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Conducting a Literature Review

Benefits of conducting a literature review.

• Steps in Conducting a Literature Review
• Summary of the Process
• Additional Resources
• Literature Review Tutorial by American University Library
• The Literature Review: A Few Tips On Conducting It by University of Toronto
• Write a Literature Review by UC Santa Cruz University Library

While there might be many reasons for conducting a literature review, following are four key outcomes of doing the review.

Assessment of the current state of research on a topic . This is probably the most obvious value of the literature review. Once a researcher has determined an area to work with for a research project, a search of relevant information sources will help determine what is already known about the topic and how extensively the topic has already been researched.

Identification of the experts on a particular topic . One of the additional benefits derived from doing the literature review is that it will quickly reveal which researchers have written the most on a particular topic and are, therefore, probably the experts on the topic. Someone who has written twenty articles on a topic or on related topics is more than likely more knowledgeable than someone who has written a single article. This same writer will likely turn up as a reference in most of the other articles written on the same topic. From the number of articles written by the author and the number of times the writer has been cited by other authors, a researcher will be able to assume that the particular author is an expert in the area and, thus, a key resource for consultation in the current research to be undertaken.

Identification of key questions about a topic that need further research . In many cases a researcher may discover new angles that need further exploration by reviewing what has already been written on a topic. For example, research may suggest that listening to music while studying might lead to better retention of ideas, but the research might not have assessed whether a particular style of music is more beneficial than another. A researcher who is interested in pursuing this topic would then do well to follow up existing studies with a new study, based on previous research, that tries to identify which styles of music are most beneficial to retention.

Determination of methodologies used in past studies of the same or similar topics.  It is often useful to review the types of studies that previous researchers have launched as a means of determining what approaches might be of most benefit in further developing a topic. By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research.

Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take. Should any additional questions arise during the course of the research, the researcher will know which experts to consult in order to quickly clear up those questions.

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• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Conducting a literature review: why do a literature review, why do a literature review.

• How To Find "The Literature"
• Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

• core research in the field
• experts in the subject area
• methodology you may want to use (or avoid)
• gaps in knowledge -- or where your research would fit in

It Also Helps You:

• Publish and share your findings
• Justify requests for grants and other funding
• Identify best practices to inform practice
• Set wider context for a program evaluation
• Compile information to support community organizing

Great brief overview, from NCSU

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The purpose of a literature review is to collect relevant, timely research on your chosen topic, and synthesize it into a cohesive summary of existing knowledge in the field. This then prepares you for making your own argument on that topic, or for conducting your own original research.

Depending on your field of study, literature reviews can take different forms. Some disciplines require that you synthesize your sources topically, organizing your paragraphs according to how your different sources discuss similar topics. Other disciplines require that you discuss each source in individual paragraphs, covering various aspects in that single article, chapter, or book.

Within your review of a given source, you can cover many different aspects, including (if a research study) the purpose, scope, methods, results, any discussion points, limitations, and implications for future research. Make sure you know which model your professor expects you to follow when writing your own literature reviews.

Tip : Literature reviews may or may not be a graded component of your class or major assignment, but even if it is not, it is a good idea to draft one so that you know the current conversations taking place on your chosen topic. It can better prepare you to write your own, unique argument.

Benefits of Literature Reviews

• Literature reviews allow you to gain familiarity with the current knowledge in your chosen field, as well as the boundaries and limitations of that field.
• Literature reviews also help you to gain an understanding of the theory(ies) driving the field, allowing you to place your research question into context.
• Literature reviews provide an opportunity for you to see and even evaluate successful and unsuccessful assessment and research methods in your field.
• Literature reviews prevent you from duplicating the same information as others writing in your field, allowing you to find your own, unique approach to your topic.
• Literature reviews give you familiarity with the knowledge in your field, giving you the chance to analyze the significance of your additional research.

Choosing Your Sources

When selecting your sources to compile your literature review, make sure you follow these guidelines to ensure you are working with the strongest, most appropriate sources possible.

Topically Relevant

Find sources within the scope of your topic

Appropriately Aged

Find sources that are not too old for your assignment

Find sources whose authors have authority on your topic

Appropriately “Published”

Find sources that meet your instructor’s guidelines (academic, professional, print, etc.)

Tip:  Treat your professors and librarians as experts you can turn to for advice on how to locate sources. They are a valuable asset to you, so take advantage of them!

Organizing Your Literature Review

Synthesizing topically.

Some assignments require discussing your sources together, in paragraphs organized according to shared topics between them.

For example, in a literature review covering current conversations on Alison Bechdel’s  Fun Home , authors may discuss various topics including:

• her graphic style
• her allusions to various literary texts
• her story’s implications regarding LGBT experiences in 20 th  century America.

In this case, you would cluster your sources on these three topics. One paragraph would cover how the sources you collected dealt with Bechdel’s graphic style. Another, her allusions. A third, her implications.

Each of these paragraphs would discuss how the sources you found treated these topics in connection to one another. Basically, you compare and contrast how your sources discuss similar issues and points.

To determine these shared topics, examine aspects including:

• Definition of terms
• Common ground
• Issues that divide
• Rhetorical context

Summarizing Individually

Depending on the assignment, your professor may prefer that you discuss each source in your literature review individually (in their own, separate paragraphs or sections). Your professor may give you specific guidelines as far as what to cover in these paragraphs/sections.

If, for instance, your sources are all primary research studies, here are some aspects to consider covering:

• Participants
• Limitations
• Implications
• Significance

Each section of your literature review, in this case, will identify all of these elements for each individual article.

You may or may not need to separate your information into multiple paragraphs for each source. If you do, using proper headings in the appropriate citation style (APA, MLA, etc.) will help keep you organized.

If you are writing a literature review as part of a larger assignment, you generally do not need an introduction and/or conclusion, because it is embedded within the context of your larger paper.

