develop interventions which can be implemented (Mallett et al. 2012) the student can make a unique and significant contribution to the field of nursing.

4.3. Criteria for postgraduate nursing students who wish to undertake a systematic review

Post-graduate nursing students wishing to conduct a systematic literature review will need to adhere to specific protocols and inclusion criteria in order to conduct an acceptable, rigorous, and robust systematic review. These criteria are listed in Table 2 .

Both the disadvantages and advantages and the criteria for conducting a systematic review should be considered before even commencing a systematic review. For example, one should consider whether the educational institution is able to provide the resources such as accessible electronic databases to conduct a comprehensive search, a librarian with experience with literature search strategies. The budget for the review should also be considered with regard to the independent reviewer, the librarian and eventually a statistician. Educational institutions should be able to provide funding for the costs when a limited number of journal articles have to be ordered via their inter-library loan services. When deciding to include quantitative studies only, thus requiring a quantitative synthesis using statistical analysis, these services should be covered in the fees of the post-graduate student, and not have to be paid additionally. Educational institutions requesting postgraduate students to conduct systematic reviews as part of their postgraduate degree should have consultants, librarians, independent reviewers and statisticians skilled in systematic reviews available for the student at no additional cost. Furthermore, suitable supervisor(s) should be identified, based on the supervisor's available time and experience as the supervisor is often expected to assist the student during the search, the appraisal, and data extraction and synthesis processes, which require experience, and can take up considerable time.

The capacity of the student (in terms of cognitive ability, administrative skills and computer literacy skills) and whether the student is willing to take up the often long and lonely process of the systematic review should be considered. Before commencing the review, an interview with the student and the supervisor could be held to address issues of computer literacy, what a systematic review contains, and the advantages and disadvantages of conducting a systematic review. The criteria which are mentioned in Table 2 could also be included. The standards for Initiating a Systematic Review by the Institute of Medicine could be used and considered by the supervisor and/or postgraduate student to obtain an overview of what is expected when initiating a systematic review (Institute of Medicine, 2011). Furthermore, disadvantages and advantages outlined in Table 1 could be discussed. A discussion/interview could be helpful so that the student can make an informed decision whether to commmence a systematic review or not. Finally, educational institutions requesting postgraduate students to conduct a systematic review as part of their degree should include the following in their curriculum with regard to research methodology so that students could acquire the competencies needed to conduct a systematic review, an introduction to systematic reviews and meta-analyses, and short learning courses on the steps of the systematic review as well as how to conduct these. We think considering the above-mentioned issues will enhance the quality of both the process of supervision and the review itself.

5. Conclusion

This paper has discussed the use of the systematic review in post-graduate nursing education. A systematic review could be a valuable research method to be used by postgraduate nursing students, by which evidence is combined in non-traditional ways, but advantages should be weighed against disadvantages and certain criteria to be able to conduct a systematic review should be considered. This paper could be used to assist the supervisor to use systematic reviews as an appropriate method in postgraduate nursing education method and to identify nursing postgraduate students who will be able to conduct this type of research. By providing information regarding the use of the systematic review in postgraduate nursing education, this paper aimed to enhance the conduct of high-quality systematic reviews by post-graduate nursing education students, which can have a positive impact on patient care.

Acknowledgements

The authors would like to thank Prof Pamela Hanes for editing the manuscript.

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Received 5 February 2015 Accepted 20 August 2015 Available online 1 October 2015

* Corresponding author. Tel.: +27 (0)41 504 2959; fax: +27 (0)41 504 2616. E-mail address: [email protected] (W. ten Ham-Baloyi).

Open access
Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

Jacqueline Maria Dias 1 ,
Muhammad Arsyad Subu 1 ,
Nabeel Al-Yateem 1 ,
Fatma Refaat Ahmed 1 ,
Syed Azizur Rahman 1 , 2 ,
Mini Sara Abraham 1 ,
Sareh Mirza Forootan 1 ,
Farzaneh Ahmad Sarkhosh 1 &
Fatemeh Javanbakh 1

BMC Nursing volume 23 , Article number: 322 ( 2024 ) Cite this article

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Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

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Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n = 24) were females and 20% ( n = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n = 6) were UAE nationals, 53% ( n = 16) were from Gulf Cooperation Council countries, while 20% ( n = 6) hailed from Africa and 7% ( n = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table 1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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PERSPECTIVE article

The potential of virtual healthcare technologies to reduce healthcare services’ carbon footprint.

