The impact of nursing education programs on healthcare delivery in low and middle-income countries (LMICs): A mixed systematic review

The impact of nursing education programs on healthcare delivery in low and middle-income countries (LMICs): A mixed systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of nursing education programs on healthcare delivery in low and middle-income countries (LMICs): A mixed systematic review Emmanuel Gasaba, Peter Taratara, Jonathan Niciza, Idrissa Bigirimana This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9040928/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: Nursing is a cornerstone of global healthcare delivery, particularly in low- and middle-income countries (LMICs) where nurses are essential to addressing the needs of underserved populations. While nursing education is intended to strengthen clinical effectiveness, the systemic impact of these programs on healthcare delivery in resource-limited settings remains insufficiently synthesized. This study focuses on the role of nursing educational programs in LMIC. Objective To synthesize existing evidence on the impact of nursing education programs for improving healthcare delivery and patient outcomes in LMICs. Methods A mixed-methods systematic review was conducted following the Joana Briggs Institute methodology. Eligibility criteria were pre-defined and registered in PROSPERO. Article were included if they (1) were related to nursing education programs in LMICs, and (2) focus on the impact of nursing education programs. A comprehensive search was performed through PubMed, Scopus, Web of Science, CINAHL, ERIC, BVS, and Embase. Quantitative and qualitative data were extracted and synthesized using a convergent integrated approach. Findings were categorized and pooled based on thematic similarity to produce an integrated evidence base. Results From the 630 identified study, 46 were included, with findings mapped across the four levels of Kirkpatrick’s Evaluation Model. The evidence demonstrated high levels of participant satisfaction and engagement (Level 1), significant acquisition and retention of both theoretical knowledge and practical clinical skills (Level 2), and successful transfer of learning into clinical practice (Level 3). These behavioral changes directly resulted in enhanced patient outcomes and strengthened health system performance (Level 4), including improved diagnostic accuracy and reduced clinical errors. Conclusion Nursing education programs in LMICs are effective catalysts for improving healthcare delivery. This review provides an integrative framework demonstrating that structured educational interventions not only enhance individual nursing competences but also drive systemic improvements in patient care and institutional capacity. Trial registration PROSPERO CRD42025646172 Nursing education programs Healthcare delivery Low and middle-income countries Healthcare providers Figures Figure 1 Figure 2 Introduction Nursing is the cornerstone of global healthcare systems, not only in low- and middle-income countries (LMICs), but globally since nurses constitute the majority of the health care workforce. In these resource-constrained settings, nurses transcend traditional clinical roles, serving as the primary providers for health promotion, disease prevention, and community-based management. This contribution is increasingly vital as LMICs grapple with a triple burden of rising chronic diseases, persistent infectious challenges, and rapid population growth (1,2). The World Health Organization (WHO) identifies the strengthening of nursing capacity as a primary lever for achieving universal health coverage (1), yet the effectiveness of these professionals is fundamentally tethered to the quality and relevance of their education (3). The correlation between advanced nursing education and patient safety is well-documented in high-income contexts (4). For instance, a 10% increase in the proportion of baccalaureate-prepared nurses has been associated with a 7% reduction in hospital mortality (5–7). However, these outcomes are not easily replicated in LMICs due to systemic barriers, including chronic shortages of qualified educators, inadequate infrastructure, and lack of standardized regulatory oversight. For example, in 2016, 52% of the WHO African region lacked functional nursing regulatory bodies, a deficit that poses significant risks to the quality of healthcare delivery, defined here as the organization of resources and personnel to provide medical services that improve outcomes and patient experience(8,9). Despite regional initiatives, such as the 2024 International Council of Nurses (ICN) meeting in Kigali which called for targeted investments in nursing to reduce medical errors, efforts remain fragmented. While various programs aim to enhance technical proficiency and professional agency, there is a lack of synthesized evidence regarding their actual impact on health system performance in LMICs. Existing literature often focuses on isolated interventions without exploring the how and why behind their success or failure (10). This Mixed Methods Systematic Review (MMSR) addresses this critical gap. By synthesizing quantitative evidence on the effectiveness of nursing programs alongside qualitative data on stakeholder perceptions and contextual mechanisms, this study provides a holistic view of how education transforms healthcare delivery. Healthcare delivery refers to the process of providing medical care and services to patients which encompasses improving the quality of care, reducing costs, and focusing on the patient experience (11) A preliminary search across major databases (PubMed, Scopus, Web of Sciences, CINHAL, Eric, PROSPERO and OSF) confirmed that no existing systematic review has yet integrated these diverse evidence types for the LMIC context. Consequently, this review aims to provide policymakers and international NGOs with the evidence-based strategies needed to optimize nursing training and, ultimately, improve patient outcomes across the globe by synthesizing existing evidence on the impact of nursing education programs for improving healthcare delivery and patient outcomes in LMICs. Review question The question which guided this review was: What are the impacts of nursing education programs for improving healthcare delivery in LMICs? Inclusion and exclusion criteria Participants : This review included studies that involved healthcare providers such as nurses and midwives working in LMICs regardless of their education levels. Phenomena of Interest : Studies that described the impact of nursing education programs of these healthcare providers on healthcare delivery in LMICs were included. The impacts on healthcare providers were assessed based on the Kirkpatrick’s evaluation model including the participants reactions to training (level 1); what healthcare providers learnt (level 2); whether what the healthcare providers learnt has been applied in practice (level 3); and the results achieved by the application of training (level 4) (12). These aspects can reflect on the patients’ outcomes, healthcare delivery system, effectiveness and efficiency of healthcare delivery, healthcare costs, nurses’ experiences or patients’ perspectives. Context : We included studies that have been conducted in LMICs by looking for the impacts of nursing education programs on healthcare delivery. Types of studies : The review included quantitative, qualitative, and mixed method of published studies that report on the impacts of nursing education programs for improving healthcare delivery in LMICs. Any studies that did not involve the participants and phenomena of interest as described above were excluded from this study. Studies conducted and published before 2015 were also excluded. Methods and Design Study method This systematic review was conducted by using the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews by following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram (13). Both qualitative and quantitative evidence were combined through data transformation and the convergent integrated approach was undertaken. The review was conducted in accordance with pre-registered protocol on PROSPERO February, 13 th 2025 (available on https://www.crd.york.ac.uk/PROSPERO/view/CRD42025646172 ). Search strategy The search strategy was conducted on February 3 rd 2025 by the assistance of a librarian. The keywords used included “nursing education programs”, “healthcare delivery”, “low and middle-income countries”, “healthcare providers/ Nurses/ midwives” to identify comprehensive and effective index terms by using Health Sciences Descriptors (DeCS) (See Appendix A for the complete search string). Following the JBI methodology for systematic review, the three-step search strategy was adopted (14). An initial limited search of PubMed and CINAHL was undertaken to identify articles on the impact of nursing education programs for improving healthcare delivery in LMICs. This was followed by an analysis of text words contained in the titles and abstracts of retrieved articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed, Scopus, Web of Science, CINAHL, Eric, BVS and Embase databases for published articles. The search string, including all identified keywords and index terms, was adapted for each one of the included databases with the assistance of a professional librarian. The reference lists of all included articles were screened for additional sources. Only studies conducted from 2015 were included, and there was no language filter applied due to advanced technology in translation. Study selection After performing the search strategies in all databases, all identified articles that met the inclusion criteria were gathered and exported into Rayyan software for references managements, duplication removal, reviewing and screening processes. The retrieved articles’ titles and abstracts were screened by two independent reviewers for potential inclusion in the systematic review based on the significance and impact of nursing education programs for improving healthcare delivery in LMICs. To be included, the article was required to be (1) related to nursing education programs in LMICs, (2) focus on the impact of nursing education programs to patients’ outcome, healthcare delivery system, the effectiveness and efficiency of healthcare delivery, healthcare costs, nurses’ experiences or patients’ perspectives. Articles were excluded if they did not display the set inclusion criteria. Articles identified during the search, and considered to meet the inclusion criteria, based on their title and abstract, were then obtained in full text screening and were assessed in detail against the inclusion criteria by the two independent reviewers. The articles were then presented in PRISMA flow diagram (15). Identified studies from references lists of the included studies were carried out in the same way. Assessment of methodological quality Each included article was assessed for methodological quality also by two independent reviewers. Quantitative studies were assessed by using the appropriate JBI critical appraisal tool for randomized controlled trials (RCTs), quasi-experimental studies, cohort or analytical cross-sectional studies, while qualitative studies were assessed using JBI critical appraisal for qualitative research regardless of their study design (16,17) A sum of 50 articles underwent the methodological quality assessment using the JBI critical appraisal tools and 46 of the 50 articles met the predefined score for inclusion. Each of the 50 studies was evaluated against predefined criteria. A minimum quality threshold of 50% was applied across appraisal tools to determine eligibility for inclusion. Studies that did not meet this threshold were excluded from the synthesis. Any disagreements between reviewers were resolved through discussion to ensure methodological rigor and consistency in the appraisal process. There are 3 quasi-experimental studies (18–20) ( Table 9 ) and one cross sectional study (21) ( Table 8 ) excluded for not meeting the set inclusion criteria. Among the 46 remaining studies, 38 were quasi-experimental studies (22–59) ( Table 4) , two RCT (60,61) ( Table 2) , two cross sectional studies (62,63) ( Table 3) , 1 cohort (64) ( Table 1) and 3 qualitative studies (65–67) ( Table 5) that met the set inclusion criteria. Table 1: Assessment of methodological quality of cohort studies included (68) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Score 1. Parvin-Nejad, et al. (2022) (64) NA Y U Y Y U Y Y Y NA U 8/11 Y=YES, N=No, U= unclear, NA= Not applicable Q1 – Q11 1) Were the two groups similar and recruited from the same population? 2) Were the exposures measured similarly to assign people to both exposed and unexposed groups? 3) Was the exposure measured in a valid and reliable way? 4) Were confounding factors identified? 5) Were strategies to deal with confounding factors stated? 6) Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? 7) Were the outcomes measured in a valid and reliable way? 8) Was the follow up time reported and sufficient to be long enough for outcomes to occur? 9) Was follow up complete, and if not, were the reasons to loss to follow up described and explored? 10) Were strategies to address incomplete follow up utilized? 11) Was appropriate statistical analysis used? Table 2: Assessment of methodological quality of randomized controlled trials included (69) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Score 1. Wang, et al. (2017) (60) Y U Y N N Y N Y Y Y Y Y Y 9/13 2.Krishnamurthy Jayanna, K., et al. (2016) (61) Y U Y U N Y N Y Y U Y Y Y 8/13 Y=YES, N=No, U= unclear, NA= Not applicable Q1 – Q13 1) Was true randomization used for assignment of participants to treatment groups? 2) Was allocation to treatment groups concealed? 3) Were treatment groups similar at the baseline? 4) Were participants blind to treatment assignment? 5) Were those delivering the treatment blind to treatment assignment? 6) Were treatment groups treated identically other than the intervention of interest? 7) Were outcome assessors blind to treatment assignment? 8) Were outcomes measured in the same way for treatment groups? 9) Were outcomes measured in a reliable way 10) Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analysed? 11) Were participants analysed in the groups to which they were randomized? 12) Was appropriate statistical analysis used? 13) Was the trial design appropriate and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? Table 3: Assessment of methodological quality of analytical cross-sectional studies included (68) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Score 1. Weinberg Steven, et al. (2019) (62) Y Y Y Y Y Y Y U 7/8 2. Ploutz, et al. (2016) (63) Y Y Y Y Y Y Y Y 8/8 Y=YES, N=No, U= unclear, NA= Not applicable Q1 – Q8 1) Were the criteria for inclusion in the sample clearly defined? 2) Were the study subjects and the setting described in detail? 3) Was the exposure measured in a valid and reliable way? 4) Were objective, standard criteria used for measurement of the condition? 5) Were confounding factors identified? 6) Were strategies to deal with confounding factors stated? 7) Were the outcomes measured in a valid and reliable way? 8) Was appropriate statistical analysis used? Table 4 : Assessment of methodological quality of quasi-experimental studies included (70) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Score Ojji, et al. (2023) (22) Y N Y N Y Y Y Y Y 7/9 Dinh, et al. (2022) (23) Y N Y N Y Y Y Y Y 7/9 Goyal, M., et al. (2019) (24) Y N Y N Y Y Y NA Y 7/9 Acharya, et al. (2019) (25) Y N Y N Y Y Y Y Y 7/9 Staveski, S. et al (2016) (26) Y N Y N Y Y Y Y Y 7/9 Charafeddine, et al. (2016) (27) Y N Y N Y Y Y NA Y 7/9 De Silva, et al. (2015) (28) Y N Y N Y Y Y U Y 6/9 Lancaster, et al. (2017) (29) Y N Y N Y Y Y NA Y 7/9 Hassan, et al. (2017) (30) Y N Y N Y Y Y U Y 6/9 Bull, et al. (2017) (31) Y N Y N Y N Y NA Y 6/9 LaVigne, et al. (2018) (32) Y N Y N N Y Y NA Y 6/9 Shah et al. (2020) (33) Y N Y N Y Y Y Y Y 7/9 Raney, et al. (2019) (34) Y N Y N Y Y Y NA Y 7/9 Mwansisya, et al. (2022) (35) Y Y Y Y Y Y Y NA Y 9/9 Gyamfi, et al. (2017) (36) Y Y Y Y Y Y Y Y Y 9/9 Kirkpatrick, et al. (2018) (37) Y N Y N N Y Y NA Y 6/9 Ndikom, et al. (2019) (38) Y Y Y Y Y Y Y Y Y 9/9 Do Thi, N, et al. (2024) (39) Y N Y N Y Y Y Y Y 7/9 Vail, B., et al. (2018) (40) Y N Y N Y Y Y Y Y 7/9 Staveski, S. L., et al. (2015) (41) Y N Y N Y Y Y NA Y 7/9 Kumar, R., et al. (2016) (42) Y Y Y Y Y Y Y Y Y 9/9 Agrawal, et al (2021) (43) Y N Y N Y Y Y U Y 6/9 Agrawal, et al (2016) (44) Y N Y N Y Y Y U Y 6/9 Ahmed, et al (2023) (45) Y N Y N Y Y Y N Y 6/9 Arlington, et al (2017) (46) Y N Y N Y Y Y Y Y 7/9 Bang, et al (2016) (47) Y N Y N Y Y Y U Y 7/9 Cavicchiolo, et al (2018) (48) Y N Y N Y Y Y Y Y 7/9 Chao, et al (20160 (49) Y N Y N Y Y Y Y Y 7/9 Creanga, et al (2020) (50) Y N Y N Y Y Y U Y 6/9 Das, et al (2016) (51) Y N Y N Y Y Y Y Y 7/9 Das, et al (2017) (52) Y N Y N Y Y Y Y Y 7/9 Downing, et al (2016) (53) Y N Y N Y Y Y Y Y 7/9 Elnour, et al (2015) (54) Y Y Y Y Y Y Y Y Y 9/9 Kamath-Rayne, et al (2017) (55) Y N Y N Y Y Y Y Y 7/9 Kumar, et al (2015) (56) Y Y Y Y Y Y Y Y Y 9/9 Seto, et al (2015) (57) Y N Y N Y Y Y N Y 6/9 Thukral, et al (2015) (58) Y N Y N Y Y Y N Y 6/9 Vail, et al (2017) (59) Y N Y N Y Y Y N Y 6/9 Y=YES, N=No, U= unclear, NA= Not applicable Q1 – Q9 1) Is it clear in the study what is the “cause” and what is the “effect” (i.e. there is no confusion about which variable comes first)? 2) Was there a control group? 3) Were participants included in any comparisons similar? 4) Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? 5) Were there multiple measurements of the outcome, both pre and post the intervention/exposure? 6) Were the outcomes of participants included in any comparisons measured in the same way? 7) Were outcomes measured in a reliable way? 8) Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? 9) Was appropriate statistical analysis used? Table 5: Assessment of methodological quality of qualitative studies included (17) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 score Rao, et al. (2022) (65) Y Y Y Y Y U N Y Y Y 8 Ayub, et al. (2024) (66) Y Y Y Y Y Y N Y Y Y 9 Bassah, et al. (2016) (67) Y Y Y Y Y Y N Y Y Y 9 Y=YES, N=No, U= unclear, NA= Not applicable Q1 – Q10 1) Is there congruity between the stated philosophical perspective and the research methodology? 2) Is there congruity between the research methodology and the research question or objectives? 3) Is there congruity between the research methodology and the methods used to collect data? 4) Is there congruity between the research methodology and the representation and analysis of data? 5) Is there congruity between the research methodology and the interpretation of results? 6) Is there a statement locating the researcher culturally or theoretically? 7) Is the influence of the researcher on the research, and vice- versa, addressed? 8) Are participants, and their voices, adequately represented? 9) Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? 10) Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? Data extraction Quantitative and qualitative data were extracted from studies included in the review by three independent reviewers by using a predesigned tool developed within Microsoft Excel to facilitate the extraction and organization of data from the included articles. The following study characteristics were extracted from each included paper ( Support document of the data extraction form ); Title, publication year, type of research paper, aim of the study, site of the study, the methods, participants, sample size, nursing education programs for improving healthcare delivery, participant satisfaction or reaction (level 1), gained knowledge, improved skills, or changed attitudes (level 2), participants behavior towards their learning (level 3), and the impact on healthcare outcomes (level 4). To capture data on the impact of education programs for improving healthcare delivery in LMICs, the framework for evaluation of nursing educational programs (71) was adapted based on the four levels of the Kirkpatrick Model (1967) (72) ( Table 6 ). Kirkpatrick’s evaluation model measures participants reactions to training (level 1); what they have learnt (level 2); whether what they learnt have been applied in practice (level 3); and whether the application of training is achieving results (level 4) (12). This extraction tool was amended based on what we proposed in the protocol. It was piloted by the reviewers on the first five included studies to ensure consistency and reliability between the reviewers and was used to extract both quantitative and qualitative data. Table 6 : Framework for evaluation of nursing educational programs [Adapted from (71)] Level 1a Learner perceptions Participants’ views on their learning experience and satisfaction with the training Level 1b Patients’ perceptions Patients view on their involvement experience Level 1c Trainers’ perceptions Trainers’ views on involving patients Level 2a Modification in attitudes and perceptions A measured change in attitudes or perceptions towards patients, their problems, needs, circumstances or care Level 2b Acquisition of knowledge and skills A measured change in understanding the concepts, procedures and principles of working with patients, and the acquisition of thinking/ problem solving, assessment and intervention skills Level 3a Changes in behavior Observation of whether the newly acquired knowledge, skills and attitudes are evident in the practice of healthcare providers (Nurses and midwives) Level 3b Changes in organizational practice Observation of wider changes in the organization/ delivery of care, attributable to patients’ involvement in an educational program Level 4 Benefits to patients and/ or their families Assessment as to whether there is a tangible difference to the well-being and quality-of-life of patients and/or their families who receive healthcare services. Data synthesis Data transformation (Qualitizing) To facilitate a seamless integration of diverse data types, this review employed a qualitizing process for all quantitative findings, including the quantitative strands of mixed-methods studies. Qualitizing involved transforming numerical results, statistical significances, and effect sizes into textual descriptions that captured the essence and direction of the findings (73). Qualitized data points were then treated as qualitative evidence, allowing them to be categorized alongside primary qualitative data into themes and sub-themes under each level of the Kirkpatrick’s model. This transformation ensured that the quantitative results could be narratively synthesized to directly address the review’s overarching questions regarding the impact of nursing education. Data synthesis and integration Following the JBI methodology for mixed-methods systematic reviews (13,74), we adopted a convergent integrated approach. A convergent integrated approach is a method of data synthesis in which qualitative and quantitative data are analyzed separately and then integrated during the interpretation or synthesis stage to generate a single, comprehensive set of findings (75). This method achieves data integration by comparing, transforming, of results from different sources so that evidence converges to provide a joint understanding of the phenomenon under investigation (74). Data synthesis followed a multi-stage thematic process integrated within the Kirkpatrick Four-level evaluation framework. Initially, the qualitized quantitative data and the primary qualitative findings were subjected to line-by-line coding to identify recurrent concepts and patterns. The codes were systematically aggregated into themes, representing the broad, high-level patterns of evidence answering what outcomes occurred at each level. To provide an analytical layer, subthemes were developed to capture the specific mechanisms, nuances, and how or why factors like barriers to implementation or psychological drivers were applied to the primary themes. Finally, under each Kirkpatrick level, these themes and sub-themes were pooled based on conceptual similarity to produce a set of integrated findings. The findings were formulated into line of action statements designed to provide evidence-based recommendations for investing in nursing education programs to optimize healthcare delivery in LMICs. Results Figure 1 below illustrates the study process by using the PRISMA flow chart. A total of 630 articles (n=630) were initially identified. After removing 91 duplicate articles, 539 articles (n=539) remained. The first screening of the identified articles based on their titles and abstracts yielded 57 articles of which one was not retrieved, 29 excluded during the full text screening either for not meeting the inclusion criteria and 27 remained. 34 articles have been identified in the reference list and only 23 met the inclusion criteria. A sum of 50 articles underwent methodological quality assessment using the JBI critical appraisal tools and 46 met the defined score for inclusion. Figure 1. PRISMA flow diagram for the study selection process. Table 7. Characteristics of articles included in the review (n = 46). Characteristics Number (n=46) Percentage Design Quantitative 37 80.4% Qualitative 3 6.6% Mixed 6 13.0% Country India 15 32.6% Uganda 3 6.5% Vietnam 3 6.5% Mozambique 2 4.3% Pakistan 4 8.7% China 1 2.2% Nigeria 2 4.3% Libanon 1 2.2% Srilank 1 2.2% Jordan 1 2.2% Botswana 1 2.2% Tanzania 2 4.3% Ghana 1 2.2% Sierra Leone 1 2.2% Taiwan 1 2.2% Sudan 1 2.2% Honduras 2 4.3% Ethiopia 1 2.2% Cameroon 1 2.2% Kenya and India 2 4.3% Participants Nurses 36 78.2% Midwives 5 10.9% Nurses and Midwives 5 10.9% Other healthcare providers 16 34.8% Physicians 13 81.1% Sanitation workers 1 6.3% Clinical officers 1 6.3% Physicians +Sanitation workers 1 6.3% Majority of the articles included in this review (80.4%) were quantitative studies. Among them, 89.2% used quasi-experimental methods (22–30,32,35,37,38,40–52,54–59,64), 5.4% used RCT (60,61) and 5.4% used cross-sectional method (62,63). 13.0% used mixed methods (31,33,34,36,39,53), while Only 6.6% used qualitative methods (65–67). Findings were distributed within the 3 continents with most studies conducted in Asia (58.7%) (23–30,34,37,39–45,49–52,56,59–61,65,66), 32.6% from Africa (22,31–33,35,36,38,46,48,53,54,62–64,67), 4.3% from central America (55,57) and other 4.3% conducted in countries located in two continents, Africa and Asia (47,58). Most participants (78.2%) were nurses, with 34.8% studies used multidisciplinary approach within 81.1% were physicians ( Table 7 ). In this review the interventions were designed to deliver a range of nursing education programs. We clustered them into two main groups: The first was courses, including pediatric acute surgical support (PASS) course (23), patient safety course (66), palliative care course (67), and stop the bleed (STB) course (64). The second, which constituted a varied type of educational interventions include mobile nurse training program (50–52), palliative care training program (32,65,67), safety training (31,45), simulation program (34,40,59), education program (25,29,30), neonatal resuscitation program (27,48,59), helping babies breathe training program (46,47,55,57), training program (22,24,28,33,35–37,39,49,60,62,63), discharge education program (26,41), pre-service education (43), virtual classroom training (44), waste management training (42,54,56), link-nurse program (53), Essential Care for Every Baby (ECEB) educational program (58), Educational package (38), and mentoring program (61). Finding synthesis The findings were reposted based on the Kirkpatrick Model that is mostly used to evaluate the training effectiveness (12). The model encompasses four elements that are commonly used to categorize the findings for the purpose of capturing the impact of the nursing education programs at different levels as shown in figure 2 below. Figure 2: An integrative thematic framework for evaluating nursing education in LMICs . Legend : This figure presents a thematic synthesis of the impact of nursing education programs on healthcare delivery. Themes and subthemes are systematically mapped across the four levels of Kirkpatrick’s Evaluation Model—Reaction, Learning, Behavior, and Results—illustrating the pathway from pedagogical satisfaction to systemic clinical improvement. Participants’ reactions The first level (on the right) identified four themes that captured the participants’ initial responses to the nursing education programs. These findings explored the nurses’ satisfaction with the training delivery and the perceived relevance of the curriculum to their specific clinical contexts in LMICs. By analyzing these reactions, this level provided critical insight into the acceptability and engagement levels required for the successful implementation of educational interventions in resource-constrained settings. Theme 1: Pedagogical satisfaction and cultural acceptability This was the first identified theme within participant reactions that presented as a predominant trend of high pedagogical satisfaction and cultural acceptability across the majority of the evaluated programs (22,23,27,28,31,33,36,39,41,46,53,56–58,60,66). Evidence clusters indicate that nursing professionals reported significant levels of satisfaction derived from the effectiveness of the training modalities (22) and the implementation of novel methodologies (21,31) that were deemed both engaging and contextually appropriate. A critical element of this positive reception was the cultural acceptability of the interventions (28), which contributed to an overall positive subjective experience for the learners (46). However, the synthesis also revealed a noteworthy counter-point; in specific instances, participants expressed dissatisfaction with certain program content (60), highlighting the necessity for curriculum alignment with local clinical realities. This satisfaction was deeply influenced by the participants’ valuation of active, hands-on, and patient-centered pedagogy (Sub-theme 1) (22,23,45,46,53). The evidence suggests a strong appreciation of interactive approaches (45) and active learning strategies (22) over traditional passive instruction. In particular, the positive reception of simulation and hands-on methods (23,46) was a recurring factor in high satisfaction scores. Furthermore, the pedagogical value was enhanced by the recognition of the patient’s voice and perspective (53), which shifted the training focus toward person-centered care. Finally, satisfaction was sustained beyond the initial training through engagement with follow-up support (46), which learners identified as a vital component for reinforcing their initial positive experience. Theme 2: Perceived utility, relevance, and clinical feasibility This was the second major identified theme of the educational interventions (18–23,31,41,45,53,56,57,60,64,66,67). Participants consistently reported that the programs were characterized by a high degree of clarity and practical usefulness (22,23,31,60), with several studies emphasizing the feasibility of implementing the learned content within resource-constrained settings (41,57,66). This sense of utility was deeply rooted in the perceived clinical relevance and professional mastery (Sub-theme 2) fostered by training (22,23,45,46,57,60,67). Learners specifically valued the programs as a means for knowledge refreshment (60) and the enhancement of existing clinical competencies (22). This relevance was further reinforced through recognition of core safety concepts (45) and a measurable improvement in practical skills and the utility of clinical equipment (46,57). Notably, the training served a diagnostic purpose for the participants themselves, allowing them to identify specific practice deficiencies (67) that had previously gone unrecognized, thereby aligning the educational content with their immediate professional needs. Theme 3: Enhanced professional confidence and readiness to change Beyond the acquisition of clinical knowledge, the synthesis revealed a significant shift in the participants’ psychological approach to care, characterized by enhanced professional confidence and a readiness to change clinical practice (46,58,62,64,66). Multiple studies reported that nursing staff experienced an immediate increase in self-reported confidence following the educational interventions (46), and that was found to be sustained over time in several longitudinal assessments (58,62,64). This burgeoning confidence was directly linked to an increased readiness to abandon outdated habits and adopt new clinical behaviors (62,66). This transition was underpinned by a deeper sense of affective empowerment and professional self-efficacy (Sub-theme 3) (22,23,27,31,62). Participants frequently exhibited a positive emotional response to the program design (22,23,27,66), which fostered a belief in their own capability to influence healthcare outcomes. This sense of empowerment was particularly evident in their perceived ability to protect patient safety (66) and their high expectations of the future impact their training would have on patient care (23). Consequently, the education programs acted as more than a technical update; they served as a catalyst for professional self-actualization, where improved self-efficacy (62) became the primary driver for implementing change in resource-limited environments. Theme 4: Commitment to sustained engagement and holistic care The theme centered on a long-term commitment to sustained engagement and the adoption of holistic care models (39,53,60). Rather than viewing education as a one-time event, participants expressed a desire for ongoing involvement with the training material (60). This was particularly evident in programs focused on complex care, where training led to a significant shift in how nurses engaged with patients, moving toward a more holistic care approach that addressed multiple patient needs simultaneously (53). The commitment was closely linked to a vocal demand for sustainability, advocacy, and programmatic refinement (Sub-theme 4) (39,60,66). Participants did not merely accept the training as provided; they actively advocated for recurrent and continued education that remains contextually relevant to the specific challenges within the LMICs (39,60). This sense of advocacy was paired with a strong intent-to-practice and a willingness to adopt new clinical tools into their daily routines (60). However, learners also provided critical feedback, noting a need for formal curriculum integration (66), and identifying areas for content enhancement to prevent post-intervention declines in knowledge or interest (60). These reactions suggest that for nursing education to be successful in the long term, it must evolve based on the participants’ calls for systemic integration and periodic reinforcement. Learning (Knowledge and Skill Acquisition) In this level, the review identified four themes that delineate the acquisition of both cognitive knowledge and practical clinical skills. Through the synthesis of the included studies, four themes emerged that capture the breadth of learning achieved, ranging from the mastery of specialized clinical procedures to the development of critical thinking and decision-making capabilities within resource-limited settings. Theme 1: Initial acquisition and longitudinal retention of cognitive knowledge A fundamental outcome of the nursing education programs was the initial acquisition and longitudinal retention of cognitive knowledge (22–30,32,33,36–39,41–45,47,49,50,53,54,56–60,62,66). The evidence demonstrate an overwhelming trend of improved knowledge acquisition across diverse clinical topics (23–30,32,33,36,38,39,41,45,50,60,66). While most programs reported initial improvements in essential knowledge (54,56–58,62), others specifically highlighted the sustained improvement in task-strengthening knowledge (22) and high-level retention months after the intervention (42,47,49). This cognitive progress was characterized by universal vs. differential cognitive mastery (Sub-theme 1) (22–25,27,30,32,35,38,39,42,45,47,50,54,60,66,67). The findings indicate immediate and multi-domain acquisition, with significant knowledge gains occurring across various health disciplines and training modules simultaneously (22–24,30,32,33,38,39,50,54,60,66). However, the evidence also revealed cross-professional variability, noting distinct differences in baseline attitudes and the rate of knowledge gain between different healthcare professions (27,42,45,47). Despite these variations, the overall results pointed to robust sustainability, with high-level knowledge retention and sustained cognitive gains observed at follow-up assessments when compared to control groups (25,35,38,39,42,47,54), underscoring the long-term effectiveness of the training programs in LMIC contexts. Theme 2: Mastery and retention of technical and clinical competencies In addition to cognitive gains, the synthesis identified a robust trend toward the mastery and retention of technical and clinical competencies (22,23,28,31,33–37,40,42–44,46–54,56,57,59,61,62,66). The educational interventions significantly enhanced clinical and team performance, specifically strengthening task-specific nursing behaviors (22,23,31,36,46,50–54,56,57,61,62,66). A significant portion of the evidence focused on assessment and diagnostic proficiency (28,33,34,37,49), particularly in the mastery of emergency and high-stakes skills such as resuscitation and trauma care (40,47,48,51,59,61). Furthermore, nursing staff demonstrated high levels of competence in essential routine care; including maternal, newborn, and reproductive health (MNH/RMNH) (35,43,44,50–53) reflecting a broad practical application of skills across diverse clinical settings (31,33,34,42,51–54,56,62). This mastery was further defined by increased technical proficiency, efficiency, and procedural accuracy (Sub-theme 2) (23,27,31,34,36,36,37,40,43,44,47,48,51,52,59–61). Participants showed specialized expertise in high-stakes and emergency mastery, specifically regarding neonatal resuscitation (NR), sepsis management, and trauma response (23,27,36,40,44,47,48,51,52,59–61). Notably, the training resulted in increased efficiency in time-critical tasks and overall operational efficiency (34,59), ensuring that life-saving procedures were performed with greater clinical precision (31,36,37). Beyond manual dexterity, the programs fostered procedural compliance, characterized by near-universal documentation accuracy and strict adherence to clinical protocols (34,43,51), which are essential for quality assurance in resource-limited healthcare systems. Theme 3: Transformation of professional attitudes and system awareness Beyond technical acquisition, the education programs facilitated a significant transformation of professional attitudes and system awareness (29,31,38,42,49,53,56,60,66). The synthesis found a demonstrable shift in professional outlooks (60), with particularly marked improvements in attitudes toward sensitive clinical areas, such as End-of-Life Care (EOLC) (29,38). Furthermore, the interventions fostered systems thinking, heightening nurses’ awareness of their role within the broader organizational structure (66). While overall improvements in nursing attitudes were widely reported (31,38,53,56,66), the evidence also offered nuanced findings regarding sustainability; specifically, some studies noted lack of sustained change in core communication competencies (49) or professional attitudes (42) over time. This suggests that while initial attitudinal shifts are strong, longitudinal reinforcement is necessary to permanently alter professional culture. This evolution in mindset was further characterized by a growing sense of professional agency, role expansion, and pedagogical competence (Sub-theme 3) (22,23,33,36,39,53,66). The programs empowered nurses to assume pedagogical and peer leadership roles (22,67), effectively turning learners into educators within their clinical units. This was accompanied by a notable increase in clinical autonomy (36,39) and a deepened sense of professional responsibility toward patient safety and outcomes (23,53,66). The learning process also triggered significant affective and interpersonal growth (53,60,66), leading to role expansions where nurses took on advanced clinical responsibilities (53). Consequently, the training did not merely update skills; it redefined the nurse’s professional identity, equipping them with the agency to lead and the interpersonal maturity to manage complex care dynamics in LMIC settings. Theme 4: Enhancement of professional self-efficacy and clinical confidence A significant outcome of the educational programs was the enhancement of professional self-efficacy and clinical confidence among participants (28,31,33,35,36,39,45,53,58,62,64). The synthesis found a significant increase in self-reported clinical confidence across a wide array of nursing specialties (28,33,35,53,58,62,64), even in instances where baseline confidence was already high (31). This acquisition of high self-efficacy (33,36,39,53) was closely tied to the participants’ increased self-assessed knowledge and skills (45), suggesting that the learning process provided nurses with the psychological assurance necessary to perceive themselves as competent clinicians within their healthcare systems. However, the durability of these gains revealed a complex reality described as the sustainability paradox: durability versus rapid decay (Sub-theme 4) (22,25,26,28,35,39,40,42,46–48,54,59). On one hand, several studies provided the good news of long-term durability, showing that cognitive and skill improvements could be sustained well beyond the initial training period (22,25,35,39,42,47,48,54). On the other hand, a significant body of evidence warned about rapid regression and decay (26,40,46,59), where gains in high-stakes skills tended to diminish without constant reinforcement. This decay was often exacerbated by complexity barriers (28,37), where more intricate clinical tasks proved harder to retain than routine ones. To address this, the evidence highlighted strategic solutions for sustainability, such as the use of booster sessions and simulation-based refreshers (47,48), which were identified as essential for transforming fleeting learning gains into permanent professional mastery. Behavior change (Transfer of learning to practice) The findings from the third level focused on the practical implementation of education in the clinical environment. Through the synthesis of existing research, five themes emerged that illustrate how nursing education programs in LMICs influence professional conduct. These themes describe the changes in daily care routines, the adoption of new clinical procedures, and the nursing behaviors that directly impact