conceptual framework research in education

What is a Conceptual Framework?

A conceptual framework sets forth the standards to define a research question and find appropriate, meaningful answers for the same. It connects the theories, assumptions, beliefs, and concepts behind your research and presents them in a pictorial, graphical, or narrative format.

Updated on August 28, 2023

What are frameworks in research?

Both theoretical and conceptual frameworks have a significant role in research.  Frameworks are essential to bridge the gaps in research. They aid in clearly setting the goals, priorities, relationship between variables. Frameworks in research particularly help in chalking clear process details.

Theoretical frameworks largely work at the time when a theoretical roadmap has been laid about a certain topic and the research being undertaken by the researcher, carefully analyzes it, and works on similar lines to attain successful results. 

It varies from a conceptual framework in terms of the preliminary work required to construct it. Though a conceptual framework is part of the theoretical framework in a larger sense, yet there are variations between them.

The following sections delve deeper into the characteristics of conceptual frameworks. This article will provide insight into constructing a concise, complete, and research-friendly conceptual framework for your project.

Definition of a conceptual framework

True research begins with setting empirical goals. Goals aid in presenting successful answers to the research questions at hand. It delineates a process wherein different aspects of the research are reflected upon, and coherence is established among them. 

A conceptual framework is an underrated methodological approach that should be paid attention to before embarking on a research journey in any field, be it science, finance, history, psychology, etc. 

A conceptual framework sets forth the standards to define a research question and find appropriate, meaningful answers for the same. It connects the theories, assumptions, beliefs, and concepts behind your research and presents them in a pictorial, graphical, or narrative format. Your conceptual framework establishes a link between the dependent and independent variables, factors, and other ideologies affecting the structure of your research.

A critical facet a conceptual framework unveils is the relationship the researchers have with their research. It closely highlights the factors that play an instrumental role in decision-making, variable selection, data collection, assessment of results, and formulation of new theories.

Consequently, if you, the researcher, are at the forefront of your research battlefield, your conceptual framework is the most powerful arsenal in your pocket.

What should be included in a conceptual framework?

A conceptual framework includes the key process parameters, defining variables, and cause-and-effect relationships. To add to this, the primary focus while developing a conceptual framework should remain on the quality of questions being raised and addressed through the framework. This will not only ease the process of initiation, but also enable you to draw meaningful conclusions from the same. 

A practical and advantageous approach involves selecting models and analyzing literature that is unconventional and not directly related to the topic. This helps the researcher design an illustrative framework that is multidisciplinary and simultaneously looks at a diverse range of phenomena. It also emboldens the roots of exploratory research. 

Fig. 1: Components of a conceptual framework

How to make a conceptual framework

The successful design of a conceptual framework includes:

• Selecting the appropriate research questions
• Defining the process variables (dependent, independent, and others)
• Determining the cause-and-effect relationships

This analytical tool begins with defining the most suitable set of questions that the research wishes to answer upon its conclusion. Following this, the different variety of variables is categorized. Lastly, the collected data is subjected to rigorous data analysis. Final results are compiled to establish links between the variables. 

The variables drawn inside frames impact the overall quality of the research. If the framework involves arrows, it suggests correlational linkages among the variables. Lines, on the other hand, suggest that no significant correlation exists among them. Henceforth, the utilization of lines and arrows should be done taking into cognizance the meaning they both imply.

Example of a conceptual framework

To provide an idea about a conceptual framework, let’s examine the example of drug development research. 

Say a new drug moiety A has to be launched in the market. For that, the baseline research begins with selecting the appropriate drug molecule. This is important because it:

• Provides the data for molecular docking studies to identify suitable target proteins
• Performs in vitro (a process taking place outside a living organism) and in vivo (a process taking place inside a living organism) analyzes

This assists in the screening of the molecules and a final selection leading to the most suitable target molecule. In this case, the choice of the drug molecule is an independent variable whereas, all the others, targets from molecular docking studies, and results from in vitro and in vivo analyses are dependent variables.

The outcomes revealed by the studies might be coherent or incoherent with the literature. In any case, an accurately designed conceptual framework will efficiently establish the cause-and-effect relationship and explain both perspectives satisfactorily.

If A has been chosen to be launched in the market, the conceptual framework will point towards the factors that have led to its selection. If A does not make it to the market, the key elements which did not work in its favor can be pinpointed by an accurate analysis of the conceptual framework.

Fig. 2: Concise example of a conceptual framework

Important takeaways

While conceptual frameworks are a great way of designing the research protocol, they might consist of some unforeseen loopholes. A review of the literature can sometimes provide a false impression of the collection of work done worldwide while in actuality, there might be research that is being undertaken on the same topic but is still under publication or review. Strong conceptual frameworks, therefore, are designed when all these aspects are taken into consideration and the researchers indulge in discussions with others working on similar grounds of research.

Conceptual frameworks may also sometimes lead to collecting and reviewing data that is not so relevant to the current research topic. The researchers must always be on the lookout for studies that are highly relevant to their topic of work and will be of impact if taken into consideration. 

Another common practice associated with conceptual frameworks is their classification as merely descriptive qualitative tools and not actually a concrete build-up of ideas and critically analyzed literature and data which it is, in reality. Ideal conceptual frameworks always bring out their own set of new ideas after analysis of literature rather than simply depending on facts being already reported by other research groups.

So, the next time you set out to construct your conceptual framework or improvise on your previous one, be wary that concepts for your research are ideas that need to be worked upon. They are not simply a collection of literature from the previous research.

Final thoughts

Research is witnessing a boom in the methodical approaches being applied to it nowadays. In contrast to conventional research, researchers today are always looking for better techniques and methods to improve the quality of their research. 

We strongly believe in the ideals of research that are not merely academic, but all-inclusive. We strongly encourage all our readers and researchers to do work that impacts society. Designing strong conceptual frameworks is an integral part of the process. It gives headway for systematic, empirical, and fruitful research.

Vridhi Sachdeva, MPharm

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Home » Conceptual Framework – Types, Methodology and Examples

Conceptual Framework – Types, Methodology and Examples

Table of Contents

Conceptual Framework

Definition:

A conceptual framework is a structured approach to organizing and understanding complex ideas, theories, or concepts. It provides a systematic and coherent way of thinking about a problem or topic, and helps to guide research or analysis in a particular field.

A conceptual framework typically includes a set of assumptions, concepts, and propositions that form a theoretical framework for understanding a particular phenomenon. It can be used to develop hypotheses, guide empirical research, or provide a framework for evaluating and interpreting data.

Conceptual Framework in Research

In research, a conceptual framework is a theoretical structure that provides a framework for understanding a particular phenomenon or problem. It is a key component of any research project and helps to guide the research process from start to finish.

A conceptual framework provides a clear understanding of the variables, relationships, and assumptions that underpin a research study. It outlines the key concepts that the study is investigating and how they are related to each other. It also defines the scope of the study and sets out the research questions or hypotheses.

Types of Conceptual Framework

Types of Conceptual Framework are as follows:

Theoretical Framework

A theoretical framework is an overarching set of concepts, ideas, and assumptions that help to explain and interpret a phenomenon. It provides a theoretical perspective on the phenomenon being studied and helps researchers to identify the relationships between different concepts. For example, a theoretical framework for a study on the impact of social media on mental health might draw on theories of communication, social influence, and psychological well-being.

Conceptual Model

A conceptual model is a visual or written representation of a complex system or phenomenon. It helps to identify the main components of the system and the relationships between them. For example, a conceptual model for a study on the factors that influence employee turnover might include factors such as job satisfaction, salary, work-life balance, and job security, and the relationships between them.

Empirical Framework

An empirical framework is based on empirical data and helps to explain a particular phenomenon. It involves collecting data, analyzing it, and developing a framework to explain the results. For example, an empirical framework for a study on the impact of a new health intervention might involve collecting data on the intervention’s effectiveness, cost, and acceptability to patients.

Descriptive Framework

A descriptive framework is used to describe a particular phenomenon. It helps to identify the main characteristics of the phenomenon and to develop a vocabulary to describe it. For example, a descriptive framework for a study on different types of musical genres might include descriptions of the instruments used, the rhythms and beats, the vocal styles, and the cultural contexts of each genre.

Analytical Framework

An analytical framework is used to analyze a particular phenomenon. It involves breaking down the phenomenon into its constituent parts and analyzing them separately. This type of framework is often used in social science research. For example, an analytical framework for a study on the impact of race on police brutality might involve analyzing the historical and cultural factors that contribute to racial bias, the organizational factors that influence police behavior, and the psychological factors that influence individual officers’ behavior.

Conceptual Framework for Policy Analysis

A conceptual framework for policy analysis is used to guide the development of policies or programs. It helps policymakers to identify the key issues and to develop strategies to address them. For example, a conceptual framework for a policy analysis on climate change might involve identifying the key stakeholders, assessing their interests and concerns, and developing policy options to mitigate the impacts of climate change.

Logical Frameworks

Logical frameworks are used to plan and evaluate projects and programs. They provide a structured approach to identifying project goals, objectives, and outcomes, and help to ensure that all stakeholders are aligned and working towards the same objectives.

Conceptual Frameworks for Program Evaluation

These frameworks are used to evaluate the effectiveness of programs or interventions. They provide a structure for identifying program goals, objectives, and outcomes, and help to measure the impact of the program on its intended beneficiaries.

