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Continued nursing education in low-income and middle-income countries: a narrative synthesis
  1. Amee Azad1,
  2. Jung-Gi Min1,
  3. Sharjeel Syed1,
  4. Sara Anderson2
  1. 1Stanford University School of Medicine, Stanford, California, USA
  2. 2ReSurge International, Sunnyvale, California, USA
  1. Correspondence to Amee Azad; adazad{at}


Introduction Continued nursing education and development can reduce mortality and morbidity of patients and can alleviate the shortage of healthcare workers by training of nurses for high-demand skill sets. We reviewed patterns of educational interventions and strategies in initiating behaviour change, improving patient outcomes or knowledge for nurses in low- and middle-income countries (LMICs).

Methods The study searched the MEDLINE (PubMed), Embase, CINAHL, Google Scholar and Web of Science databases. The study included interventional studies on continued nursing education from 2007 to 2017. Of the 6216 publications retrieved, 98 articles were included and analysed by three independent reviewers.

Results Of the 98 studies that met inclusion criteria, five were randomised controlled trials, five were qualitative in design and the remaining 88 were quasi-experimental, before-and-after studies. Of these studies, the median sample size of participants was 64, and the majority were conducted in Asia (53.6%). During the 10-year study period, 20.4% was conducted in 2015, the highest proportion, with a general increase in number of studies over time from 2007 to 2017. Main themes that arose from the review included train-the-trainer models, low-dose/high-frequency models, use of multiple media for training, and emphasis on nurse empowerment, strong international partnerships, and the integration of cultural context. Overall, the studies were limited in quality and lacked rigorous study design.

Conclusion Continued nursing education in LMICs is essential and effective in improving nurses’ knowledge base, and thus patient outcomes and quality of care. Long-term, randomised studies are needed to understand how training strategies compare in impact on nurses and patients.

  • review
  • descriptive study
  • public health
  • health systems

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  • Handling editor Kerry Scott

  • Contributors AA, J-GM and SS conceived of and designed the study. AA, J-GM and SS acquired the data. AA, J-GM, SS and SA contributed to the review of the articles and interpretation of the results. AA took the lead in writing the manuscript. All authors provided critical feedback and helped shape the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

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