healthcare delivery Theme 1: Successful transfer of skills and immediate improvement in clinical behavior The most prominent finding at this level was the successful transfer of skills and a rapid improvement in clinical behavior following the educational interventions (25,31,36,39,48,53,57,58,60,63,64,67). Participants demonstrated a tangible change in practice (60,67) and an immediate clinical improvement in care delivery (25). The shift was not only qualitative but also operational, characterized by a measurable change in clinical practice speed and procedural efficiency (36,48). Evidence clusters further indicate an improved independent screening capacity (63) and a consistent uptake of new clinical behaviors (31,36,39,53,67), suggesting that the training was sufficiently practical to be applied directly within the workflow of LMIC healthcare settings. This behavioral shift was underpinned by enhanced clinical proficiency and high-fidelity skill application (Sub-theme 1) (37,39,40,50–53,55,58,63,64,67). Learners demonstrated high sensitivity for detecting significant pathology (37) and an increased application of high-stakes skills, such as neonatal resuscitation (NR) and essential newborn care (ENC) (40,55). Specifically, training led to higher odds of performing core newborn practices, including skin-to-skin contact and eye care (51,52), as well as a sustained improvement in labor practice (52). The proficiency extended to specialized domains, such as the successful uptake of generalist palliative care (53) and the effective detection of rheumatic heart disease (RHD) (63). Crucially, this high-fidelity application was fueled by the participants’ belief in their own efficacy to improve patient outcomes (39), ensuring that the uptake of clinical skills was both accurate and aligned with the identified needs of the patient population (67). Theme 2: Enhanced adherence to specialized clinical protocols and safety standards This was the second major behavioral theme (26,31,36,37,40,53,55,61,63). Educational interventions led to a significant increase in documentation compliance (26) and the adoption of evidence-based assessment tools (36). This adherence was particularly noted in high-stakes environments, where participants demonstrated high fidelity to clinical protocols, such as the Parasternal Long-Axis (PLAX) view in Focused Cardiac Ultrasound (FCU) (37), neonatal resuscitation practices (40,55), and medication safety standards (66). The synthesis suggests that training programs successfully standardized nursing behavior, leading to more consistent palliative care delivery (53) and the reliable use of independent screening protocols (61,63) across varied clinical settings. This standardization was driven by the systematic integration of assessment, triage, and referral protocols (Sub-theme 2) (36,53,60,61,63,67). Rather than being performed in isolation, clinical tasks became part of a larger organizational workflow. This was evidenced by the routinization of cognitive screening (60) and a more routine approach to risk assessment (36). Education also significantly improved triaging and referral behavior (53), with several studies noting that trained nurses were able to influence hospital-wide referral systems (61) and demonstrate high proficiency in specialist referrals (36). By accurately identifying both patient and organizational needs through enhanced screening (36,67) and effectively utilizing skills for specialized screenings like Rheumatic Heart Disease (RHD) (63), nurses acted as critical gatekeepers, ensuring more efficient and safer pathways through the healthcare system. Theme 3: Sustained longitudinal change in nursing practice and institutional capacity A critical finding within the behavioral domain was the evidence of sustained longitudinal change in nursing practice and institutional capacity (42,43,50–52,61). Unlike interventions that show only short-term spikes in performance, these programs resulted in sustained behavioral compliance with new clinical standards (42). This was particularly evident in maternal and neonatal health, where there were higher odds of long-term practice retention for intrapartum and newborn care (50–52). Furthermore, the behavioral shift among nurses translated into improved institutional capacity and facility readiness, as trained staff were better equipped to manage complex patient care pathways and improve overall system performance (43,61). This systemic improvement was deeply integrated with the evolution of patient-centered communication and proactive care (Sub-theme 3) (31,36,51,53,60,67). The synthesis found that nurses moved beyond task-oriented care to embrace proactive care approaches and relationship-centered care, which significantly contributed to trust building within the community (53). Significant improvements were noted in interpersonal communication (67) and patient advising (60), including more effective guidance to mothers regarding newborn health (51). Moreover, nurses demonstrated skillful counseling on lifestyle and treatment adherence (36) and engaged in peer advocacy (66). By shifting toward this proactive and communicative model, the nursing workforce not only improved the clinical accuracy of care but also the interpersonal quality and human-centeredness of the healthcare delivery system in LMICs. Theme 4: Peer-to-peer knowledge diffusion and professional attitudinal shifts The synthesis highlighted that behavior change often extended beyond the direct participants of the training through peer-to-peer knowledge diffusion and professional attitudinal shifts (43,53). Trained nurses acted as agents of change, with evidence showing that new knowledge was frequently shared with colleagues who had not attended the formal sessions (53). This informal diffusion of skills (53) served to normalize advanced clinical behaviors across the workforce. Furthermore, this collaborative environment fostered a collective change in professional attitudes (53), where the culture of the clinical unit began to align with the new standards of practice introduced by the education program (43). Supporting this cultural shift were measurable gains in operational efficiency and institutional quality standards (Sub-theme 4) (26,42,43,48,50,61). The behavioral changes were often driven by the direct task relevance of the training, which made adoption intuitive for the nursing staff (42). These changes led to significant improvements in administrative and clinical rigor, such as sustained practice change in documentation (26,61) and the achievement of institutional quality benchmarks (43). Operationally, the impact was seen in successful anticipation of clinical needs, leading to earlier start times and a reduced duration of procedures (48). High compliance with intrapartum practices (50) further underscored that improved facility readiness was a direct result of nurses successfully integrating their newfound technical skills into the institutional workflow (61). Theme 5: Persistent gaps, implementation barriers, and psychological friction Despite the documented successes in behavior change, the synthesis identified significant persistent gaps, implementation barriers, and psychological friction that hindered full practice transformation (48,60,66,67). The evidence clusters highlighted inter-organizational barriers (60) and practice change gaps characterized by significant delays in the initiation of new protocols (48). Furthermore, even when knowledge was present, implementation barriers often prevented its application (66). On a psychological level, some participants reported low self-efficacy or persistent discomfort when attempting to perform newly learned tasks in a high-pressure clinical environment (67), suggesting that technical training alone may not be sufficient to overcome deeply rooted professional anxieties. These challenges were further articulated as persistent behavioral gaps and structural implementation barriers (Sub-theme 5) (25,42,60,66,67). Structurally, the most significant impediment to behavior change was time constraints due to severe staffing shortages (66), which forced nurses to prioritize basic survival tasks over advanced clinical protocols. Behaviorally, some studies noted lack of change in specialist referral tendencies (60) and a failure to sustain practice change over the long term (25). Interestingly, one study noted a persistent behavioral gap in physician compliance (42), suggesting that nursing behavior change can be stifled if the broader multidisciplinary team does not support the new standards. Finally, despite training, deficits in therapeutic communication regarding sensitive topics, such as palliative care or terminal diagnoses remained a persistent challenge (67), indicating that behavioral shifts in affective and interpersonal domains may require more intensive, long-term mentorship. Results: Impact on healthcare delivery and patient outcomes The highest level of the Kirkpatrick model assesses the organizational and clinical impact of educational interventions. The synthesis identified three primary themes reflecting how nursing education translates into measurable improvements in patient health and healthcare delivery systems. Theme 1: Significant improvement in patient clinical outcomes (Morbidity and mortality) The most critical evidence of the effectiveness of nursing education programs was the significant improvement in patient clinical outcomes, specifically regarding morbidity and mortality rates (25–27,37,48,49). Educational interventions led to an immediate decrease in Central Line-Associated Bloodstream Infection (CLABSI) rates (25) and a major reduction in patient morbidity related to surgical site infections (SSIs) (26,27). Most notably in maternal and newborn care, programs contributed to a decreased neonatal mortality rate (48). Beyond physical health, education in specialized nursing care also yielded psychological benefits, including decreased patient memory and behavioral problems, as well as reduced depressive symptoms (49). These clinical improvements were largely facilitated by the enhancement of diagnostic accuracy and clinical service access (Sub-theme 1) (37). The synthesis found that specialized training (such as Point-of-Care Ultrasound) enhanced the diagnostic value of nursing assessments (37). When nurses utilized a combined strategy of clinical skills and advanced diagnostic tools, the system achieved high overall diagnostic accuracy, which directly improved the effectiveness of service delivery (37). Consequently, the education programs served as a vital bridge to improved access to healthcare and more efficient triage (37), ensuring that patients were correctly identified and treated earlier in their clinical course. Theme 2: Enhanced effectiveness and efficiency of healthcare service delivery Beyond direct clinical outcomes, the synthesis demonstrated that nursing education programs resulted in enhanced effectiveness and efficiency of healthcare service delivery (25,27,37,49,53). A significant finding was that efficiency was maintained even as patient outcomes improved, suggesting that better-trained nurses do not necessarily require more time, but rather use their time more effectively (25). The evidence indicates a broad improvement in the effectiveness of healthcare delivery across various specialties (27,49), particularly through the implementation of optimal screening strategies (37). Furthermore, the evolution of nursing roles through education led to enhanced access to specialized services (53), allowing facilities to provide higher-tier care that was previously unavailable to the patient population. This operational success was underpinned by the strengthening of workforce capacity and resource optimization (Sub-theme 2) (65). Education acted as a catalyst for enhanced structural and workforce capacity, transforming the nursing staff into a more resilient and versatile resource (65). By improving the skill set of the existing workforce, healthcare facilities were able to achieve optimized resource and service availability (65). This indicates that nursing education is a high-value investment for LMICs, as it maximizes the utility of limited human and material resources, ensuring that the health system can deliver a higher volume and quality of care without a proportional increase in infrastructure costs. Theme 3: Strengthening of institutional capacity and systemic sustainability The final dimension of the Level 4 analysis identifies the strengthening of institutional capacity and systemic sustainability as a direct result of nursing education (53,65). The evidence suggests that when nurses are empowered through training, there is a measurable shift in organizational capacity and system-level performance(65). This goes beyond individual competence to the institutionalization of practices (53), where new clinical behaviors become the established standard for the entire facility. This systemic strengthening ensures that the benefits of the intervention are not lost when individual staff members rotate or leave, but are instead embedded into the operational framework of the institution. This long-term impact is driven by systemic institutionalization, referral integration, and organizational ownership (Sub-theme 3) (53,65). A key marker of success was the institutionalization of palliative care processes (65), showing that complex care models can be successfully integrated into LMIC hospitals. Furthermore, these programs facilitated the integration of nurses into formal referral pathways (53), positioning them as central figures in the continuum of care. Crucially, the evidence highlights the emergence of internal advocacy and organizational ownership (53), where the healthcare facilities themselves take responsibility for maintaining and defending the new standards of care. By fostering this sense of ownership, nursing education serves as a cornerstone for building resilient, self-sustaining healthcare systems that are less dependent on external interventions and more capable of internal quality improvement. Table 8: Assessment of methodological quality of for analytical cross-sectional studies excluded (68) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Score 1. Chan, et al. (2019) (21) N Y N Y N N Y U 3/8 Y=YES, N=No, U= unclear, NA= Not applicable 1) Were the criteria for inclusion in the sample clearly defined? 2) Were the study subjects and the setting described in detail? 3) Was the exposure measured in a valid and reliable way? 4) Were objective, standard criteria used for measurement of the condition? 5) Were confounding factors identified? 6) Were strategies to deal with confounding factors stated? 7) Were the outcomes measured in a valid and reliable way? 8) Was appropriate statistical analysis used? Table 9: Assessment of methodological quality of quasi-experimental studies excluded (70) References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Score Kistner, et al. (2024) (18) Y N Y N N N N U N 2/9 Shahrakivahed, et al (2015) (19) Y N N N N N Y Y Y 4/9 Stolz, et al (2015) (20) Y N N N N Y Y Y U 4/9 Y=YES, N=No, U= unclear, NA= Not applicable 1) Is it clear in the study what is the “cause” and what is the “effect” (i.e. there is no confusion about which variable comes first)? 2) Was there a control group? 3) Were participants included in any comparisons similar? 4) Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? 5) Were there multiple measurements of the outcome, both pre and post the intervention/exposure? 6) Were the outcomes of participants included in any comparisons measured in the same way? 7) Were outcomes measured in a reliable way? 8) Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? 9) Was appropriate statistical analysis Discussion This systematic review synthesized evidence from 46 peer-reviewed studies to examine the impact of nursing education programs on healthcare delivery and patient outcomes in LMICs. Our findings indicate that when education is culturally contextualized and pedagogically relevant, it acts as a primary catalyst for professional empowerment and systemic clinical improvement. By mapping these findings to an integrative thematic framework (Fig. 2), this discussion explores how individual learning transitions into institutional capacity, while also addressing the systemic translation gaps that often hinder long-term sustainability in resource-constrained settings. The integrative pathway: From pedagogical engagement to systemic change The centerpiece of this review is the integrative thematic framework (Fig. 2), which illustrates that nursing education in LMICs does not function in isolation but acts as a catalyst for a multi-level ripple effect. While traditional evaluations often treat Kirkpatrick’s levels as independent silos (76–78), our framework demonstrates a progressive and reinforcing pathway. We argue that pedagogical satisfaction (Level 1: Reaction) is not an end in itself, but the generator of the emotional buy-in required for competency acquisition (Level 2: Learning). This mastery, in turn, fosters the professional confidence necessary to exercise clinical autonomy in challenging environments (Level 3: Behavior), ultimately culminating in enhanced patient safety and systemic resilience (Level 4: Results). Consequently, we suggest that Kirkpatrick’s levels should be viewed not merely as a descriptive taxonomy, but as a causal mechanism that reflects the sequential transformation required to bridge the gap between education and clinical impact. Bridging the cultural gap: Contextualizing reaction and learning (Level 1& 2) While our findings indicate a high degree of participant satisfaction and knowledge gain across diverse LMIC settings, the thematic synthesis suggests that in resource-limited contexts, reaction is heavily mediated by the perceived relevance of the curriculum to local clinical challenges. This aligns with broader theoretical frameworks, such as those proposed by Phillips as cited in (77), which identify relevance of training as one of the core dimensions of participant reaction. Our results further specify this dimension for LMICs, demonstrating that when resources are scarce, the utility of content in solving immediate, real-world clinical obstacles becomes the primary determinant of educational buy-in. This engagement serves as a prerequisite for Level 2 (Learning) mastery. Specifically, the superior outcomes observed in programs utilizing culturally adapted materials and simulation-based learning suggest that effectiveness in LMICs is predicated on the contextualization of pedagogy. By providing a safe-to-fail environment that mirrors local clinical realities, these methods provide empirical support for the shift away from homogenizing universalist models inherited from colonial structures (79). When nursing education prioritizes local epidemiological needs and sociocultural realities over Western-centric standards, it creates a more equitable and transformative learning environment. As argued by Ramli et al. (2025), integrating local knowledge systems is a strategic imperative in the Global South; our synthesis confirms that such integration acts as the primary driver of competency acquisition and knowledge retention among nurses in resource-limited settings. Empowerment as a catalyst for clinical autonomy (Level 3) The most significant finding at Level 3 is the emergence of professional empowerment and clinical autonomy. In many LMICs, nurses and midwives serve as the primary, and sometimes only, healthcare providers available, particularly in rural or remote regions (80,81). Our synthesis indicates that educational programs targeting advanced clinical decision-making trigger a fundamental shift in professional identity, where nurses move from task-oriented care toward evidence-based, proactive leadership. This shift aligns with Kanter’s Theory of structural empowerment, which posits that when organizational leadership creates environments where staff have access to information, resources, and support, they are optimized to perform their jobs well and provide higher-quality care (82). As Travers et al. (2020) observed, empowered nursing staff perform their duties more effectively and are more likely to participate in the planning, decision-making, and interdisciplinary teams required to manage complex clinical settings (82). Our framework (Fig. 2) specifically highlights this critical transition between individual attitudinal shifts and institutional capacity. The thematic synthesis revealed that peer-to-peer knowledge diffusion (Theme 4) acts as the operational engine of this transformation. As nurses gain clinical competence, they develop the psychological safety required to lead peer mentorship initiatives. This creates a sustainable cycle of knowledge transfer within the facility, where empowered nurses become learning leaders who stabilize the workplace environment and promote safer clinical practices (83) Furthermore, our findings suggest that this empowerment enables a critical form of task-shifting. In this context, the nursing workforce moves beyond mere clinical accuracy to improve the interpersonal quality and human-centeredness of the delivery system. As nurses become psychologically empowered, they demonstrate greater employee agility and a higher propensity for knowledge-sharing (83). This cultural shift is mirrored by measurable gains in operational efficiency and institutional quality standards (Sub-theme 4), which directly improve institutional capacity and facility readiness. Ultimately, this confirms that in LMICs, the impact of education is not limited to the individual bedside; rather, it scales upward. By adopting a communicative and proactive model, nurses effectively stabilize the healthcare system, ensuring that facility performance remains resilient even in the absence of specialized medical staff. By fostering psychological safety and structural support, education provides the foundation for higher facility readiness and better-standardized patient care pathways. Consequently, Level 3 behavior change in LMICs acts as the essential bridge that transforms individual learning into the systemic clinical improvements and institutional resilience seen at Level 4. The implementation bottleneck: Navigating the translation gap (Level 4) While this review identified significant positive impacts on patient outcomes, including reduced mortality rates, improved infection control, and enhanced diagnostic accuracy, the transition from Level 3 (Behavior) to Level 4 (Results) is where the translation gap is most evident. Our findings suggest that in LMICs, the impact of nursing education on healthcare delivery is context-dependent and intrinsically linked to the availability of clinical resources. As highlighted by our framework (Fig. 2), even the most highly trained and empowered nurse cannot translate their skills into improved patient outcomes if the system lacks essential supplies, medications, or supportive supervision. This systemic limitation is supported by the work of Malematja et al. (2025), who found that insufficient resources at the primary healthcare level leads to a quality-of-service crisis. When essential tools are unavailable, nursing staff become overwhelmed by the need to improvise or borrow resources, which inevitably delays nursing interventions and diminishes the quality of care. This resource scarcity creates a secondary crisis of trust; as patients feel neglected or experience delayed care, they lose confidence in the healthcare system, leading to increased complaints and legal risks for the facility (84). Furthermore, the translation gap is exacerbated by extreme workforce shortages. While our review shows that education improves individual efficiency, the burden remains immense in regions like Africa, which has only 13 nurses and midwives per 10,000 population compared to 83 in Europe (WHO), as cited in (84). This disparity puts an unsustainable strain on the existing workforce, where the extra effort required to complete nursing interventions in a resource-poor environment can lead to burnout, effectively neutralizing the long-term benefits of educational programs. Beyond the immediate physical resource gap, our review highlights that sustainability is the ultimate determinant of Level 4 outcomes. In many LMIC contexts, systemic clinical improvements are often transient, tied to the duration of specific projects or donor-funded workshops rather than being embedded within national health strategies. Our framework warns that without institutionalizing education; these gains are vulnerable to the reality of staff migration and brain drain. When highly trained nurses are empowered with new competencies (Level 3) but remain unsupported by the hardware of functional infrastructure and fair compensation (Level 4), they are more likely to seek better opportunities abroad, taking the institutional memory and Level 4 impact with them. As suggested by the emergence of learning leaders within our framework—referring to empowered nurses who drive continuous peer-to-peer knowledge diffusion—long-term impact is predicated on the institutionalization of these leadership behaviors. This requires moving away from one-off training workshops toward integrated longitudinal education models supported by local policy and continuous professional development (CPD) frameworks. Without this policy-level integration, the software of education risks becoming obsolete as trained staff migrate or initial enthusiasm wanes, hindering the permanent transformation of healthcare delivery. This creates a critical "So What?" for policymakers: to achieve lasting system resilience, governments and international partners must shift their focus from funding isolated training events to funding permanent, integrated systems. Long-term impact is predicated on creating a supportive environment that retains talent through standardized career pathways and improved working conditions. Education acts as the catalyst for systemic clinical improvement, but its success is predicated on a supportive environment that provides the hardware (staffing, supplies, and infrastructure) to match the software (knowledge and empowerment) gained through training. Ultimately, Level 4 results in LMICs should be viewed not just as a measure of educational success, but as a reflection of the synergy between a competent workforce and a functional healthcare system. These nursing education programs remain necessary because education creates the leaders who stabilize the system, but the system must be strong enough to keep them. Only by bridging the gap between individual empowerment and structural stability can LMICs prevent the leakage of expertise and ensure that educational investments translate into permanent improvements in patient safety and healthcare delivery. Strengths and limitations Strengths A major strength of this review is the use of an integrative thematic framework, which allowed for a nuanced synthesis of both qualitative and quantitative data across 46 diverse studies by using the JBI methodology. By mapping these findings to a modified Kirkpatrick model, this study moves beyond a simple description of educational outcomes to identify the causal mechanisms, such as professional empowerment and peer-to-peer diffusion that drive clinical change in LMICs. Furthermore, the inclusion of recent literature (2015 up to 2025) ensures that the review captures the most current discourse on decolonizing curricula and health system resilience in the Global South. Limitations Despite the strengths, several limitations must be acknowledged. First, there is a high degree of heterogeneity among the included studies, ranging from small-scale clinical workshops to national education reforms, which limit the ability to perform a meta-analysis or generalize specific effect sizes. Second, many studies focused heavily on Level 1 (Reaction) and Level 2 (Learning), with fewer studies providing long-term, longitudinal data on Level 4 (Patient Results). Finally, while we identified resource scarcity as a major bottleneck, the specific impact of different types of resources shortages like human resources vs. medical supplies could not always be isolated due to the overlapping nature of systemic challenges in primary literature. Conclusion This systematic review of 46 studies demonstrates that nursing education in LMICs is a powerful catalyst for healthcare transformation, moving beyond individual skill acquisition to drive systemic clinical improvement. By utilizing an integrative thematic framework, this study reveals that the impact of educational interventions follows a progressive causal pathway: from cultural engagement and pedagogical relevance (Levels 1 & 2) to professional empowerment and the emergence of learning leaders (Level 3), ultimately contributing to enhanced patient safety and institutional resilience (Level 4). The findings underscore that for nursing education to be effective in resource-limited settings, it must be culturally contextualized and decolonized, moving away from universalist Western models toward curricula that address local epidemiological realities. Furthermore, this review identifies a critical translation gap at the systemic level. While education provides the software of professional competence and clinical autonomy, its long-term success is predicated on the hardware of supportive infrastructure, adequate staffing, and essential resources. To prevent the leakage of expertise through brain drain and to ensure the sustainability of clinical gains, policymakers must shift from funding isolated training workshops to investing in permanent, integrated healthcare systems. This includes the institutionalization of longitudinal professional development and the creation of supportive work environments that retain talent. Ultimately, nursing education is essential for stabilizing healthcare delivery in the Global South; however, its potential is fully realized only when a competent, empowered workforce is met with a resilient and well-resourced health system. Recommendations for research and practice To translate these findings into sustainable impact, nursing practice and policy in LMICs must transition from top-down, isolated training events toward the institutionalization of learning Leadership. This requires healthcare facilities to foster safe-to-fail environments where empowered nurses are encouraged to lead peer-mentorship initiatives, thereby stabilizing the local workforce. Crucially, stakeholders and donors must recognize that educational software is only effective when paired with clinical hardware; thus, investments in training must be matched by a commitment to supply chain stability and infrastructure to ensure that new competencies can be practiced. Furthermore, nursing curricula should be decolonized, prioritizing culturally adapted simulations and materials that reflect local epidemiological realities rather than Western-centric standards. Accompanying these practical shifts, the research agenda must move toward longitudinal Level 4 evaluations that track patient outcomes and trust for at least 12–24 months post-intervention to measure true sustainability. There is also an urgent need for economic evaluations to determine the return on investment of nursing education in terms of prevented complications and reduced hospital stays. Finally, future research should specifically investigate the intersection of staff migration and brain drain, quantifying how the loss of trained personnel affects institutional memory and identifying the specific policy-level incentives required to retain learning leaders within their home countries. Declarations Conflicts of Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Authors’ contributions EG, PT, JN, and IB contributed to the study conception and design. EG, PT, and JN coordinated the study implementation and screening process. EG, JN, and IB performed data extraction, quality appraisal, and evidence synthesis. EG drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content and read and approved the final version. Funding Our review did not receive any grant from any funding agency in the public, commercial, or not-for-profit organization. Data availability No datasets were generated or analyzed during the current study. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Acknowledgements Not applicable. References State of the world’s nursing 2020: investing in education, jobs and leadership [Internet]. [cited 2026 Jan 21]. Available from: https://www.who.int/publications/i/item/9789240003279 Crisp N, Iro E. Nursing Now campaign: raising the status of nurses. The Lancet. 2018;391(10124):920–1. 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Supplementary Files Dataextraction.xlsx PRISMA2020checklist.docx SearchstrategiesforAlldatabases.docx PRISMA2020abstractchecklist.docx AppendixA.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Apr, 2026 Reviews received at journal 07 Apr, 2026 Reviews received at journal 06 Apr, 2026 Reviewers agreed at journal 05 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviews received at journal 01 Apr, 2026 Reviewers agreed at journal 01 Apr, 2026 Reviewers invited by journal 28 Mar, 2026 Editor assigned by journal 26 Mar, 2026 Editor invited by journal 16 Mar, 2026 Submission checks completed at journal 14 Mar, 2026 First submitted to journal 14 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9040928","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617129020,"identity":"031654ff-d93d-4830-ba15-e9801fc45067","order_by":0,"name":"Emmanuel Gasaba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYJACZgSzwAZIMDYeIEGLQRpISwNJWg6DKbxa5N2PP/xcUGMTrdt+9pjEB4PzdmvbDwNtAYrg0mJ4JsdYesaxtNxtZ/LSJGcY3E7ediYRqAUo0oBLS0MOgzQP2+HcbQdyzKR5gFrMDgC1MDYcxq2l//nj3zz//uduO//GTPqPwblks/MP8WuRl0gwk+ZtO5C77QbQFgaDA3ZmNwjYYiDxxsx6Zl8yUMsbY8seg+QEsxtAWxLw+EW+P/3x7YJvdkCH5Rje+FFhZ292Pv3hgw81NrhtOYAmkAhWmYBDOdgWdLPs8SgeBaNgFIyCEQoADq1nG2BxnYkAAAAASUVORK5CYII=","orcid":"","institution":"National Institute of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Gasaba","suffix":""},{"id":617129021,"identity":"8ecd59b2-c96f-49c8-bcc2-1796d5db70ae","order_by":1,"name":"Peter Taratara","email":"","orcid":"","institution":"Katanning Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Taratara","suffix":""},{"id":617129023,"identity":"98a3ed12-1531-4fd4-a902-ec69587c017d","order_by":2,"name":"Jonathan Niciza","email":"","orcid":"","institution":"Bahçeşehir Cyprus University","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Niciza","suffix":""},{"id":617129025,"identity":"1c1f3846-aa9c-42bd-9ba8-fa5514368a86","order_by":3,"name":"Idrissa Bigirimana","email":"","orcid":"","institution":"National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Idrissa","middleName":"","lastName":"Bigirimana","suffix":""}],"badges":[],"createdAt":"2026-03-05 14:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9040928/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9040928/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106289016,"identity":"36abf7c5-345c-4350-bd50-a70c518ff5a2","added_by":"auto","created_at":"2026-04-07 07:27:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":111070,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram for the study selection process.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/8da726740aeec966dfa86781.jpg"},{"id":106289041,"identity":"853ec16b-ab00-4eb2-b4a4-ec59200f4467","added_by":"auto","created_at":"2026-04-07 07:28:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1103920,"visible":true,"origin":"","legend":"\u003cp\u003eAn integrative thematic framework for evaluating nursing education in LMICs\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegend\u003c/em\u003e: \u003cem\u003eThis figure presents a thematic synthesis of the impact of nursing education programs on healthcare delivery. Themes and subthemes are systematically mapped across the four levels of Kirkpatrick’s Evaluation Model—Reaction, Learning, Behavior, and Results—illustrating the pathway from pedagogical satisfaction to systemic clinical improvement.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/05c340b053442e19ab2c8e2a.jpg"},{"id":106289217,"identity":"26bb01a8-5e4b-4565-9d93-b4259c5f3dbc","added_by":"auto","created_at":"2026-04-07 07:29:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3435005,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/688effca-7e6f-4f64-96ec-9ed1ae530c58.pdf"},{"id":106289066,"identity":"cdf1c846-4ccb-4168-adb0-fcc774e7738c","added_by":"auto","created_at":"2026-04-07 07:28:06","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":88261,"visible":true,"origin":"","legend":"","description":"","filename":"Dataextraction.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/6af53efa1e1ee1ebc64dda84.xlsx"},{"id":106289114,"identity":"aadc4934-7157-4a40-94b4-10f7c3a41031","added_by":"auto","created_at":"2026-04-07 07:28:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32654,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/78a66fe2bc6c2b894ce9f2f6.docx"},{"id":106289064,"identity":"378cb89f-db90-4ff3-83f9-cf2743c4b73b","added_by":"auto","created_at":"2026-04-07 07:28:06","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16027,"visible":true,"origin":"","legend":"","description":"","filename":"SearchstrategiesforAlldatabases.docx","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/5c4ac36a90c789df8563e1d9.docx"},{"id":106288971,"identity":"24169cc5-563b-4606-ae98-6b7ef042692f","added_by":"auto","created_at":"2026-04-07 07:27:46","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":26962,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020abstractchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/8f767c4a00f5a389009bc514.docx"},{"id":106289017,"identity":"6449f3b8-501b-4d32-9ee1-0b6d46b4db29","added_by":"auto","created_at":"2026-04-07 07:27:53","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":17212,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9040928/v1/502cae2a0e5845d659ffcd6f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of nursing education programs on healthcare delivery in low and middle-income countries (LMICs): A mixed systematic review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNursing is the cornerstone of global healthcare systems, not only in low- and middle-income countries (LMICs), but globally since nurses constitute the majority of the health care workforce. In these resource-constrained settings, nurses transcend traditional clinical roles, serving as the primary providers for health promotion, disease prevention, and community-based management. This contribution is increasingly vital as LMICs grapple with a triple burden of rising chronic diseases, persistent infectious challenges, and rapid population growth (1,2). The World Health Organization (WHO) identifies the strengthening of nursing capacity as a primary lever for achieving universal health coverage (1), yet the effectiveness of these professionals is fundamentally tethered to the quality and relevance of their education (3).\u003c/p\u003e\n\u003cp\u003eThe correlation between advanced nursing education and patient safety is well-documented in high-income contexts (4). For instance, a 10% increase in the proportion of baccalaureate-prepared nurses has been associated with a 7% reduction in hospital mortality (5–7). However, these outcomes are not easily replicated in LMICs due to systemic barriers, including chronic shortages of qualified educators, inadequate infrastructure, and lack of standardized regulatory oversight. For example,\u0026nbsp;in 2016, 52% of the WHO African region lacked functional nursing regulatory bodies, a deficit that poses significant risks to the quality of healthcare delivery, defined here as the organization of resources and personnel to provide medical services that improve outcomes and patient experience(8,9).\u003c/p\u003e\n\u003cp\u003eDespite regional initiatives, such as the 2024 International Council of Nurses (ICN) meeting in Kigali which called for targeted investments in nursing to reduce medical errors, efforts remain fragmented. While various programs aim to enhance technical proficiency and professional agency, there is a lack of synthesized evidence regarding their actual impact on health system performance in LMICs. Existing literature often focuses on isolated interventions without exploring the how and why behind their success or failure (10).\u003c/p\u003e\n\u003cp\u003eThis Mixed Methods Systematic Review (MMSR) addresses this critical gap. By synthesizing quantitative evidence on the effectiveness of nursing programs alongside qualitative data on stakeholder perceptions and contextual mechanisms, this study provides a holistic view of how education transforms healthcare delivery. Healthcare delivery refers to the process of providing medical care and services to patients which encompasses improving the quality of care, reducing costs, and focusing on the patient experience (11)\u003c/p\u003e\n\u003cp\u003eA preliminary search across major databases (PubMed, Scopus, Web of Sciences, CINHAL, Eric, PROSPERO and OSF) confirmed that no existing systematic review has yet integrated these diverse evidence types for the LMIC context. Consequently, this review aims to provide policymakers and international NGOs with the evidence-based strategies needed to optimize nursing training and, ultimately, improve patient outcomes across the globe by synthesizing existing evidence on the impact of nursing education programs for improving healthcare delivery and patient outcomes in LMICs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReview question\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe question which guided this review was: What are the impacts of nursing education programs for improving healthcare delivery in LMICs?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion and exclusion criteria\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e: This review included studies that involved healthcare providers such as nurses and midwives working in LMICs regardless of their education levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhenomena of Interest\u003c/em\u003e\u003c/strong\u003e: Studies that described the impact of nursing education programs of these healthcare providers on healthcare delivery in LMICs were included. The impacts on healthcare providers were assessed based on the Kirkpatrick’s evaluation model including the participants reactions to training (level 1); what healthcare providers learnt (level 2); whether what the healthcare providers learnt has been applied in practice (level 3); and the results achieved by the application of training (level 4) (12). These aspects can reflect on the patients’ outcomes, healthcare delivery system, effectiveness and efficiency of healthcare delivery, healthcare costs, nurses’ experiences or patients’ perspectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext\u003c/em\u003e\u003c/strong\u003e: We included studies that have been conducted in LMICs by looking for the impacts of nursing education programs on healthcare delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTypes of studies\u003c/em\u003e\u003c/strong\u003e: The review included quantitative, qualitative, and mixed method of published studies that report on the impacts of nursing education programs for improving healthcare delivery in LMICs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAny studies that did not involve the participants and phenomena of interest as described above were excluded from this study. Studies conducted and published before 2015 were also excluded.