If, however, your literature review is a standalone assignment, it is a good idea to include some sort of introduction and conclusion to provide your reader with context regarding your topic, purpose, and any relevant implications or further questions. Make sure you know what your professor is expecting for your literature review’s content.

Typically, a literature review concludes with a full bibliography of your included sources. Make sure you use the style guide required by your professor for this assignment.

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Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

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Literature Reviews and Systematic Reviews of Research: The Roles and Importance

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• First Online: 15 October 2023
• pp 3925–3928
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• Hale Ilgaz 4 ,
• Gloria Natividad 5 &
• Arif Altun 6  

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There are several studies in the literature from different subject topics, with different perspectives, variables, outputs, and findings. It is very important to get information from a scientific study during research processes. Therefore, the main aim of this chapter is putting together literature reviews and systematic review studies for presenting a holistic view to the field by using scientific methodology. We are very welcome to consider the studies written with this methodology without topic limitation in learning, design, and technology area.

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Brocke, J. V., Simons, A., Niehaves, B., Riemer, K., Plattfaut, R., & Cleven, A. (2009). Reconstructing the giant: On the importance of rigour in documenting the literature search process. ECIS . In: S. Newell, E. Whitley, N. Pouloudi, J. Wareham & L. Mathiassen (Eds.), Proceedings of the ECIS 2009, 17th European conference on information systems (pp. 2206–2217). Verona.

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Kim, Y. S. (2017). The importance of literature review in research writing. Retrieved from: https://owlcation.com/humanities/literature_review

Research Guides. (2019). Systematic reviews: What is a systematic review? Retrieved from http://libguides.newcastle.edu.au/sysreviews

Uman, L. S. (2011). Systematic reviews and meta-analyses. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 20 (1), 57–59.

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Ilgaz, H., Natividad, G., Altun, A. (2023). Literature Reviews and Systematic Reviews of Research: The Roles and Importance. In: Spector, J.M., Lockee, B.B., Childress, M.D. (eds) Learning, Design, and Technology. Springer, Cham. https://doi.org/10.1007/978-3-319-17461-7_141

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• Steps in Conducting a Literature Review

What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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What is the Purpose of a Literature Review?

4-minute read

• 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

Literature Review Editing Services 

Ensure your literature review is polished and ready for submission by having it professionally proofread and edited by our expert team. Our literature review editing services will help your research stand out and make an impact. Not convinced yet? Send in your free sample today and see for yourself! 

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The advantage of literature reviews for evidence-based practice

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BENEFITS OF LITERATURE REVIEW TO RESEARCH

Introduction.

Literature review offers lots of benefits to researcher. However, for the purpose of this post I will like to be direct. Below are few benefits of Literature review to researchers:

• A thorough exploration of the literature review will help to articulate our own research problems, objectives, as well as formulating our research questions or hypothesis.
• It helps to know the existing GAPS
• It helps to notices the important concepts and variables and how they were operationalized
• It widens the researcher knowledge of the problem
• It gives researchers detailed knowledge of the method and design that he can adopt or use new ones.
• It helps the researcher to arrive at picking a suitable scope
• It suggested theories previously used

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• Volume 33, Issue 5
• Routine versus prompted clinical debriefing: aligning aims, mechanisms and implementation
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• http://orcid.org/0000-0003-3630-5845 Emma Claire Phillips 1 , 2 ,
• http://orcid.org/0000-0002-9178-1425 Victoria Tallentire 1 , 2
• 1 NHS Lothian , Edinburgh , UK
• 2 Scottish Centre for Simulation and Clinical Human Factors , Larbert , UK
• Correspondence to Dr Emma Claire Phillips, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK; e.c.phillips{at}doctors.org.uk

https://doi.org/10.1136/bmjqs-2023-016836

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• Continuing education, continuing professional development
• Crisis management
• Safety culture
• Significant event analysis, critical incident review

The great art of learning is to understand but little at a time. —John Locke

Clinical debriefing (CD) is rapidly gaining traction as a valuable activity. CD is usually conducted as a guided exploration and reflection of clinical events in an attempt to bridge the gap between experience and understanding, with the ultimate aim of influencing future practice. 1 CD has the potential to improve outcomes for staff, teams, patients and systems. 2 3 The evidence for CD exists and continues to grow; benefits range from changes in staff attitudes 4 to favourable outcomes following cardiac arrest. 5 Despite this, some clinicians have been sceptical about the impact of CD, and there are various barriers which may limit implementation. These include lack of clear purpose, actual or perceived lack of time, lack of experienced debriefers and cultural resistance to change. 6 Our focus should now be shifting towards overcoming barriers to implementation, a disappointingly difficult feat. 7 8 The paper by Paxino et al 9 in this issue of BMJ Quality & Safety responds to this call and suggests that a lack of standardised terminology to describe CD practices may be part of the implementation problem.

Paxino et al use scoping review methodology to explore how contextual factors relating to interdisciplinary CD are described in the existing literature, and whether these can be used to differentiate approaches to CD. They explore 46 studies using the ‘Who–What–When–Where–Why–How’ framework, with particular emphasis on contextual factors related to the ‘What’ and ‘When’ elements to differentiate between CD approaches. Based on their findings, they reconceptualise the terminology of CD practices into ‘prompted’ (further differentiated into ‘immediate’ and ‘delayed’) and ‘routine’ (further differentiated into ‘postoperative’ and ‘end of shift’), and propose a move away from a one-size-fits-all way of describing CD practices. They argue that there are potential problems with some pre-existing terminology, such as the temperature metaphors of ‘hot’ and ‘cold’ debriefs. For example, a ‘hot’ debrief is generally one done immediately following an event 10 ; however, this terminology may have negative connotations regarding how the debrief should be done (fast, rushed) or the emotional state of the participants (upset, stressed). Moreover, they highlight that pre-existing classifications of CD practices are inconsistent, ambiguous and potentially inaccurate. A lack of standardised terminology may limit implementation of CD by creating confusion among staff wishing to facilitate or participate in a CD, lack of confidence in initiating the correct approach for a specific context, inconsistent delivery, unclear intention of the debrief and potentially inappropriate implementation which may lead to harm.

