Administration approaches of nursing assistants in hospitals: a scoping review

Abstract

Objectives

The administration of nursing assistants (NAs) is closely associated with patient outcomes, but studies evaluating intrahospital administration of NAs are limited. This study aimed to identify existing literature on intrahospital NAs’ administration approaches.

Design

Scoping review.

Data sources

PubMed, Embase, CINAHL, Scopus, ProQuest, CNKI, APA PsycInfo, Wanfang Med, SinoMed, Ovid Emcare, NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR were searched for articles published between January 2011 and March 2022.

Eligibility criteria for selecting studies

Qualitative, quantitative or mixed-method studies and evidence syntheses that evaluate administration approaches, models and appraisal tools of intrahospital NAs were included.

Data extraction and synthesis

Two independent reviewers conducted search, data selection and data extraction according to Joanna Briggs Institute guidance and methodology for scoping review. The quality of included studies was assessed using Mixed Methods Appraisal Tool or AMSTAR V.2. Data were synthesised using narrative methods and frequency effect size analysis.

Results

Thirty-six studies were eligible, with acceptable quality. We identified 1 administration model, 9 administration methods, 15 educational programmes and 7 appraisal tools from the included studies. The frequency effect size analysis yielded 15 topics of the main focus at four levels, suggesting that included articles were mainly (33%) focused on the competency of NAs, and the lectures were the most (80%) used strategy in quality improvement projects. Evidence from the studies was of low-to-moderate quality, indicating huge gaps between evidence-based research and management practice.

Conclusions

Practical intrahospital administration approaches were revealed, and fifteen primarily focused topics were identified. We should explore this area more thoroughly using structured frameworks and standardised methodology. This scoping review will help managers find more effective ways to improve the quality of care. Researchers may focus more on evidence-based practice in NA administration using the 15 topics as a breakthrough.

Strengths and limitations of this study.

• First scoping review of practical administration approaches for nursing assistants (NAs) in hospitals.

• Presenting the main topics and focus of related articles.

• Development of the NA administration was widely varied among countries.

• Most of the included studies were of moderate-to-low methodological quality, and a huge gap exists between evidence-based research and management practice.

Background

Nursing assistants (NAs) are trained allied nursing personnel who provide or assist with basic care or support under the direction of onsite licensed nursing staff.¹ In 2019, there were approximately 1.73 million NAs in the USA, and this number in the European Union was 4.67 million in 2018,^{2 3} indicating that NAs have become the mainstay of care. As an integral part of routine healthcare, NAs are providing more care in hospitals due to the increasing ageing population and the shortage of registered nurses (RNs) in recent years,^{4 5} thereby raising the criticality of NA administration. Nursing administration is now challenged by diverse educational backgrounds and the communication and connection between NAs and RNs.^6–8

Standards and regulations of NAs have been established in several countries, for example, OBRA 1987 Act in the USA,⁹ the Cavendish Review and other documents in the European Union^{10 11} and the Care Certificate in the UK.¹² And in China, the National Health Commission emphasised the standardised regulation of NAs in 2019, providing instructions on NA training.¹³ However, the documents provided requirements for NA education, qualifications and training, but not for broader administration settings. There have not been uniform intrahospital NA administration regulations across countries.

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 confused NAs and their administrators.^14–19 The faultiness of these aspects would directly affect the quality of care. A higher turnover rate was associated with fewer infection events, and 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 appropriate management strategies. In the USA, NAs are also named certified NAs (CNAs) and unlicensed assistive personnel and the names were nurse/nursing aides (NAs), healthcare assistants (HCAs) and nursing auxiliaries in the UK. Nursing attending workers (NAW) and NAs were 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 several care duties that directly affect the outcomes of patients in hospitals. However, much of the previous research on nursing administration was developed in long-term care settings, and limited studies have been conducted in hospitals. Due to the scarcity of primary studies, organising systematic reviews or other evidence syntheses is challenging, and therefore scoping reviews are needed and timely to identify existing evidence and assess the feasibility of conducting evidence-based research. In this article, we reviewed available administration approaches and assessment tools for NAs in inpatient care settings, described the current progress of this field and presented a vision for further research and evidence synthesis.

Aims and research questions

This review aimed to identify, describe and synthesise current knowledge and the existing literature on NAs’ administration approaches and models, as well as education, skill training and multidimensional appraisal in hospitals. Two research questions were raised for intrahospital NA administration:

• What are the available approaches, models, programmes and tools?

• What are the most focused topics and most used methods of the existing studies?

Methods

Study design and protocol

The review was conducted according to Joanna Briggs Institute (JBI) guidance and methodology for scoping review^{27 28} and reported using the Preferred Reporting Items for Systematic reviews and Meta-analyses—Extension for Scoping Reviews (PRISMA-ScR).²⁹ A structured protocol³⁰ was prepared a priori according to the PRISMA Protocols 2015 statement and explanation^{31 32} and PRISMA-ScR.

Eligibility criteria

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

1. Participants: NAs (or certificated NAs, nurse aides, etc).

2. Setting: hospital.

3. Study type: qualitative, quantitative or mixed researches, evidence-based reviews, guidelines, consensus or related dissertations.

4. Focus: specific approaches or models, or overall administration models, programmes, tools or frameworks.

5. Methodology: reported clear intervention/exposure methods and evaluation tools.

6. Language: English or Chinese.

7. Peer-reviewed studies published between January 2011 and March 2022.

The exclusion criteria were:

1. Participants: other healthcare personnel, students or orderlies; or mixed participants with different occupations, and NAs 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.

4. Outcome: not reported key administrational outcomes.

Search strategy and study selection

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), general databases (Scopus, ProQuest and CNKI) and evidence-based practice databases (NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR). The initial search was completed in November 2021, and we updated the results in March 2022.