\u003c/p\u003e"},{"header":"Methods and Design","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy method\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review was conducted by using the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews by following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram (13). Both qualitative and quantitative evidence were combined through data transformation and the convergent integrated approach was undertaken. The review was conducted in accordance with pre-registered protocol on PROSPERO February, 13\u003csup\u003eth\u003c/sup\u003e 2025 (available on https://www.crd.york.ac.uk/PROSPERO/view/CRD42025646172 ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSearch strategy\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe search strategy was conducted on February 3\u003csup\u003erd\u003c/sup\u003e 2025 by the assistance of a librarian. The keywords used included \u0026ldquo;nursing education programs\u0026rdquo;, \u0026ldquo;healthcare delivery\u0026rdquo;, \u0026ldquo;low and middle-income countries\u0026rdquo;, \u0026ldquo;healthcare providers/ Nurses/ midwives\u0026rdquo; to identify comprehensive and effective index terms by using Health Sciences Descriptors (DeCS) (See \u003cstrong\u003eAppendix A\u003c/strong\u003e for the complete search string).\u003c/p\u003e\n\u003cp\u003eFollowing the JBI methodology for systematic review, the three-step search strategy was adopted (14). An initial limited search of PubMed and CINAHL was undertaken to identify articles on the impact of nursing education programs for improving healthcare delivery in LMICs. This was followed by an analysis of text words contained in the titles and abstracts of retrieved articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed, Scopus, Web of Science, CINAHL, Eric, BVS and Embase databases for published articles. The search string, including all identified keywords and index terms, was adapted for each one of the included databases with the assistance of a professional librarian. The reference lists of all included articles were screened for additional sources. Only studies conducted from 2015 were included, and there was no language filter applied due to advanced technology in translation. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy selection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter performing the search strategies in all databases, all identified articles that met the inclusion criteria were gathered and exported into Rayyan software for references managements, duplication removal, reviewing and screening processes.\u003c/p\u003e\n\u003cp\u003eThe retrieved articles\u0026rsquo; titles and abstracts were screened by two independent reviewers for potential inclusion in the systematic review based on the significance and impact of nursing education programs for improving healthcare delivery in LMICs. To be included, the article was required to be (1) related to nursing education programs in LMICs, (2) focus on the impact of nursing education programs to patients\u0026rsquo; outcome, healthcare delivery system, the effectiveness and efficiency of healthcare delivery, healthcare costs, nurses\u0026rsquo; experiences or patients\u0026rsquo; perspectives. Articles were excluded if they did not display the set inclusion criteria. Articles identified during the search, and considered to meet the inclusion criteria, based on their title and abstract, were then obtained in full text screening and were assessed in detail against the inclusion criteria by the two independent reviewers. The articles were then presented in PRISMA flow diagram (15). Identified studies from references lists of the included studies were carried out in the same way.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssessment of methodological quality\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach included article was assessed for methodological quality also by two independent reviewers. Quantitative studies were assessed by using the appropriate JBI critical appraisal tool for randomized controlled trials (RCTs), quasi-experimental studies, cohort or analytical cross-sectional studies, while qualitative studies were assessed using JBI critical appraisal for qualitative research regardless of their study design (16,17)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA sum of 50 articles underwent the methodological quality assessment using the JBI critical appraisal tools and 46 of the 50 articles met the predefined score for inclusion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach of the 50 studies was evaluated against predefined criteria. A minimum quality threshold of 50% was applied across appraisal tools to determine eligibility for inclusion. Studies that did not meet this threshold were excluded from the synthesis. Any disagreements between reviewers were resolved through discussion to ensure methodological rigor and consistency in the appraisal process. There are 3 quasi-experimental studies (18\u0026ndash;20)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(\u003cstrong\u003eTable 9\u003c/strong\u003e) and one cross sectional study (21)\u0026nbsp;(\u003cstrong\u003eTable 8\u003c/strong\u003e)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eexcluded for not meeting the set inclusion criteria.\u003c/p\u003e\n\u003cp\u003eAmong the 46 remaining studies, 38 were quasi-experimental studies (22\u0026ndash;59) (\u003cstrong\u003eTable 4)\u003c/strong\u003e, two RCT (60,61) (\u003cstrong\u003eTable 2)\u003c/strong\u003e, two cross sectional studies\u0026nbsp;(62,63) (\u003cstrong\u003eTable 3)\u003c/strong\u003e, 1 cohort (64) (\u003cstrong\u003eTable 1)\u003c/strong\u003e and 3 qualitative studies (65\u0026ndash;67) (\u003cstrong\u003eTable 5)\u003c/strong\u003e that met the set inclusion criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Assessment of methodological quality of cohort studies included\u003c/strong\u003e (68)\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1. Parvin-Nejad, et al. (2022)\u0026nbsp;(64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8/11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ1 \u0026ndash; Q11\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Were the two groups similar and recruited from the same population? 2) Were the exposures measured similarly to assign people to both exposed and unexposed groups? 3) Was the exposure measured in a valid and reliable way? 4) Were confounding factors identified? 5) Were strategies to deal with confounding factors stated? 6) Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? 7) Were the outcomes measured in a valid and reliable way? 8) Was the follow up time reported and sufficient to be long enough for outcomes to occur? 9) Was follow up complete, and if not, were the reasons to loss to follow up described and explored? 10) Were strategies to address incomplete follow up utilized? 11) Was appropriate statistical analysis used?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Assessment of methodological quality of randomized controlled trials included\u003c/strong\u003e (69)\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1. Wang, et al. (2017) (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2.Krishnamurthy Jayanna, K., et al. (2016) (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8/13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ1 \u0026ndash; Q13\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Was true randomization used for assignment of participants to treatment groups? 2) Was allocation to treatment groups concealed? 3) Were treatment groups similar at the baseline? 4) Were participants blind to treatment assignment? 5) Were those delivering the treatment blind to treatment assignment? 6) Were treatment groups treated identically other than the intervention of interest? 7) Were outcome assessors blind to treatment assignment? 8) Were outcomes measured in the same way for treatment groups? 9) Were outcomes measured in a reliable way 10) Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analysed? 11) Were participants analysed in the groups to which they were randomized? 12) Was appropriate statistical analysis used? 13) Was the trial design appropriate and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Assessment of methodological quality of analytical cross-sectional studies included\u003c/strong\u003e (68)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1. Weinberg Steven, et al. (2019)\u0026nbsp;(62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2. Ploutz, et al. (2016)\u0026nbsp;(63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ1 \u0026ndash; Q8\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Were the criteria for inclusion in the sample clearly defined? 2) Were the study subjects and the setting described in detail? 3) Was the exposure measured in a valid and reliable way? 4) Were objective, standard criteria used for measurement of the condition? 5) Were confounding factors identified? 6) Were strategies to deal with confounding factors stated? 7) Were the outcomes measured in a valid and reliable way? 8) Was appropriate statistical analysis used?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e: \u003cstrong\u003eAssessment of methodological quality of quasi-experimental studies included\u0026nbsp;\u003c/strong\u003e(70)\u003c/p\u003e\n\u003ctable style=\"float: left;width: 4.7e+2pt;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOjji, et al. (2023)\u0026nbsp;(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDinh, et al. (2022) (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGoyal, M., et al. (2019) (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcharya, et al. (2019) (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eStaveski, S. et al (2016) (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCharafeddine, et al. (2016) (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDe Silva, et al. (2015) (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLancaster, et al. \u0026nbsp;(2017) (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHassan, et al. (2017) (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBull, et al. (2017) (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLaVigne, et al. (2018) (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eShah \u0026nbsp;et al. (2020) (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRaney, et al. (2019) (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMwansisya, et al. (2022) (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGyamfi, et al. (2017)\u0026nbsp;(36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKirkpatrick, et al. (2018) (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNdikom, et al. (2019) (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDo Thi, N, et al. (2024) (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVail, B., et al. (2018) (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eStaveski, S. L., et al. (2015)\u0026nbsp;(41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKumar, R., et al. (2016) (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAgrawal, et al (2021) (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAgrawal, et al (2016) (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAhmed, et al (2023) (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eArlington, et al (2017) (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBang, et al (2016) (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCavicchiolo, et al (2018) (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eChao, et al (20160 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCreanga, et al (2020) (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDas, et al (2016) (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDas, et al (2017) (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDowning, et al (2016) (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eElnour, et al (2015) (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKamath-Rayne, et al (2017) (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKumar, et al (2015) (56) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSeto, et al (2015) (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eThukral, et al (2015) (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVail, et al (2017) (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\n \u003cv:shapetype id=\"_x0000_t202\" coordsize=\"21600,21600\" o:spt=\"202\" path=\"m,l,21600r21600,l21600,xe\"\u003e\u0026nbsp;\u003cv:stroke joinstyle=\"miter\"\u003e\u0026nbsp;\u003cv:path gradientshapeok=\"t\" o:connecttype=\"rect\"\u003e\u0026nbsp;\u003c/v:path\u003e\u0026nbsp;\u003c/v:stroke\u003e\u0026nbsp;\u003c/v:shapetype\u003e\n \u003cv:shape id=\"Text_x0020_Box_x0020_35\" o:spid=\"_x0000_s1027\" type=\"#_x0000_t202\" 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participants included in any comparisons measured in the same way? 7) Were outcomes measured in a reliable way? 8) Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? 9) Was appropriate statistical analysis used?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Assessment of methodological quality of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003equalitative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;studies included\u0026nbsp;\u003c/strong\u003e(17)\u003c/p\u003e\n\u003ctable style=\"float: left;width: 4.5e+2pt;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003escore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRao, et al. (2022) (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAyub, et al. (2024) (66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBassah, et al. (2016)\u0026nbsp;(67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\n \u003cv:shape id=\"Text_x0020_Box_x0020_36\" o:spid=\"_x0000_s1026\" type=\"#_x0000_t202\" 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fillcolor=\"white [3201]\" strokecolor=\"white [3212]\" strokeweight=\".5pt\"\u003e\u0026nbsp;\u003cv:textbox\u003e\u0026nbsp;\u003c/v:textbox\u003e\u0026nbsp;\u003c/v:shape\u003e\n\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eQ1 \u0026ndash; Q10\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1) Is there congruity between the stated philosophical perspective and the research methodology? 2) Is there congruity between the research methodology and the research question or objectives? 3) Is there congruity between the research methodology and the methods used to collect data? 4) Is there congruity between the research methodology and the representation and analysis of data? 5) Is there congruity between the research methodology and the interpretation of results? 6) Is there a statement locating the researcher culturally or theoretically? 7) Is the influence of the researcher on the research, and vice- versa, addressed? 8) Are participants, and their voices, adequately represented? 9) Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? 10) Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eData extraction\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative and qualitative data were extracted from studies included in the review by three independent reviewers by using a predesigned tool developed within Microsoft Excel to facilitate the extraction and organization of data from the included articles. The following study characteristics were extracted from each included paper (\u003cem\u003eSupport document of the data extraction form\u003c/em\u003e); Title, publication year, type of research paper, aim of the study, site of the study, the methods, participants, sample size, nursing education programs for improving healthcare delivery, participant satisfaction or reaction (level 1), gained knowledge, improved skills, or changed attitudes (level 2), participants behavior towards their learning (level 3), and the impact on healthcare outcomes (level 4). To capture data on the impact of education programs for improving healthcare delivery in LMICs, the framework for evaluation of nursing educational programs (71) was adapted based on the four levels of the Kirkpatrick Model (1967) (72) (\u003cstrong\u003eTable 6\u003c/strong\u003e). Kirkpatrick\u0026rsquo;s evaluation model measures participants reactions to training (level 1); what they have learnt (level 2); whether what they learnt have been applied in practice (level 3); and whether the application of training is achieving results (level 4) (12). This extraction tool was amended based on what we proposed in the protocol. It was piloted by the reviewers on the first five included studies to ensure consistency and reliability between the reviewers and was used to extract both quantitative and qualitative data. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e: Framework for evaluation of nursing educational programs [Adapted from (71)]\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 1a\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLearner perceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eParticipants\u0026rsquo; views on their learning experience and satisfaction with the training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 1b\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients\u0026rsquo; perceptions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients view on their involvement experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 1c\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTrainers\u0026rsquo; perceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTrainers\u0026rsquo; views on involving patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 2a\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModification in attitudes and perceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eA measured change in attitudes or perceptions towards\u0026nbsp;patients, their problems, needs, circumstances or care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 2b\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAcquisition of knowledge and skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eA measured change in understanding the concepts, procedures and principles of working with patients, and the acquisition of thinking/ problem solving, assessment and intervention skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 3a\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChanges in behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObservation of whether the newly acquired knowledge, skills and attitudes are evident in the practice of healthcare providers (Nurses and midwives)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 3b\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChanges in organizational practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eObservation of wider changes in the organization/ delivery of care, attributable to patients\u0026rsquo; involvement in an educational program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBenefits to patients and/ or their families\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAssessment as to whether there is a tangible difference to the well-being and quality-of-life of patients and/or their families who receive healthcare services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData transformation\u003c/em\u003e\u003c/strong\u003e (Qualitizing)\u003c/p\u003e\n\u003cp\u003eTo facilitate a seamless integration of diverse data types, this review employed a qualitizing process for all quantitative findings, including the quantitative strands of mixed-methods studies. Qualitizing involved transforming numerical results, statistical significances, and effect sizes into textual descriptions that captured the essence and direction of the findings (73). Qualitized data points were then treated as qualitative evidence, allowing them to be categorized alongside primary qualitative data into themes and sub-themes under each level of the Kirkpatrick\u0026rsquo;s model. This transformation ensured that the quantitative results could be narratively synthesized to directly address the review\u0026rsquo;s overarching questions regarding the impact of nursing education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData synthesis and integration\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the JBI methodology for mixed-methods systematic reviews (13,74), we adopted a convergent integrated approach. A convergent\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eintegrated approach is a method of data synthesis in which qualitative and quantitative data are analyzed separately and then integrated during the interpretation or synthesis stage to generate a single, comprehensive set of findings (75). This method achieves data integration by comparing, transforming, of results from different sources so that evidence converges to provide a joint understanding of the phenomenon under investigation (74). \u0026nbsp;Data synthesis followed a multi-stage thematic process integrated within the Kirkpatrick Four-level evaluation framework. Initially, the qualitized quantitative data and the primary qualitative findings were subjected to line-by-line coding to identify recurrent concepts and patterns.