key: cord-0333212-6a16ivt9
authors: Zeng, B.-t.; Jin, Y.-h.; Cheng, S.-d.; Ding, Y.-m.; Du, J.-w.
title: Administration approaches of nursing assistants in hospitals: a scoping review
date: 2022-03-22
journal: nan
DOI: 10.1101/2022.03.20.22272663
sha: 7292244dc94dfd79a99c396534d9e047ecadf81a
doc_id: 333212
cord_uid: 6a16ivt9

Objectives: Administration of nursing assistants is closely associated with patient outcomes, but the current circumstances are tough and need improvement. There was limited research evaluating the intrahospital administration of nursing assistants, and there is a lack of available systematic reviews of the area. The aim of this article was to identify and synthesize the literature on intrahospital nursing assistants' administration approaches. Design: Scoping review. Search strategy: We searched PubMed, Embase, APA PsycInfo, Wanfang Med, SinoMed, CINAHL, Ovid Emcare, Scopus, ProQuest, CNKI, NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR for English and Chinese language articles published between January 2011 and March 2022. Publications on administration approaches, models and appraisal tools of nursing assistants in hospitals, including qualitative, quantitative, mix-methods studies and evidence syntheses, were considered eligible. Results: 36 eligible studies were included for the review with an acceptable quality. We identified one administration model, nine administration methods, fifteen educational programmes and seven appraisal tools from the included studies. The frequency effect size analysis yielded 15 topics of main focus at four levels, whilst suggesting that the previous articles were mostly (33%) focused on the competency of nursing assistants, and the lectures were the most (80%) used strategy in quality improvement projects. The evidence-based quality of the original studies was considerably low, indicating the huge gaps between the evidence-based research and the management practice. Conclusions: A series of practical intrahospital administration approaches was revealed, and fifteen mostly focused topics were identified. We need probe more thoroughly in this area, based more on effective management theories and frameworks, and employing methods of higher quality. This scoping review will help managers find more effective methods to improve the quality of care. Researchers may focus more on evidence-based nursing skills and methods in nursing assistant administration using the 15 topics as breakthrough points.

instructions on NA training. 13 Despite this, the effect and efficacy of these standards remain unclear, and evidence is scared.

The efficacy of the miscellaneous administration approaches followed by healthcare facilities was vague, leading to the grim current circumstances of NA administration. Lack of crucial competency, high turnover rate, low vocational identity, and low self-efficiency were all stumping NAs and their administrators. [14] [15] [16] [17] [18] [19] The faultiness of these aspects would directly affect quality of care. A higher turnover rate was associated with fewer infection events, while the retention rate was positively linked with clinical outcomes. 20 21 The self-efficacy of NAs was associated with their burnout rate, which was very dangerous for care outcomes. 22 In addition, communication among NAs, other nursing staff and administrators also needed improvement. NAs reported discontentment with administrators' not understanding their work problems, 23 and the performance of NAs also was influenced by relationships among NAs, RNs and other clinical staff. 24 Various definitions, duties and unbalanced development of NAs worldwide 25 26 have created barriers to identifying applicable management strategies. In the US, NAs are called certified nursing assistants (CNAs) and unlicensed assistive personnel (UAPs), while this occupation also was named nurse/nursing aides (NAs), health care assistants (HCAs) and nursing auxiliaries in the UK. Nursing attending workers (NAW) and nursing assistants (NA) were both used in China. 26 The communication of research from different countries is always confusing, and valid approaches and practices are needed to address the current chaos.

NAs take up a number of care duties that affect the outcomes of patients directly in hospitals, but most of the previous studies on nursing administration were developed in long-term care settings, and there was limited research taking place in hospitals. Due to the inadequacy of primary studies, it is challenging to organize systematic reviews or other evidence syntheses, hence the need and timeliness of a scoping review to identify the available evidence and assess the feasibility of undertaking evidence-based researches. In this paper, we reviewed the available administration approaches and assessment tools for NAs in inpatient care settings, introduced the current progress of this field, and presented an outlook for further researches and evidence syntheses.

This scoping review aimed to identify, describe and synthesize current knowledge and the existing literature on nursing assistants' administration approaches and models, including education, skill training and multidimensional appraisal in hospitals. Three research questions were asked for intrahospital NA administration:

-What are the available approaches, programs or tools? -What are the available models or frameworks? -What are the most focused topics and most performed methods of the existing researches?