We ran a preliminary search in PubMed to identify keywords, search fields and related topics. We used PubMed PubReMiner³³ 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. Full search strategy is displayed in online supplemental file 1. References of all included studies were manually searched using terms ‘assistant’ and ‘aide’.

All publications were imported into EndNote V.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 minimise the inconsistency of the reviewers. Two reviewers screened all the studies independently according to the eligibility criteria. Divergences were discussed by the reviewers together or with a third researcher.

Data charting

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

Quality appraisal

The Mixed Methods Appraisal Tool (MMAT) V.2018^{34 35} was applied for qualitative, quantitative or mixed-methodological studies. AMSTAR V.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 V.2, after items that were not applicable were excluded, we conducted a grade of overall confidence according to the criteria by Shea et al³⁶

Data synthesis

Eligible studies were divided into administration approaches, education and training and appraisal tools. We summarised 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 al³⁷

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.

Results

The search identified 1973 related studies, among which 538 were Chinese publications. Overall, 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, and one study published from 2011 to 2021 were manually identified from the reference lists. Ultimately, we identified 36 eligible studies^38–73 for our scoping review (figure 1).

Figure 1.

Preferred Reporting Items for Systematic reviews and Meta-analyses flow diagram for study selection.

Study characteristics

Study characteristics and contents are displayed in table 1. Settings, limitations, fundings and competing interests of the studies are shown in online supplemental file 5.

Table 1.