\u003c/p\u003e\n\u003cp\u003eThe codes were systematically aggregated into themes, representing the broad, high-level patterns of evidence answering what outcomes occurred at each level. To provide an analytical layer, subthemes were developed to capture the specific mechanisms, nuances, and how or why factors like barriers to implementation or psychological drivers were applied to the primary themes. Finally, under each Kirkpatrick level, these themes and sub-themes were pooled based on conceptual similarity to produce a set of integrated findings. The findings were formulated into line of action statements designed to provide evidence-based recommendations for investing in nursing education programs to optimize healthcare delivery in LMICs.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure 1 below illustrates the study process by using the PRISMA flow chart. A total of 630 articles (n=630) were initially identified. After removing 91 duplicate articles, 539 articles (n=539) remained. The first screening of the identified articles based on their titles and abstracts yielded 57 articles of which one was not retrieved, 29 excluded during the full text screening either for not meeting the inclusion criteria and 27 remained. 34 articles have been identified in the reference list and only 23 met the inclusion criteria. A sum of 50 articles underwent methodological quality assessment using the JBI critical appraisal tools and 46 met the defined score for inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u0026nbsp;\u003c/strong\u003ePRISMA flow diagram for the study selection process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7.\u0026nbsp;\u003c/strong\u003eCharacteristics of articles included in the review (n = 46).\u003c/p\u003e\n\u003ctable\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n=46)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"20\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVietnam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMozambique\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePakistan\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNigeria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLibanon\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSrilank\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eJordan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBotswana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTanzania\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSierra Leone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTaiwan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSudan\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHonduras\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEthiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCameroon\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKenya and India\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMidwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNurses and Midwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther healthcare providers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePhysicians \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSanitation workers \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical officers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePhysicians +Sanitation workers \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMajority of the articles included in this review (80.4%) were quantitative studies. Among them, 89.2% used quasi-experimental methods (22\u0026ndash;30,32,35,37,38,40\u0026ndash;52,54\u0026ndash;59,64), 5.4% used RCT (60,61) and 5.4% used cross-sectional method (62,63). 13.0% used mixed methods (31,33,34,36,39,53), while Only 6.6% used qualitative methods (65\u0026ndash;67). Findings were distributed within the 3 continents with most studies conducted in Asia (58.7%) (23\u0026ndash;30,34,37,39\u0026ndash;45,49\u0026ndash;52,56,59\u0026ndash;61,65,66), 32.6% from Africa (22,31\u0026ndash;33,35,36,38,46,48,53,54,62\u0026ndash;64,67), 4.3% from central America (55,57) \u0026nbsp;and other 4.3% conducted in countries located in two continents, Africa and Asia (47,58). Most participants (78.2%) were nurses, with 34.8% studies used multidisciplinary approach within 81.1% were physicians (\u003cstrong\u003eTable 7\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this review the interventions were designed to deliver a range of nursing education programs. We clustered them into two main groups: The first was courses, including pediatric acute surgical support (PASS) course\u0026nbsp;(23), patient safety course (66), palliative care course (67), and stop the bleed (STB) course (64). The second, which constituted a varied type of educational interventions include mobile nurse training program (50\u0026ndash;52), palliative care training program (32,65,67), safety training (31,45), simulation program (34,40,59), education program (25,29,30), neonatal resuscitation program (27,48,59), helping babies breathe training program (46,47,55,57), training program (22,24,28,33,35\u0026ndash;37,39,49,60,62,63), discharge education program (26,41), pre-service education (43), virtual classroom training (44), waste management training (42,54,56), link-nurse program (53), Essential Care for Every Baby (ECEB) educational program (58), Educational package (38), and mentoring program (61).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinding synthesis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings were reposted based on the Kirkpatrick Model that is mostly used to evaluate the training effectiveness (12). The model encompasses four elements that are commonly used to categorize the findings for the purpose of capturing the impact of the nursing education programs at different levels as shown in figure 2 below.\u003cv:shape id=\"Picture_x0020_1\" o:spid=\"_x0000_i1025\" type=\"#_x0000_t75\"\u003e\n \u003cv:imagedata src=\"file:///C%3A/Users/adr8178/AppData/Local/Temp/msohtmlclip1/01/clip_image004.emz\" o:title=\"\"\u003e\u0026nbsp;\u003c/v:imagedata\u003e\n \u003c/v:shape\u003e\n\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2:\u0026nbsp;\u003c/strong\u003eAn integrative thematic framework for evaluating nursing education in LMICs\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegend\u003c/em\u003e: \u003cem\u003eThis figure presents a thematic synthesis of the impact of nursing education programs on healthcare delivery. Themes and subthemes are systematically mapped across the four levels of Kirkpatrick\u0026rsquo;s Evaluation Model\u0026mdash;Reaction, Learning, Behavior, and Results\u0026mdash;illustrating the pathway from pedagogical satisfaction to systemic clinical improvement.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u0026rsquo; reactions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first level (on the right) identified four themes that captured the participants\u0026rsquo; initial responses to the nursing education programs. These findings explored the nurses\u0026rsquo; satisfaction with the training delivery and the perceived relevance of the curriculum to their specific clinical contexts in LMICs. By analyzing these reactions, this level provided critical insight into the acceptability and engagement levels required for the successful implementation of educational interventions in resource-constrained settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Pedagogical satisfaction and cultural acceptability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was the first identified theme within participant reactions that presented as a predominant trend of high pedagogical satisfaction and cultural acceptability across the majority of the evaluated programs (22,23,27,28,31,33,36,39,41,46,53,56\u0026ndash;58,60,66). Evidence clusters indicate that nursing professionals reported significant levels of satisfaction derived from the effectiveness of the training modalities (22) and the implementation of novel methodologies (21,31) that were deemed both engaging and contextually appropriate. A critical element of this positive reception was the cultural acceptability of the interventions (28), which contributed to an overall positive subjective experience for the learners (46). However, the synthesis also revealed a noteworthy counter-point; in specific instances, participants expressed dissatisfaction with certain program content (60), highlighting the necessity for curriculum alignment with local clinical realities.\u003c/p\u003e\n\u003cp\u003eThis satisfaction was deeply influenced by the participants\u0026rsquo; valuation of active, hands-on, and patient-centered pedagogy (Sub-theme 1) (22,23,45,46,53). The evidence suggests a strong appreciation of interactive approaches (45) and active learning strategies (22) over traditional passive instruction. In particular, the positive reception of simulation and hands-on methods \u0026nbsp;(23,46) was a recurring factor in high satisfaction scores. Furthermore, the pedagogical value was enhanced by the recognition of the patient\u0026rsquo;s voice and perspective (53), which shifted the training focus toward person-centered care. Finally, satisfaction was sustained beyond the initial training through engagement with follow-up support (46), which learners identified as a vital component for reinforcing their initial positive experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Perceived utility, relevance, and clinical feasibility\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was the second major identified theme of the educational interventions (18\u0026ndash;23,31,41,45,53,56,57,60,64,66,67). Participants consistently reported that the programs were characterized by a high degree of clarity and practical usefulness (22,23,31,60), with several studies emphasizing the feasibility of implementing the learned content within resource-constrained settings (41,57,66).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis sense of utility was deeply rooted in the perceived clinical relevance and professional mastery (Sub-theme 2) fostered by training (22,23,45,46,57,60,67). Learners specifically valued the programs as a means for knowledge refreshment (60) and the enhancement of existing clinical competencies (22). This relevance was further reinforced through recognition of core safety concepts (45) and a measurable improvement in practical skills and the utility of clinical equipment (46,57). Notably, the training served a diagnostic purpose for the participants themselves, allowing them to identify specific practice deficiencies (67) that had previously gone unrecognized, thereby aligning the educational content with their immediate professional needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Enhanced professional confidence and readiness to change\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeyond the acquisition of clinical knowledge, the synthesis revealed a significant shift in the participants\u0026rsquo; psychological approach to care, characterized by enhanced professional confidence and a readiness to change clinical practice (46,58,62,64,66). Multiple studies reported that nursing staff experienced an immediate increase in self-reported confidence following the educational interventions (46), and that was found to be sustained over time in several longitudinal assessments (58,62,64). This burgeoning confidence was directly linked to an increased readiness to abandon outdated habits and adopt new clinical behaviors (62,66).\u003c/p\u003e\n\u003cp\u003eThis transition was underpinned by a deeper sense of affective empowerment and professional self-efficacy (Sub-theme 3) (22,23,27,31,62). Participants frequently exhibited a positive emotional response to the program design (22,23,27,66), which fostered a belief in their own capability to influence healthcare outcomes. This sense of empowerment was particularly evident in their perceived ability to protect patient safety (66) and their high expectations of the future impact their training would have on patient care (23). Consequently, the education programs acted as more than a technical update; they served as a catalyst for professional self-actualization, where improved self-efficacy (62) became the primary driver for implementing change in resource-limited environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Commitment to sustained engagement and holistic care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe theme centered on a long-term commitment to sustained engagement and the adoption of holistic care models (39,53,60). Rather than viewing education as a one-time event, participants expressed a desire for ongoing involvement with the training material (60). This was particularly evident in programs focused on complex care, where training led to a significant shift in how nurses engaged with patients, moving toward a more holistic care approach that addressed multiple patient needs simultaneously (53).\u003c/p\u003e\n\u003cp\u003eThe commitment was closely linked to a vocal demand for sustainability, advocacy, and programmatic refinement (Sub-theme 4) (39,60,66). Participants did not merely accept the training as provided; they actively advocated for recurrent and continued education that remains contextually relevant to the specific challenges within the LMICs (39,60). This sense of advocacy was paired with a strong intent-to-practice and a willingness to adopt new clinical tools into their daily routines (60). However, learners also provided critical feedback, noting a need for formal curriculum integration (66), and identifying areas for content enhancement to prevent post-intervention declines in knowledge or interest (60). These reactions suggest that for nursing education to be successful in the long term, it must evolve based on the participants\u0026rsquo; calls for systemic integration and periodic reinforcement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning (Knowledge and Skill Acquisition)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this level, the review identified four themes that delineate the acquisition of both cognitive knowledge and practical clinical skills. \u0026nbsp; Through the synthesis of the included studies, four themes emerged that capture the breadth of learning achieved, ranging from the mastery of specialized clinical procedures to the development of critical thinking and decision-making capabilities within resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Initial acquisition and longitudinal retention of cognitive knowledge\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA fundamental outcome of the nursing education programs was the initial acquisition and longitudinal retention of cognitive knowledge (22\u0026ndash;30,32,33,36\u0026ndash;39,41\u0026ndash;45,47,49,50,53,54,56\u0026ndash;60,62,66). The evidence demonstrate an overwhelming trend of improved knowledge acquisition across diverse clinical topics (23\u0026ndash;30,32,33,36,38,39,41,45,50,60,66). While most programs reported initial improvements in essential knowledge (54,56\u0026ndash;58,62), others specifically highlighted the sustained improvement in task-strengthening knowledge (22) and high-level retention months after the intervention (42,47,49).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis cognitive progress was characterized by universal vs. differential cognitive mastery (Sub-theme 1) (22\u0026ndash;25,27,30,32,35,38,39,42,45,47,50,54,60,66,67).\u0026nbsp;The findings indicate immediate and multi-domain acquisition, with significant knowledge gains occurring across various health disciplines and training modules simultaneously (22\u0026ndash;24,30,32,33,38,39,50,54,60,66). However, the evidence also revealed cross-professional variability, noting distinct differences in baseline attitudes and the rate of knowledge gain between different healthcare professions (27,42,45,47). Despite these variations, the overall results pointed to robust sustainability, with high-level knowledge retention and sustained cognitive gains observed at follow-up assessments when compared to control groups (25,35,38,39,42,47,54), underscoring the long-term effectiveness of the training programs in LMIC contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Mastery and retention of technical and clinical competencies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to cognitive gains, the synthesis identified a robust trend toward the mastery and retention of technical and clinical competencies (22,23,28,31,33\u0026ndash;37,40,42\u0026ndash;44,46\u0026ndash;54,56,57,59,61,62,66). The educational interventions significantly enhanced clinical and team performance, specifically strengthening task-specific nursing behaviors (22,23,31,36,46,50\u0026ndash;54,56,57,61,62,66). A significant portion of the evidence focused on assessment and diagnostic proficiency (28,33,34,37,49), particularly in the mastery of emergency and high-stakes skills such as resuscitation and trauma care (40,47,48,51,59,61). Furthermore, nursing staff demonstrated high levels of competence in essential routine care; including maternal, newborn, and reproductive health (MNH/RMNH) (35,43,44,50\u0026ndash;53) reflecting a broad practical application of skills across diverse clinical settings (31,33,34,42,51\u0026ndash;54,56,62).\u003c/p\u003e\n\u003cp\u003eThis mastery was further defined by increased technical proficiency, efficiency, and procedural accuracy (Sub-theme 2) (23,27,31,34,36,36,37,40,43,44,47,48,51,52,59\u0026ndash;61). \u0026nbsp;Participants showed specialized expertise in high-stakes and emergency mastery, specifically regarding neonatal resuscitation (NR), sepsis management, and trauma response (23,27,36,40,44,47,48,51,52,59\u0026ndash;61). Notably, the training resulted in increased efficiency in time-critical tasks and overall operational efficiency (34,59), ensuring that life-saving procedures were performed with greater clinical precision (31,36,37). Beyond manual dexterity, the programs fostered procedural compliance, characterized by near-universal documentation accuracy and strict adherence to clinical protocols (34,43,51), which are essential for quality assurance in resource-limited healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Transformation of professional attitudes and system awareness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeyond technical acquisition, the education programs facilitated a significant transformation of professional attitudes and system awareness (29,31,38,42,49,53,56,60,66). The synthesis found a demonstrable shift in professional outlooks (60), with particularly marked improvements in attitudes toward sensitive clinical areas, such as End-of-Life Care (EOLC) (29,38). Furthermore, the interventions fostered systems thinking, heightening nurses\u0026rsquo; awareness of their role within the broader organizational structure (66). While overall improvements in nursing attitudes were widely reported (31,38,53,56,66), the evidence also offered nuanced findings regarding sustainability; specifically, some studies noted lack of sustained change in core communication competencies (49) or professional attitudes (42) over time. This suggests that while initial attitudinal shifts are strong, longitudinal reinforcement is necessary to permanently alter professional culture.\u003c/p\u003e\n\u003cp\u003eThis evolution in mindset was further characterized by a growing sense of professional agency, role expansion, and pedagogical competence (Sub-theme 3) (22,23,33,36,39,53,66). The programs empowered nurses to assume pedagogical and peer leadership roles (22,67), effectively turning learners into educators within their clinical units. This was accompanied by a notable increase in clinical autonomy (36,39) and a deepened sense of professional responsibility toward patient safety and outcomes (23,53,66). The learning process also triggered significant affective and interpersonal growth\u0026nbsp;(53,60,66),\u0026nbsp;leading to role expansions where nurses took on advanced clinical responsibilities\u0026nbsp;(53). Consequently, the training did not merely update skills; it redefined the nurse\u0026rsquo;s professional identity, equipping them with the agency to lead and the interpersonal maturity to manage complex care dynamics in LMIC settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Enhancement of professional self-efficacy and clinical confidence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA significant outcome of the educational programs was the enhancement of professional self-efficacy and clinical confidence among participants (28,31,33,35,36,39,45,53,58,62,64).