The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses -Extension for Scoping Reviews (PRISMA-ScR), 27 and Joanna Briggs Institute (JBI) guidance and methodology for scoping review 28 29 were also consulted. A structured protocol 30 was prepared a priori according to the PRISMA Protocols (PRISMA-P) 2015 statement and explanation 31 32 and PRISMA-ScR.

This review was designed to identify studies that showed clear methods, mainly focused on NAs, and discussed at least one administration-related topic. The inclusion criteria were:

(1) Participants: nursing assistants (or certificated nursing assistants, nurse aides, etc.); (2) Setting: hospital;

(3) Study type: Qualitative, quantitative or mixed researches, controlled trials, evidence-based reviews, guidelines, consensus, or related dissertations; (4) Focus: specific approaches or models, or overall administration models, programs, tools or frameworks; (5) Methodology: reporting clear intervention/exposure methods and evaluation tools; (6) Language: English or Chinese; (7) Peer-reviewed studies published between January 2011 and March 2022.

Studies met the criteria below were excluded: (1) Participants: other healthcare personnel, students, or orderlies; or mixed participants with different occupations, and nursing assistants were not discussed or presented separately;

(2) Focus: focusing on specific areas, and the conclusions were only fit for the focused areas. (3) Setting: long-term care facilities, nursing homes, or skilled nursing facilities; and (4) Outcome: not reporting key evaluation outcomes.

For initial screening, we retrieved comprehensive, medical, nursing and evidence-based databases as follows: medical databases (PubMed, Embase, APA PsycInfo, Wanfang Med and SinoMed); nursing databases (CINAHL and Ovid Emcare), comprehensive databases (Scopus, ProQuest and CNKI) and evidence-based databases (NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR). The initial searching completed in November 2021 and was updated in March 2022.

A prior limited search was done in PubMed to identify keywords, search fields, and related topics. We used PubMed PubReMiner 33 to identify related keywords for search strategy establishment. Afterwards, search strategies in each database were developed, including key terms: nursing assistants, nursing aides, nursing auxiliar*, administr*, educat*, training, apprais*, organization and administration. Complete strategies are displayed in online supplemental file 1. References of all included studies were manually searched for more evidence using the key terms "assistant" and "aide".

All publications were imported into EndNote 20.2 (build 15709) for citation management, and duplicates were removed. A brief screening checklist (online supplemental file 2) was developed for study selection to help minimize the inconsistency of the reviewers. Two reviewers screened all the studies independently according to the eligibility criteria. Any disagreements or hesitations were discussed by the reviewers together or with a third researcher until a consensus arose.

Article characteristics, sample size and participant demographics, focused topics, study designs and outcomes were charted from eligible studies. A structured data charting tool (online supplemental file 3) was designed by two researchers for data charting and was continuously refined. Data charting of all eligible studies was performed by two authors independently and was corroborated by a third researcher.

The Mixed Methods Appraisal Tool (MMAT) Version 2018 34 35 was applied for qualitative, quantitative or mixedmethodological studies, and AMSTAR 2, a critical appraisal tool for systematic reviews 36 , was used for the critical appraisal of evidence-based reviews. An overall score was carried out for each included study. For the MMAT, we calculated the percentage of items answered "Yes" in Section 2, and for AMSTAR 2, after items that were not applicable were excluded, we conducted a grade of overall confidence according to the criteria by Shea et al. 36 

Eligible studies were divided into three fields: administration approaches, education and training, and appraisal tools. We summarized the study types, main focus and detailed intervention/exposure measures for the administration, education and training fields. For studies on practical tools, detailed tool information and psychometrics were extracted. For further interpretation, we conducted a frequency effect size analysis of the area of the main focuses and intervention strategies based on the calculating effect size method from the metasummary methodology introduced by Sandelowski et al. 37 

The searching identified 1,973 related studies (1,902 initially and 71 updated), among which 538 were Chinese language studies. A total of 467 duplicates were removed, and after reviewing the title and the abstract, 138 publications remained for full-text screening, where 103 articles were excluded (see online supplemental file 4). Thirty-five studies from databases were included in the scoping review. Thirteen studies published from 2011 to 2021 were manually identified from the reference lists of the included studies, and one study was included. Ultimately, we identified 36 eligible studies for our scoping review, of which 11 were Chinese language text (figure 1).