1 Faculty of Medicine and Health, University of New England, Armidale, NSW, Australia
2 New England Virtual Health Network (NEViHN), Armidale, NSW, Australia
3 School of Nursing, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia

The COVID-19 pandemic demonstrated the potential to reduce our carbon footprint especially by reducing travel. We aim to describe healthcare and health education services’ contribution to the global climate emergency and identify the need for increased use of virtual health service delivery and undergraduate/postgraduate education to help reduce the impact of health service and health education delivery on the environment. Health care services, as one of the largest contributors to carbon emissions, must take steps to rapidly reduce their carbon footprint. Health services have unfortunately paid little attention to this issue until recently. Virtual healthcare and education have a valuable role in transition to a net carbon-zero outcome. Given the increasing use of and satisfaction with virtual health services such as telehealth, and the increase in virtual education opportunities, it is important that a concerted effort is undertaken to increase their use across health services and education in the future.

Introduction

The potential of virtual healthcare technologies to reduce healthcare services’ carbon footprint.

Healthcare services have become one of the largest contributors to greenhouse gas emissions (GHG) globally accounting for 4.4% of net GHG emissions ( 1 , 2 ) as modern medical technology has become carbon emission intensive ( 3 ). Unfortunately, the healthcare sector continues to contribute significantly to GHGs ( 4 ). In fact, the healthcare sector has a significant and growing carbon footprint through energy consumption, transport, and product manufacture, use, and disposal ( 2 ). Unfortunately, healthcare services have only recently taken notice of this issue ( 2 ), and thus lag other sectors in taking action to reduce their climate impact ( 5 ). Tertiary education institutions, where most health professional education is delivered, are also high contributorus to GHGs mostly through travel, electricity and water consumption, and paper usage ( 6 ). Given the need for most health students to travel to attend mandatory clinical placements, which for some students amounts to large distances, is a growing concern.

Given the serious impacts of climate change on human and animal health and on the environment, it is timely to reflect on the carbon footprint of health and health education services and take action to reduce this footprint. It is paradoxical that the health sector, responsible for improving health outcomes, also directly contributes to poor health outcomes through excessive carbon emissions. The COVID-19 pandemic dramatically changed the way healthcare services and health education are delivered including an increased use of virtual technologies, especially telehealth, in place of face-to-face appointments and online teaching in place of face-to-face teaching. Telehealth services, which include telephone and video consultations as well as digital monitoring devices, also have benefits for the consumer. Travel costs and time away from home/work/family are reduced, access to services, especially specialist services for people living in rural and remote areas, is enhanced, chronic conditions are better managed as telehealth makes regular follow-up possible, wait times to see specialists are reduced, readmissions are decreased, and exposure to other patients and the general public in waiting rooms and during travel is reduced ( 7 , 8 ). In addition, given that evidence suggests virtual student education has similar outcomes to real-life clinical placements ( 9 ), efforts need to be made to increase these opportunities for students.

Virtual health as a strategy to reduce the health service carbon footprint

Among the contributors to health’s carbon footprint is the use of road and air travel for patients to attend face-to-face healthcare consultations, and travel by staff to consult with patients in rural and remote locations including their home, and to attend meetings ( 4 ). Experiences arising from the COVID-19 pandemic provide important data that demonstrates how health services’ contribution to GHGs can be reduced. During the pandemic, the use of virtual health technologies such as telehealth (both video and telephone consultations) increased dramatically ( 10 ) and subsequent research has shown that virtual healthcare not only offers a satisfactory alternative to face-to-face consultations but also reduces the need for patients (and providers) to travel ( 11 ). Tsagkaris et al. ( 3 ) claim important learnings from the COVID-19 pandemic include that virtual healthcare technologies such as telehealth offer effective alternatives to face-to-face healthcare visits, reducing the need for patients to travel to attend health consultations and reducing environmental costs ( 4 ). Reducing unnecessary patient travel has been identified as an effective way of reducing the carbon footprint of health services ( 12 ). Telehealth services such as video and telephone consultaions and in-home digital monitoring devices offer a means of achieving this outcome.