Study characteristics

Study	Type	Objective	Participants and demographics	Methodologies: theory/framework, sampling, intervention/exposure, evaluation and statistical methods	Key findings and outcomes
Appleby38; the UK	MMS	Nurses’ and HCAs’ intentions to implement a ‘care round checklist’	N=270 270 nurses and HCAs; 40% HCAs, approx. 110 Response rate 38%	Theory: the theory of planned behavior; Scale development: semistructured qualitative interview; Scoring: Likert scale; Statistical method: exploratory factor analysis; correlations	A 66-item questionnaire to measure nurses’ and HCAs’ intentions was developed and consistency reliability was achieved The questionnaire explained 24.2% of HCAs’ intentions, which were predicted by attitude and practice habits Positive beliefs of HCAs towards implementing the checklist were associated with patients, colleagues, delegation and communication. One negative was distraction, and effective use of the checklist depended on staff numbers
Campbell et al39; the USA	O	Relational quality of RN and NA, and manager’s influence on the quality and patient safety	N=1152 889 RNs and 263 NAs; from 53 full-time inpatient units	Database: hospital survey on patient safety culture survey results; Evaluation: a seven-item leader–member exchange questionnaire to evaluate relational quality, and a four-dimension manager to influence composite measures derived from AHRQ survey composites; Statistical method: paired t-test	Manager influence had a strong relationship with overall perceptions of safety regardless of the relational quality perceptions of RNs and NAs
Campbell et al40; the USA	ES	Interventions for teamwork, delegation and communication between RNs and NAs	Seven studies on NAs, RNs and LPNs	Methodology: integrative review; Searching: PRISMA; Critical appraisal: Mixed Methods Appraisal Tool and SQUIRE V.2.0	A multiconstruct approach to promote teamwork, communication and/or delegation was essential TeamSTEPPS, crew resource management and simulation or other teamwork enhancement activities were effective for promoting teamwork Lecture format with multiple modalities, improving of shift process by SBART, role play, simulation and virtual training would help improve communication Avatars in a virtual hospital and a traditional lecture based on ANA principles including role playing would influence delegation
Dutton and Kozachik41; the USA	PPT	The utilisation, satisfaction and effect of a web-based stress management programme (BREATHE)	N=31 31 nursing staff, of which 6 CNAs. F:M 29:2 Majority age 30–49, ethnicity black, diploma baccalaureate	Theory: the translation framework Knowledge to Action for developing the project; Intervention: web-based survey and 2-month web-based intervention using the programme; Evaluation: Nurse Stress Scale for measuring stress; Statistical method: paired t-test	BREATHE programme could support nurses to manage their stress Death and dying, conflict with MD, workload and uncertainty related to treatment were improved by the BREATHE programme, while other subscales showed no significant improvement
Dykes et al42; the USA	MMS	Developing and testing the Self Efficacy for Preventing Falls—Nurse/Assistant (SEPFN/SEPFA) scales	N=83 27 CNAs in phase I and III, 269 CNAs in the survey, 83 were included in the data analysis	Theory: classical measurement theory; Scale development: focus groups for phase I and III, and reliability test in phase IV; Scale scoring: six-point Likert system; Sampling: snowball; Statistical method: independent and paired t-test, and Cronbach’s α for consistency reliability	SEPFN/SEPFA scales achieved psychometric adequacy and were recommended to measure self-efficacy beliefs in preventing falls
Feng et al43; China	O	Working conditions of NAs employed by hospital or company	N=538 538 NAs in 10 hospitals	Evaluation: questionnaire on demographics, vocational identity and stability, and working satisfaction Statistical method: chi-square test	NAs employed by hospital only had significant differences on age (younger), education background, vocational stability and identity, and working satisfaction (all better) between those employed by company
Friesen and Andersen44; Canada	ES	Evidence on collaborative or intradisciplinary palliative education strategies for HCAs	16 studies on HCAs, from the UK, the USA, Canada and Australia	Qualitative metasummary	Six implications for implementing a collaborative palliative educational workshop: previewing teaching process with HCAs a priori; the content should be practical; all HCAs should attend; ensuring the benefits were transferrable to care settings; ensuring HCAs were able to use newly acquired skills; and choosing education strategies that HCAs favoured
Gao and Zhao45; China	PPT	Effectiveness of dual management model (by hospital and company) on NAWs	N=1344 patients	Intervention: NAs from companies were dual managed by hospital (hospital—nursing department—care unit) and company; Evaluation: a questionnaire on competency, patient satisfaction, complaints, execution of duties, and compliance with hospital regulations; Statistical method: Cronbach’s α and Spearman correlation for reliability and validity, and chi-square test for results	There was a significant increase in working competency and patient satisfaction after a dual-management intervention There was no significant decrease in complaint events after the intervention
Geoffrion et al46; Canada	ES	The effectiveness of education and training methods to prevent workplace aggression	N=1688 9 studies with 1688 HCWs	Cochrane Handbook for Systematic Reviews of Interventions	Evidence on education to prevent workplace aggression was mixed. Participants may not benefit from education on preventing aggression Education may increase HCWs’ personal knowledge and positive attitudes on aggression Education may not have effects on skills and adverse outcomes on aggression
Haigh and Garside47; the UK	MMS	Impact of the care certificate on the HCAs	N=11 11 HCAs	Evaluation: a mixed methods 18-item questionnaire on feedback of the care certificate; Statistical method: only descriptive	Most participants found the care certificate to be of benefit, regardless of experience or education background It was uncertain if the care certificate made a difference to HCAs’ practice
Haraldsson et al.48; Sweden	O	To compare a questionnaire with technical measurements (electromyography) on assessment of workload of CNAs	N=16 16 CNAs, F:M 15:1 Median (min–max): weight 62 (56–92) kg, height 164 (158–181) cm, working time 475 (457–504) min, break time 66.5 (50–95) min	Evaluation: the Structured Multidisciplinary Evaluation Tool (SMET); surface electromyography to assess workload; Statistical method: correlation matrix	There are significant correlations between the SMET questionnaire and surface electromyography outcomes There are correlations between the inclinometer measures of upper back flexion and self-estimation of work support and demands
Kennerly et al49; the USA	O	Psychometric properties of the Nursing Culture Assessment Tool	N=340 340 RNs, LPNs and CNAs CNA response rate: 10% F:M 318:22 38.8% working in acute care settings Working experience median 15.23 years	Theory: the polytomous universal model; Sampling: convenience sampling via mail; Evaluation: the Nursing Culture Assessment Model; Statistical method: Cronbach’s α for consistency reliability, exploratory factor analyses for validity; logistic regression for differential item functioning	Reliability and validity of all subscales and the overall tool were achieved regardless of whether nursing professionals to use it All subscales can be interpreted individually
Lee et al50; the USA	MMS	An education programme on safe patient handling and mobility	N=236 224 nursing staff in pilot education, and 12 in house-wide education. 281 course trainers and 98 coaches were trained for the programme	Intervention: 3-phase development of the education programme: pilot, house-wide and ongoing education; Evaluation: descriptive and qualitative evaluation	A 4–8-hour education programme aimed at safe transfer, patient mobility and prevention of nursing staff’s injury was developed including prework, application, trainer and peer coach courses, through online learning, demonstration, skill evaluation and coaching
Liu et al.51; China	PPT	Effectiveness of a comprehensive administration approach of NAWs on patient and RN’s satisfaction	N=150 150 NAWs, (mean±SD) age 48.72±4.56 working experience 3.53±0.97 years	Intervention: a management model, where NAWs were managed by the nursing department, head nurses and RNs triply, and a refined prejob, enrolment and continuing education system; Evaluation: a questionnaire on attitude, ward environment and care quality; Statistical method: Cronbach’s α for reliability, and t-test for outcomes	The novel management model significantly improved patient and RN’s satisfaction on NAWs, and reduced unreasonable charge events of NAWs
Ma et al52; China	PPT	Effectiveness of failure modes and effects analysis (FMEA) method in NAW administration	N=50 50 NAWs in a ward	Intervention: improving of job responsibilities, prework and continuing education, and quality control according to the FMEA scoring; Evaluation: FMEA scoring on severity, occurrence and detection; Statistical method: independent t-test	The FMEA method ran well in NAW administration, with the intervention according to FMEA significantly improving severity, occurrence and detection scores
McKenzie et al53; the UK	Qual	Effect of a simulation-based education programme on HCAs	N=6 6 HCAs having attended the Crisis Avoidance and Resource Management	Intervention: the Crisis Avoidance and Resource Management programme; Qualitative evaluation: focus groups; semistructured interview	Four themes (role of HCA, realism and learning through simulation, impact of simulation on patient safety and programme structure) were identified from the focus group The simulation course (the Crisis Avoidance and Resource Management) was positively received by HCAs and was beneficial for knowledge, confidence, team-working, communication and patient safety
Monteiro et al54; Brazil	Q	Work capacity of NAs	N=651 651 participants, of which 241 NAs F:M 83:17 Mean age 39.9 Response rate 89.4%	Evaluation: the Work Ability Index; Statistical method: univariate and multiple logistic regression	Age, body mass index, and duration of the work were associated with work ability (capacity)
Nie et al.55; China	PT	Effectiveness of a group collaborative training model for NAs	N=60 60 NAs, F:M 78:21 (Mean±SD) age 41.5±9.35	Intervention: lecture, practical training and simulation study intragroups, including cardiopulmonary resuscitation, living care and clinical care; Evaluation: practical test, patient and clinical professional’s satisfaction of NA working, and NA’s approval rate of the education programme	90% of NAs passed the competency test, with an average score of 88.51 out of 100 More than 90% of patients, clinical professionals and NAs approved of the education programme