An overview of the study characteristics and contents is displayed in table 1. Fundings and Conflicts of the studies are shown in online supplemental file 5. The information sheet can significantly improve NAWs' awareness of regulation, safety and patient privacy, and patients were more satisfied with NAWs. not mentioned HCA, health care assistant; approx., approximately; PBC, perceived behavioural control; RN, registered nurse; NA, nursing assistants (or nursing aides); NAW, nursing attending worker; N/A, not applicable; LPN, licenced practical nurse; CNA, certified nursing assistant; F:M, female to male ratio; HCW, healthcare workers; AIN, assistant in nursing; UAP, unlicensed assistive personnel; yrs, years Two theses, three evidence syntheses and 31 original research papers were included. For study types, 25 articles presented quantitative designs (17 interventional and eight descriptive), one was qualitative, and seven studies employed mixed methods. Most studies (19 of 24) with interventions applied a quasi-experimental, controlled study before and after test (CBA) design, while one study 57 presented a post-then-pretest design. 74 Focus group interviews were the most employed method in qualitative and mixed methods studies. The three evidence syntheses were of different types: one integrated review, 40 one qualitative metasummary, 44 and one systematic review. 46 All 33 original studies were conducted in hospitals due to our inclusion criteria, and the sample size ranged from six to 700 NAs. Three studies 45 64 71 were focused on patients' attitudes, and did not report the demographics of NAs. Only one study 54 reported a higher than 60% response rate, while others ranged from 10% to 40%.

The methodological quality appraisal results of the studies are listed in online supplemental file 6. The mean score of all 33 original studies assessed by the MMAT reached a level of 65%, and for evidence-based reviews, two of the studies 40 44 received a "very low" rating, while the other one 46 got a "high". Overall, the methodological quality of the included studies was considered acceptable.

Fourteen studies addressed various administration approaches and focuses, as listed in table 2. The development of NA administration in China was still preliminary, and articles by Chinese researchers were more fixated on employment models. Five studies 43 45 51 68 71 were aimed at the change of management and employment from company-led to hospital-led, or double-track, with consistent positive results on satisfaction and NA/NAW working competency after intervention. Other original studies identified four practical tools or methods, i.e., the Failure Mode and Effects Analysis (FMEA), 52 the Activities of Daily Living (ADL) scale, 59 the Quality Control Circle, 69 and an information sheet to patients, 73 as well as two valuable programmes on stress and CNA-patient relationships. 41 58 Negative outcomes were found on turnover rates after a CNA orientation coach 62 and on adverse events with the addition of AINs to acute wards. 64 Meanwhile, several approaches, including crew resource management, the TeamSTEPPS programme, 75 and the SBART shift model, were summarized by an integrated review from Campbell et al. 40 Education and Training Each of the 13 research papers developed an education programme with different topics, while two evidence reviews 44 46 discussed educational strategies on palliative care and workplace aggression with wide availability (table 2) . NA knowledge and skills were most emphasized. Six studies highlighted five aspects of NA competency: patient handling, 50 67 palliative care, 44 dementia, 57 restorative care 60 and routine work capacity. 55 Of other studies, two 53 63 improved patient safety, two 56 65 were on communication, two 61 66 pointed at continuing education and the other two 46 72 focused on self-protection. The strategies taken ranged from classical lectures to web-based learning, simulation and practical training. The mixed outcome of education on workplace aggression was reviewed by Geoffrion et al., 46 addressing the needs of further study in this area.