Telehealth (also called telemedicine) is a recent development. It describes various forms of remote consultation that can encompass a range of digital tools including both video and telephone consultations and digital monitroring devices ( 13 , 14 ). A recent review highlighted issues around accessibility and establishing a therapeutic relationship as among the major concerns in the use of video abd telephone telehealth platforms ( 14 ). There is evidence to suggest that video supported telehealth is preferred over telephone consultations and that telehealth is rated as more effective than telephone consultations by patients ( 15 ). Telephone consultations however generally require a lower level of digital literacy and may represent enhanced accessibility over other methods for remote consultations ( 14 ). Overall, telehealth has been viewed satisfactorily by patients ( 16 , 17 ) with benefits including less travel, less time away from home and work, and lower costs ( 18 ).

Other virtual healthcare innovations such as digital devices (including wearable and implantable devices, remote imaging, and mobile apps), allow patients to be assessed and monitored effectively at home ( 1 , 4 , 19 , 20 ). These alternative means of health assessment and monitoring, and healthcare delivery offer potential to reduce the carbon footprint of healthcare services, by reducing the need for patients and staff to burn fossil fuels while traveling to attend healthcare consultations and home or clinic visits ( 18 ). There is also a likely reduction in the scope of emissions, associated with disposables and consumables ( 12 ), with remote consultations. The environmental benefits of the reduction of travel were demonstrated during the COVID-19 pandemic when an 8.8% reduction in global emissions reported in the first half of 2020 compared to the same period of 2019 ( 21 ). While there have been some concerns raised about the use of virtual health technologies acceptance, use of virtual health is increasing ( 18 , 22 ).

Potential for virtual health undergraduate and postgraduate student clinical placements to help reduce the carbon footprint

There is an urgent need to develop more sustainable health education practices to help reduce climate change. Unfortunately, it appears that while health educators have the knowledge to do this, they lack the pedagogical expertise to teach this information ( 10 ). To address this issue, a recent Australian study identified the need to embed sustainable health education, policy and practice using “…an evidence based, interdisciplinary whole health and tertiary education approach” (p. 325) ( 23 ). Most health professional training programs require students to undergo workplace training under the supervision of an experienced educator/clinician. Nursing regulatory bodies in the United Kingdom and United States have already supported the replacement of some face-to-face clinical placements with virtual simulation ( 24 ). Virtual simulation activities have the potential to reduce the need for travel to attend clinical placements hence reducing GHG emissions and reducing student costs.

Evaluations of virtual simulation placements in nursing are positive with a recent study finding that the virtual clinical replacement experience was statistically significant reporting greater confidence in areas such as patient safety, communication, and leadership, as well as greater perceived support in the workplace ( 9 ). The use of virtual simulation with medical students has also been positive with students reporting being better prepared for the clinical environment ( 25 ). Virtual technologies offer an adjunct or even an alternative to clinical placements that can help reduce the health services’ carbon footprint.