Nørgaard et al56; Denmark	PPT	Development and effectiveness of a training programme for communication skills	N=148 181 participants, of which 30 NAs, and 148 completed entire process F:M 86:14	Theory and model: the Calgary–Cambridge Observation Guide; the self-efficacy theory; Intervention: a 3-day training programme; Qualitative evaluation: focus group interview for training contents and questionnaire; Quantitative evaluation: a 19-item self-efficacy questionnaire; Statistical method: paired t-test and linear regression	A 3-day training programme on communication with patients and colleagues was developed The training programme significantly improved communication skills and self-efficacy, which was durable, presenting 6 months after the training
Pfeifer et al57 the USA	MMS	Effect of an education programme on dementia patients’ care	N=428 428 CNAs	Intervention: a 1-hour dementia education programme; Qualitative method: two open-ended questions; Quantitative method: a three-item Likert-type questionnaire	A multimodal education programme for CNAs on dementia was developed The dementia education programme made a significant improvement on CNAs’ knowledge and communication skills on dementia
Prestia and Dyess58; the USA	PPT	Effect of a care partner programme on relationships between CNAs and patients	All CNAs in a 333-bed hospital	Theory: caring theory Intervention: a 1-day care partner programme, including discussion, expectations, FISH philosophy and video, the AIDET tool (acknowledge, introduce, duration, explain and thank) and interactions; Evaluation: a patient satisfaction score from the Hospital Consumer Assessment of Healthcare Providers and System survey	The care partner programme significantly increased hospitals’ scores of patient satisfaction
Qiu et al59; China	PPT	Application of Activities of Daily Living Scale in NA administration	N=162 162 NAs (Mean±SD) Age 44.6±6.9	Intervention: patients who need NA care were divided into four grades according to Activities of Daily Living Scale scores, and NAs provided different care according to the score; Evaluation: questionnaires on patient and nursing personnel’s satisfaction on NA care quality, NA satisfaction, and NA turnover rate; Statistical method: Cronbach’s α for reliability, and Mann-Whitney U test and chi-square test for outcomes	Patient, nursing personnel and NAs’ satisfaction were all significantly improved after intervention, and NA turnover rate was decreased
Ritchie et al60; the UK	PPT	Effect of a quality improvement education programme on restorative care practice	N=36 36 NAs and all patients in their wards	Theory and model: 4Es (engage, educate, execute and evaluate) model and quality improve process; Intervention: a didactic study day and a 3–4-hour ward-based practice session, taught by a physical therapist; Evaluation: independent observation and scoring of preintervention and postintervention care events; Barthel and Abbreviated Mental Test scales for patients	The training programme significantly increased restorative care events and decreased the number of patients receiving no NA-led restorative care Patient characteristics (Barthel scores and Abbreviated Mental Test scores), beds occupancy and recuperating rates showed no significant difference
Small et al61; the USA	PPT	Development of a continuing education programme for patient care technicians	N=29 approx. 15 RNs and 14 patient care technicians	Intervention: education sessions and teaching plans were developed by RNs; Evaluation: four-point Likert scales on teamwork, peer support and communication, and open questions on the topic were asked	A continuing inpatient education programme for patient care technicians was developed, and the feedback was positive
Swann62; the USA	O	Education and recognition to improve NA’s retention	Approx. 700 NAs	Theory: Imogene King’s Theory of Goal Attainment; Intervention: CNA orientation coaches (6% NAs took part); Evaluation: a retrospective descriptive survey to measure retention rate of NAs, 1 year prior to and after the intervention	The turnover rate did not decrease significantly after the intervention The Imogene King’s Theory (including stress, body image and self-growth) was not supported and not applicable on NA retention, by the research outcome
Tom63; the USA	PPT	Development and effectiveness of a patient safety aide training orientation programme	N=32 32 patient safety aides	Theory: Jean Watson’s Theory of Human Caring; Intervention: a 2-day safety aide training orientation, competency and validation programme in Durham Veterans’ Affairs Medical Center (DVAMC); Evaluation: a six-item patient safety aides survey, five-item DVAMC evaluation, and monthly patient elopement and falls incidents; Statistical method: paired t-test	The programme significantly improved the preparedness and decreased the fall events, while patient elopement did not show a significant decrease The training programme may help maximise cost-effectiveness
Twigg et al64; Australia	O	Impact of adding AINs to acute care ward on adverse patient outcome	33 AIN wards and 31 non-AIN wards, 256 302 records of patients	Theory: the Patient Care System Model; Exposure: AIN introduced in the hospital; Evaluation: CBA within ward type, and post-test evaluation between AIN and non-AIN type; Statistical method: OR	The adding of AIN significantly increased failure to rescue, urinary tract infection, and falls with injury, while it decreased mortality There were no decreases on adverse events for patients spending more time on AIN wards
Wagner65; the USA	PPT	Development and effectiveness of a delegation–communication learning programme	N=37 14 UAPs and 23 RNs (for UAP) F:M 71:29, age 18–59, high school diploma 29%, vocational certificate 29%	Intervention: a lecture-format programme including principles, case scenarios and examples; Evaluation: independent observation for baseline survey, and a questionnaire from the Hopkins Learning Needs Assessment and the Kærnested and Bragadóttir delegation for RNs and UAPs; the National Database of Nursing Quality Indicators and the Press-Ganey patient satisfaction levels for patient outcome; Statistical method: independent t-test	The intervention improved the unit fall rate and pressure injury rate All but one item ‘losing respect because of delegation’ showed no significant improvement after intervention Staff favoured a hard-copy format to review the lecture while working
Ward et al66; the USA	PPT	Development of a continuing education programme for CNAs	N=130 approx. 130 CNAs	Intervention: educational offering on the run (eDOOR) programme, using eye-catching flyers, a 1-hour simulation skills lab, and a mini-inservice; Evaluation: needs assessment survey, and a 10-item CNA knowledge test	A programme for CNA continuing education was developed, including eDOOR methods and simulation, and received positive responses from CNAs There was no significant increase in the CNA knowledge test scores
Wilson et al67; the USA	PPT	Development and effectiveness of a patient handling education programme for NAs	N=254 254 NAs F:M approx. 10:1 age 18–61	Intervention: an 8-hour education programme, including lectures and simulation taught by healthcare professionals and physical therapists; Evaluation: a 10-item knowledge test and a 10-item confidence and comfort level in handling patient and transfer questionnaire; Statistical method: paired t-test, Wilcoxon rank test and Spearman correlation	An education programme, including patient transfer, lifting, ambulating and braces and protheses in the form of lecture and simulation was developed The programme can significantly improve NAs’ knowledge, confidence and comfort on patient handling
Wu et al68; China	PPT	Effectiveness of hospital management and training of NAWs	N=65 65 NAWs F:M 62:38 55% primary school background	Intervention: a holistic management system including: NAW management centre, hospital regulations, continuing education, information system and software, charge scales and humanised management; Evaluation: NAW competency test, and patient and clinical professional’s satisfaction	Skills and knowledge of NAWs was significantly improved after intervention Satisfaction of patients and clinical professionals was improved
Yu69; China	PPT	Effectiveness of applying quality control circle to NAW’s hand hygiene administration	N=9 9 NAWs in a psychiatric ward	Intervention: Quality Control Circle for continuing quality improvement, and fishbone diagram for analysing reasons. Education, facility improving and hand hygiene monitoring were used for increased compliance of hand hygiene of NAWs; Evaluation: independent observation of hand washing times, points, and methods; a hand hygiene compliance questionnaire; colony forming units at hand surface after hand washing	The Quality Control Circle method improved NAW’s hand hygiene situation and compliance significantly
Zhao et al70; China	PPT	Effectiveness of a patient-oriented stratified training model for NAs	N=75 75 NAs F:M 51:24 (Mean±SD) Age 50.7±3.4 Working experience 2.3±1.2 years	Intervention: a training work group for development of training programme; Barthel Scale for four-grade stratification of patients, and a three-grade occupation certificate for NAs with different training contents and hours; Evaluation: NA knowledge and skill exam, and patient and nursing professionals’ satisfaction on NAs	A stratified, patient-oriented NA management approach was identified There was significant improvement on NA competency, and patient and nursing professionals’ satisfaction after the training model set on
Zhi et al71; China	O	Patient satisfaction under different administration models of NA	144 hospitals, 6211 patients	Evaluation: a 5-item Likert scale on satisfaction; Statistical method: Mann-Whitney U test and Kruskal-Wallis test for demographics and satisfaction, chi-square test and binary logistic regression for different models	Satisfaction for NAs under the direct hospital management model was higher than under others (commercial company, company-hospital joint, and self-employed) Patients with higher family income tended to score higher
Zhu et al72; China	PT	Self-protection training of NAWs during COVID-19 pandemic	N=37 37 NAWs F:M 35:2 (Mean±SD) Age 49.38±7.98 Working experience 3.14±2.09 years	Theory: Kirkpatrick Model—reaction, learning, behaviour and result (4R); Intervention: a ‘dual feedback, tertiary training and four-level evaluation’ training model, including a training work group, training taught by company, nursing department and wards about protection skills and knowledge using video and lecture, and a practical exam; Evaluation: NAW satisfaction, practical exam, independent observation of self-protection behaviour and nosocomial infection rate	100% of the NAWs were satisfied with the training programme, with a mean score of 91.6 out of 100 on the competency exams 94.59% of the NAWs followed self-protection behaviour instructions, and no infection events occurred in the 3 months after training
Zhu et al73; China	PPT	An inform sheet for patients to make NAW’s care known better	N=39 39 NAWs, 55 participants F:M of NAW 29:10	Intervention: an information sheet from NAWs to patients, including: what to care, what not to do, how to care, responsibilities of NAWs and personalised care; Evaluation: awareness rate of NAW routing works, and satisfaction of patients	The information sheet can significantly improve NAWs’ awareness of regulation, safety and patient privacy, and patients were more satisfied with NAWs