\u0026nbsp;The synthesis found a significant increase in self-reported clinical confidence across a wide array of nursing specialties (28,33,35,53,58,62,64), even in instances where baseline confidence was already high (31). This acquisition of high self-efficacy (33,36,39,53) was closely tied to the participants\u0026rsquo; increased self-assessed knowledge and skills (45), suggesting that the learning process provided nurses with the psychological assurance necessary to perceive themselves as competent clinicians within their healthcare systems.\u003c/p\u003e\n\u003cp\u003eHowever, the durability of these gains revealed a complex reality described as the sustainability paradox: durability versus rapid decay (Sub-theme 4) (22,25,26,28,35,39,40,42,46\u0026ndash;48,54,59). On one hand, several studies provided the good news of long-term durability, showing that cognitive and skill improvements could be sustained well beyond the initial training period (22,25,35,39,42,47,48,54). On the other hand, a significant body of evidence warned about rapid regression and decay (26,40,46,59), where gains in high-stakes skills tended to diminish without constant reinforcement. This decay was often exacerbated by complexity barriers (28,37), where more intricate clinical tasks proved harder to retain than routine ones. To address this, the evidence highlighted strategic solutions for sustainability, such as the use of booster sessions and simulation-based refreshers (47,48), which were identified as essential for transforming fleeting learning gains into permanent professional mastery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBehavior change (Transfer of learning to practice)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings from the third level focused on the practical implementation of education in the clinical environment. Through the synthesis of existing research, five themes emerged that illustrate how nursing education programs in LMICs influence professional conduct. These themes describe the changes in daily care routines, the adoption of new clinical procedures, and the nursing behaviors that directly impact healthcare delivery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Successful\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003etransfer of skills and immediate improvement in clinical behavior\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most prominent finding at this level was the successful transfer of skills and a rapid improvement in clinical behavior following the educational interventions (25,31,36,39,48,53,57,58,60,63,64,67). Participants demonstrated a tangible change in practice (60,67)\u0026nbsp;and an immediate clinical improvement in care delivery\u0026nbsp;(25). The shift was not only qualitative but also operational, characterized by a measurable change in clinical practice speed and procedural efficiency\u0026nbsp;(36,48). Evidence clusters further indicate an improved independent screening capacity\u0026nbsp;(63)\u0026nbsp;and a consistent uptake of new clinical behaviors\u0026nbsp;(31,36,39,53,67), suggesting that the training was sufficiently practical to be applied directly within the workflow\u0026nbsp;of LMIC healthcare settings.\u003c/p\u003e\n\u003cp\u003eThis behavioral shift was underpinned by enhanced clinical proficiency and high-fidelity skill application (Sub-theme 1) (37,39,40,50\u0026ndash;53,55,58,63,64,67). Learners demonstrated high sensitivity for detecting significant pathology (37) and an increased application of high-stakes skills, such as neonatal resuscitation (NR) and essential newborn care (ENC) (40,55). Specifically, training led to higher odds of performing core newborn practices, including skin-to-skin contact and eye care (51,52), as well as a sustained improvement in labor practice (52). The proficiency extended to specialized domains, such as the successful uptake of generalist palliative care (53) and the effective detection of rheumatic heart disease (RHD) (63). Crucially, this high-fidelity application was fueled by the participants\u0026rsquo; belief in their own efficacy to improve patient outcomes (39), ensuring that the uptake of clinical skills was both accurate and aligned with the identified needs of the patient population (67).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Enhanced adherence to specialized clinical protocols and safety standards\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was the second major behavioral theme (26,31,36,37,40,53,55,61,63). Educational interventions led to a significant increase in documentation compliance (26)\u0026nbsp;and the adoption of evidence-based assessment tools\u0026nbsp;(36). This adherence was particularly noted in high-stakes environments, where participants demonstrated high fidelity to clinical protocols, such as the Parasternal Long-Axis (PLAX) view in Focused Cardiac Ultrasound (FCU)\u0026nbsp;(37), neonatal resuscitation practices\u0026nbsp;(40,55), and medication safety standards\u0026nbsp;(66). The synthesis suggests that training programs successfully standardized nursing behavior, leading to more consistent palliative care delivery\u0026nbsp;(53)\u0026nbsp;and the reliable use of independent screening protocols\u0026nbsp;(61,63)\u0026nbsp;across varied clinical settings.\u003c/p\u003e\n\u003cp\u003eThis standardization was driven by the systematic integration of assessment, triage, and referral protocols (Sub-theme 2)\u0026nbsp;(36,53,60,61,63,67). Rather\u0026nbsp;than being performed in isolation, clinical tasks became part of a larger organizational workflow. This was evidenced by the routinization of cognitive screening (60) and a more routine approach to risk assessment (36). Education also significantly improved triaging and referral behavior (53), with several studies noting that trained nurses were able to influence hospital-wide referral systems (61) and demonstrate high proficiency in specialist referrals (36). By accurately identifying both patient and organizational needs through enhanced screening (36,67) and effectively utilizing skills for specialized screenings like Rheumatic Heart Disease (RHD) (63), nurses acted as critical gatekeepers, ensuring more efficient and safer pathways through the healthcare system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Sustained longitudinal change in nursing practice and institutional capacity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA critical finding within the behavioral domain was the evidence of sustained longitudinal change in nursing practice and institutional capacity (42,43,50\u0026ndash;52,61). Unlike interventions that show only short-term spikes in performance, these programs resulted in sustained behavioral compliance with new clinical standards (42). This was particularly evident in maternal and neonatal health, where there were higher odds of long-term practice retention for intrapartum and newborn care (50\u0026ndash;52). Furthermore, the behavioral shift among nurses translated into improved institutional capacity and facility readiness, as trained staff were better equipped to manage complex patient care pathways and improve overall system performance (43,61).\u003c/p\u003e\n\u003cp\u003eThis systemic improvement was deeply integrated with the evolution of patient-centered communication and proactive care (Sub-theme 3) (31,36,51,53,60,67). The synthesis found that nurses moved beyond task-oriented care to embrace proactive care approaches and relationship-centered care, which significantly contributed to trust building within the community (53). Significant improvements were noted in interpersonal communication (67) and patient advising (60), including more effective guidance to mothers regarding newborn health (51). Moreover, nurses demonstrated skillful counseling on lifestyle and treatment adherence (36) and engaged in peer advocacy (66). By shifting toward this proactive and communicative model, the nursing workforce not only improved the clinical accuracy of care but also the interpersonal quality and human-centeredness of the healthcare delivery system in LMICs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Peer-to-peer knowledge diffusion and professional attitudinal shifts\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe synthesis highlighted that behavior change often extended beyond the direct participants of the training through peer-to-peer knowledge diffusion and professional attitudinal shifts (43,53). Trained nurses acted as agents of change, with evidence showing that new knowledge was frequently shared with colleagues who had not attended the formal sessions (53). This informal diffusion of skills (53) served to normalize advanced clinical behaviors across the workforce. Furthermore, this collaborative environment fostered a collective change in professional attitudes (53), where the culture of the clinical unit began to align with the new standards of practice introduced by the education program (43). Supporting this cultural shift were measurable gains in operational efficiency and institutional quality standards (Sub-theme 4) (26,42,43,48,50,61). The behavioral changes were often driven by the direct task relevance of the training, which made adoption intuitive for the nursing staff (42). These changes led to significant improvements in administrative and clinical rigor, such as sustained practice change in documentation (26,61) and the achievement of institutional quality benchmarks (43). Operationally, the impact was seen in successful anticipation of clinical needs, leading to earlier start times and a reduced duration of procedures (48). High compliance with intrapartum practices (50) further underscored that improved facility readiness was a direct result of nurses successfully integrating their newfound technical skills into the institutional workflow (61).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 5: Persistent gaps, implementation barriers, and psychological friction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the documented successes in behavior change, the synthesis identified significant persistent gaps, implementation barriers, and psychological friction that hindered full practice transformation (48,60,66,67). The evidence clusters highlighted inter-organizational barriers (60) and practice change gaps characterized by significant delays in the initiation of new protocols (48). Furthermore, even when knowledge was present, implementation barriers often prevented its application (66). On a psychological level, some participants reported low self-efficacy or persistent discomfort when attempting to perform newly learned tasks in a high-pressure clinical environment (67), suggesting that technical training alone may not be sufficient to overcome deeply rooted professional anxieties.\u003c/p\u003e\n\u003cp\u003eThese challenges were further articulated as persistent behavioral gaps and structural implementation barriers (Sub-theme 5) (25,42,60,66,67). Structurally, the most significant impediment to behavior change was time constraints due to severe staffing shortages (66), which forced nurses to prioritize basic survival tasks over advanced clinical protocols. Behaviorally, some studies noted lack of change in specialist referral tendencies (60) and a failure to sustain practice change over the long term (25). Interestingly, one study noted a persistent behavioral gap in physician compliance (42), suggesting that nursing behavior change can be stifled if the broader multidisciplinary team does not support the new standards. Finally, despite training, deficits in therapeutic communication regarding sensitive topics, such as palliative care or terminal diagnoses remained a persistent challenge (67), indicating that behavioral shifts in affective and interpersonal domains may require more intensive, long-term mentorship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: Impact on healthcare delivery and patient outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe highest level of the Kirkpatrick model assesses the organizational and clinical impact of educational interventions. The synthesis identified three primary themes reflecting how nursing education translates into measurable improvements in patient health and healthcare delivery systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Significant improvement in patient clinical outcomes (Morbidity and mortality)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most critical evidence of the effectiveness of nursing education programs was the significant improvement in patient clinical outcomes, specifically regarding morbidity and mortality rates (25\u0026ndash;27,37,48,49). Educational interventions led to an immediate decrease in Central Line-Associated Bloodstream Infection (CLABSI) rates (25) and a major reduction in patient morbidity related to surgical site infections (SSIs) (26,27). Most notably in maternal and newborn care, programs contributed to a decreased neonatal mortality rate (48). Beyond physical health, education in specialized nursing care also yielded psychological benefits, including decreased patient memory and behavioral problems, as well as reduced depressive symptoms (49). These clinical improvements were largely facilitated by the enhancement of diagnostic accuracy and clinical service access (Sub-theme 1) (37). The synthesis found that specialized training (such as Point-of-Care Ultrasound) enhanced the diagnostic value of nursing assessments (37). When nurses utilized a combined strategy of clinical skills and advanced diagnostic tools, the system achieved high overall diagnostic accuracy, which directly improved the effectiveness of service delivery (37). Consequently, the education programs served as a vital bridge to improved access to healthcare and more efficient triage (37), ensuring that patients were correctly identified and treated earlier in their clinical course.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Enhanced effectiveness and efficiency of healthcare service delivery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeyond direct clinical outcomes, the synthesis demonstrated that nursing education programs resulted in enhanced effectiveness and efficiency of healthcare service delivery (25,27,37,49,53). A significant finding was that efficiency was maintained even as patient outcomes improved, suggesting that better-trained nurses do not necessarily require more time, but rather use their time more effectively (25). The evidence indicates a broad improvement in the effectiveness of healthcare delivery across various specialties (27,49), particularly through the implementation of optimal screening strategies (37). Furthermore, the evolution of nursing roles through education led to enhanced access to specialized services (53), allowing facilities to provide higher-tier care that was previously unavailable to the patient population.\u003c/p\u003e\n\u003cp\u003eThis operational success was underpinned by the strengthening of workforce capacity and resource optimization (Sub-theme 2) (65). Education acted as a catalyst for enhanced structural and workforce capacity, transforming the nursing staff into a more resilient and versatile resource (65). By improving the skill set of the existing workforce, healthcare facilities were able to achieve optimized resource and service availability (65). This indicates that nursing education is a high-value investment for LMICs, as it maximizes the utility of limited human and material resources, ensuring that the health system can deliver a higher volume and quality of care without a proportional increase in infrastructure costs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Strengthening of institutional capacity and systemic sustainability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe final dimension of the Level 4 analysis identifies the strengthening of institutional capacity and systemic sustainability as a direct result of nursing education (53,65). The evidence suggests that when nurses are empowered through training, there is a measurable shift in organizational capacity and system-level performance(65). This goes beyond individual competence to the institutionalization of practices (53), where new clinical behaviors become the established standard for the entire facility. This systemic strengthening ensures that the benefits of the intervention are not lost when individual staff members rotate or leave, but are instead embedded into the operational framework of the institution.\u003c/p\u003e\n\u003cp\u003eThis long-term impact is driven by systemic institutionalization, referral integration, and organizational ownership (Sub-theme 3) (53,65). A key marker of success was the institutionalization of palliative care processes (65), showing that complex care models can be successfully integrated into LMIC hospitals. Furthermore, these programs facilitated the integration of nurses into formal referral pathways (53), positioning them as central figures in the continuum of care. Crucially, the evidence highlights the emergence of internal advocacy and organizational ownership (53), where the healthcare facilities themselves take responsibility for maintaining and defending the new standards of care. By fostering this sense of ownership, nursing education serves as a cornerstone for building resilient, self-sustaining healthcare systems that are less dependent on external interventions and more capable of internal quality improvement.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 8:\u0026nbsp;\u003c/strong\u003eAssessment of methodological quality of for analytical cross-sectional studies excluded\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(68)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 241px;\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 241px;\"\u003e\n \u003cp\u003e1. Chan, et al. (2019)\u0026nbsp;(21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1) Were the criteria for inclusion in the sample clearly defined? 2) Were the study subjects and the setting described in detail? 3) Was the exposure measured in a valid and reliable way? 4) Were objective, standard criteria used for measurement of the condition? 5) Were confounding factors identified? 6) Were strategies to deal with confounding factors stated? 7) Were the outcomes measured in a valid and reliable way? 8) Was appropriate statistical analysis used?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 9: Assessment of methodological quality of quasi-experimental studies excluded\u0026nbsp;\u003c/strong\u003e(70)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eReferences\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eKistner, et al. (2024) (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e2/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eShahrakivahed, et al (2015)\u0026nbsp;(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e4/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eStolz, et al (2015)\u0026nbsp;(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e4/9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eY=YES, N=No, U= unclear, NA= Not applicable\u003c/p\u003e\n\u003cp\u003e1) Is it clear in the study what is the \u0026ldquo;cause\u0026rdquo; and what is the \u0026ldquo;effect\u0026rdquo; (i.e. there is no confusion about which variable comes first)? 2) Was there a control group? 3) Were participants included in any comparisons similar? 4) Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? 5) Were there multiple measurements of the outcome, both pre and post the intervention/exposure? 6) Were the outcomes of participants included in any comparisons measured in the same way? 7) Were outcomes measured in a reliable way? 8) Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? 9) Was appropriate statistical analysis\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This systematic review synthesized evidence from 46 peer-reviewed studies to examine the impact of nursing education programs on healthcare delivery and patient outcomes in LMICs. Our findings indicate that when education is culturally contextualized and pedagogically relevant, it acts as a primary catalyst for professional empowerment and systemic clinical improvement. By mapping these findings to an integrative thematic framework (Fig.\u0026nbsp;2), this discussion explores how individual learning transitions into institutional capacity, while also addressing the systemic translation gaps that often hinder long-term sustainability in resource-constrained settings.\u003c/p\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eThe integrative pathway: From pedagogical engagement to systemic change\u003c/h2\u003e \u003cp\u003eThe centerpiece of this review is the integrative thematic framework (Fig.\u0026nbsp;2), which illustrates that nursing education in LMICs does not function in isolation but acts as a catalyst for a multi-level ripple effect. While traditional evaluations often treat Kirkpatrick\u0026rsquo;s levels as independent silos (76\u0026ndash;78), our framework demonstrates a progressive and reinforcing pathway. We argue that pedagogical satisfaction (Level 1: Reaction) is not an end in itself, but the generator of the emotional buy-in required for competency acquisition (Level 2: Learning). This mastery, in turn, fosters the professional confidence necessary to exercise clinical autonomy in challenging environments (Level 3: Behavior), ultimately culminating in enhanced patient safety and systemic resilience (Level 4: Results). Consequently, we suggest that Kirkpatrick\u0026rsquo;s levels should be viewed not merely as a descriptive taxonomy, but as a causal mechanism that reflects the sequential transformation required to bridge the gap between education and clinical impact.