These results are a welcome addition to existing review articles of current CD practices, such as a recent systematic review of CD tools, 1 and instructional ‘top tips’ papers. 11 However, despite this useful recategorisation of CD approaches (routine and prompted), it is important to recognise that different aims and underlying mechanisms will exist for these alternative forms of CD. A deeper appreciation of these mechanisms is essential in order to align delivery of CD to desired benefits and to overcome barriers to implementation. We have detailed below two examples of such underlying mechanisms and how they relate to both Paxino et al’ s categorisations and to the overarching aims of a particular CD.

Routine CD to learn

While the idea of conducting a CD routinely is not new, for example, postoperatively or at the end of a shift, CD is more frequently carried out following adverse or unanticipated events. 1 Paxino et al found that just 14 of the 46 studies referred to routine CD (vs prompted). Embedding CD into a routine context, making it proactive rather than just reactive, could have considerable benefits in terms of learning. First, this encourages us to move away from only thinking about learning from when things go wrong (aligned with more conventional patient safety principles) towards generating learning from success and everyday practice (aligned with contemporary views on patient safety). Second, if staff become accustomed to having these types of discussions in low-stakes scenarios, they may be more comfortable and confident to engage in CD following a challenging or emotive case, as discussed further below.

There is a paucity of literature to draw upon related to cultural challenges in implementation of CD. However, work does exist examining healthcare cultural change on a broader scale. Scott et al 14 highlight key sources of resistance to cultural change in healthcare, including: lack of ownership by individuals or groups, negative external influences from stakeholders, lack of appropriate leadership and cultural diversity between professional subgroups. The common theme is that people are an essential part of the change process. In figure 1 , we suggest potential methods for how we can positively influence the cultural shift required to accept and embed CD. These apply to both the routine and prompted contexts, and are based on our own experiences and opinions, using Scott et al’ s work and applying it to the CD context. The ultimate aim is to make CD part of our routine practice, and promoting cultural change is an important step in making this happen. However, we must be patient with these changes, prioritising sustainability over short-term success. We advocate more emphasis on addressing culture to influence effective implementation of CD, with a view to delivering CD for learning from routine clinical events.

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Engaging people to influence clinical debriefing (CD) culture in healthcare. GMC, General Medical Council; NHS, National Health Service.

Prompted CD to learn or manage

So far, we have considered routine CD as a process designed to create learning points that will impact future practice and ultimately enhance patient safety, known as ‘debriefing-to-learn’. 15 Moving to consider Paxino et al’ s second categorisation of prompted CD leads us to also consider the potentially different aims and mechanisms at play in that context. The differences are likely to be due to the level of staff emotions potentially present in a prompted CD which are less likely to be relevant to routine CD.

In terms of the aim, ‘debriefing-to-treat’, as a way of attempting to reduce the longer-term psychological impact of a traumatic event, has been shown to be unhelpful and potentially harmful. 16 The underlying psychological mechanisms for this association are not fully understood, but may involve re-exposure serving as further trauma, or the group setting interrupting normal individual adaptive processes and preferences. 15 When individuals or teams show high levels of distress, the purpose of a CD should change accordingly, and a ‘debriefing-to-manage’ approach has been advocated. 15 This is where the focus of the debrief is on giving participants space to focus on reactions to an event, rather than focusing on the experience itself in detail. Paxino et al’ s scoping review 9 excluded papers primarily describing psychologically focused debriefings, but noted that some of the included studies ‘reported an intersection between quality improvement and supporting the emotional and psychological needs of team members’. Therefore, the aim of a prompted CD may be either to learn, to manage emotional responses or an amalgamation of both.

Human emotional responses are inconveniently unpredictable, both in terms of individual responses to the same event and in proportionality of response in relation to the clinical significance of the event. A team that appears keen to explore the lessons from a patient safety perspective soon after a clinical event may consist of some individuals who might find such exploration more triggering than they, or others, had anticipated. This highlights that learning following prompted CD may be complicated by the impact of the event.

The relationship between learning and emotions is complex, but is of growing interest to both medical educators and organisational scientists. Medical practice involves significant emotional experiences, and such emotions can have important and long-lasting effects on memory, cognition and learning. For example, stress has been associated with greater memory consolidation, but also increased inaccuracy in the detail of what is recalled. 17 Some learning theories that are particularly pertinent to health professionals’ education incorporate emotions as a core element of the pedagogical process. 18 One such example is transformative learning (TL), a theory describing learning that challenges established perspectives through acknowledgement of the ways in which pre-existing assumptions and relationships influence the meaning that is derived from new experiences. 19 Unlike many pedagogical theories, TL resonates with the complex emotional and social reality of the clinical workplace. It explicitly incorporates an emotional ‘trigger’, such as guilt or shame, that initiates perspective transformation. 19 The essential affective component as part of the learning process is, however, at odds with the prevailing rhetoric of heightened emotion presenting an obstacle to learning in both simulated and real clinical environments. 15 20 It would therefore seem that there is much left to explore and understand about CD with regard to how much emotion is too much, and the complex relationships between emotion, learning and psychological sequelae. Paxino et al seek to remove assumptions about the emotional state of participants in their recontextualisation of CD practice, by replacing current ‘hot’ and ‘cold’ terminology. While this does seem prudent, it may be both unrealistic and unhelpful to entirely disentangle emotions and learning in relation to CD.