Conceptual Frameworks for Organizational Analysis

These frameworks are used to analyze and evaluate organizational structures, processes, and performance. They provide a structured approach to understanding the relationships between different departments, functions, and stakeholders within an organization.

Conceptual Frameworks for Strategic Planning

These frameworks are used to develop and implement strategic plans for organizations or businesses. They help to identify the key factors and stakeholders that will impact the success of the plan, and provide a structure for setting goals, developing strategies, and monitoring progress.

Components of Conceptual Framework

The components of a conceptual framework typically include:

• Research question or problem statement : This component defines the problem or question that the conceptual framework seeks to address. It sets the stage for the development of the framework and guides the selection of the relevant concepts and constructs.
• Concepts : These are the general ideas, principles, or categories that are used to describe and explain the phenomenon or problem under investigation. Concepts provide the building blocks of the framework and help to establish a common language for discussing the issue.
• Constructs : Constructs are the specific variables or concepts that are used to operationalize the general concepts. They are measurable or observable and serve as indicators of the underlying concept.
• Propositions or hypotheses : These are statements that describe the relationships between the concepts or constructs in the framework. They provide a basis for testing the validity of the framework and for generating new insights or theories.
• Assumptions : These are the underlying beliefs or values that shape the framework. They may be explicit or implicit and may influence the selection and interpretation of the concepts and constructs.
• Boundaries : These are the limits or scope of the framework. They define the focus of the investigation and help to clarify what is included and excluded from the analysis.
• Context : This component refers to the broader social, cultural, and historical factors that shape the phenomenon or problem under investigation. It helps to situate the framework within a larger theoretical or empirical context and to identify the relevant variables and factors that may affect the phenomenon.
• Relationships and connections: These are the connections and interrelationships between the different components of the conceptual framework. They describe how the concepts and constructs are linked and how they contribute to the overall understanding of the phenomenon or problem.
• Variables : These are the factors that are being measured or observed in the study. They are often operationalized as constructs and are used to test the propositions or hypotheses.
• Methodology : This component describes the research methods and techniques that will be used to collect and analyze data. It includes the sampling strategy, data collection methods, data analysis techniques, and ethical considerations.
• Literature review : This component provides an overview of the existing research and theories related to the phenomenon or problem under investigation. It helps to identify the gaps in the literature and to situate the framework within the broader theoretical and empirical context.
• Outcomes and implications: These are the expected outcomes or implications of the study. They describe the potential contributions of the study to the theoretical and empirical knowledge in the field and the practical implications for policy and practice.

Conceptual Framework Methodology

Conceptual Framework Methodology is a research method that is commonly used in academic and scientific research to develop a theoretical framework for a study. It is a systematic approach that helps researchers to organize their thoughts and ideas, identify the variables that are relevant to their study, and establish the relationships between these variables.

Here are the steps involved in the conceptual framework methodology:

Identify the Research Problem

The first step is to identify the research problem or question that the study aims to answer. This involves identifying the gaps in the existing literature and determining what specific issue the study aims to address.

Conduct a Literature Review

The second step involves conducting a thorough literature review to identify the existing theories, models, and frameworks that are relevant to the research question. This will help the researcher to identify the key concepts and variables that need to be considered in the study.

Define key Concepts and Variables

The next step is to define the key concepts and variables that are relevant to the study. This involves clearly defining the terms used in the study, and identifying the factors that will be measured or observed in the study.

Develop a Theoretical Framework

Once the key concepts and variables have been identified, the researcher can develop a theoretical framework. This involves establishing the relationships between the key concepts and variables, and creating a visual representation of these relationships.

Test the Framework

The final step is to test the theoretical framework using empirical data. This involves collecting and analyzing data to determine whether the relationships between the key concepts and variables that were identified in the framework are accurate and valid.

Examples of Conceptual Framework

Some realtime Examples of Conceptual Framework are as follows:

• In economics , the concept of supply and demand is a well-known conceptual framework. It provides a structure for understanding how prices are set in a market, based on the interplay of the quantity of goods supplied by producers and the quantity of goods demanded by consumers.
• In psychology , the cognitive-behavioral framework is a widely used conceptual framework for understanding mental health and illness. It emphasizes the role of thoughts and behaviors in shaping emotions and the importance of cognitive restructuring and behavior change in treatment.
• In sociology , the social determinants of health framework provides a way of understanding how social and economic factors such as income, education, and race influence health outcomes. This framework is widely used in public health research and policy.
• In environmental science , the ecosystem services framework is a way of understanding the benefits that humans derive from natural ecosystems, such as clean air and water, pollination, and carbon storage. This framework is used to guide conservation and land-use decisions.
• In education, the constructivist framework is a way of understanding how learners construct knowledge through active engagement with their environment. This framework is used to guide instructional design and teaching strategies.

Applications of Conceptual Framework

Some of the applications of Conceptual Frameworks are as follows:

• Research : Conceptual frameworks are used in research to guide the design, implementation, and interpretation of studies. Researchers use conceptual frameworks to develop hypotheses, identify research questions, and select appropriate methods for collecting and analyzing data.
• Policy: Conceptual frameworks are used in policy-making to guide the development of policies and programs. Policymakers use conceptual frameworks to identify key factors that influence a particular problem or issue, and to develop strategies for addressing them.
• Education : Conceptual frameworks are used in education to guide the design and implementation of instructional strategies and curriculum. Educators use conceptual frameworks to identify learning objectives, select appropriate teaching methods, and assess student learning.
• Management : Conceptual frameworks are used in management to guide decision-making and strategy development. Managers use conceptual frameworks to understand the internal and external factors that influence their organizations, and to develop strategies for achieving their goals.
• Evaluation : Conceptual frameworks are used in evaluation to guide the development of evaluation plans and to interpret evaluation results. Evaluators use conceptual frameworks to identify key outcomes, indicators, and measures, and to develop a logic model for their evaluation.

Purpose of Conceptual Framework

The purpose of a conceptual framework is to provide a theoretical foundation for understanding and analyzing complex phenomena. Conceptual frameworks help to:

• Guide research : Conceptual frameworks provide a framework for researchers to develop hypotheses, identify research questions, and select appropriate methods for collecting and analyzing data. By providing a theoretical foundation for research, conceptual frameworks help to ensure that research is rigorous, systematic, and valid.
• Provide clarity: Conceptual frameworks help to provide clarity and structure to complex phenomena by identifying key concepts, relationships, and processes. By providing a clear and systematic understanding of a phenomenon, conceptual frameworks help to ensure that researchers, policymakers, and practitioners are all on the same page when it comes to understanding the issue at hand.
• Inform decision-making : Conceptual frameworks can be used to inform decision-making and strategy development by identifying key factors that influence a particular problem or issue. By understanding the complex interplay of factors that contribute to a particular issue, decision-makers can develop more effective strategies for addressing the problem.
• Facilitate communication : Conceptual frameworks provide a common language and conceptual framework for researchers, policymakers, and practitioners to communicate and collaborate on complex issues. By providing a shared understanding of a phenomenon, conceptual frameworks help to ensure that everyone is working towards the same goal.

When to use Conceptual Framework

There are several situations when it is appropriate to use a conceptual framework:

• To guide the research : A conceptual framework can be used to guide the research process by providing a clear roadmap for the research project. It can help researchers identify key variables and relationships, and develop hypotheses or research questions.
• To clarify concepts : A conceptual framework can be used to clarify and define key concepts and terms used in a research project. It can help ensure that all researchers are using the same language and have a shared understanding of the concepts being studied.
• To provide a theoretical basis: A conceptual framework can provide a theoretical basis for a research project by linking it to existing theories or conceptual models. This can help researchers build on previous research and contribute to the development of a field.
• To identify gaps in knowledge : A conceptual framework can help identify gaps in existing knowledge by highlighting areas that require further research or investigation.
• To communicate findings : A conceptual framework can be used to communicate research findings by providing a clear and concise summary of the key variables, relationships, and assumptions that underpin the research project.

Characteristics of Conceptual Framework

key characteristics of a conceptual framework are:

• Clear definition of key concepts : A conceptual framework should clearly define the key concepts and terms being used in a research project. This ensures that all researchers have a shared understanding of the concepts being studied.
• Identification of key variables: A conceptual framework should identify the key variables that are being studied and how they are related to each other. This helps to organize the research project and provides a clear focus for the study.
• Logical structure: A conceptual framework should have a logical structure that connects the key concepts and variables being studied. This helps to ensure that the research project is coherent and consistent.
• Based on existing theory : A conceptual framework should be based on existing theory or conceptual models. This helps to ensure that the research project is grounded in existing knowledge and builds on previous research.
• Testable hypotheses or research questions: A conceptual framework should include testable hypotheses or research questions that can be answered through empirical research. This helps to ensure that the research project is rigorous and scientifically valid.
• Flexibility : A conceptual framework should be flexible enough to allow for modifications as new information is gathered during the research process. This helps to ensure that the research project is responsive to new findings and is able to adapt to changing circumstances.