AIN, assistant in nursing; approx, approximately; CNA, certified nursing assistant; ES, evidence synthesis; F:M, female-to-male ratio; HCA, healthcare assistant; HCW, healthcare workers; LPN, licenced practical nurse; MMS, mixed methods study; N/A, not applicable; NA, nursing assistants (or nursing aides); NAW, nursing attending worker; O, observational quantitative study; PPT, pretest and post-test quantitative study; PRISMA, Preferred Reporting Items for Systematic reviews and Meta-analyses; PT, post-test quantitative study; Qual, qualitative study; RN, registered nurse; UAP, unlicensed assistive personnel.

The articles were mainly from the USA and China, and 22 of 36 studies were published in the last 5 years (2017–2022). Overall, 2 theses, 3 evidence syntheses and 31 original research papers were included. Overall, 25 articles presented quantitative designs (17 interventional and eight descriptive), 1 was qualitative and 7 studies employed mixed methods. Most studies (19 of 24) with interventions applied a quasiexperimental, pretest and post-test design, while 1 study⁵⁷ presented a retrospective post-then-pretest design.⁷⁴ Focus group interviews were the most employed method in qualitative and mixed methods studies. The three evidence syntheses were in different types: one integrated review,⁴⁰ one qualitative metasummary⁴⁴ and one systematic review.⁴⁶

All 33 original studies were conducted in hospitals due to our inclusion criteria, and the sample size ranged from 6 to 700 NAs. Three studies^{45 64 71} were focused on patients’ attitudes and did not report the demographics of NAs. Only one study⁵⁴ 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, 2 of the studies^{40 44} received a ‘very low’ rating, while the other 1⁴⁶ got a ‘high’. Overall, the methodological quality of the included studies was considered acceptable.