We found seven valid appraisal tools on NA administration with stable psychometrics from the included studies (table  2): (1) HCA & RNs' intention questionnaire; 38 (2) LMX-7 relational quality questionnaire from Campbell et al. 39 and developed by Graen et al.; 76 (3) NA working questionnaire 47 , first built by Parahoo; 77 (4) the Nursing Culture Assessment Tool (NCAT); 49 (5) the Structured Multidisciplinary Evaluation Tool (SMET) from Haraldsson et al. 48 and developed by the author in 2016; 78 (6) Self-Efficacy for Preventing Falls -Assistants (SEPFA); 42 (7) the Work Ability Index from Monteiro et al. 54 and produced by Ilmarinen. 79 Three of seven papers developed original scales and tested reliability and validity. Four studies examined the psychometrics of existing questionnaires or applied questionnaires to NA administration and reported eligible outcomes. The main focuses were diverse, from working capacity and workload to relationships, intentions and nursing culture. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 22, 2022. ;  https://doi.org/10.1101/2022.03.20.22272663 doi: medRxiv preprint Ritchie 60 (2017) restorative care a didactic day and a three-to-four-hour practice session, using lectures and practical training, taught by a physical therapist. Small 61 (2012) continuing education a continuing and normalized education program based on teaching plans from RNs at shifts, using lectures, demonstration and return demonstration. Tom 63 (2016) patient safety a two-day patient safety aide training program by the Veteran Affair Department, with lectures and a competency test. Wagner 65 (2018) delegation and communication a half-hour learning program with lectures and video, taught by the practitioner investigator. Ward 66 (2014) continuing education the eDOOR (educational offering on the run) program, with flyers, simulation, and miniin-service study. Wilson 67 (2011) patient handling and mobility an eight-hour education program (two four-hour parts) with lectures, demonstration, discussion and simulations. Zhao 70 (2020) knowledge and skills patient and nursing staff's satisfaction an ADL-stratified, patient-oriented training model, with a 40-hour training for all levels of NAWs and a 32-to-48-hour stratified training for different levels, using lectures and practical training. Zhu 72 (2021) self-protection a tertiary training model by companies, nursing department and wards using lectures, practical training, competency test and continuing improving. 

We derived frequency effect size analysis on the included studies' main focuses and strategies (table 3 and online  supplemental file 7) . Fifteen main focuses were identified at four levels. The most reported focuses were competency at the NA level (frequency effect size 33%), communication and clinical staff satisfaction (both 14%) at the clinical personnel level, and patient satisfaction (25%) at the patient level. Both topics at the fourth facility management level (retention and care quality control) were at a 6% level of effect size.

Twenty studies contained the theme for education and training strategies. Face-to-face lectures were still the most employed method (80%), followed by simulation and role play and practical training (both 30%). We also noted that flyers with various knowledge and skills for CNA continuing education were designed by Ward et al., 66 which was a unique and effective method not adopted by other studies. Since the significant heterogeneity existed, we failed to . CC-BY 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 22, 2022. ;  distinguish themes and codes in studies on NA administration methods, thus simply summarising their objectives. Approximately 62% of the studies evaluated tools for administration, and the other five papers were on hospital management models (38%). 

In this review, we outlined existing administration tools, management models, education programs and scales for appraisal from previous studies. The included studies implied the need to develop more studies on tools, theories and educational strategies for NA administration in hospitals with better evidence quality. Gaps in NA administration development and current circumstances between developed and developing areas were noted and needed improvement.

Twenty-three focuses were initially found by the frequency effect analysis, while they were combined to form 15 topics. NA knowledge and skills were most widely considered, with a trend of being more specified for contents of competency improving. The Care Certificate Program 12 identified basic competencies for carers, which have been applied to certificate training. Most of the studies conducted an on-the-job training mode, thus the necessity of exploring advanced competency to avoid repeats. Focuses that contributed smaller effect sizes may denote the possible directions of future studies. NA intentions, relationships of NA-other nursing staff and NA-patients, workload, stress and retention in hospitals needed deeper investigation. Existing studies revealed that all of the factors above influence the quality of care at the RN or nursing home level, [80] [81] [82] [83] while evidence of influence and improvement methods of NAs in hospitals is limited.

Eleven groups of educational strategies were applied to 20 included studies. 90% of the studies employed at least two groups of strategies, with an average of 2.60, and more multiple education methods may result in more positive outcomes. 84 A simulation was highlighted because it has proven effective in nursing education, 85 86 and a debrief simulation method also was recommended. 87 Web-based training has become a modern trend, especially during the COVID-19 pandemic. 88 However, it is worth noting that the evidence on the effectiveness of e-learning in nursing . CC-BY 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 22, 2022. ;  education is still mixed. 89 90 Nevertheless, the effectiveness of these methods applied to NAs needs further exploration due to the educational background gaps between NAs, RNs and nursing students. Moreover, half of the articles used interactive methods, e.g., simulation, discussion and group study, and more interactive methods have been gradually used and evaluated in NA education and training in recent years. We suggest that theories should be identified and applied to each programme, with only one-third of the included studies developing programmes based on a specified theory or conceptual framework.