Advantages of Conceptual Framework

Advantages of the Conceptual Framework are as follows:

• Clarity : A conceptual framework provides clarity to researchers by outlining the key concepts and variables that are relevant to the research project. This clarity helps researchers to focus on the most important aspects of the research problem and develop a clear plan for investigating it.
• Direction : A conceptual framework provides direction to researchers by helping them to develop hypotheses or research questions that are grounded in existing theory or conceptual models. This direction ensures that the research project is relevant and contributes to the development of the field.
• Efficiency : A conceptual framework can increase efficiency in the research process by providing a structure for organizing ideas and data. This structure can help researchers to avoid redundancies and inconsistencies in their work, saving time and effort.
• Rigor : A conceptual framework can help to ensure the rigor of a research project by providing a theoretical basis for the investigation. This rigor is essential for ensuring that the research project is scientifically valid and produces meaningful results.
• Communication : A conceptual framework can facilitate communication between researchers by providing a shared language and understanding of the key concepts and variables being studied. This communication is essential for collaboration and the advancement of knowledge in the field.
• Generalization : A conceptual framework can help to generalize research findings beyond the specific study by providing a theoretical basis for the investigation. This generalization is essential for the development of knowledge in the field and for informing future research.

Limitations of Conceptual Framework

Limitations of Conceptual Framework are as follows:

• Limited applicability: Conceptual frameworks are often based on existing theory or conceptual models, which may not be applicable to all research problems or contexts. This can limit the usefulness of a conceptual framework in certain situations.
• Lack of empirical support : While a conceptual framework can provide a theoretical basis for a research project, it may not be supported by empirical evidence. This can limit the usefulness of a conceptual framework in guiding empirical research.
• Narrow focus: A conceptual framework can provide a clear focus for a research project, but it may also limit the scope of the investigation. This can make it difficult to address broader research questions or to consider alternative perspectives.
• Over-simplification: A conceptual framework can help to organize and structure research ideas, but it may also over-simplify complex phenomena. This can limit the depth of the investigation and the richness of the data collected.
• Inflexibility : A conceptual framework can provide a structure for organizing research ideas, but it may also be inflexible in the face of new data or unexpected findings. This can limit the ability of researchers to adapt their research project to new information or changing circumstances.
• Difficulty in development : Developing a conceptual framework can be a challenging and time-consuming process. It requires a thorough understanding of existing theory or conceptual models, and may require collaboration with other researchers.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Affiliations.

• 1 Division of Critical Care Medicine, Department of Pediatrics (MW Zackoff),. Electronic address: [email protected].
• 2 Division of General and Community Pediatrics, Department of Pediatrics (FJ Real, MD Klein), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
• 3 Division of General Pediatrics, Department of Pediatrics, and Department of Healthcare Policy and Research, Weill Cornell Medical Center (EL Abramson), New York, NY.
• 4 Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California, Davis (S-TT Li).
• 5 Department of Medical Education, University of Virginia School of Medicine (ME Gusic), Charlottesville, Va.
• PMID: 30138745
• DOI: 10.1016/j.acap.2018.08.003

Historically, health sciences education has been guided by tradition and teacher preferences rather than by the application of practices supported by rigorous evidence of effectiveness. Although often underutilized, conceptual frameworks-theories that describe the complexities of educational and social phenomenon-are essential foundations for scholarly work in education. Conceptual frameworks provide a lens through which educators can develop research questions, design research studies and educational interventions, assess outcomes, and evaluate the impact of their work. Given this vital role, conceptual frameworks should be considered at the onset of an educational initiative. Use of different conceptual frameworks to address the same topic in medical education may provide distinctive approaches. Exploration of educational issues by employing differing, theory-based approaches advances the field through the identification of the most effective educational methods. Dissemination of sound educational research based on theory is similarly essential to spark future innovation. Ultimately, this rigorous approach to medical education scholarship is necessary to allow us to establish how our educational interventions impact the health and well-being of our patients.

Keywords: conceptual framework; educational research; scholarship.

Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Publication types

• Education, Medical / methods*
• Education, Medical / standards
• Evidence-Based Practice / methods*

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The instrumental value of conceptual frameworks in educational technology research

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• Published: 06 December 2014
• Volume 63 , pages 53–71, ( 2015 )

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• Pavlo D. Antonenko 1  

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Scholars from diverse fields and research traditions agree that the conceptual framework is a critically important component of disciplined inquiry. Yet, there is a pronounced lack of shared understanding regarding the definition and functions of conceptual frameworks, which impedes our ability to design effective research and mentor novice researchers. This paper adopts John Dewey’s instrumental view of theory to discuss the prevalent definitions of a conceptual framework, outline its key functions, dispel the popular misconceptions regarding conceptual frameworks, and suggest strategies for developing effective conceptual frameworks and communicating them to the consumers of research. Examples of hypothetical and existing empirical studies in the field of educational technology are used to illustrate the analysis. It is argued in this article that conceptual frameworks should be viewed as an instrument for organizing inquiry and creating a compelling theory-based and data-driven argument for the importance of the problem, rigor of the method, and implications for further development of theory and enhancement of practice.

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See Fig.  2 .

A concept map of the original conceptual framework in the Niederhauser et al. ( 2000 ) study

See Fig.  3 .

A concept map of the modified conceptual framework in the Niederhauser et al. ( 2000) ) study. The differences are presented in bold font

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Antonenko, P.D. The instrumental value of conceptual frameworks in educational technology research. Education Tech Research Dev 63 , 53–71 (2015). https://doi.org/10.1007/s11423-014-9363-4

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A conceptual framework for improving teaching and learning in undergraduate stem courses .

• Juan Salinas The University of Texas Rio Grande Valley
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Hispanic-Serving Institutions (HSIs) are often characterized as Hispanic enrolling (rather than serving) that practice deficit-based systems that continue to marginalize Hispanics and other underrepresented students, especially in STEM fields.  Extant research on HSIs stresses the importance of investigations into the value of grassroots advocacy groups as external influencers of institutional servingness through deeper engagement with the Hispanic community. Using a novel Family-Centered Theory of Change (FCTC) that addresses diversity, equity, and inclusion, we integrated concepts of intersectionality and servingness into a Family Integrated Education Serving and Transforming Academia (FIESTA) framework. We investigated the potential transformational impact of FIESTA on students, families, faculty, and administrators at The University of Texas Rio Grande Valley (UTRGV), an institution with over 90 % Hispanic population. Preliminary findings shed light on how the FIESTA framework can help reshape an HSI’s identity from “Hispanic enrolling” to a true Hispanic-Serving Institution through Family-Centered Pedagogy. The Family-Centered Pedagogy was defined as the enrichment of the learning experience in which students complement their own instruction by drawing from the experience and ancestral knowledge of their families, supported by the FCTC developed by AVE Frontera, our community partner.​ 

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Mohan D , Elmer J , Arnold RM, et al. Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage : A Pilot Randomized Clinical Trial . JAMA Netw Open. 2023;6(5):e2313569. doi:10.1001/jamanetworkopen.2023.13569

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Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage : A Pilot Randomized Clinical Trial

• 1 Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 2 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 3 Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 4 Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 5 Division of Palliative Care, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 6 Department of Engineering and Environmental Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania

Question   Can deliberate practice (goal-oriented training with a coach who provides immediate, personalized performance feedback) improve diagnostic reasoning in trauma triage?

Findings   In this pilot randomized clinical trial of a novel deliberate practice intervention, 93% of participants received 3 planned coaching sessions, and most participants (93%) described the sessions as entertaining and valuable. During a simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than the triage decisions of physicians in the control group.

Meaning   The deliberate practice intervention was feasible, acceptable, and effective in the laboratory, setting the stage for a future phase 3 clinical trial.

Importance   Diagnostic errors made during triage at nontrauma centers contribute to preventable morbidity and mortality after injury.

Objective   To test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage.

Design, Setting, and Participants   This pilot randomized clinical trial was conducted online in a national convenience sample of 72 emergency physicians between January 1 and March 31, 2022, without follow-up.

Interventions   Participants were randomly assigned to receive either usual care (ie, passive control) or a deliberate practice intervention, consisting of 3 weekly, 30-minute, video-conferenced sessions during which physicians played a customized, theory-based video game while being observed by content experts (coaches) who provided immediate, personalized feedback on diagnostic reasoning.

Main Outcomes and Measures   Using the Proctor framework of outcomes for implementation research, the feasibility, fidelity, acceptability, adoption, and appropriateness of the intervention was assessed by reviewing videos of the coaching sessions and conducting debriefing interviews with participants. A validated online simulation was used to assess the intervention’s effect on behavior, and triage among control and intervention physicians was compared using mixed-effects logistic regression. Implementation outcomes were analyzed using an intention-to-treat approach, but participants who did not use the simulation were excluded from the efficacy analysis.

Results   The study enrolled 72 physicians (mean [SD] age, 43.3 [9.4] years; 44 men [61%]) but limited registration of physicians in the intervention group to 30 because of the availability of the coaches. Physicians worked in 20 states; 62 (86%) were board certified in emergency medicine. The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions and with coaches delivering 95% of session components (642 of 674). A total of 21 of 36 physicians (58%) in the control group participated in outcome assessment; 28 of 30 physicians (93%) in the intervention group participated in semistructured interviews, and 26 of 30 physicians (87%) in the intervention group participated in outcome assessment. Most physicians in the intervention group (93% [26 of 28]) described the sessions as entertaining and valuable; most (88% [22 of 25]) affirmed the intention to adopt the principles discussed. Suggestions for refinement included providing more time with the coach and addressing contextual barriers to triage. During the simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than those in the control group (odds ratio; 13.8, 95% CI, 2.8-69.6; P  = .001).