Approaches and models

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 studies43 45 51 68 71 were aimed at the change of management and employment from company led to hospital led, or double track, with consistently positive results on satisfaction and NA/NAW working competency after intervention. Other original studies identified four practical tools or methods, that is, the Failure Modes and Effects Analysis (FMEA),⁵² the Activities of Daily Living (ADL) Scale,⁵⁹ the Quality Control Circle (QCC)⁶⁹ and an information sheet to patients,⁷³ as well as two programmes on stress and CNA–patient relationships.^{41 58}

Table 2.

Administration approaches, training and education programmes, appraisal tools and main focuses (n=36)

Theme 1: Administration approaches (n=14)
Study	Main focus	Programme/model	Contents
Campbell et al40*	Teamwork Communication	Crew resource management; TeamSTEPPS75; SBART for shift; ANA principles	Not applicable. (This integrated review reported five programmes and virtual simulation scenarios from the previous studies.)
Dutton et al41	Stress	BREATHE stress management programme	Six modules including introduction of stress, assessing stress, identifying stressors, managing stress, avoiding negative coping and mental health
Feng et al43	Vocational identity Work satisfaction	Hospital-only employment model	NAWs were only employed by hospitals and were managed by the nursing department
Gao and Zhao45	Competency Patient satisfaction	Dual employment mode by hospital and company	A tertiary management from hospital: the hospital president, the nursing department and wards head nurse; NAW group leader and head nurse management in wards; and the company management
Liu et al51	Patient satisfaction Nurse satisfaction	Three-level comprehensive management model	A three-level nursing department—head nurse—bed nurse management modal, including regulation and responsibilities, NAW prework training, performance incentive mechanism and care quality control standards
Ma et al52	Job responsibility Care quality control	FMEA model	An FMEA group including head nurses and hospital managers scored the severity, detection and occurrence, and then found approaches to solve the problem
Pfeifer et al57	Relationships of CNAs and patients Patient satisfaction	Care partner programme	A shared mental model education was conducted, including seven aspects on expectations, discussion of current care, teaching of relationships building, discussion on patient experiences, education on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and caring skill stations
Qiu et al59	Patient satisfaction NA satisfaction Turnover/retention	Activities of Daily Living (ADL) Scale stratified and management model	ADL was used to stratify patients and NAW care contents into four levels so as to make care and charge standards
Swann62	Turnover/retention	CNA orientation coaches	A 2-hour programme on clinical and emergency skills
Twigg et al64	Adverse patient outcome	Adding AINs to acute wards	Not applicable
Wu et al68	Competency Patient satisfaction Clinical professional satisfaction	A holistic NAW-centred management model	NAWs received unified management from NAW centre. Regulations, working formulations, continuing education, care quality control by 360° evaluation, application of information system and humanised management were used
Yu69	Hand hygiene	Quality Control Circle (QCC)	A QCC group for observing and analysing NAW’s hand hygiene. Fish bone diagram for analysing factors of low compliance, and brainstorm for intervention methods. Education, facilities adding and everyday detection were used for improving
Zhi et al71	Patient satisfaction	Direct hospital management model	NAWs were only employed by hospitals and were managed by the nursing department or NAW centre.
Zhu et al73	Awareness of work contents Patient satisfaction	Informed sheet	The inform sheet contained care requirements and personalised requirements, signed by both NAWs and patients and leaving to patients

Theme 2: Education and training (n=15)
Study	Main focus	Educational strategy
Friesen and Andersen44*	Palliative care	Collaborative or intradisciplinary palliative education strategies from 16 studies, methods including lectures, case studies, practical training, learning groups, role play, discussions, slide presentations, web-based learning, workshops and feedback discussions
Geoffrion et al46*	Workplace aggression	Education interventions from nine studies, methods including online learning, group discussions, lectures, videos, simulation and role play
Lee et al50	Patient handling and mobility	A 4–8-hour online and face-to-face education programme for nursing staff taught by trained coaches
McKenzie et al53	Patient safety	The Crisis Avoidance and Resource Management using scenarios, taught by senior nurses
Nie et al55	Knowledge and skills patient, clinical professionals and NA satisfaction	A group collaborative training, including lectures, practical training, simulation and group role play
Nørgaard et al56	Communication	A 3-day training programme using role play, lectures, discussions and communication practice, with a 6-month interval between the first 2 days and the last day
Pfeifer et al.57 (2018)	Dementia	A 1-hour dementia education programme using lectures, videos and scenarios
Ritchie et al60	Restorative care	A didactic day and a 3–4-hour practice session, using lectures and practical training, taught by a physical therapist
Small et al61	Continuing education	A continuing and normalised education programme based on teaching plans from RNs at shifts, using lectures, demonstration and return demonstration
Tom63	Patient safety	A 2-day patient safety aide training programme by the Veteran Affair Department, with lectures and a competency test
Wagner65	Delegation and communication	A half-hour learning programme with lectures and video, taught by the practitioner investigator
Ward et al66	Continuing education	The educational offering on the run programme, with flyers, simulation and mini-in-service study
Wilson et al67	Patient handling and mobility	An 8 hour education programme (two 4 hour parts) with lectures, demonstration, discussion and simulations
Zhao et al70	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 32–48-hour stratified training for different levels, using lectures and practical training
Zhu et al72	Self-protection	A tertiary training model by companies, nursing department and wards using lectures, practical training, competency test and continuing improving