Evidence that reduced travel leads to reduced GHG emissions

A Spanish study by Morcillo Serra et al. ( 26 ) found that 640,000 digital consultations and 3,060,000 medical reports downloaded remotely by patients during the COVID-19 pandemic in 2020 avoided an estimated 6,700 net tons of CO 2 emissions. That study demonstrates the potential reduction in GHG that can be achieved through the increased use of virtual health. Numerous studies have been recently conducted that demonstrate similar reductions if virtual health was used as an alternative to traditional consultations ( 4 , 27 ). While there is the potential for increased GHG emissions associated with use of electricity used to power increased digitalisation of healthcare services, often overlooked in many studies conducted to date, these increases were found to be far less than those associated with patient and staff travel ( 4 , 27 ). In one study that did include assessment of energy used to run equipment for telehealth, it was estimated that telerehabilitation services resulted in carbon cost savings when the patient travels over 7.2 kms to attend the appointment ( 28 ). It is important to remember that the different virtual technologies use differing amounts of GHGs with video enhanced telehealth more GHG emission intensive than telephone calls ( 4 ). The review by Purohit et al. ( 4 ) reveals the importance of considering the medical specialty, geography, and time. It seems that the higher the level of specialization corresponds with a greater reduction in travel, since specialized centres serviced a wider geographic region. For example, studies of telephone consultations in place of face-to-face visits have been evaluated. A study of post-renal transplant services telephone follow-up appointments for 30 patients resulted in a saving of 39.3 km travel equating to a saving of 8.00 kg CO 2 per consultation ( 29 ), and a study of pre-surgical telephone consultations in Texas, where large distances were traveled to the one specialist service, resulted in carbon footprint reductions of 271 kg CO 2 per consultation ( 30 ). Similarly, evaluations of video conference CO 2 savings have also been positive. For example, the use of videoconferencing for telerehabilitation in Sweden which included the energy consumption of the equipment as well as travel savings demonstrated that 238 apointments resulted in a saving of 82,310 km giving a range of 87.5–175 kg CO 2 per consultation ( 28 ).

Need for urgent action

A recent editorial ( 31 ), identified the need for urgent action and proposed we are facing a global health emergency. Health services must not only deliver healthcare to those made ill from the climate crisis, but also radically reduce their own emissions ( 2 ). Health professionals and educators must take an urgent role in developing and utilising strategies that help reduce the health services’ and health education carbon footprint. In Australia, where health travel is extensive due to the size of the country, it is even more urgent to tackle this wicked problem. Outside of emergency responses, telehealth has shown to have similar outcomes to standard consultations for many health conditions including diabetes and cardiac conditions ( 27 ). Greater implementation of virtual healthcare and education technologies offers an opportunity to reduce the need for travel and in turn, reduce the healthcare carbon footprint. Efforts are needed to ensure research approaches, education and policy are developed to facilitate greater use and evaluation of virtual healthcare services. Similarly, educators need to look for opportunities to reduce the need for travel, especially travel over large distances, for students to attend clinical placements or fieldwork requirements. The potential for carbon emission reductions in this area is huge.

Health services, as every sector of society, have a responsibility to take action to reduce the impacts of humans on the environment. Virtual healthcare and education services have a valuable role in transition to net carbon-zero healthcare/education services for the future. As the current evidence suggest a strong relationship between carbon footprint reductions and average distance travelled, countries with larger distances to travel for face-to-face consukltations may benefit more by enhancing their use of telehealth services for patient consuktations where possible. Given the increasing use of and satisfaction with virtual health services such as telehealth, it is important that there is a concerted effort to increase their use across health services. It is also imperative that health education adopts ways to improve student/educator awareness of the need to reduce the health carbon footprint and adopts virtual health education practices that have the potential to further reduce the current health education carbon footprint. Given the need to reduce the GHGs emitted by health services and education services, health professionals and educators have a pivotal role in building healthier, more equitable and sustainable health services and education by adopting practices that have a lesser impact on the environment. Greater efforts are needed to ensure research approaches, education, and policy are developed to support the increased use of virtual healthcare services and undergraduate and postgraduate student clinical placements, and to ensure ongoing evaluation of these services as they are integrated into mainstream healthcare and tertiary education.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author contributions

KU: Conceptualization, Investigation, Writing – original draft, Writing – review & editing. JW: Conceptualization, Investigation, Writing – original draft, Writing – review & editing. DJ: Writing – original draft, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

We acknowledge the members of the Aboriginal Advisory Group who participated in and advised on this project. The authors also acknowledge and thank the University of New England Health librarian Jane Lally for her assistance with the search strategy for this review.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

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Keywords: telehealth, planetary health, virtual healthcare, carbon emissions, digital healthcare, virtual health education, climate change

Citation: Usher K, Williams J and Jackson D (2024) The potential of virtual healthcare technologies to reduce healthcare services’ carbon footprint. Front. Public Health . 12:1394095. doi: 10.3389/fpubh.2024.1394095

Received: 01 March 2024; Accepted: 30 April 2024; Published: 16 May 2024.