Implementation of routine and prompted CD

Paxino et al present a comprehensive review of the existing literature of CD practices, and propose the new categories of routine and prompted CD. This useful distinction helps us appreciate that these types of CD differ not only in terms of the ‘When’ but also the ‘Why’ regarding the aims of the debrief—to learn and/or to manage emotional responses. It is likely that there are different factors that facilitate and hinder the implementation of routine and prompted, and two examples (culture related to routine CD and the role of emotions in learning in prompted CD) have been explored. As we move away from a one-size-fits-all perspective of CD practices which has existed in the past, understanding the distinction between types of CD, in terms of their aims and underlying mechanisms, is an important step towards effective implementation. For those wishing to practise CD, Paxino et al’ s new categorisation may help in clarifying aims and developing an implementation strategy. We encourage both clinicians and researchers to further explore concepts such as context, culture and the relationship between emotions and learning related to CD in order to build our collective understanding of how to optimally deliver CD for healthcare staff.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

Not applicable.

Acknowledgments

Thank you to Dr Samantha Smith for her constructive feedback on this editorial.

• Phillips EC ,
• Tallentire V , et al
• Schmutz JB ,
• Koncicki ML ,
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• Petrosoniak A ,
• Gabriel J ,
• Sjöberg F ,
• Schönning E ,
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• Marshall S , et al
• Walker CA ,
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• Taylor C , et al
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• Zaklama R ,
• Szabo RA , et al
• ↵ Culture eats strategy for breakfast . The Management Center , Available : https://www.managementcentre.co.uk/management-consultancy/culture-eats-strategy-for-breakfast/ [Accessed 12 Dec 2023 ].
• Campbell RJ
• Mannion R ,
• Davies HTO , et al
• Schmutz S ,
• Seelandt JC , et al
• ↵ Psychological Debriefing in people exposed to a recent traumatic event . World Health Organisation , Available : https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre/other-significant-emotional-and-medical-unexplained-somatic-complaints/psychological-debriefing-in-people-exposed-to-a-recent-traumatic-event [Accessed 15 Dec 2023 ].
• Van Schalkwyk SC ,
• Brewer TF , et al
• Teteris E , et al

Contributors ECP and VT—conception and design of the work, drafting and revising of the paper and approval of the final version for submission. Both authors agree to be accountable for all aspects of the work.

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

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Linked Articles

• Systematic review What and when to debrief: a scoping review examining interprofessional clinical debriefing Julia Paxino Rebecca A Szabo Stuart Marshall David Story Elizabeth Molloy BMJ Quality & Safety 2023; 33 314-327 Published Online First: 30 Dec 2023. doi: 10.1136/bmjqs-2023-016730

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Transformations That Work

• Michael Mankins
• Patrick Litre

More than a third of large organizations have some type of transformation program underway at any given time, and many launch one major change initiative after another. Though they kick off with a lot of fanfare, most of these efforts fail to deliver. Only 12% produce lasting results, and that figure hasn’t budged in the past two decades, despite everything we’ve learned over the years about how to lead change.

Clearly, businesses need a new model for transformation. In this article the authors present one based on research with dozens of leading companies that have defied the odds, such as Ford, Dell, Amgen, T-Mobile, Adobe, and Virgin Australia. The successful programs, the authors found, employed six critical practices: treating transformation as a continuous process; building it into the company’s operating rhythm; explicitly managing organizational energy; using aspirations, not benchmarks, to set goals; driving change from the middle of the organization out; and tapping significant external capital to fund the effort from the start.

Lessons from companies that are defying the odds

Idea in Brief

The problem.

Although companies frequently engage in transformation initiatives, few are actually transformative. Research indicates that only 12% of major change programs produce lasting results.

Why It Happens

Leaders are increasingly content with incremental improvements. As a result, they experience fewer outright failures but equally fewer real transformations.

The Solution

To deliver, change programs must treat transformation as a continuous process, build it into the company’s operating rhythm, explicitly manage organizational energy, state aspirations rather than set targets, drive change from the middle out, and be funded by serious capital investments.

Nearly every major corporation has embarked on some sort of transformation in recent years. By our estimates, at any given time more than a third of large organizations have a transformation program underway. When asked, roughly 50% of CEOs we’ve interviewed report that their company has undertaken two or more major change efforts within the past five years, with nearly 20% reporting three or more.

• Michael Mankins is a leader in Bain’s Organization and Strategy practices and is a partner based in Austin, Texas. He is a coauthor of Time, Talent, Energy: Overcome Organizational Drag and Unleash Your Team’s Productive Power (Harvard Business Review Press, 2017).
• PL Patrick Litre leads Bain’s Global Transformation and Change practice and is a partner based in Atlanta.

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• Biophys Rev
• v.11(5); 2019 Oct

The benefits of writing a Review

Damien hall.

1 Laboratory of Biochemistry and Genetics, NIDDK, NIH, Bld. 8, Bethesda, MD 20892-0830 USA

2 Institute for Protein Research, Osaka University, 3-1- Yamada-oka, Suita, Osaka, 565-0871 Japan

The main body of articles contained within this Special Issue review the background areas of keynote seminars presented at the 4 th Symposium on Nanoengineering for Mechanobiology (N4M) held in Genoa, Italy, in late March of 2019. The underlying themes of the N4M Symposium and this Special Issue derived from it are

• (i) How mechanical environments, through the exertion of various fields and forces, determine the function and outcomes of the cells and tissues, and
• (ii) Techniques and outcomes for the identification of the mechanical properties of cells and tissues, as well as the individual molecules and structures occurring within them.