Theme 3: Appraisal tools (n=7)
Study	Main focus	Tools	Contents	Reliability and validity
Appleby38	Intention to following a checklist	A 66-item intention questionnaire	5 demographic items, 7 on clinical context, 7 on habit, 17 on attitude, 15 on subjective norm and 15 on perceived behaviour control	Overall Cronbach’s α 0.83 for HCAs; 24.2% of HCA’s intentions were explained
Campbell et al39	Relational quality between RN and NA and patient safety	A seven-item leader–member exchange questionnaire by Graen and Uhl-Bien76	Seven items on leader satisfaction, understanding, recognition, problem-solving, ‘bail you out’ for employees and confidence and relationships of leader	Overall Cronbach’s α 0.89 for NAs
Dykes et al42	Preventing falls	An eight-item Self-Efficacy for Preventing Falls—Assistant scales	Eight items on confidence, communication, understanding of the environment and team working for preventing falls	Overall Cronbach’s α 0.69–0.74; item total correlation 0.3–0.7
Haigh and Garside47	Feedback of the care certificate	An 18-item questionnaire	Eighteen items on confidence, knowledge and skills and attitudes	Not specified
Haraldsson et al48	Workload	The Structured Multidisciplinary Evaluation Tool (SMET)	22 items on movement, position, pace, eyesight, sitting, noise, space, lighting of workplace and working condition, attitude and satisfaction	Validity test: p values of correlation between SMET subgroup scores and surface electromyography measure outcome were ranged from 0.001 to 0.05, indicating the effectiveness
Kennerly et al49	Nursing culture	The Nursing Culture Assessment Tool	19 items and 6 subscales on expectations, behaviours, teamwork, communication, satisfaction and commitment	Overall Cronbach’s α 0.92, and subscales ranged from 0.60 to 0.93 Validity test: subscale correlations 0.27–0.74, comparative fit index 0.94
Monteiro et al54	Working capacity	The Work Ability Index	Seven items on current work ability, diseases and work impairment	Not specified

*This article is an evidence synthesis.

AIN, assistant in nursing; CNAs, certified nursing assistants; HCAs, healthcare assistants; NA, nursing assistant; NAWs, nursing attending workers; RNs, registered nurses.

Negative outcomes were found in turnover rates after a CNA orientation coach⁶² and in adverse events with the addition of assistants in nursing (AINs) to acute wards.⁶⁴ Meanwhile, several approaches, including crew resource management, the TeamSTEPPS programme⁷⁵ and the SBART shift model, were summarised by an integrated review from Campbell et al⁴⁰

Education and training programs

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 emphasised. Six studies highlighted five aspects of NA competency: patient handling,^{50 67} palliative care,⁴⁴ dementia,⁵⁷ restorative care⁶⁰ and routine work capacity.⁵⁵ Of other studies, two^{53 63} improved patient safety, two^{56 65} were on communication, two^{61 66} pointed to 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 need of further study in this area.

Appraisal tools

We found seven valid appraisal tools for NA administration with stable psychometrics from the included studies (table 2):

1. HCA and RNs’ intention questionnaire.³⁸

2. A seven-item leader–member exchange relational quality questionnaire from Campbell et al³⁹ and developed by Graen and Uhl-Bien.⁷⁶

3. NA working questionnaire.⁴⁷

4. The Nursing Culture Assessment Tool.⁴⁹

5. The Structured Multidisciplinary Evaluation Tool from Haraldsson et al⁴⁸ and developed by Haraldsson in 2016.⁷⁷

6. Self-Efficacy for Preventing Falls—Assistants.⁴²

7. The Work Ability Index from Monteiro et al⁵⁴ and produced by Ilmarinen.⁷⁸

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 ranged from working capacity and workload to relationships, intentions and nursing culture.

Frequency effect size analysis

We conducted frequency effect size analysis on the included studies’ main focuses and strategies (table 3 and online supplemental file 7 figure S1). 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.

Table 3.

Frequency effect size analysis of main focuses and intervention methods

Topics	Studies	Frequency effect size
Main focus (n=36)
Level 1: nursing assistant
Competency (skills and knowledge)	44 45 47 50 52 54 55 57 60 67 68 70	33%
Self-efficacy, job-related identity and responsibility	43 47 49 52 73	14%
Satisfaction	43 49 52 55 59	14%
Continuing education	61 66 68	8%
Self-protection	46 72	6%
Workload and stress	41 48	6%
Intention	38	3%
Level 2: clinical personnel
Communication and teamwork	40 47 49 56	14%
Clinical/nursing staff satisfaction	51 55 59 68 70	14%
Relationship	39	3%
Level 3: patient
Patient satisfaction	45 51 55 58 59 68 70 71 73	25%
Patient safety	42 45 53 63 64	11%
Relationships	58	3%
Level 4: facility management
Retention/turnover	59 62	6%
Care quality control	52 69	6%
Intervention method
Education and training (n=20)
Lecture	50–52 55–58 60 61 63 65 67–70 72	80%
Simulation/role play	50 55 58 66–68	30%
Practical training	52 55 56 68 70 72	30%
Exam	62 63 66 69 72	25%
Discussion	50 56 58 67	20%
Video	50 57 65 68	20%
Demonstration	61 67–69	20%
Web-based training	41 50	10%
Group study	50 55	10%
Scenario	53 57	10%
Flyer	66	5%

Twenty studies contained the theme of education and training strategies. Face-to-face lectures were still the most employed method (80%), followed by simulation, role play and practical training (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. Due to the significant heterogeneity, we failed to distinguish themes in studies on NA administration methods and only summarised their objectives. Approximately 62% of the studies evaluated tools for administration, and the other five papers were on hospital management models (38%).