Reviewed by:

Copyright © 2024 Usher, Williams and Jackson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Kim Usher, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Systematic review as a research method in post-graduate nursing education
A systematic review could be a valuable research method to be used by postgraduate nursing students, by which evidence is combined in non-traditional ways, but advantages should be weighed against disadvantages and certain criteria to be able to conduct a systematic review should be considered.
Systematic review as a research method in post-graduate nursing education
According to Gough, Oliver, and Thomas (2012), a system-. atic review is a research method that is undertaken to review. research literature, using systematic and rigorous methods. Systematic ...
Systematic review as a research method in post-graduate nursing education
Whether PhD theses in European biomedical graduate programs can be partly or entirely based on systematic reviews is analyzed to contribute to higher acceptance of SRs as a type of research that forms the basis of a PhD thesis. Expand. 18. Highly Influenced. PDF.
Systematic review as a research method in post-graduate nursing education
A sys- Systematic reviews are increasingly being used as a tematic review is a cost-effective research method which preferred research method for the education of post-graduate does not require a lengthy ethical approval process, and may nursing students (Bettany-Saltikov, 2012; Sambunjak & Puljak, generate more high-quality masters and ...
Systematic review as a research method in post-graduate nursing education
In South Africa, there appears to be poor understanding about using a systematic review as an acceptable research method in post-graduate nursing education. The lack of understanding may result in research supervisors being unable to guide post-graduate students, such as masters and doctoral students, in using the systematic review methodology ...
Systematic review methodology in graduate nursing education
Systematic reviews use a rigorous and transparent method to provide an unbiased synthesis of multiple studies to answer a clinical question. 6. Systematic reviews are the gold standard of research syntheses and a critical element of informing nursing practice and the development of best practice guidelines. 6,7 Performing a systematic review is ...
Systematic review as a research method in postgraduate nursing education
We conclude that a systematic review could be a useful and acceptable method for research in post-graduate nursing education. However, the method's benefits and disadvantages should be considered before a post-graduate student embarks on such a journey. In South Africa, there appears to be poor understanding about using a systematic review as ...
PDF Systematic review as a research method in post-graduate nursing education
views as a useful and acceptable research method to be used by post-graduate nursing students in South Africa. We conclude that a systematic review could be a useful and acceptable method for research in post-graduate nursing education. However, the method's beneﬁts and disadvantages should be considered before a post-graduate student
Systematic review methodology in graduate nursing education
By sharing knowledge and resources during the systematic review process, the PhD and DNP students further a unique but necessary dimension to nursing education. Graduate nursing students need relevant knowledge and the tools to further nursing research as an integral part of evidence-based practice. 8 The systematic review process can provide ...
Systematic review as a research method in post-graduate nursing
In South Africa, there appears to be poor understanding about using a systematic review as an acceptable research method in post-graduate nursing education. The lack of understanding may result in research supervisors being unable to guide post-graduate students, such as masters and doctoral students, in using the systematic review methodology in the completion of an academic qualification ...
Systematic review as a research method in postgraduate nursing education
In South Africa, there appears to be poor understanding about using a systematic review as an acceptable research method in post-graduate nursing education. The lack of understanding may result in research supervisors being unable to guide post-graduate students, such as masters and doctoral students, in using the systematic review methodology ...
Systematic review as a research method in postgraduate nursing education
In South Africa, there appears to be poor understanding about using a systematic review as an acceptable research method in post-graduate nursing education. The lack of understanding may result in research supervisors being unable to guide post-graduate students, such as masters and doctoral students, in using the systematic review methodology in the completion of an academic qualification.
How to Write a Systematic Review: A Narrative Review
Background. A systematic review, as its name suggests, is a systematic way of collecting, evaluating, integrating, and presenting findings from several studies on a specific question or topic.[] A systematic review is a research that, by identifying and combining evidence, is tailored to and answers the research question, based on an assessment of all relevant studies.[2,3] To identify assess ...