The articles are written by a collection of physicists and engineers working at the biophysics/medical engineering interface. They cover the full armamentarium of micron to nanometer scale engineering, manipulation and observation methodologies (including the most modern microscopy, spectroscopy and nanoscopy techniques), this Special Issue arguably constitutes one of the most fundamental representations of classical physical principles applied to cell and tissue behavior published in the journal to date. I would like to congratulate the Special Issue Editors Massimo Vassalli, Marco Capitanio, Aldo Ferrari, and Boris Martinac for the interesting array of Review articles they have commissioned and for their collective efforts in keeping the Issue on schedule. A summary of the individual Reviews included within this Special Issue is provided within the main Editorial (Ferrari et al. 2019 ) and I refer the interested reader there for a useful precis of contents.

To provide some additional perspective on the mechanobiology field, the Special Issue Editors have commissioned a number of topical Commentaries. First amongst these is a brief look into the possible future of mechanobiology research written by a senior researcher in the field, Prof. Jochen Guck of the Max Planck Center for Physics of light (Guck 2019 ). Following this is a Commentary from the President of the European Society of Biomechanics (Prof. M a Angeles Peréz Anson) who has written about the work of that Society to facilitate mechanobiology research from the microscopic to macroscopic level (Pérez 2019 ). Next we hear from a young researcher (Assist. Prof. Robert Steward Jr.) just setting up a laboratory in the mechanobiology field (Steward 2019 ). Rounding out these commentaries is a piece written by the Director (Prof. Peter Kohl) and Senior Staff (Dr. Julia Verheyen and Dr. Remi Peyronnet) of the Institut für Experimentelle Kardiovaskuläre Medizin (IEKM) who provide an inside perspective on the establishment and maintenance of a dedicated Mechanobiology Institute comprising over fifty academic staff and students (Verheyen et al. 2019 ).

Project Deal

Moving beyond Special Issue topics, I now introduce that relate to the running of the journal. To start, I note the positive advantages soon to be provided to the journal through its scheduled participation in “Project Deal” ( 2019 ). This is an agreement between more than 700 German academic institutions (that collectively constitute the Alliance of German Science Organizations) and the major science publishing houses (Project Deal 2019 ). Its aim is to provide an open-access reading and publishing arrangement for researchers based at the Alliance of German Science Organizations affiliated research centers. As recently outlined in a memorandum of understanding between Springer-Nature and the Project Deal parties, the benefits for readers and authors of Biophysical Reviews will be both regional and international in nature (Springer Memorandum 2019 ). For affiliated German-based researchers, publication within Biophysical Reviews will automatically involve an open-access arrangement with no additional open-access fee required. By guaranteeing all German-based research published within Biophysical Reviews is to be open access, Project Deal also provides significant benefit to international readers of the journal, by effectively guaranteeing access to this subset of articles to anyone with an internet connection.

The Michèle Auger Award

Readers of the journal are reminded of the upcoming deadline October 31 st for nominations for the “Michèle Auger Award for Young Scientists’ Independent Research,” which will be granted to a single candidate performing biophysical research, who at the time of application, is under 40 years of age. Prof. Michèle Auger was a valued Member of the Biophysical Reviews Editorial Board and her recent death was a sad loss felt by all associated with the journal. More about her life and works can be read within the online IUPAB Newsletter (IUPAB 2018 ). Described more completely in a prior Editorial (Hall 2019 ), the memorial award consists of a plaque, a free personal subscription to the journal, and an invitation to submit a single-author Review article to Biophysical Reviews. The winner’s article will carry a short foreword about the life and works of Prof. Michèle Auger. Candidate nominations (either self or via direct recommendation) are requested in the form of a candidate’s one page curriculum vitae , along with five original papers. Submissions may be sent by email to any of the Senior Editors of the journal (Chief Editor, Executive Editors), with the winner announced in early December.

Becoming a Reviewer of Manuscripts

One recent, and rather interesting, phenomenon is the sudden increase in direct inquiries volunteering/requesting to act as assessors of submitted review articles. While this groundswell of collegiality should be applauded, I suspect that at least some part of this relatively recent upswing in desire to perform reviewing duty stems from a wish to maximize an individual’s Publons’ score—the new metric introduced by Clarivate Analytics (Publons 2019 ). 1 My response to the authors of such requests 2 is to suggest to the correspondent that by far the best way of being included in the Biophysical Review’s Reviewer pool is to first establish an association with the journal by submitting and publishing a single-author review article. Prior to submission of a Review, inquiries should be made with the Chief Editor to discuss both the suitability of the topic and a timeframe for submission (typically 4 to 6 months from the point of official invitation). Through the act of publishing within Biophysical Reviews, each author is then included within a database that includes personal descriptions of specialist subject areas along with up to date personal contact details. Such information is consulted by the relevant Handling Editors when seeking potential assessors of a manuscript.

To close out this Editorial, I would like to briefly describe the beneficial and negative aspects to keep in mind when contemplating writing a review article. On the positive side, a well-written review can be a benefit to both the author and others interested in the same scientific area. The benefits to self and community are three-fold