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBridging the cultural gap: Contextualizing reaction and learning (Level 1\u0026 2)\u003c/h3\u003e\n\u003cp\u003eWhile our findings indicate a high degree of participant satisfaction and knowledge gain across diverse LMIC settings, the thematic synthesis suggests that in resource-limited contexts, reaction is heavily mediated by the perceived relevance of the curriculum to local clinical challenges. This aligns with broader theoretical frameworks, such as those proposed by Phillips as cited in (77), which identify relevance of training as one of the core dimensions of participant reaction. Our results further specify this dimension for LMICs, demonstrating that when resources are scarce, the utility of content in solving immediate, real-world clinical obstacles becomes the primary determinant of educational buy-in. This engagement serves as a prerequisite for Level 2 (Learning) mastery. Specifically, the superior outcomes observed in programs utilizing culturally adapted materials and simulation-based learning suggest that effectiveness in LMICs is predicated on the contextualization of pedagogy. By providing a safe-to-fail environment that mirrors local clinical realities, these methods provide empirical support for the shift away from homogenizing universalist models inherited from colonial structures (79). When nursing education prioritizes local epidemiological needs and sociocultural realities over Western-centric standards, it creates a more equitable and transformative learning environment. As argued by Ramli et al. (2025), integrating local knowledge systems is a strategic imperative in the Global South; our synthesis confirms that such integration acts as the primary driver of competency acquisition and knowledge retention among nurses in resource-limited settings.\u003c/p\u003e\n\u003ch3\u003eEmpowerment as a catalyst for clinical autonomy (Level 3)\u003c/h3\u003e\n\u003cp\u003eThe most significant finding at Level 3 is the emergence of professional empowerment and clinical autonomy. In many LMICs, nurses and midwives serve as the primary, and sometimes only, healthcare providers available, particularly in rural or remote regions (80,81). Our synthesis indicates that educational programs targeting advanced clinical decision-making trigger a fundamental shift in professional identity, where nurses move from task-oriented care toward evidence-based, proactive leadership.\u003c/p\u003e \u003cp\u003eThis shift aligns with Kanter\u0026rsquo;s Theory of structural empowerment, which posits that when organizational leadership creates environments where staff have access to information, resources, and support, they are optimized to perform their jobs well and provide higher-quality care (82). As Travers et al. (2020) observed, empowered nursing staff perform their duties more effectively and are more likely to participate in the planning, decision-making, and interdisciplinary teams required to manage complex clinical settings (82).\u003c/p\u003e \u003cp\u003eOur framework (Fig.\u0026nbsp;2) specifically highlights this critical transition between individual attitudinal shifts and institutional capacity. The thematic synthesis revealed that peer-to-peer knowledge diffusion (Theme 4) acts as the operational engine of this transformation. As nurses gain clinical competence, they develop the psychological safety required to lead peer mentorship initiatives. This creates a sustainable cycle of knowledge transfer within the facility, where empowered nurses become learning leaders who stabilize the workplace environment and promote safer clinical practices (83)\u003c/p\u003e \u003cp\u003eFurthermore, our findings suggest that this empowerment enables a critical form of task-shifting. In this context, the nursing workforce moves beyond mere clinical accuracy to improve the interpersonal quality and human-centeredness of the delivery system. As nurses become psychologically empowered, they demonstrate greater employee agility and a higher propensity for knowledge-sharing (83). This cultural shift is mirrored by measurable gains in operational efficiency and institutional quality standards (Sub-theme 4), which directly improve institutional capacity and facility readiness.\u003c/p\u003e \u003cp\u003eUltimately, this confirms that in LMICs, the impact of education is not limited to the individual bedside; rather, it scales upward. By adopting a communicative and proactive model, nurses effectively stabilize the healthcare system, ensuring that facility performance remains resilient even in the absence of specialized medical staff. By fostering psychological safety and structural support, education provides the foundation for higher facility readiness and better-standardized patient care pathways. Consequently, Level 3 behavior change in LMICs acts as the essential bridge that transforms individual learning into the systemic clinical improvements and institutional resilience seen at Level 4.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eThe implementation bottleneck: Navigating the translation gap (Level 4)\u003c/h2\u003e \u003cp\u003eWhile this review identified significant positive impacts on patient outcomes, including reduced mortality rates, improved infection control, and enhanced diagnostic accuracy, the transition from Level 3 (Behavior) to Level 4 (Results) is where the translation gap is most evident. Our findings suggest that in LMICs, the impact of nursing education on healthcare delivery is context-dependent and intrinsically linked to the availability of clinical resources. As highlighted by our framework (Fig.\u0026nbsp;2), even the most highly trained and empowered nurse cannot translate their skills into improved patient outcomes if the system lacks essential supplies, medications, or supportive supervision.\u003c/p\u003e \u003cp\u003eThis systemic limitation is supported by the work of Malematja et al. (2025), who found that insufficient resources at the primary healthcare level leads to a quality-of-service crisis. When essential tools are unavailable, nursing staff become overwhelmed by the need to improvise or borrow resources, which inevitably delays nursing interventions and diminishes the quality of care. This resource scarcity creates a secondary crisis of trust; as patients feel neglected or experience delayed care, they lose confidence in the healthcare system, leading to increased complaints and legal risks for the facility (84).\u003c/p\u003e \u003cp\u003eFurthermore, the translation gap is exacerbated by extreme workforce shortages. While our review shows that education improves individual efficiency, the burden remains immense in regions like Africa, which has only 13 nurses and midwives per 10,000 population compared to 83 in Europe (WHO), as cited in (84). This disparity puts an unsustainable strain on the existing workforce, where the extra effort required to complete nursing interventions in a resource-poor environment can lead to burnout, effectively neutralizing the long-term benefits of educational programs.\u003c/p\u003e \u003cp\u003eBeyond the immediate physical resource gap, our review highlights that sustainability is the ultimate determinant of Level 4 outcomes. In many LMIC contexts, systemic clinical improvements are often transient, tied to the duration of specific projects or donor-funded workshops rather than being embedded within national health strategies. Our framework warns that without institutionalizing education; these gains are vulnerable to the reality of staff migration and brain drain. When highly trained nurses are empowered with new competencies (Level 3) but remain unsupported by the hardware of functional infrastructure and fair compensation (Level 4), they are more likely to seek better opportunities abroad, taking the institutional memory and Level 4 impact with them.\u003c/p\u003e \u003cp\u003eAs suggested by the emergence of learning leaders within our framework\u0026mdash;referring to empowered nurses who drive continuous peer-to-peer knowledge diffusion\u0026mdash;long-term impact is predicated on the institutionalization of these leadership behaviors. This requires moving away from one-off training workshops toward integrated longitudinal education models supported by local policy and continuous professional development (CPD) frameworks. Without this policy-level integration, the software of education risks becoming obsolete as trained staff migrate or initial enthusiasm wanes, hindering the permanent transformation of healthcare delivery.\u003c/p\u003e \u003cp\u003eThis creates a critical \"So What?\" for policymakers: to achieve lasting system resilience, governments and international partners must shift their focus from funding isolated training events to funding permanent, integrated systems. Long-term impact is predicated on creating a supportive environment that retains talent through standardized career pathways and improved working conditions. Education acts as the catalyst for systemic clinical improvement, but its success is predicated on a supportive environment that provides the hardware (staffing, supplies, and infrastructure) to match the software (knowledge and empowerment) gained through training.\u003c/p\u003e \u003cp\u003eUltimately, Level 4 results in LMICs should be viewed not just as a measure of educational success, but as a reflection of the synergy between a competent workforce and a functional healthcare system. These nursing education programs remain necessary because education creates the leaders who stabilize the system, but the system must be strong enough to keep them. Only by bridging the gap between individual empowerment and structural stability can LMICs prevent the leakage of expertise and ensure that educational investments translate into permanent improvements in patient safety and healthcare delivery.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section3\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eA major strength of this review is the use of an integrative thematic framework, which allowed for a nuanced synthesis of both qualitative and quantitative data across 46 diverse studies by using the JBI methodology. By mapping these findings to a modified Kirkpatrick model, this study moves beyond a simple description of educational outcomes to identify the causal mechanisms, such as professional empowerment and peer-to-peer diffusion that drive clinical change in LMICs. Furthermore, the inclusion of recent literature (2015 up to 2025) ensures that the review captures the most current discourse on decolonizing curricula and health system resilience in the Global South.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite the strengths, several limitations must be acknowledged. First, there is a high degree of heterogeneity among the included studies, ranging from small-scale clinical workshops to national education reforms, which limit the ability to perform a meta-analysis or generalize specific effect sizes. Second, many studies focused heavily on Level 1 (Reaction) and Level 2 (Learning), with fewer studies providing long-term, longitudinal data on Level 4 (Patient Results). Finally, while we identified resource scarcity as a major bottleneck, the specific impact of different types of resources shortages like human resources vs. medical supplies could not always be isolated due to the overlapping nature of systemic challenges in primary literature.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review of 46 studies demonstrates that nursing education in LMICs is a powerful catalyst for healthcare transformation, moving beyond individual skill acquisition to drive systemic clinical improvement. By utilizing an integrative thematic framework, this study reveals that the impact of educational interventions follows a progressive causal pathway: from cultural engagement and pedagogical relevance (Levels 1 \u0026amp; 2) to professional empowerment and the emergence of learning leaders (Level 3), ultimately contributing to enhanced patient safety and institutional resilience (Level 4).\u003c/p\u003e \u003cp\u003eThe findings underscore that for nursing education to be effective in resource-limited settings, it must be culturally contextualized and decolonized, moving away from universalist Western models toward curricula that address local epidemiological realities. Furthermore, this review identifies a critical translation gap at the systemic level. While education provides the software of professional competence and clinical autonomy, its long-term success is predicated on the hardware of supportive infrastructure, adequate staffing, and essential resources.\u003c/p\u003e \u003cp\u003eTo prevent the leakage of expertise through brain drain and to ensure the sustainability of clinical gains, policymakers must shift from funding isolated training workshops to investing in permanent, integrated healthcare systems. This includes the institutionalization of longitudinal professional development and the creation of supportive work environments that retain talent. Ultimately, nursing education is essential for stabilizing healthcare delivery in the Global South; however, its potential is fully realized only when a competent, empowered workforce is met with a resilient and well-resourced health system.\u003c/p\u003e\n\u003ch3\u003eRecommendations for research and practice\u003c/h3\u003e\n\u003cp\u003eTo translate these findings into sustainable impact, nursing practice and policy in LMICs must transition from top-down, isolated training events toward the institutionalization of learning Leadership. This requires healthcare facilities to foster safe-to-fail environments where empowered nurses are encouraged to lead peer-mentorship initiatives, thereby stabilizing the local workforce. Crucially, stakeholders and donors must recognize that educational software is only effective when paired with clinical hardware; thus, investments in training must be matched by a commitment to supply chain stability and infrastructure to ensure that new competencies can be practiced. Furthermore, nursing curricula should be decolonized, prioritizing culturally adapted simulations and materials that reflect local epidemiological realities rather than Western-centric standards.\u003c/p\u003e \u003cp\u003eAccompanying these practical shifts, the research agenda must move toward longitudinal Level 4 evaluations that track patient outcomes and trust for at least 12\u0026ndash;24 months post-intervention to measure true sustainability. There is also an urgent need for economic evaluations to determine the return on investment of nursing education in terms of prevented complications and reduced hospital stays. Finally, future research should specifically investigate the intersection of staff migration and brain drain, quantifying how the loss of trained personnel affects institutional memory and identifying the specific policy-level incentives required to retain learning leaders within their home countries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEG, PT, JN, and IB contributed to the study conception and design. EG, PT, and JN coordinated the study implementation and screening process. EG, JN, and IB performed data extraction, quality appraisal, and evidence synthesis. EG drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content and read and approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur review did not receive any grant from any funding agency in the public, commercial, or not-for-profit organization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analyzed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eState of the world\u0026rsquo;s nursing 2020: investing in education, jobs and leadership [Internet]. 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The revised JBI critical appraisal tool for the assessment of risk of bias for randomized controlled trials. JBI Evid Synth. 2023;21(3):494\u0026ndash;506.\u003c/li\u003e\n\u003cli\u003eBarker TH, Habibi N, Aromataris E, Stone JC, Leonardi-Bee J, Sears K, et al. The revised JBI critical appraisal tool for the assessment of risk of bias for quasi-experimental studies. JBI Evid Synth. 2024;22(3):378\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eRobinson K, Webber M. Models and effectiveness of service user and carer involvement in social work education: A literature review. Br J Soc Work. 2013;43(5):925\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eKirkpatrick DL, Craig RL, Bittel LR. Evaluation of training. Eval Short-Term Train Rehabil. 1970;35.\u003c/li\u003e\n\u003cli\u003eNzabonimpa JP. Quantitizing and qualitizing (im-)possibilities in mixed methods research. 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J Healthc Leadersh. 2024 Nov;Volume 16:443\u0026ndash;54. doi:10.2147/JHL.S482087\u003c/li\u003e\n\u003cli\u003eMalematja DN, Nkosi EM, Nene SE. The impact of insufficient resources on the quality-of-service delivery at a primary healthcare clinic in Limpopo. Curationis. 2025 Apr 30;48(1):a2696. doi:10.4102/curationis.v48i1.2696\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nursing education programs, Healthcare delivery, Low and middle-income countries, Healthcare providers","lastPublishedDoi":"10.21203/rs.3.rs-9040928/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9040928/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eNursing is a cornerstone of global healthcare delivery, particularly in low- and middle-income countries (LMICs) where nurses are essential to addressing the needs of underserved populations. While nursing education is intended to strengthen clinical effectiveness, the systemic impact of these programs on healthcare delivery in resource-limited settings remains insufficiently synthesized. This study focuses on the role of nursing educational programs in LMIC.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo synthesize existing evidence on the impact of nursing education programs for improving healthcare delivery and patient outcomes in LMICs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods systematic review was conducted following the Joana Briggs Institute methodology. Eligibility criteria were pre-defined and registered in PROSPERO. Article were included if they (1) were related to nursing education programs in LMICs, and (2) focus on the impact of nursing education programs. A comprehensive search was performed through PubMed, Scopus, Web of Science, CINAHL, ERIC, BVS, and Embase. Quantitative and qualitative data were extracted and synthesized using a convergent integrated approach. Findings were categorized and pooled based on thematic similarity to produce an integrated evidence base.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom the 630 identified study, 46 were included, with findings mapped across the four levels of Kirkpatrick\u0026rsquo;s Evaluation Model. The evidence demonstrated high levels of participant satisfaction and engagement (Level 1), significant acquisition and retention of both theoretical knowledge and practical clinical skills (Level 2), and successful transfer of learning into clinical practice (Level 3). These behavioral changes directly resulted in enhanced patient outcomes and strengthened health system performance (Level 4), including improved diagnostic accuracy and reduced clinical errors.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNursing education programs in LMICs are effective catalysts for improving healthcare delivery. This review provides an integrative framework demonstrating that structured educational interventions not only enhance individual nursing competences but also drive systemic improvements in patient care and institutional capacity.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003ePROSPERO CRD42025646172\u003c/p\u003e","manuscriptTitle":"The impact of nursing education programs on healthcare delivery in low and middle-income countries (LMICs): A mixed systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 07:24:05","doi":"10.21203/rs.3.rs-9040928/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-08T10:19:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T18:28:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T01:24:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211215351695521593319590185918517303941","date":"2026-04-05T16:48:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162805260360725915726196067342648990946","date":"2026-04-03T11:23:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T12:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37121951605074124977221598291757127699","date":"2026-04-01T11:32:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-28T13:18:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T04:16:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T19:55:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-14T17:08:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-03-14T17:02:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5a90063-6be9-46f4-9c14-4f67348c96b4","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T11:10:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 07:24:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9040928","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9040928","identity":"rs-9040928","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}