Postgraduate nurse education and the implications for nurse and patient
Review methods. A systematic search following PRISMA guidelines and the Joanna Briggs Institute's framework was conducted. ... This systematic review examined research publications reporting the implications of postgraduate nursing qualifications on patient outcomes, as well as the benefits to organisations and advantages to the nurses ...
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Promoting Ethical Sensitivity in Nursing Education: A Systematic Review
Nursing ethical sensitivity was positively linked to the nurse's ethical decision-making ability and a case study-oriented teaching program has proven effective in enhancing ethical sensitivity among nursing students. Abstract: Introduction: Nursing ethical sensitivity refers to a nurse's capacity for thoughtful consideration of ethical issues when faced with dilemmas. In the nursing ...
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Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada's legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses' (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education ...
Systematic review as a research method in post-graduate nursing education
A systematic review is a cost-effective research method which does not require a lengthy ethical approval process, and may generate more high-quality masters and doctoral graduates who will fulfil the need for postgraduate education and supervision (Academy of Science in South Africa, 2010). However, in South Africa there is little ...
Systematic review as a research method in postgraduate nursing education
According to Gough, Oliver, and Thomas (2012), a system-. atic review is a research method that is undertaken to review. research literature, using systematic and rigorous methods. Systematic ...
Healthcare
Nursing students' integration of theoretical knowledge and practical abilities is facilitated by their practice of nursing skills in a clinical environment. A key role of preceptors is to assess the learning goals that nursing students must meet while participating in clinical practice. Consequently, the purpose of this study was to explore the current evidence in relation to competency ...
Nursing students' stressors and coping strategies during their first
Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses' sources of stress and coping styles ...
Systematic review methodology in graduate nursing education
This article may set the field for an informed debate on systematic reviews as a useful and acceptable research method to be used by post-graduate nursing students in South Africa.
Preconditioning of MSCs for Acute Neurological Conditions: From ...
This systematic review aims to gather evidence on the mechanisms triggered by diverse preconditioning strategies for mesenchymal stem cells (MSCs) and their impact on their potential to treat ischemic and traumatic injuries affecting the nervous system. The 52 studies included in this review report nine different types of preconditioning, namely, manipulation of oxygen pressure, exposure to ...
The learning experiences and career development ...
The study employed a phenomenological research method to gain insights into nursing graduate students' perceptions of university training programs. The preliminary interview outline was developed through a literature review and group discussions. ... Some interviewees in this study indicated a lack of systematic ethical literacy education at ...
A Systematic Review of Humor Employed in Teaching English as a Second
This study presents a systematic review focused on the use of humor in ESL teaching within Asian countries. Its objectives are to acquire comprehensive knowledge of the current research status, research participants and methods, and research perspectives, and to examine the outcomes of incorporating humor into ESL instruction in Asian contexts in order to pinpoint research gaps for future studies.
PDF Systematic review as a research method in post-graduate nursing education
A systematic review could be a valuable research method to be used by postgraduate nursing students, by which evidence is combined in non-traditional ways, but advantages should be weighed against ...
What are the thoughts of postgraduate nursing students regarding the
DOI: 10.1016/j.nepr.2024.103947 Corpus ID: 269460498; What are the thoughts of postgraduate nursing students regarding the 'Applied Scientific Research' course? A qualitative study on achievements, benefits, challenges, and suggested solutions.
Frontiers
Greater efforts are needed to ensure research approaches, education, and policy are developed to support the increased use of virtual healthcare services and undergraduate and postgraduate student clinical placements, and to ensure ongoing evaluation of these services as they are integrated into mainstream healthcare and tertiary education.

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How to Write a Systematic Review: A Narrative Review

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Introduction

Virtual health as a strategy to reduce the health service carbon footprint

Potential for virtual health undergraduate and postgraduate student clinical placements to help reduce the carbon footprint

Evidence that reduced travel leads to reduced GHG emissions

Need for urgent action

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