Conclusions and Relevance   In this pilot randomized clinical trial, coaching was feasible and acceptable and had a large effect on simulated trauma triage decisions, setting the stage for a phase 3 trial.

Trial Registration   ClinicalTrials.gov Identifier: NCT05168579

Half of all injured patients present initially to a nontrauma center, where a clinician must evaluate and stabilize the patient’s injuries and determine whether they warrant transfer to a trauma center. 1 , 2 Timely and guideline-concordant referral reduces mortality by 10% to 25%, increases rates of functional independence, and shortens the duration of pain and disability. 3 - 9 Despite 40 years of efforts by stakeholders to standardize triage practices, undertriage remains common, particularly among patients older than 65 years. 10 - 13 Diagnostic errors—defined as the failure to establish an accurate and timely explanation of the patient’s health problem—are an important cause of undertriage. 14 , 15

Deliberate practice, defined as goal-oriented training in the presence of a content expert who can provide personalized, immediate feedback to improve performance, has successfully improved outcomes across multiple domains, including sports, combat, and surgery. 16 - 18 However, the use of deliberate practice to improve diagnostic reasoning is uncommon and, to our knowledge, has never been tried in trauma triage. 19

The objective of this pilot randomized clinical trial was to test the feasibility (practicability), fidelity (delivery of tasks), acceptability (palatability), adoption (intention to try behaviors), appropriateness (fitting the user’s goals and needs), and effect (compliance with clinical guidelines) of a novel deliberate practice intervention in trauma triage.

We conducted a pilot randomized clinical trial of a deliberate practice intervention to improve diagnostic reasoning in trauma triage between January 1 and March 31, 2022, without follow-up. We enrolled and randomized a national respondent-driven sample of physicians to the intervention group or to a passive control group. We structured the process evaluation of the intervention using the Proctor framework of outcomes for implementation research and followed the Consolidated Standards of Reporting Trials Extension ( CONSORT Extension ) reporting guideline (ie, extension for pilot and feasibility trials) in reporting our results. 20 , 21 We previously published the trial protocol with a priori hypotheses about criteria for defining success. 22 The University of Pittsburgh Human Research Protection Office approved the study. Trial participants provided digital written informed consent at the time of enrollment (trial protocol in Supplement 1 ).

To recruit participants for the study, we contacted physicians who had previously participated in our research and asked them to refer us to 2 colleagues. We sought board-certified emergency physicians who treated adult patients in the emergency department of either a nontrauma center or a Level III or IV trauma center in the US and who therefore would have responsibility for performing trauma triage in their clinical practice. Respondents received a screening questionnaire with details about the trial, a consent form, and items querying their demographic characteristics. Racial and ethnic categories were specified by the study team based on National Institutes of Health criteria. 23 Physicians who provided consent were randomized in a 1:1 ratio, stratified by prior participation in our research, using a schema built in Stata, version 16.0 (StataCorp LLC), with block sizes of 4 ( Figure 1 ). Although we could not blind study personnel and participants, we masked physicians’ exposure during analysis.

Three members of the study team with expertise in trauma surgery (D.M. and R.M.F.) and emergency medicine (J.E.) acted as the coaches. We standardized the fidelity of intervention delivery in 3 ways. First, prior to the trial, we conducted three 1-hour training sessions, supervised by experts in deliberate practice (R.M.A., B.F., and D.B.W.). Second, we created a coaching manual as a reference that summarized the learning objectives, core tasks of the coaching sessions, and the pedagogical strategies that coaches should use (a full draft of the coaching manual is in the eAppendix in Supplement 2 ). Finally, coaches met weekly with the full study team during the trial to debrief and to discuss strategies for managing issues that had arisen. Based on these sessions, we made several modifications to the intervention, including condensing the content to increase the time spent on each decision principle and identifying additional pedagogical strategies that coaches could use to engage participants in the sessions (eg, retrieval practice during sessions 2 and 3).

The intervention consisted of 3 weekly, 30-minute, video-conferenced coaching sessions, in which the participant played a trauma triage video game, the coach observed his or her performance, and they discussed best practice decision principles in trauma triage. We describe the conceptual framework of the intervention in Figure 2 .

We used a single-player, theory-based puzzle video game, previously developed by our group to improve diagnostic reasoning in trauma triage ( Shift: The Next Generation ). 24 To allow its use as a training task, we adapted the user interface and game mechanics in collaboration with Schell Games, creating Shift With Friends . The game included 10 levels, each covering a separate decision principle and involving a 5-step game loop (eFigure in Supplement 2 ): players triaged 10 injured patients over 90 seconds, compared 2 cases to identify similarities or differences so that they could derive the rule for the level, received standardized feedback on their performance, reviewed the decision principle, and finally received a synthesis of the evidence supporting the decision principle.

Both the participant and the coach logged into Zoom, and the participant shared his or her screen so that the coach could observe gameplay. The coach would select the levels covered during the session, personalizing the selection to the needs and skills of the participant. The coach would also encourage the participant to “think aloud” as he or she played, using observations made during the process to provide feedback tailored to improve the participant’s diagnostic reasoning. Each session covered 1 to 3 decision principles and included 6 to 8 tasks (eg, introductions or debriefing).

We did not ask trial participants randomly assigned to the control group to engage in any additional continuing medical education, with the intention of replicating usual care.

After randomization, participating physicians received written instructions on how to complete the trial tasks. We had the capacity to provide coaching for 30 physicians. We therefore asked those in the intervention group to select 1 of the 2 blocks (January or February) in which we offered coaching and to sign up for three 30-minute sessions within the block. Based on availability, we paired participants with a coach on a first-come, first-served basis. After the sessions, we asked participants to complete a survey, a semistructured debriefing interview, and an online simulation. We asked participants in the passive control group to complete the same simulation within 3 weeks of the start of the trial. The trial tasks took approximately 3 hours for those in the intervention group and 1 hour for those in the control group. Participants received 3 personalized reminder emails at weekly intervals or until they completed the trial tasks. We offered a financial incentive to increase response rates, setting its size with a wage-based model of reimbursement. 25 , 26 Physicians in the intervention group received an iPad with the game and Zoom app preloaded, which they used for the coaching sessions and which they kept as their honorarium (approximate value, $300). Those in the control group received a $100 gift card after they completed the simulation.

Using the Proctor framework of outcomes for implementation research, we assessed both implementation and service outcomes. 20 We defined the implementation outcomes as feasibility, fidelity, acceptability, adoption, and appropriateness. Using the National Institutes of Health stage model of intervention development, which recommends assessment of efficacy in the laboratory before moving to real-world testing, 27 we defined the service outcome (efficacy) as compliance with clinical practice guidelines, measured using a simulation.

Each respondent described his or her personal characteristics on the screening questionnaire at the time of enrollment. We maintained a database with a list of scheduled coaching sessions, which was updated daily with the status of the sessions.

We recorded all the coaching sessions and automatically uploaded them to a secure server hosted by the University of Pittsburgh. Two members of the study team (K.R. and J.L.B.) developed a codebook to assess the delivery of session tasks, refined it until they achieved acceptable interrater reliability (Cohen κ = 0.84), and independently applied it to the recordings. Coding discrepancies were resolved through consensus (D.M., K.R., and J.L.B.). We used NVivo qualitative analysis software (QSR International) for data management.

Participants in the intervention group provided structured assessments of the acceptability of the intervention using the User Engagement Scale–Short Form to evaluate the video game (a validated 12-item instrument with a 5-point Likert scale) and the Wisconsin Surgical Coaching Rubric to evaluate the quality of the coaching (a 4-item instrument with a 5-point scale). 28 , 29 They also participated in semistructured debriefing interviews after the final coaching session, during which they discussed their perception of the acceptability, adoption, and appropriateness of the intervention. Two members of the study team (K.R. and J.L.B.) coded the interviews using the same process as for the coaching sessions (Cohen κ = 0.84).

We used a validated 2-dimensional simulation to assess compliance with guidelines after exposure to the intervention. 30 The simulation required participants to respond to 10 cases over 42 minutes: 4 severely injured patients, 2 minimally injured patients, and 4 critically ill nontrauma patients (ie, distractor patients). New patients arrived at prespecified but unpredictable intervals, so that users managed multiple patients concurrently. Without clinical intervention by the player, severely injured patients and critically ill distractor patients decompensated and died over the course of the simulation. Each case included a 2-dimensional rendering of the patient, a chief symptom, vital signs that updated every 30 seconds, a history, and a written description of the physical examination. Users could request information by selecting from a prespecified list of 250 medications, studies, and procedures. They could place orders and request consultations. Each case ended when either the player made a disposition decision (admit, discharge, or transfer) or the patient died. We asked all trial participants to complete the simulation online; responses were uploaded and stored on a secure server hosted by the University of Pittsburgh.

We summarized physician characteristics using mean (SD) values for continuous variables and counts and percentages for categorical variables. We analyzed implementation outcomes using an intention-to-treat approach but excluded from the efficacy analysis participants who did not use the simulation. We had 2 criteria for the success of the trial: efficacy and feasibility. Our primary hypothesis was that physicians exposed to the intervention would undertriage 25% fewer patients or more on the simulation than physicians in the control group. All P values were from 2-sided tests and results were deemed statistically significant at P  < .05. Our secondary hypothesis was that we could deliver 3 coaching sessions to 90% or more of participants. All analyses were conducted in Stata, version 16.0 (StataCorp LLC).