We found one main administration model from Chinese studies, and nine methods or theories were discovered. In China, NAWs were employed by companies, hospitals, or were self-employed, 91 92 where the company employment model took the majority. 93 Based on agreements between hospitals and service companies, the selection and training of NAWs were conducted by directors and executors of companies, leading to uncontrolled quality of care and muddled management. 91 94 Hence, the hospital management model was proposed for improvement and proved effective in the included studies. The studies showed a three-level model where NAWs were managed by (1) nurse departments or NAW centres, (2) head nurses and (3) ward nurses together. The review revealed significant heterogeneity, inadequate quality of evidence and unrepresentative samples of related studies of this area. Further analysis of the hospital management model and the effectiveness of other mature models in Chinese hospitals is considered to be the next evaluation step.

The FMEA model, ADL scale and Quality Control Circle have rarely been evaluated in intrahospital NA management. The FMEA model has already been employed in hospital administration for long 95 96 and has received pretty good results, but the efficacy of the FMEA mode on NAs is little known. The ADL scale was first developed by Katz 97 and is one of the most widely used tools for assessing patient functions. Different ADL scores and levels represented different statuses and care needs of patients to guide managers to a more cost-effective and patient-oriented model of NA allocation. The Quality Control Circle was first developed in Japan in the 1950s 98 and was widely applied to company management. Limited studies have evaluated quality circles in hospital management with mixed outcomes. 99 The efficacy of this method after the addition of NAs to health care facilities needs more exploration.

Other original papers 41 58 developed or evaluated programmes to improve administration, i.e., the BREATHE programme and the Care Partner Programs. Despite the pretty outcomes, the small sample size placed barriers to the widespread application of their designs. Additional studies on approaches to widen the applicability and design of more diverse programmes are crucial.

Three studies 46 62 64 reported notable negative or mixed outcomes. The systematic review from Geoffrion 46 et al. supposed that both patients and healthcare workers may not benefit from educational programmes on workplace aggression for clinical staff, revealing that other approaches or the education for patients may be conducted for the improvement of NA safety. Swann 62 evaluated the influence of the CNA orientation coaches on the retention rate and derived a negative result, while Twigg 64 placed an analysis of adding AINs to acute care wards with unexpected outcomes on failure to rescue, urinary tract infection, and falls. The sample of the latter two articles was still limited, with the potential risk of inadequate study designs (observational study to evaluate the interventions), so researchers may conduct more studies on their topics in spite of the discouraged results.

We appraised the quality of evidence of the included studies based on the five-level evidence system from the Oxford Centre for Evidence-based Medicine. 100 As a result, all included original studies were at level III and level IV (for questions on common-Q1, prognosis-Q3, treatment benefits-Q4, and worthwhile-Q7), which indicated a low to moderate quality of evidence. Due to the lack of high-quality evidence, we hoped that more randomized controlled trials would be presented to help improve the evidence-based practice of NA administration, despite existing ethical and methodological issues. In addition, few studies reported their designs and outcomes in extenso, where the participant demographics, sampling, detailed and full outcomes, and the assessment of potential bias (for quantitative study) were the most obscure areas. We suggest that reporting guidelines, e.g., SQUIRE 2.0, 101 should be followed when reporting research outcomes to improve the methodological quality and availability of the studies.

Several gaps were concluded for the NA administration area: (1) NA definitions, regulations and circumstances varied widely among countries, especially between high-income and those with moderate to low incomes, which created barriers to global evidence and practical experience shared processes; (2) The limited sample sizes and nonrandomized study designs of the included studies may decrease the reliability of outcomes; (3) The low quality of existing evidence may not support the evidence-based syntheses and practice for care quality improvement, and (4) Theories and conceptual frameworks were often neglected in the study designs. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 22, 2022. ;  https://doi.org/10.1101/2022.03.20.22272663 doi: medRxiv preprint

The diversified intervention methods of the included studies led to significant heterogeneity so barriers existed for further analysis and synthesis. We included only Chinese and English articles, while studies published in other languages were excluded, thus leading to a potential risk of bias. Furthermore, more studies may not be included for analysis in other social sciences databases, as NA administration is a broad, multidisciplinary and interdisciplinary topic. We also noted that three included evidence-based reviews addressed 32 original studies, where 13 studies were published between 2011 and 2021 but were not included in our scoping review, implying a potential risk of incomprehensiveness of our work.