• (i) Reading the literature: Without doubt there are many noble scientists who right after their morning run begin each day by summarizing the most recent pertinent literature in their field. For other less diligent scientists (myself very much included), the process of writing a review article compels the author to undertake a serious examination of the published literature. This forced confrontation aspect helps to mold the Review writing researcher into something more resembling a research scholar, i.e., one who performs original work cognizant of already published work in the field. To my mind if this was the only benefit it would indeed be sufficient.
• (ii) Scouting and pedagogy: Depending on the author’s/authors’ style, there will be a varied mixture of teaching and reportage within each review article. Pedagogical aspects are particularly important when the author is addressing interfacial topics comprising a number of different subject areas, some of which are likely to be unfamiliar to the typical reader. This type of Review provides the author many of the same benefits as gotten from an actual teaching duty, i.e., one rapidly becomes aware of their own level of understanding when forced to teach the material to another in a formal setting. The scouting aspect comes into play when writing a cutting edge Review for an expert audience. In this format, rather than teaching the reading audience something, the author is instead acting in the role of forward-deployed reconnaissance scout, whose job is to report latest information about maneuvers on the research battlefront. This practiced ability to effectively condense and communicate complex information represents an amazingly useful skill—both for the author and for all scientists working within the field whom are reading the work.
• (iii) Writing and synthesis: Like many activities, scientific writing, based on the collation of results and synthesis of concepts and ideas, definitely improves the more you do it. In today’s modern world, many scientists may not actually write a lot of the papers in which they are listed as an author due to pressures associated with paper production or a defined system of paper production existing within the structure of the laboratory. In such circumstances, the writing of a single-author review article each 1 or 2 years can be of great benefit in the training of capable independent scientists, equipping them for an independent research career. Due to the fact that it is not entirely dependent upon the generation of results in the laboratory (as with a primary research paper), a review article provides scientists, both old and new, with a more accessible point of entry to engage the published literature and practice their skills in scientific argument and synthesizing literature results into cohesive paradigms.

Whilst the preceding points make a case for writing a review article, there are also a number of downsides. These negative aspects are again three-fold

• (i) Time away from primary research: The primary role of a professional research scientist is the generation of new scientific understanding gained through the performance of experiments, with this knowledge typically packaged and presented in the form of a research paper. Such primary research papers, in which the case is made for the acceptance and meaning of new scientific results, are therefore distinct from secondary research papers, such as review articles, which discuss the collective meaning of published results from a number of primary literature sources. Career success for research-focused academics is largely correlated with the number and impact of the primary research articles they produce. Performing high-level original research takes time and very often usable blocks of time are a researcher’s most valuable item. Spending the necessary time to genuinely engage with the review writing process (and therefore accrue the benefits described above) can further diminish one’s available work time to the point that the researcher’s major goal of producing original knowledge, can be temporarily suspended or relegated to the second-tier priority level. Potential authors beware!
• (ii) Too many reviews: One of the benefits alluded to above was that afforded to the field by a Review containing valuable teaching material and/or the latest key field specific information. However, as may have been noticed by some researchers, the total volume of scientific literature (both primary and secondary) is undergoing an explosion and we are currently at risk of being swamped with too much information. A practical manifestation of this increasing amount of content is the growing trend for Reviews to include a front section that reviews the Reviews, prior to moving onto an analysis of the primary literature. Review writers must weigh up the benefits of adding another review article to an already saturated and over-reviewed field. Of potential use to the author contemplating adding a Review to a crowded field is to first begin by writing a paragraph describing the positives and negatives of already existing review articles along with how their prospective Review will be different from the others. Arriving at an honest answer to this question should assist with the author’s decision-making process.
• (iii) Superficial/usual suspect reviews: Under significant work and deadline pressures, the specter of superficiality can quietly enter the room and take its spot at the authorship table. The product of this unwanted assistance is a review article which is similar in content and structure to other Reviews, with the tendency to reference a common set of articles. While not seeking to make perfect the enemy of the good, I think that these types of Reviews can be destructive for all involved for a number of reasons. With regard to the author: In producing such superficial review articles, the author(s) do not gain any of the positive benefits associated with engaging the literature nor do they gain any significant advantage associated with practice at writing and/or argument development. With regard to the field: Superficiality can inflict its damage in a number of ways. The first is by removing those direct benefits associated with high-quality pedagogy, latest information update and/or novel synthesis and presentation that are either absent or resemble efforts made in other recent review articles. The second way in which superficiality can be destructive is through the reinforcement of citation patterns. Many readers will be familiar with the existence of highly cited articles that after being given a careful read through, seem to be not entirely deserving of the citation attention paid to them. Sometimes this over-citation effect can be the result of purposeful preferential selection by so-called science citation cartels (Wallace et al. 2012 ; Fister et al. 2016 ). However, over-citation can also result from a less sinister set of intentions due to superficiality/rushing of latter derivative Reviews which use an earlier Review as a directive template. In today’s metric-driven world, the danger is indeed extant that citation lions may sometimes emerge from indifference!

It is hoped that this somewhat wide-ranging Editorial may have provided some food for thought for readers of the journal. As the journal’s reason for being is literally to both publish high-quality topical reviews and to facilitate the growth of biophysics in all areas of the world, it would be advantageous if the net result of this sojourn into Review writing imperatives has been on the whole more positive/encouraging than negative. The journal requests that interested authors discuss their ideas for a Review article with their local Editorial Board Members and/or Senior Editors of the journal prior to submission. If the topic is judged a suitable fit, they will then receive the much coveted official invitation to submit their Review article to IUPAB’s Biophysical Reviews.

Acknowledgements

I would like to thank Ms. Shiela Chavez and Mr. John Matthew Dela Cruz for their efforts in assembling this Special Issue. I would like to thank Ms. L. Sayuri, Ms. M. Satoko, and Ms. I. Sakura for numerous stimulating discussions on science and history during the course of writing this Editorial. I thank Prof. Wilma Olson, Prof. Cristobal dos Remedios, Dr. Reed Wickner, Dr. Herman Edskes, and Dr. Meran Lloyd-Owen for helpful comments made on an initial draft of this article. I would like to acknowledge the Institute for Protein Research at Osaka University for continuing remarkable support.

This study was financially supported by the US Government in the form of an ORISE Established Scientist Position carried out at the NIDDK. This research was supported in part by an appointment to the National Library of Medicine (NLM) Research Participation Program. This program is administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy (DOE) and the National Library of Medicine (NLM). ORISE is managed by ORAU under DOE contract number DE-SC0014664.

All opinions expressed in this paper are the author’s and do not necessarily reflect the policies and views of NLM, DOE, or ORAU/ORISE.