Discussion

This review outlined existing administration tools, management models, education programmes and appraisal scales from previous studies. The results implied a need to investigate more on administration models and frameworks for NA administration in hospitals. High-quality evidence of the efficacy of existing educational strategies was scarce. Gaps in NA administration development and current circumstances between developed and developing areas were noted and needed improvement.

Approaches and models

Existing articles for administration approaches, models and frameworks were scarce. Only 14 studies presented evaluations on these topics, and the focuses were region-specific, that is, researchers from China and the Europe–US region typically targeted different objectives.

In China, NAWs were employed by companies or hospitals, or were self-employed.^{79 80} The company employment model took the majority.⁸¹ The selection and training of NAWs were conducted by directors and executors of companies but not clinical professionals, leading to uncontrolled quality of care and muddled management.^{79 82} The researchers proposed to improve this context. Included Chinese studies showed a three-tiered hierarchical model where NAWs were managed by (1) nurse departments or NAW centres, (2) head nurses and (3) ward nurses. However, this review revealed remarkable heterogeneity and unrepresentative sampling in this area. Further investigation of the hospital management model and the effectiveness of other mature models in Chinese hospitals can be the next step.

Chinese researchers also evaluated the FMEA model, ADL Scale and QCC. FMEA and QCC were widely used mature models in hospital routine management,^83–86 but have rarely been evaluated for NAs. However, without any new points added, the ideas were only a panning from nurses to NAs. On the other hand, the application of ADL Scale was more innovative. ADL was first developed by Katz⁸⁷ and is one of the most widely used tools for assessing patient functions. Different ADL scores and levels represented patients’ statuses and care needs to guide managers to a more cost-effective and patient-oriented model of NA allocation.

For researchers from the countries where NA industry has been highly developed, a holistic programme was typically their focus. They also focused on more humanistic aspects such as communication, workload, safety, etc. They^{41 58} developed or evaluated programmes to improve administration, that is, the TeamSTEPPS programme, BREATHE programme and the Care Partner Programmes. The programmes were well-designed and of good availability, but the small sample size still placed barriers to their widespread application. Additional studies on approaches to widen the applicability and design of more diverse programmes are crucial.

The difference in the hotspots of the research area was strongly related to the degree of development of NA industry in different regions. Our included studies were strongly demand driven. In a region where NA regulations were not yet well-established, relevant studies tended to be more primary and discuss basic administration structures, for example, employment modes. On the contrary, in countries where NAs were mandated by law to be employed and managed by healthcare institutes themselves, the topic was no longer necessary for research, and researchers have turned to explore more advanced knowledge.

Educational strategies

Overall, 11 groups of educational strategies were applied to 20 included studies. In total, 90% of the studies employed at least two groups of strategies, with an average of 2.60, and multiple education methods may result in more positive outcomes compared with single-method teaching.⁸⁸ A simulation was highlighted because it has been shown to be effective in nursing education,^{89 90} and a debrief simulation method was recommended.⁹¹ Web-based training has become a modern trend, especially during the COVID-19 pandemic.⁹² However, the evidence regarding the effectiveness of e-learning in nursing education remains unclear.^{93 94} Moreover, half of the articles used interactive methods, for example, simulation, discussion and group study. We found this to be a trend in NA education and training in recent years. When transferring these teaching methods to NAs, attention should be paid to the educational background gap between NAs and nursing students.

Focuses and topics

Overall, 23 focuses were initially found by the frequency effect analysis, where 15 topics were distilled. NA knowledge and skills were most widely considered, with a trend of being more specified for improving competency. 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 more investigation. Existing studies revealed that all of the factors above influenced the quality of care at the RN or nursing home level,^95–98 but evidence of influence and improvement methods of NAs in hospitals is limited.

A noteworthy point was that much of the research in this area of NA was essentially a transposition of methods previously applied among RNs to NAs, within all three fields this review investigated. FMEA, QCC and patient satisfaction were significant examples. However, as discussed above, researchers should be very careful when dealing with the differences in educational background and job content between RNs and NAs.

Negative outcomes

Three studies^{46 62 64} reported notable negative or mixed outcomes. The systematic review from Geoffrion et al⁴⁶ 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. Swann⁶² evaluated the influence of the CNA orientation coaches on the retention rate and derived a negative result, while Twigg et al⁶⁴ 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 discouraging results.

Gaps

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 non-randomised study designs of the included studies may decrease the reliability of outcomes. (3) The included studies were of low-to-moderate quality of evidence and availability, and the study design was not reported in-detailed. There were barriers between existing studies and evidence-based practice. (4) Theories and conceptual frameworks were often neglected in the study designs.

Limitations

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 3 included evidence-based reviews addressed 32 original studies, where 13 studies were published between 2011 and 2022 but were not included in our scoping review, implying a potential risk of incomprehensiveness of our work.

Conclusion

This scoping review demonstrated the practical administration approaches and focus from previous studies for hospital NAs. The review found a total of 9 administration methods, 1 administration model, 15 education and training programmes and 7 appraisal tools. With the frequency effect size analysis, 15 main focus groups 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 recognised, and more studies on NAs in hospitals are expected. Researchers should draw more attention to evidence-based methods in the administration area, resulting in continuous improvement, global sharing and system establishment of intrahospital NAs’ administration.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article or uploaded as online supplemental information, and the protocol of this study are openly available (DOI: 10.13140/RG.2.2.29106.12483/1).

Ethics statements

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Not applicable.

Ethics approval

Not applicable.