This scoping review demonstrated the practical administration approaches and focus from previous studies for hospital nursing assistants. The review found a total of nine administration methods, one administration model, 15 education and training programmes, and seven appraisal tools. With the frequency effect size analysis, 15 groups of main focus and 11 educational strategies used for improving administration were outlined. The insight from our review will add knowledge to effective NA administration for hospital managers and head nurses and help to improve the quality of care with increasing evidence.

Barriers remain between the intrahospital NA administration area and evidence-based nursing research and practice. The endeavour to apply evidence-based methods to administration will be arduous but will contribute greatly to improved outcomes.

We expect that the administration approaches concluded by our study will help leaders interpret more about effective management to improve quality of care and benefit all clinical staff and patients. The difference between hospitals and long-term care settings should be recognized, and more studies for NAs in hospitals are expected. Researchers should draw more attention to evidence-based methods in the administration area, resulting in continuing improvement, global sharing and system establishment of intrahospital nursing assistants' administration. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 22, 2022. ;  https://doi.org/10.1101/2022.03.20.22272663 doi: medRxiv preprint

SOC Definitions

Healthcare personnel statistics -nursing and caring professionals

Characterizing the direct care health workforce in the United States

NSI Nursing Solutions. 2021 NSI National Health Care Retention & RN Staffing Report

United States registered nurse workforce report card and shortage forecast: a revisit

A systematic review of activities undertaken by the unregulated nursing assistant

Relational quality between the RN and nursing assistant: essential for teamwork and communication

the coding index and coding rules and conventions

Omnibus Budget Reconciliation Act of 1987: Conference report filed in House, H. Rept. 100-495, 100 th Congress December

The Cavendish Review

The education, training and qualifications of nursing and care assistants across Europe

Skills for Care, Skills for Health, Health Education England. The Care Certificate Workbook

National Health Commision of the People's Republic of China]. [Strengthening the training and standardized management of nursing assistants

Teaching and maintaining behavior management skills in the nursing home

CNA empowerment: Effects on job performance and work attitudes

An approach to recruitment and retention of certified nursing assistants using innovation and collaboration

Characteristics and recruitment paths of certified nursing assistants in rural and urban nursing homes

Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey

The importance of supervision in retention of CNAs

Association between nursing home staff turnover and infection control citation

Burnout risk and protection factors in certified nursing aides

Certified nursing assistants' perceptions and generational differences

Nursing assistants' desired roles, perceptions of nurses' expectations and effect on team participation: a cross-sectional study

The current situation of nursing staff grading at home and abroad, and assumption of nursing staff grading in China

PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation

Guidance for conducting systematic scoping reviews

The Joanna Briggs Institute reviewers' manual 2015: methodology for JBI scoping reviews

Administration models of education, training and appraisal of nursing assistants in inpatient care: a protocol for a scoping review

Preferred reporting items for systematic review and meta-analysis protocols

Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews

AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or nonrandomised studies of healthcare interventions, or both

Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings

Implementing guideline-checklists: Evaluating health care providers intentional behaviour using an extended model of the theory of planned behaviour

Manager's influence on the registered nurse and nursing assistant relational quality and patient safety culture

Interventions to promote teamwork, delegation and communication among registered nurses and nursing assistants: an integrative review

Evaluating the outcomes of a web-based stress management program for nurses and nursing assistants

Scales for assessing self-efficacy of nurses and assistants for preventing falls

The comparison research of the working conditions of nursing assistants under directly and indirectly employed management models

Outcomes of collaborative and interdisciplinary palliative education for health care assistants: a qualitative metasummary

Dual management based on evidence-based nursing care in organizing nursing attending workers

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

Effects of the Care Certificate on healthcare assistants' ability to identify and manage deteriorating patients

