Reporting is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines(29).
Search and screening results
Figure 1 is a flow diagram adapted from the PRISMA 2020 statement(38). It provides a summary of the sources searched and the records assessed for eligibility. We obtained a total of 85,251 records from electronic databases and grey literature searches. After screening for eligibility and excluding records based on the eligibility criteria, a total of 73 records were included in the final full-text review, data charting, and synthesis.
Summary statistics
Characteristics of sources: Majority of the paperswere observational studies followed by grey literature. Records from high-income settings accounted for a majority of the eligible full texts. That is, United Kingdom (UK) had the highest number of sources (n=19 [25%]) followed by the United States of America(n=13[17%]) and Australia(n=7[9%]) respectively. Japan, Israel, Benin, Hong Kong, Malawi, Brazil, and Uganda had 1 report each.
The hospital setting: Only 47(n=64%) of the papers described the type of care setting. Our synthesis established that these relevant sources yielded a mix of rural and urban(n=22), inpatient-only (n=18) and outpatient-only(n=2), nursing care homes (n=12), both inpatient and outpatient(n=9) with a mix of children and adult care settings. Moreover, of the sources that mentioned a type of setting, public and private hospitals were reported in 30(40%) and 13(17%) papers respectively. Twelve papers(16%) had a mix of both private and public. Additional File 4 provides more information on the setting as reported in the included papers.
Characterising CAs
Conceptually, we note that many titles are currently used for the identification or description of CAs in different countries and regions (Additional File 5). Only a few select similarities exist, for instance, “nursing assistant” is used in Australia, Hong Kong, China, New Zealand, the United States of America (USA), and the UK. UK has the highest number of terms/name variations that describe CAs (>21), followed by Australia and Canada (>11 each) then the USA and Hong Kong China (>7 each). Consequently, the term “Assistant” is the most common stem word followed by “support staff/worker” in what are typically compound terms for CAs. Figure 2 is a word cloud illustration of these variations. The other variations are summarised in Additional File 6 and in order of the most common to the least common.
Objective 1: Duties performed to CAs in hospital settings.
Duties ascribed to CAs.
A majority (78%, n=58) of the records mentioned specific tasks performed by CAs in their care setting or facility. Our review was able to chart and curate 58 different tasks and these were grouped into 7 broad categories (illustrated in Table 2). That is, direct patient care (n= 53 records), housekeeping (n= 26 records), clerical and portering (n= 19 records each), patient flow management and ordering laboratory tests (n=4 records each). Emergency response and first aid was the least reported task category.
Table 2 unpacks the specific tasks performed under broad and sub-categories. It was noted that vital signs monitoring, patient hygiene, and feeding are top of the list of direct care duties whereas environment and surface cleaning, stock taking, equipment care and device functionality checks are the most common housekeeping tasks. However, a few outstanding papers had CAs performing more extended roles that require an extra level of knowledge and skills i.e., flu vaccination, drug injections(24, 39, 40), catheterisation(24, 40, 41, 42, 43, 44), phlebotomy(44, 45, 46, 47, 48, 49), Electrocardiogram (ECG) monitoring(39, 44, 46, 49, 50, 51, 52), wound/colostomy care(24, 27, 39, 40, 41, 42, 44, 49, 51, 53), resuscitation(54), and requesting laboratory tests(52, 55, 56, 57). These extended roles are observed mainly in high-income countries (Australia, Canada, and UK, and the USA) and not in low and middle-income countries(LMICs).
Objective 2a: Impact of CAs on patient care and their experiences
Only 20 (27%) papers reported some form of patient care outcomes. With the aid of NVIVO 12 Plus(37), a thematic analysis approach was used to examine and curate the impact of CAs on patient care. The emerging themes were then assigned sentiment labels on whether they had a positive, neutral, or negative effects on care. As shown in Table 3, the papers report a mix of both positive and negative effects.
Objective 2b: Nurses’ perception and experiences towards CAs.
Only 23(32%) papers reported on nurses’ experience of working with CAs. With the aid of NVIVO, a sentiment analysis approach was used to code and curate themes related to nurses’ experiences of working with CAs at the individual level. The emergent themes were grouped into either positive, neutral, or negative sentiments as illustrated in Table 4.
Objective 3: Clinical and organisational governance frameworks that regulate activities of CAs.
3a Regulatory and clinical governance mechanisms
Only 33 (45%) of the records mentioned some form of an organisational regulatory or clinical governance mechanism for the CAs - 8 in the UK(26, 27, 39, 41, 42, 54, 73, 81, 82, 83, 84), 6 in the USA(26, 51, 65, 70, 85, 86, 87, 88), 3 were from Taiwan China(75, 89), 2 from Canada(24, 40), and 2 from Australia(26, 51), and 1 each from Japan(72), Brazil(68), Sweden(76), Kenya(90), Malawi(66), and Uganda(91). Moreover, Brazil, Kenya, Malawi, and Uganda are the only LMICs reporting some form of clinical governance mechanism. However, for Kenya and Uganda, it is largely a proposed framework and not an already operationalised one.
We note that these mechanisms vary substantially within and across the 15 countries reviewed(Additional File 8). However, notable similarities in some countries include a requirement for completion of a competency-based training curriculum in a work setting and that there is delegation and supervision by a qualified(registered) nurse. The majority of countries lack a legislative framework that standardises or regulates the training of CAs. Moreover, nearly all the countries (93%) do not have a task-shifting/sharing policy that guide the delegation and supervision of tasks.
3b Training / Capacity Development
Only 41 (55%) of eligible papers reported some level of training requirement (pre-service or in-service) and this was reported in several countries including Australia, Benin, Canada, Israel, Kenya, Malawi, the Republic of Ireland, Taiwan, China, UK, and the USA. Sources from Brazil, Hong Kong, China, Sweden, Uganda, and Japan did not report any form of training requirement before or after the recruitment of CAs.
Our review establishes that nearly all the CAs are required to undertake onboarding training and continue with in-service competency skills training at their own pace. The skills development period varies substantially across all the countries reviewed. For instance, the minimum in-service (on-the-job) training duration ranged between 1- 48 hours(61, 66, 70) whereas the maximum in-service training period was undertaken between 126 to 672 days(26, 51, 92).
Training Topics/Content
The majority of the theory and practical learnings covered topics and skills related to basic nursing care (e.g., taking vital signs, simple wound care, taking weight and height measurements, specimen collection, or patient hygiene), workplace health and safety (including cleanliness and basic first aid), communication skills, infection prevention and control (including equipment processing), anatomy and physiology, confidentiality, privacy, and dignity as the most common training topics. The least common topics mentioned include family support/centred care, health promotion, human growth and development, food, and nutrition, and counselling. A detailed list is found in Additional File 9.