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.