We quantified the percentage of coach-participant dyads that completed three 30-minute sessions (to measure feasibility) and summarized the percentage of session tasks delivered to participants (to measure fidelity). We summarized participant responses to the User Engagement Scale–Short Form and to the Wisconsin Surgical Coaching Rubric (to measure acceptability). We also summarized themes that arose during the semistructured interviews (to further assess acceptability and to assess appropriateness and adoption).

We summarized the time spent and the decisions made for each severely injured trauma case (n = 4) on the simulation (eg, diagnostic testing or administration of blood products) using median values and IQRs, and we scored disposition decisions as consistent with the American College of Surgeons guidelines or not. To compare differences between the intervention and control groups, we fit a mixed-effects logistic regression model, clustered at the participant level, with the transfer decision as the dependent variable and physicians’ exposure as the primary independent variable. Given the statistical power, we did not adjust for any potential confounders (eg, practice environment). In a post hoc sensitivity analysis, we excluded physicians who had previously participated in our research.

We designed the experiment to detect a 25% (large effect size) reduction in undertriage between physicians in the intervention and control groups, with an α of .05 and a power of 80%, using the Cohen method of estimating power for behavioral trials. Based on these estimates, and anticipating a 67% retention rate in the control group, we planned to recruit 30 physicians for each group. 31

We randomly assigned 72 physicians to the 2 groups of the trial but limited registration of physicians in the intervention group to 30 because of the availability of the coaches ( Figure 1 ). Physicians were mostly middle aged (mean [SD], age, 43.3 [9.4] years]), male (44 [61%]), White (47 [65%]), and board-certified in emergency medicine (62 [86%]) and had completed Advanced Trauma Life Support certification (64 [89%]) ( Table 1 ). They lived in 20 states, primarily in the Northeast and Southeast (38 [53%])

Of the 36 physicians in the control group, 21 (58%) finished the virtual simulation. The characteristics of the responders and nonresponders are listed in eTable 1 in Supplement 2 . Of the 30 physicians registered to receive the intervention, 24 (80%) responded to the survey, 28 (93%) participated in the debriefing interviews, and 26 (87%) used the virtual simulation.

We summarize our assessment of the intervention in Table 2 . Most physicians (28 of 30 [93%]) completed 3 coaching sessions; 2 of 30 (7%) completed 2 sessions. The sessions lasted a mean of 31.2 (0.2) minutes; participants covered a mean (SD) of 5.2 (1.1) decision principles during the 3 sessions. Coaches covered 95% of the tasks (642 of 674), pooled across the 3 sessions. The component most frequently missed was the debriefing (19% [6 of 32]), usually because of time constraints.

In semistructured interviews, most participants (93% [26 of 28]) in the intervention group described the sessions as entertaining, providing a useful refresher of guidelines, distilling clear learning points, and modeling valuable communication scripts for emergency department physicians. Most participants responded that the length and number of sessions were appropriate (80% [16 of 20]) and would recommend the intervention (87% [20 of 23]). Of the 25 physicians who discussed adoption of the principles, 6 (24%) reported having used the material since completing the coaching sessions, while 16 (64%) said they would use the material in the future. Some participants (7 of 28 [25%]) had reservations about the program. For example, 1 participant noted a discordance between the intervention and the realities of clinical practice; another responded that the time commitment was excessive. We provide additional qualitative assessments of the intervention by participants in the Box .

Participant Assessments of the Acceptability, Appropriateness, and Adoption of the Intervention During Semistructured Interviews

Acceptability, theme: intervention valuable (26 of 28 [93%]).

Subtopic: entertaining and fun

Sample quotations:

“I mean I personally liked it a lot, so I was actually looking forward to doing the next session. The cases were fun to do and still at the end the review allowed you to sort of put it together, and get better at it actually, for the next time.”

“I’d never done anything like that before in any of my training. But I liked that it felt like a game, and I liked getting the feedback from the person instantly through the coaching. I thought that was definitely, that’s how I learn best, getting some feedback right away.”

“It was a good way of engaging and teaching information because I think I’ve been on Zoom the past year and a half listening to lectures and no one’s listening. So, this was for the you know adult learners who you know need kind of more than just listening to someone talk and look at the same slides you know it’s a much better way to learn.”

Subtopic: a useful refresher of guidelines

“Yeah, I think it’s perfect. You know I think we as physicians we feel like, ‘Oh you know I’m going through training I know everything’ but we know that we forget.”

“I think they were helpful. I realized that maybe some of my decisions that I make at work are not the best, like sometimes I’ll choose not to transfer patients when according to the simulation and according to you know speaking to the surgeon, I know they should be, even though I have the resources available and so that was really good to point that out to me. So, I think it’s actually going to change my practice a little bit.”

Subtopic: provides evidence that underlies practice; distills clear learning point

Sample quotation:

“I know when to transfer and I know when not to but then you know kind of distilling it into what is it exactly about this patient, what are the reasons we make that decision. I guess it’s not like I sit and think about it. It was just kind of like that’s what we always do or that’s what we know what we usually do but this kind of like helped me kind of clarify in my mind what those criteria are. And I thought you know for someone [who] had no experience at a trauma center and they were going to go work somewhere that it’ll be a great way for them too especially at the resident level as well, but even anyone that was just changing their practice environment, using that too, it was a good way of engaging and teaching information…”

Subtopic: provides language to discuss cases with consultant services

“I found [the sessions] valuable. They helped concretize some principles that I think I will use next time I’m actually speaking to somebody on the other end of the phone. And [coach] had a nice suggestion about how to, you know, craft that conversation. Because it’s a frustrating piece of our jobs, trying to get folks accepted and sort of make the right pitch to our person. And so, I think this was helpful for me to refine that language. You know, even though, I’ve been doing it [xx] years I feel like I’ve refined it quite a lot, but there’s always opportunity to get it a little bit better.”

Subtopic: provides an opportunity to potentially improve patient outcomes

“I think if you know if other people can kind of pick up some of these learning lessons, more people will survive these traumas, so. Especially if you can somehow target like the critical access hospitals where there’s only like 1 or 2 docs, those are the places where if they can kind of, the lessons that the game has to teach [inaudible] I think it’ll save a lot of lives…”

Theme: intervention not valuable (7 of 28 [25%])

Subtopic: does not reflect realities of clinical practice

“You’re asking me to transfer a patient out based on let’s say their age or injury, and you know a lot of the times the surgeon in house, if I’m working in a small hospital, I only know what they can handle and cannot handle, and it’s not totally up to me to transfer someone out. If I call a surgeon and they would say, ‘Hey I can take care of that, please admit to my service.’ Defying that has some repercussions if you’re working in a small hospital, you cannot just say I work independently. Nobody does. Right? You work as part of a hospital or part of a group or team. So, there’s lots of gray lines, sometimes somebody says I can take care of, or I cannot take care of, and you based on the rest of the team. Right, this game almost made it seem like it’s not a team, you’re making the decision and I don’t think that’s true. So, it made it very black and white and that’s not true.”

Subtopic: rudimentary

“You know, a number of the concepts the app is designed to teach or reinforce were those that I consider myself reasonably well familiar with. So, from that standpoint, I’m not sure I learned a ton, although I can certainly see its utility for other providers.”

Appropriateness

Theme: time burden (20 of 28 [71%]).

Subtopic: participants responded that the length and number of sessions were appropriate (16 of 20 [80%])

“They were great, [coach] was wonderful, the game was fun. They were just the right amount of length, you know what I mean we did like a I think a half an hour 3 times it was like, we got to play like 1 or 2 games each time it wasn’t like it got like, it wasn’t like too long I suppose. Enough to keep you interested.”

Subtopic: participants wanted more time with the coach (3 of 20 [15%])

“Again, I think as I said, the length of the session I think should be a little bit longer maybe. Just when you start to feel comfortable, they’re like, ‘Okay that’s it.’ And I know it’s hard for any doctors to get together for more than any tiny period of time, but I think the process was fulfilling and might’ve been even more so with longer sessions.”

Subtopic: participants responded that the time commitment was excessive (1 of 20 [5%])

“I think so I think it’s like you know worth the experience…it can be a little bit more streamlined, and you know hour and a half seems a lot of time for that…”

Theme: would recommend (23 of 28 [82%])

Subtopic: unreservedly (20 of 23 [87%])

“I didn’t know what this was going to be frankly…when I signed up; but I was pleasantly surprised. I think it was very engaging. I almost would, you know if this was available, I would probably use it for my own doctors at my department. I think people would find it very useful. So very pleasantly surprised and very happy to participate in this to the end.”

Suptopic: for others or with some changes (3 of 23 [13%])

“I think there’s probably a zone in between where I work (where every trauma gets transferred) and others (where there are criteria for what to transfer) where you get the most value…”

Theme: adoption (25 of 28 [89%])

Subtopic: have already done so (6 of 25 [24%])

“Yeah, so I work with residents. So, although it was useful to me, you know, every time like I do something and like something I just learned comes up I kind of pass it on to somebody else. They’re like, ‘Oh why are we thinking about transferring him,’ ‘Oh it’s because he’s frail’ or ‘Oh it’s because you know he has 2 organs injured’ or you know something like that.”