Comparing the Structured Multidisciplinary work Evaluation Tool (SMET) questionnaire with technical measurements of physical workload in certified nursing assistants in a medical ward setting

Development and psychometric testing of the nursing culture assessment tool

Safe patient handling and mobility: development and implementation of a large-scale education program

FMEA method in the management of nursing workers in hospital

Simulation-based education in support of HCA development

Work capacity evaluation among nursing aides

Application of group collaborative training model in field training for nursing assistants

Communication skills training increases self-efficacy of health care professionals

The impact of education on certified nursing assistants' identification of strategies to manage behaviors associated with dementia

Maximizing caring relationships between nursing assistants and patients: Care Partners

Practice and effects of construction of nursing assistant classification service standards based on Activities of Daily Living Scale

Impact of an educational training program on restorative care practice of nursing assistants working with hospitalized older patients

Continuing education for patient care technicians: a unit-based, RN-led initiative

The Effect of Training and Recognition on Nursing Assistant Retention in Acute Care Settings

Improving Patient Safety through Patient Safety Aide (Sitter) Competency Education [doctor's dissertation

The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: an analysis of administrative health data

Improving patient care outcomes through better delegation-communication between nurses and assistive personnel

Educating certified nursing assistants educational offerings on the run and more

Application of hospital management model to the management of nurse attendants

Application of Quality Control Circle to hand hygiene of nursing assistants in psychiatric geriatric wards

Effects of stratified training of nursing assistants based on patient demands

Patient satisfaction with non-clinical nursing care provided by the nursing assistant under different management models in Chinese public tertiary hospital

Practice of nursing assistant self-protection training program during the epidemic period of COVID-19

Effectiveness of the inform sheet in the management of nursing assistants

Post-then-pre evaluation: Measuring behavior change more accurately

Relationship-based approach to leadership: development of leader-member exchange (LMX) theory of leadership over 25 years: applying a multi-level multi-domain perspective

Nursing Research: Principles, Process and Issues

Structured Multidisciplinary work Evaluation Tool: development and validation of a multidisciplinary work questionnaire

The work ability index (WAI)

Nurse's aides in nursing homes: the relationship between organization and quality

Do assistive devices, training, and workload affect injury incidence? Prevention efforts by nursing homes and back injuries among nursing assistants

Multidisciplinary in-hospital teams improve patient outcomes: a review

The link between leadership and safety outcomes in hospitals

The role of conceptual frameworks in nursing practice, administration, education, and research

Technology-enhanced simulation for health professions education: a systematic review and meta-analysis

Effects of simulation technology-based learning on nursing students' learning outcomes: a systematic review and meta-analysis of experimental studies

Debriefing methods and learning outcomes in simulation nursing education: a systematic review and meta-analysis

Distance learning in clinical medical education amid COVID-19 pandemic in Jordan: current situation, challenges, and perspectives

Effects of e-learning in a continuing education context on nursing care: systematic review of systematic qualitative, quantitative, and mixed-studies reviews

Conventional vs. e-learning in nursing education: a systematic review and metaanalysis

Analysis of the nursing assistant management models in China

Study on the situation, problem and strategies about nursing assistants in health institutions of Z province

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Acknowledgements: We acknowledge Ms. Zhuo Lin and Ms. Zhang Yu-jing for their ideas on study design, data synthesis, and manuscript refinement.

Duplicate records removed (n = 467) Automatically moved by title words (n = 14)Records screened for title (n = 1,492)

Records screened for abstract (n = 400) 12 records had no abstract

Records assessed for eligibility (n = 138)Records excluded: (n = 103) setting (n = 15) specific area / main focus (n = 13) participant (n = 24) methodology (n = 26) outcome (n = 5) not a research paper or evidence synthesis (n = 10) conference abstract (n = 2) full text not found (n = 7) publication year (n = 1)Records identified from: Citation searching (n = 13)Records assessed for eligibility (n = 10) Records excluded: (n = 9) setting (n = 3) main focus (n = 2) methodology (n = 1) no outcome (n = 1) not a research paper (n=2)Studies included in review (n = 36)

Records sought for retrieval (n = 13)Records not retrieved: (n = 3) having been included (n = 1) having been excluded (n = 2)