Compliance with ethical standards

The author declares no competing interests.

1 Publons aims to measure one’s prestige and collegiality in critiquing manuscripts through the peer review cycle.

2 Particularly for those just starting out as newly minted PhD holders.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Clarivate Analytics (Publons) (2019) https://publons.com/about/home/
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• http://orcid.org/0000-0002-5111-7861 Amit K Dutta 1 ,
• http://orcid.org/0000-0003-2472-3409 Vishal Sharma 2 ,
• Abhinav Jain 3 ,
• Anshuman Elhence 4 ,
• Manas K Panigrahi 5 ,
• Srikant Mohta 6 ,
• Richard Kirubakaran 7 ,
• Mathew Philip 8 ,
• http://orcid.org/0000-0003-1700-7543 Mahesh Goenka 9 ,
• Shobna Bhatia 10 ,
• http://orcid.org/0000-0002-9435-3557 Usha Dutta 2 ,
• D Nageshwar Reddy 11 ,
• Rakesh Kochhar 12 ,
• http://orcid.org/0000-0002-1305-189X Govind K Makharia 4
• 1 Gastroenterology , Christian Medical College and Hospital Vellore , Vellore , India
• 2 Gastroenterology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
• 3 Gastroenterology , Gastro 1 Hospital , Ahmedabad , India
• 4 Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
• 5 Gastroenterology , All India Institute of Medical Sciences - Bhubaneswar , Bhubaneswar , India
• 6 Department of Gastroenterology , Narayana Superspeciality Hospital , Kolkata , India
• 7 Center of Biostatistics and Evidence Based Medicine , Vellore , India
• 8 Lisie Hospital , Cochin , India
• 9 Apollo Gleneagles Hospital , Kolkata , India
• 10 Gastroenterology , National Institute of Medical Science , Jaipur , India
• 11 Asian Institute of Gastroenterology , Hyderabad , India
• 12 Gastroenterology , Paras Hospitals, Panchkula , Chandigarh , India
• Correspondence to Dr Amit K Dutta, Gastroenterology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India; akdutta1995{at}gmail.com

https://doi.org/10.1136/gutjnl-2024-332154

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• PROTON PUMP INHIBITION
• META-ANALYSIS

We read with interest the population-based cohort studies by Abrahami et al on proton pump inhibitors (PPI) and the risk of gastric and colon cancers. 1 2 PPI are used at all levels of healthcare and across different subspecialties for various indications. 3 4 A recent systematic review on the global trends and practices of PPI recognised 28 million PPI users from 23 countries, suggesting that 23.4% of the adults were using PPI. 5 Inappropriate use of PPI appears to be frequent, although there is a lack of compiled information on the prevalence of inappropriate overuse of PPI. Hence, we conducted a systematic review and meta-analysis on the inappropriate overuse of PPI globally.

Supplemental material

Overall, 79 studies, including 20 050 patients, reported on the inappropriate overuse of PPI and were included in this meta-analysis. The pooled proportion of inappropriate overuse of PPI was 0.60 (95% CI 0.55 to 0.65, I 2 97%, figure 1 ). The proportion of inappropriate overuse by dose was 0.17 (0.08 to 0.33) and by duration of use was 0.17 (0.07 to 0.35). Subgroup analysis was done to assess for heterogeneity ( figure 2A ). No significant differences in the pooled proportion of inappropriate overuse were noted based on the study design, setting (inpatient or outpatient), data source, human development index of the country, indication for use, sample size estimation, year of publication and study quality. However, regional differences were noted (p<0.01): Australia—40%, North America—56%, Europe—61%, Asia—62% and Africa—91% ( figure 2B ). The quality of studies was good in 27.8%, fair in 62.03% and low in 10.12%. 6

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Forest plot showing inappropriate overuse of proton pump inhibitors.

(A) Subgroup analysis of inappropriate overuse of proton pump inhibitors (PPI). (B) Prevalence of inappropriate overuse of PPI across different countries of the world. NA, data not available.

This is the first systematic review and meta-analysis on global prescribing inappropriateness of PPI. The results of this meta-analysis are concerning and suggest that about 60% of PPI prescriptions in clinical practice do not have a valid indication. The overuse of PPI appears to be a global problem and across all age groups including geriatric subjects (63%). Overprescription increases the patient’s cost, pill burden and risk of adverse effects. 7–9 The heterogeneity in the outcome data persisted after subgroup analysis. Hence, this may be inherent to the practice of PPI use rather than related to factors such as study design, setting or study quality.

Several factors (both physician and patient-related) may contribute to the high magnitude of PPI overuse. These include a long list of indications for use, availability of the drug ‘over the counter’, an exaggerated sense of safety, and lack of awareness about the correct indications, dose and duration of therapy. A recently published guideline makes detailed recommendations on the accepted indications for the use of PPI, including the dose and duration, and further such documents may help to promote its rational use. 3 Overall, there is a need for urgent adoption of PPI stewardship practices, as is done for antibiotics. Apart from avoiding prescription when there is no indication, effective deprescription strategies are also required. 10 We hope the result of the present systematic review and meta-analysis will create awareness about the current situation and translate into a change in clinical practice globally.

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Patient consent for publication.

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• Abrahami D ,
• McDonald EG ,
• Schnitzer ME , et al
• Jearth V , et al
• Malfertheiner P ,
• Megraud F ,
• Rokkas T , et al
• Shanika LGT ,
• Reynolds A ,
• Pattison S , et al
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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

X @drvishal82

Contributors AKD: concept, study design, data acquisition and interpretation, drafting the manuscript and approval of the manuscript. VS: study design, data acquisition, analysis and interpretation, drafting the manuscript and approval of the manuscript. AJ, AE, MKP, SM: data acquisition and interpretation, critical revision of the manuscript, and approval of the manuscript. RK: study design, data analysis and interpretation, critical revision of the manuscript and approval of the manuscript. MP, MG, SB, UD, DNR, RK: data interpretation, critical revision of the manuscript and approval of the manuscript. GKM: concept, study design, data interpretation, drafting the manuscript, critical revision and approval of the manuscript.