“Yeah, I worked 60 hours the last few days in the community setting and had had several trauma patients that I thought about these sessions and what the best course of care would be, and it actually really is kind of impactful I think.”

Subtopic: plan to do so in the future (16 of 25 [64%])

“Yeah, I think I will be able to, yeah definitely. Because we see trauma every day, minor trauma, some major which we have to transfer…”

Subtopic: not specifically (3 of 25 [12%])

“Not specifically like I said I think there are some general learning concepts that were confirmatory for me, again I think they were fairly basic in nature so certainly it is valuable because it confirms what someone already knows and I think for some it will be again very valuable and into the theme would be, again something new for them.”

Responses to the surveys also were positive. For example, 96% (23 of 24) agreed or strongly agreed that their experience with the game was worthwhile, and 100% (24 of 24) strongly agreed that the coach provided constructive feedback. We provide complete responses to the surveys in eTable 2 in Supplement 2 .

Physicians in the intervention group spent a median of 5.3 minutes (IQR, 3.6-7.7 minutes) on severely injured cases and entered a median of 10 orders per case (IQR, 8-13 orders per case), while those in the control group spent a median of 6.8 minutes (IQR, 4.8-9.2 minutes) and entered a median of 11 orders per case (IQR, 9.5-15.0 orders per case). Physicians in the intervention group were more likely than physicians in the control group to transfer severely injured patients to trauma centers (51% [50 of 99] vs 15% [13 of 84]; odds ratio, 13.8; 95% CI 2.8-69.6; P  = .001). The effect of the intervention remained after excluding the 12 physicians who had used the simulation in prior research, participated in this trial, and completed trial tasks (57% [43 of 76] vs 17% [11 of 64]; odds ratio, 16.3; 95% CI, 2.8-94.3; P  = .002).

In this pilot randomized clinical trial, we delivered a novel deliberate practice intervention to practicing emergency medicine physicians with high fidelity. Most physicians described the intervention as valuable and the time required as appropriate. They also reported intentions to adopt the lessons learned during the training sessions. The intervention had an effect on physicians’ adherence to trauma triage practice guidelines during an online simulation.

These results confirm those of previous studies, which demonstrated the ability of deliberate practice to facilitate the acquisition of expertise in medicine, across domains as varied as communication in the emergency department or intensive care unit, resuscitation, and surgery. 32 - 36 For example, a meta-analytic comparative review of the literature on skill acquisition in procedural domains (eg, laparoscopic surgery) identified a correlation between the use of deliberate practice and positive outcomes ( r  = 0.71). 32 Our study expands on these results by focusing on diagnostic reasoning and targeting the performance of physicians in practice rather than medical trainees.

If these results transfer to the clinical setting, deliberate practice could address national priorities to improve public health outcomes. 14 , 37 Injury is the leading cause of loss of life among people younger than 45 years and the leading cause of loss of independence among people older than 65 years. 38 More generally, diagnostic errors affect between 8% and 15% of all hospital admissions in the US, with cognitive factors in clinician decision-making contributing to 75% of the errors. 39 , 40

This pilot randomized clinical trial allowed us to test several concerns about delivering a deliberate practice intervention in trauma triage. One concern was how to design a training task that captured the core challenges of trauma triage at nontrauma centers—uncertainty, time pressure, and low rates of true-positive cases. The use of a customized video game provided physicians with an opportunity to practice the diagnostic task repeatedly and rapidly. A second concern was how to help participants refine the heuristics (intuitive judgments) guiding their judgments. Having participants think aloud while playing the game gave coaches access to participants’ cognitive processes, expressed in their natural terms, helping coaches to select and to convey potentially missed cues (eg, frailty). A third concern was the feasibility and acceptability of such an intervention among busy practicing clinicians. We found that most physicians enrolled in the trial, albeit a self-selected sample, relished the opportunity to interact with someone whom they perceived as a content expert. In debriefing interviews, respondents emphasized the social aspect of the intervention, underscoring the value they found in the connections that they formed with the coach.

This study has several limitations. First, we used a passive rather than an active control as the comparator, which may have magnified the effect of the intervention. Second, attrition in the completion of the virtual simulation differed among the control and intervention groups, which we attribute to engagement. Attrition could have introduced bias, if missingness was not random. However, we have no reason to believe that this was the case. Third, our observations may lack generalizability because of the characteristics of our convenience sample. Fourth, we did not cluster our analysis at the coach level during this pilot trial but plan to test this potential mediator of effect in the future.

This successful pilot randomized clinical trial sets the stage for a planned phase 3 trial of our novel behavioral intervention. The trial also provides evidence that deliberate practice can support judgment tasks, as well as the procedural tasks addressed in most applications, and therefore extends the utility of the method.

Accepted for Publication: March 31, 2023.

Published: May 17, 2023. doi:10.1001/jamanetworkopen.2023.13569

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Mohan D et al. JAMA Network Open .

Corresponding Author: Deepika Mohan, MD, MPH, University of Pittsburgh, 3550 Terrace St, 606D Scaife Hall, Pittsburgh, PA 15261 ( [email protected] ).

Author Contributions: Drs Mohan and Barnes had full access to all of the quantitative data and qualitative data, respectively, in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mohan, Arnold, Forsythe, Fischhoff.

Acquisition, analysis, or interpretation of data: Mohan, Elmer, Arnold, Forsythe, Rak, Barnes, White.

Drafting of the manuscript: Mohan.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mohan, Barnes.

Obtained funding: Mohan.

Administrative, technical, or material support: Mohan, Forsythe, Rak, Barnes.

Supervision: Arnold, White.

Conflict of Interest Disclosures: Dr Mohan reported receiving grants from Pfizer outside the submitted work. Dr Arnold reported serving on the board of directors for VitalTalk and serving as the palliative care section head for UpToDate. Dr White reported receiving grants from the National Institute on Aging and the National Cancer Institute during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by grants DP2 LM012339 (Dr Mohan), R21 AG072072 (Dr Mohan), K23 NS097629 (Dr Elmer), and K24 HL148314 (Dr White) from the National Institutes of Health.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3 .

Additional Contributions: The authors thank the development team at Schell Games and the trial participants.

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International Student Mobility, Opportunity, and the Voluntariness of Migration

A new conceptual approach.

• Lisa Ruth Brunner University of British Columbia
• Bernhard Streitwieser George Washington University
• Rajika Bhandari Rajika Bhandari Advisors

As higher education, migration, and mobility intertwine in increasingly complex ways, we need a new way to analyze international student mobility (ISM). Unpacking ISM’s “messiness” brings to light two key interfacing continua: first, the discretion to move, and second, opportunity through movement. Recognizing this confluence not only better explains the reproduction, amplification, dissolvement, and restructuring of privilege in international education, but also highlights the need to visibilize students from displaced, refugee, and forced-migrant backgrounds.

Author Biographies

Lisa ruth brunner, university of british columbia.

Lisa Ruth Brunner is a postdoctoral research fellow at the Center for Migration Studies at the University of British Columbia, Canada. E-mail: [email protected].

Bernhard Streitwieser, George Washington University

Bernhard Streitwieser is an associate professor of international education and international affairs at the Graduate School of Education and Human Development at George Washington University, United States, and director of GW’s Refugee Educational Advancement Laboratory. E-mail: [email protected].

Rajika Bhandari, Rajika Bhandari Advisors

Rajika Bhandari is the founder of Rajika Bhandari Advisors, United States. E-mail: rajika@ rajikabhandari.com.

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Towards a national policy on nursing education and training: an imperative framework for integrating nursing education within South Africa’s post-school education system

• Vhothusa Edward Matahela   ORCID: orcid.org/0000-0002-3210-0618 1 , 2 &
• Nonhlanhla Jabulile Makhanya   ORCID: orcid.org/0009-0002-7747-2148 1  

BMC Nursing volume  23 , Article number:  286 ( 2024 ) Cite this article

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The aim of this study article is to present an analysis of the first national policy framework, which provides a coherent approach to integrating nursing education into a newly defined band for higher education programmes in South Africa. The significance of this policy framework is ensuring the seamless transition from legacy nursing programmes to NQF-registered nursing programmes. It explores the agenda-setting process, analyses the prevailing context and outlines the rationale for the policy. Walt and Gilson’s policy triage analysis process outlines the key elements of the policy development process. Drawing upon Tarlov’s two-phased public policy development process, the article outlines the steps completed in the policy development process. Recommendations are proposed to expand access, improve quality and diversify the provisioning of nursing education and training in South Africa.

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Introduction

Nurses and midwives in South Africa comprise more than 56% of the total health workforce [ 1 ]. They are central in addressing the quadruple burden of diseases: the coinciding epidemics of HIV, AIDS and tuberculosis; high maternal and child mortality; noncommunicable diseases; and violence and injuries [ 2 ]. South Africa’s healthcare system recognizes nurses and midwives as the cornerstone of health service delivery. They are often the first and sometimes the sole interface with healthcare users, particularly at the primary healthcare level. For example, the country has the highest number of people living with HIV [ 3 ], thus an increase in the demand for an adequate nursing and midwifery workforce to strengthen the public health sector’s response to HIV and AIDS, including initiation of antiretroviral therapy and its management at primary health care level. In addition, the Covid-19 epidemic has had an unprecedent reversal of gains in the reduction of country’s child and maternal mortality rates, which are now well behind the Sustainable Developmental Goals. Currently, the country’s institutional maternal mortality (iMMR) stands at 120 per 100,000 live births, the infant mortality rate at 25 deaths per 1,000 live births, and the institutional neonatal death rate is 12 per 1,000 live births. There is a need for massification of nurses and midwives with required skills mix for the country to combat high maternal and neonatal mortality rates [ 4 ]. The dynamic nature of health system demands a high level of competence to meet current and future population health needs, which underscores the importance of well-prepared clinical nurse practioners. The government holds the directive to harmonise nursing programmes with service delivery and clinical competencies to conform with national practice standards [ 5 ]. Nurse training has historically been offered under interim arrangement and not fully integrated into the post-school education system. The advent of the new National Qualifications Framework (NQF) provided an opportunity for nursing education to be integrated into the post-school education system. Hence, a policy was needed to align nursing education with post-school education legislative prescripts to foster transformative, high-quality education for nurses to effectively produce safe and competent practitioners, thus addressing population health needs [ 6 ]. This is referred to as the National Policy on Nursing Education and Training. This policy should become the overarching framework that ensures coherent implementation of NQF-aligned nursing programmes by all providers of nursing education programmes [ 7 , 8 ]. The policy needed to undergo a robust policy development process, extensive stakeholder engagement and validation, political engagement, along with an integrated socio-economic assessment process for successful implementation. This article presents a rigorous analysis of this first national policy framework. The framework aims to ensure an inclusive and coherent approach to nursing education and training with recommendations to facilitate seamless adoption thereof.

Section 52(a-d) of the National Health Act (Act 61 of 2003) mandate that the Minister of Health provide a consistent supply of healthcare professionals with the requisite skill mix to meet current and future health demands [ 9 ]. Cognizant of the centrality of nursing and midwifery services in ensuring a responsive health system, Minister of Health Dr A. Motsoaledi, in 2011, convened a National Nursing Summit that aimed to address the challenges facing the nursing profession [ 10 ]. Through deliberate engagement modalities, including explicit political support, presentations, dialogues and sharing experiences from community of practices, the Summit allowed nurses to reflect on issues affecting their profession and the health system and anticipated reforms. This approach culminated in a Nursing Compact, thus providing a summary of resolutions taken collectively by the nursing profession [ 11 ]. Chief amongst the resolutions was a need to develop a national policy intended to provide uniformity in the offering of nursing programmes. The specific focus areas included student recruitment, selection and admission; funding and support; clinical education and training of nurses; and non-alignment of nursing qualifications to the provisions of the NQF Act (Act 67 of 2008) [ 12 ].

The translation of the Nursing Compact into a National Policy for Nursing Education and Training became the logical point of departure. This process reiterated the diverse contextual realities of the nine South African provinces from a strengths-based perspective and the necessity of optimising resources for nursing education and training. An integrated approach to nursing education was proposed. A discussion of the cascade of processes followed to analyse the existing framework and propose elements for the policy follows.

Research methodology

The policy development process of Walt and Gilson’s Policy Triangle Analysis Framework [ 13 ], illustrated in Fig.  1 below, served as an analogy for analysing the framework to integrate nursing education into the higher education band. The Policy Triangle Analysis Framework considers the context, actor, content and process components. The context refers to the prevailing circumstances informing the policy; actors are key informants who were central in formulating and implementing the policy; content is about the policy elements; and process refers to how the policy is initiated, formulated, negotiated, communicated, implemented and evaluated [ 14 ]. This approach enabled a thorough examination of the various factors that could influence the policy development and implementation processes [ 15 ] and guided the authors toward more effective planning for successful execution.

Walt and Gilson’s (1994) policy triangle analysis framework

Recent legal imperatives required alignment of all nursing education programmes to the higher education prescripts and health system demands. A national overarching framework became apparent; this framework was to ensure alignment of health service expectations and higher education prescripts. The context required developing a national policy to steer stakeholders through the transitional period, providing a directive for implementation. Thus, the policy would need to outline the basis for a uniform framework within which nursing education could be provided.

Crucial to effective decision-making is understanding the characteristics of the diverse stakeholders (actors) involved in the policy development and implementation process. Stakeholders included those from the quadruple helix system (government, academia, industry and communities) and included government officials, nursing educators, healthcare professionals, students and other relevant parties. It was essential to gain a comprehensive understanding of their respective roles, interests and power dynamics to foster consensus and garner support for the proposed reforms.

Throughout the policy development journey, a reiterative and reciprocal stakeholder engagement process was conducted. Participants were actively engaged and were kept informed about the progress made at each stage. Engagement occurred through formal and informal consultations whereby input was received on policy proposals within specific thematic areas. Furthermore, these stakeholders critically reviewed and analysed the final draft policy for its fitness for purpose and adequacy of content. As the central figure for nursing in the country, the Chief Nursing Officer (CNO) led the process, solicited input and provided comprehensive oversight to ensure a well-informed policy. This was to be kept in line with the execution of the Government Chief Nursing and Midwifery Officers’ policy advice and responsibilities, as outlined by the World Health Organisation [ 5 , 16 ]. See Fig.  2 below.

Role of government chief nursing and midwifery officers.

(Source: WHO [ 5 , 16 ])

The following stakeholders played pivotal roles in the development of the nursing education and training policy:

A Technical Working Group (TWG) was established that included experts in nursing education and practice to offer technical expertise and insights;

The College Principals and Academic Staff Association (CPASSA) addressed disparities in nursing education and training;

Provincial Directors for Nursing Practice contributed to the partnership between health establishments and nursing education institutions (NEIs) for clinical education;

The National Department of Health’s (NDoH’s) Health Workforce Management and provincial counterparts in Human Resource Management and Organisational Development provided input on health workforce planning to align policy with national health strategies;

The South African Nursing Council (SANC) guided the policy alignment with nursing competency frameworks and prepared new qualifications;

The Forum for University Nursing Deans in South Africa (FUNDISA) shared experiences and insights about legacy nursing programmes in higher education;

The private nursing sector ensured the inclusion of industry concerns within the policy framework;

The Council on Higher Education (CHE) ensured policy alignment with qualification and programme requirements;

The Department of Higher Education and Training (DHET) provided input on academic planning, student enrolment and monitoring, while the Joint Health Science Education Committee (JHSEC) coordinated and aligned health sciences education strategy and financing;

The National Treasury advised on the financing model, which included a standardised bursary system and access to grants earmarked for health professions education;

The Department of Planning, Monitoring and Evaluation in the office of the Presidency (DPME) assessed the policy’s alignment with the socioeconomic impact assessment and quality assurance frameworks.

Once the comprehensive consultation process was concluded, the policy was approved by the National Health Council (NHC), which is the highest decision-making structure for the health sector prescribed in the Health Act (Act 61 of 2003) [ 9 ].

This stage entailed examining the policy formulation and implementation processes to help identify the stages, actors and steps involved in developing and enacting the policy [ 17 ]. The process phase of the policy framework analysis facilitated the identification of potential bottlenecks or areas that required improvement to ensure smooth implementation. Tarlov’s two-phase framework was employed [ 18 ] as depicted in Fig.  3 . The framework is aligned with the government’s National Policy Development Framework [ 19 ], which facilitates the monitoring and evaluation of the policy.

Adaptation of Tarlov’s public policy development process [ 20 ]

Phase 1: Public consensus/national agenda building

Step 1: values and beliefs.

In this phase, values central to the provision of nursing education and training were adopted, including an education system informed by patient-centred care, safe nursing practice, evidence-based nursing practice, student-centred teaching and learning, professionalism, and service orientation and career focus. Whilst Tarlov’s model provides for values and beliefs as key tenants of the Public Consensus/National Agenda Building phase, this study specifically identified values as the only pertinent factor in this context.

Step 2: Problem or issue emerges

In this step, specific problems that needed to be addressed by the policy were identified. Firstly, prior to the advent of the new NQF, programmes leading to nursing qualifications were offered by diverse NEIs with varying settings, management and governance models. Inadvertently, NEIs’ different governance practices affected recruitment, selection, progression and articulation toward achieving full qualifications for prescribed nursing categories. Hence the need for a national policy to give effect to the provisions of the NQF within the context of nursing education.

Secondly, inadequate internal management systems led to overproduction of lower categories of nurses as elucidated by a survey conducted by the regulatory body [ 21 ]. This inadvertently perpetuated a mismatch between available nurses and service delivery demands. Furthermore, limited clinical training impeded the attainment of requisite competencies for professional registration [ 8 , 22 ].

Thirdly, there was massification of production of nurses through two streams of one of the programmes. For instance, both colleges and universities produced registered nurses and midwives through separate degree and diploma programmes [ 23 ]. This resulted in service disharmony and hindered smooth articulation and transfer of credits between programmes. Key amongst these concerns was that midwifery training was accelerated [ 24 , 25 ], which could potentially impact on student midwives’ competencies within their prescribed scope of practice.

The fourth problem related to the dual status of students in pre-registration nursing programmes. There was a lack of uniformity/standard position in the country concerning the status of the students in nursing and systems of managing students. For instance, college students were employees with full benefits, whilst university students had full student status. The net effect was misalignment between graduates’ skills and competencies and health service delivery requirements.