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

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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The White House 1600 Pennsylvania Ave NW Washington, DC 20500

Fact Sheet: Vice President Harris Announces Historic Advancements in Long-Term Care to Support the Care   Economy

Actions are the latest in a series of steps the Biden-Harris Administration has taken to improve safety, provide support for care workers and family caregivers, and to expand access to affordable, high-quality care

Everyone deserves to be treated with dignity and respect and to have access to quality care. That’s why, today, Vice President Harris is announcing two landmark final rules that fulfill the President’s commitment to safety in care, improving access to long-term care and the quality of caregiving jobs. Ensuring that all Americans, including older Americans and people with disabilities, have access to care – including home-based care – that is safe, reliable, and of high quality is an important part of the President’s agenda and a part of the President’s broader commitment to care. Today’s announcements deliver on the President’s promise in the State of the Union to crack down on nursing homes that endanger resident safety as well as his historic Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers , which included the most comprehensive set of executive actions any President has taken to improve care for millions of seniors and people with disabilities while supporting care workers and family caregivers.

Cracking Down on Inadequate Nursing Home Care

Medicare and Medicaid pay billions of dollars per year to ensure that 1.2 million Americans that receive care in nursing homes are cared for, yet too many nursing homes chronically understaff their facilities, leading to sub-standard or unsafe care. When facilities are understaffed, residents may go without basic necessities like baths, trips to the bathroom, and meals – and it is less safe when residents have a medical emergency. Understaffing can also have a disproportionate impact on women and people of color who make up a large proportion of the nursing home workforce because, without sufficient support, these dedicated workers can’t provide the care they know the residents deserve. In his 2022 State of the Union address, President Biden pledged that he would “protect seniors’ lives and life savings by cracking down on nursing homes that commit fraud, endanger patient safety, or prescribe drugs they don’t need.”

The Nursing Home Minimum Staffing Rule finalized today will require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day). This means a facility with 100 residents would need at least two or three RNs and at least ten or eleven nurse aides as well as two additional nurse staff (which could be registered nurses, licensed professional nurses, or nurse aides) per shift to meet the minimum staffing standards. Many facilities would need to staff at a higher level based on their residents’ needs. It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety. Adequate staffing is proven to be one of the measures most strongly associated with safety and good care outcomes.

To make sure nursing homes have the time they need to hire necessary staff, the requirements of this rule will be introduced in phases, with longer timeframes for rural communities. Limited, temporary exemptions will be available for both the 24/7 registered nurse requirement and the underlying staffing standards for nursing homes in workforce shortage areas that demonstrate a good faith effort to hire.

Strong transparency measures will ensure nursing home residents and their families are aware when a nursing home is using an exemption.

This rule will not only benefit residents and their families, it will also ensure that workers aren’t stretched too thin by having inadequate staff on site, which is currently a common reason for worker burnout and turnover. Workers who are on the frontlines interacting with residents and understanding their needs will also be given a voice in developing staffing plans for nursing homes. The Biden-Harris Administration also continues to invest in expanding the pipeline of nursing workers and other care workers, who are so essential to our economy, including through funding from the U.S. Department of Health and Human Services.

Improving Access to Home Care and the Quality of Home Care Jobs

Over seven million seniors and people with disabilities, alongside their families, rely on home and community-based services to provide for long-term care needs in their own homes and communities. This critical care is provided by a dedicated home care workforce, made up disproportionately by women of color, that often struggles to make ends meet due to low wages and few benefits. At the same time, home care is still very inaccessible for many Medicaid enrollees, with more than threequarters of home care providers not accepting new clients, leaving hundreds of thousands of older Americans and Americans with disabilities on waiting lists or struggling to afford the care they need.

The “Ensuring Access to Medicaid Services” final rule, finalized today, will help improve access to home care services as well as improve the quality caregiving jobs through its new provisions for home care. Specifically, the rule will ensure adequate compensation for home care workers by requiring that at least 80 percent of Medicaid payments for home care services go to workers’ wages. This policy would also allow states to take into account the unique experiences that small home care providers and providers in rural areas face while ensuring their employees receive their fair share of Medicaid payments and continued training as well as the delivery of quality care. Higher wages will likely reduce turnover, leading to higher quality of care for older adults and people with disabilities across the nation, as studies have shown. States will also be required to be more transparent in how much they pay for home care services and how they set those rates, increasing the accountability for home care providers. Finally, states will have to create a home care rate-setting advisory group made up of beneficiaries, home care workers and other key stakeholders to advise and consult on provider payment rates and direct compensation for direct care workers.

Strong Record on Improving Access to Care and Supporting Caregivers

Today’s new final rules are in addition to an already impressive track record on delivering on the President’s Executive Order on Care. Over the last year, the Biden-Harris Administration has:

• Increased pay for care workers, including by proposing a rule to gradually increase pay for Head Start teachers by about $10,000, to reach parity with the salaries of public preschool teachers.
• Cut child care costs for low-income families by finalizing a rule that will reduce or eliminate copayments for more than 100,000 working families, and lowering the cost of care for lower earning service members, thereby reducing the cost of child care for nearly two-thirds of children receiving care on military bases. Military families earning $45,000 would see a 34% decrease in the amount they pay for child care.
• Supported family caregivers by making it easier for family caregivers to access Medicare beneficiary information and provide more support as they prepare for their loved ones to be discharged from the hospital. The Administration has also expanded access to mental health services for tens of thousands of family caregivers who are helping veterans.

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