Step 3: Knowledge development and research

During this step relevant information related to the issues identified in Step 2 was gathered, including data, research findings, expert opinions, and any other insights that could contribute to a comprehensive understanding (knowledge) of the problems. A thorough analysis of available data and research findings was conducted to identify patterns, root causes, potential solutions, and the likely impact of different policy options. Simultaneously, several consultation workshops were held to engage key stakeholders. These consultation workshops covered activities such as consolidation, identification, review, collation, analysis, verification, brief development, and the establishment of a working group. Additionally, a composite thematic document was created and subjected to content validation through a think tank.

Step 4: Public awareness

Awareness campaigns were held with stakeholders central to policy implementation including academics, provincial heads of health, labour unions, regulatory bodies, higher education and senior management teams in provinces. Inputs from stakeholders were collated to produce the draft concept document. The background document was further improved based on input from the TWG. The National Stakeholder Consultative Meeting output was compiled into a composite document.

Phase 2: Political/public policy actions

Step 5: political engagement.

Cognisant of the implications of the policy to provincial structures responsible for quality, quantity, and relevance in nurse production, a focussed engagement was held with administrative Heads of Health (HoDs) in the nine provinces. During the workshops the policy was subjected to scrutiny by the HODs in preparation for brefing their Members of Executive Council (MECs). Specific focus was given to validation of policy for fitness for purpose, content accuracy and sufficiency. Given that MECs are political heads of provincial health departments and also members of the NHC - the highest decision-making body of the sector prescribed in the Act [ 9 ], a thorough briefing was essential to garner their support for policy approval by the NHC.

Step 6: Public policy deliberation and adoption

During this phase, the draft policy was subjected to NDoH statutory processes, including review by the National Department’s Legal Unit. The policy was declared to have met the socio-economic impact assessment (SEIAS) and quality assurance frameworks of the Department of Policy Monitoring and Evaluation (DPME). Conducting the SEIAS empowered policymakers and other decision makers to assess the potential effects of the proposed policy on diverse stakeholders and sectors to minimise any negative impacts. The policy was then finalised, and its approval was sought from the NHC.

Step 7: Interest group activation

The policy was presented to the NHC for adoption and subsequently submitted to the minister, who signed the policy for final approval on 31 January 2019. The policy was gazetted on 05 April 2019. The Minister conducted a policy launch event to introduce the policy to the relevant stakeholders.

Step 8: Regulation, experience and revision

NEIs began implementing the approved policy. Policy implementation tools (guidelines) were developed. The Office of the CNO began conducting supportive visits to evaluate the implementation of the policy and assess its effectiveness. The steps followed in developing the policy are summarised in Fig.  4 .

Nursing education policy framework development process

The rationale for developing the policy was to ensure a unified system of nursing education and training:

To address the evolving healthcare landscape, there is a need for a national framework that is aligned with health service demands and sound education principles. This framework can guide NEIs to prepare to offer higher education qualification subframework (HEQSF)– aligned nursing programmes.

The policy has broad elements that are designed around challenges in the provisioning of of nursing education programmes. Its primary objective is to establish a consistent framework for nursing education that enables smooth transitions between different nursing programmes. Furthermore, the policy aims to enhance the quality and alignment of nursing education with professional registration requirements. It serves as a national guideline for locating nursing educationwithin a post-school education system. The key elements include the following:

Implementing a standardised system to attract a diverse range of students to nursing programmes;

Ensuring the competency and capability of the nursing and midwifery workforce; and

Enhancing the synchronisation and standardisation of nursing education and training through strengthened clinical training platforms.

The policy ensures alignment of higher education prescripts to health service demands by providing a framework that can guide NEIs to prepare to offer higher education qualification subframework (HEQSF)-aligned nursing programmes. Thus, expanding access, improving quality and diversifying the provision of nursing education and training through policy imperatives discussed below.

Uniformly promote compliance with all legislative requirements for provisioning of nursing programmes

Accreditation and registration.

All NEIs, both public and private, along with their programmes, must be accredited by the SANC and CHE and registered with the SAQA. Accreditation and registration need to be aligned with applicable legislation as prerequisites for offering programmes in the HEQSF so that nursing qualifications can be recognised and registered by the SANC.

Optimizing students’ fitness for practice

Full student status must be retained for the entire study period. Registration with the SANC should occur within a specified timeframe after admission to an NEI. Evolving educational landscapes should take into consideration the characteristics and needs of the student population.

A standardised system to attract and recruit diverse students into nursing programmes, with a uniform recruitment and selection framework and progression across nursing programmes

Entry, admission and selection requirements.

Three entry-level programmes designed as standalone qualifications determine access to nursing programmes. These entry levels can either be at Auxiliary, Diploma or Bachelor programmes.

The NDoH developed an implementation guideline for standardised recruitment, selection and admission of students to new nursing programmes. This ensures standardised recruitment, selection and admission procedures for individuals with NEIs. These guidelines aim to guarantee that the actions and decisions of NEIs, which affect the quality, quantity and relevance of the future nursing workforce, are equity-minded and socially accountable to priority health continuum problems and service needs of the communities and regions served by education institutions.

Provision for experiential knowledge

Students with prior experience in the nursing/midwifery context and who acquire knowledge through the workplace and other learning settings can have their prior learning recognised. National policies that underpin experiential based kniowledge are implemented accordingly.

Career pathways

In line with the NQF, the policy provides for seamless, predictable and coherent career pathways within the nursing qualifications. After a lengthy and protracted processes over a period of several years, involving collaboration between the SANC and critical partners [ 26 , 27 ], nursing qualifications were eventually aligned to the NQF as depicted in Fig.  5 .

Career pathways for nursing (adopted from Bezuidenhout et al. [ 27 ]) and SANC, 2016 [ 28 ]

Although the policy provides provisions for the introduction of new clinical programmes at the NQF Level 7 in a phased-in approach, there have not been any additional clinical programmes at this level. In addition to the current midwifery programme, the need for other advanced diplomas should be explored, and additional clinical programmes should align with health service needs and disease burdens.

A synchronised and standardised system for clinical training through the strengthening of clinical platforms

Clinical teaching and learning.

The health authority retains overall coordination of clinical teaching and learning to optimize standardisation. Accordingly, a framework for collaborative action in the form of a memorandum of understanding (MOU) between the health authority and NEIs has been developed. The MOU stipulates all institutional arrangements and resources requisite to optimize clinical learning experience of students.

Synchronised and collaborative partnerships between the two departments (NDoH and DHET) and their respective councils (SANC and CHE)

The NDoH and DHET collaborated to define a legal framework to guide transitional arrangements that have been put in place to ensure that nursing colleges can continue to operate until they are declared as higher education colleges. This also involves creating an enabling environment for the accreditation of new qualifications on the HEQSF, registration of new qualifications on the NQF, recognition of new programmes by the SANC and enabling the public nursing colleges to market and enrol students on the new qualifications.

A uniform and standardised financing mechanism for nursing education and training

A costing exercise was conducted to determine the uniformity of the provisioning and management of nursing education and training and to operationalise the policy within the requirements of higher education and the regulatory framework. Ultimately, it was concluded that there was a need to leverage available funding streams (intersectoral, interprofessional and interprovincial) to promote access to and optimise nursing education resources [ 8 ]. Although nursing colleges have been re-established as providers of post-school education programmes, they remain funded by the provincial fiscus. Invariably, this institutional type cannot tap into established funding earmarked for post-school education programmes. Thus, there is a need to align funding for programmes offered by colleges with a funding framework for the post-school education funding model.

The policy served as a key impetus for accelerating the process of repositioning NEIs within the post-school education system. It serves as an instrument for nursing education and training to function within both healthcare and higher education policy frameworks.

The inclusion and active involvement of clinical nurse leaders in the policy development process, particularly as members of the TWG, has enhanced the quality and applicability of teaching and learning, both in classroom and clinical settings. This collaboration between nursing education and clinical services continued through the development of policy implementation tools and resulted in enhanced acceptance and adherence to the tools and promotion of a seamless transition for nursing students from education to practice/service. Alignment of the policy with the government’s National Policy Development Framework enhances monitoring and evaluation efforts. Insights and lessons gained from the policy development process and stakeholder engagement, along with the resulting policy imperatives, can be leveraged to expedite the integration of other related health sciences professions into higher education. This approach will ensure a continuous supply of professionals with the necessary skill mix to support a responsive healthcare system.

Data availability

All data generated or analysed during this study are included in this published article.

Abbreviations

Chief Nursing Officer

College Principals and Academic Staff Association

Council on Higher Education

Department of Higher Education and Training

Department of Planning, Monitoring and Evaluation in the Presidency

Forum for University Nursing Deans in South Africa

Higher Education Qualification Subframework

Joint Health Science Education Committee

Member of Executive Committee

Memorandum of Understanding

National Department of Health

National Health Council

National Qualifications Framework

Nursing Education Institution

South African Nursing Council

South African Qualifications Authority

Socioeconomic Impact Assessment

Technical Working Group

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Acknowledgements

Our heartfelt thanks extend to Professor Petra Bester (North-West University) for her invaluable contribution as a critical reader of this manuscript.

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Matahela, V.E., Makhanya, N.J. Towards a national policy on nursing education and training: an imperative framework for integrating nursing education within South Africa’s post-school education system. BMC Nurs 23 , 286 (2024). https://doi.org/10.1186/s12912-024-01880-6

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