Hrev_master Healthcare in Low-resource Settings 2024; volume 12:13014 Readiness of nursing students for clinical practice: a literature review Oswati Hasanah,1,2 Rr Tutik Sri Haryati,1 Dessie Wanda,1 Nur Agustini,1 Masfuri1 1Faculty of Nursing, Universitas Indonesia, Depok, West Java; 2Faculty of Nursing, Universitas Riau, Pekan Baru, Riau, Indonesia Abstract Clinical placement in nursing education largely depends on the nursing student’s readiness to engage patient care. This review aims to illustrate the level of practice readiness in nursing students preparing for clinical placement, explore gender differences in practice readiness, identify the measurement tools used to assess readiness, and explore the various aspects of readiness measured. A systematic search was performed in the PubMed, SCOPUS, Ebsco, ProQues, ERIC, MEDLINE (EBSCOhost) databases. Relevant studies focused on nursing students, practice readiness before or during the professional education phase, and publications from 2018-2023. From 634 records, and seven articles meet the inclusion criteria. The studies utilized three primary measurement tools: the Casey-Fink Readiness for Practice Survey, RIPLS, and custom instruments to assess practice readiness. Results indicated high readiness scores for professional responsibilities and commu- nication skills, interprofessional education, and mixed readiness for clinical practice and treating COVID-19 patients. These find- ings highlight the diverse factors influencing nursing students’ pre- paredness for clinical practice. The assessment of readiness for practice in nursing students has diverse aspects. Nursing education- al institutions need to make efforts in developing learning strate- gies before students enter the clinical environment. Introduction Nursing is a critical and dynamic profession that plays a vital role in the healthcare system. The quality of care provided by nurses directly impacts the health of patients,1,2 making it impera- tive to ensure that prospective nurses are adequately prepared for clinical practice before going into the field.3 Clinical practice is a crucial component of nursing education, offering students the chance to apply theoretical knowledge to actual patient care situ- ations.4,5 Several factors can obstruct the integration of theory into nursing clinical practice, such as insufficient resources, inade- quate guidance, and limited time for practice.6 Clinical practice in nursing is an important step in preparing students for professional practice.5 The goal of clinical practice is to prepare students with the skills and competencies needed to deliver patient care effectively, efficiently, and safely.7 However, the success of clinical practice is highly dependent on the readi- ness of nursing students to engage in patient care. 8 Preparation before starting clinical practice covers a wide range of competen- cies, including technical skills, problem-solving ability, communi- cation, and teamwork skills.7 The concept of practice readiness has gained attention in nurs- ing education research in recent years, with various studies explor- ing factors that contribute to or hinder nursing students’ readiness for practice. However, research has predominantly concentrated on the practice readiness of newly graduated nurses or new nurses when entering the workforce. It is suggested that the healthcare system, work environment, and the quality of interactions in the workplace affect the performance of nursing graduates. These novice nurses gradually develop practice readiness through a tran- sitional continuum, ultimately achieving readiness based on fac- tors within their educational environment and workplace. Speaking of the clinical education process and the clinical educa- tion environment that new nurses go through, they also need thor- ough preparation and practice readiness in the academic education phase (clinical placement) in order to facilitate them in learning to apply theoretical knowledge to actual patient care situations. Several studies have identified factors that influence practice Correspondence: Oswati Hasanah, Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia E-mail: unni_08@yahoo.com Key word: nursing student; nursing education; clinical practice; student readiness; preparedness. Contributions: all authors contributed to this article, OH, RR, DW, NA and MM contributed to the data curation, extraction, analysis (i.e. critical appraisal) and analysis. Furthermore, the OH made a significant contri- bution to the study conceptualization, drafted the original review article, and interpreted the data. RR, DW, NA and MM contributed for revised the review by providing advice regarding the content Ethical approval: not applicable. Availability of data and material: the full list of references and datasets supporting the finding of this study can be accessed in the relevant pub- lished articles included in this review. Conflcit of interest: all authors declare that we have no conflict of inter- est on this research Funding: this study was independently funded by the authors Conference presentation: this work was presented at the 3rd International Nursing Scholar Congress 2023, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia. Acknowledgement: we would like to thank the scholarship providers, namely the Indonesian Education Scholarship (BPI). The Indonesian Endowment Funds for Education (LPDP) and Education Financing Service Center (Puslapdik) for their support for one of Our Investigator (OH) in carrying out the doctoral program in nursing. Received: 4 September 2024. Accepted: 4 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:13014 doi:10.4081/hls.2024.13014 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:13014] [page 734] Non -co mmerc ial us e o nly readiness in nursing students when clinical placement, including personal characteristics, educational factors,9,10 cognitive aspects, psychological attributes, and social influences,9-11 nursing educa- tion curriculum12,13 and clinical environment,9,14 Therefore, there is a need for adequate planning and preparation to ensure that nursing students are ready for clinical practice, and these factors must be considered to enable nursing students to have an effective clinical practice experience that is beneficial to their learning. Practice readiness is an important concept in nursing education that is influenced by various factors. Understanding the picture of practice readiness of students is essential in developing effective teaching strategies and interventions that improve nursing stu- dents’ clinical performance. This review will contribute to the existing literature on practice readiness in nursing education clini- cal placement and as a consideration in policy making in nursing education and nursing clinical practice guidelines. Currently, many studies and reviews have been conducted to explore the concept of practice readiness in nursing students so that a review on practice readiness itself in nursing students is needed. This literature review seeks to offer a summary of the overall practice readiness of nursing students who will be starting the clinical practice phase, explore gender differences in practice readiness, and examine the measurement tools used to assess readi- ness. Understanding these aspects is crucial for ensuring students are well-prepared for clinical practice, identifying and addressing gender-specific needs, and ensuring reliable and valid assessments of readiness. By doing so, educators and policymakers can develop strategies to enhance nursing education and better support all stu- dents. The findings of this review are expected to have positive implications for nursing education. The information from this review can be used as a consideration for policy making in nursing education, curriculum and practice guidelines in order to improve clinical practice readiness for nursing students and in the long run will improve the quality of patient care. Materials and Methods Design The study focuses on nursing students, with no intervention or comparison involved, and aims to describe clinical practice readi- ness. Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure clear and transparent reporting. The PRISMA flow chart (Figure 1) was utilized in this study to enhance transparency and facilitate the replication of the research.15 The specific research question aimed to provide an overview of practice readiness among nursing students. Practice readiness is a crucial aspect of the clinical mentoring process during the profes- sional education phase. It is also important for educational policy- makers to understand, as it helps identify the challenges faced by nursing students. This insight can help in creating strategies to enhance the practice readiness of future professional students and the job readiness of upcoming professional nurses. The implemen- tation of this research is specifically influenced by the limited information related to how the actual picture of practice readiness (readiness to practice) quantitatively and qualitatively in nursing students, before conducting clinical practice or professional prac- tice when clinical placement. Search methods The databases utilized were PubMed, SCOPUS, EBSCO, ProQuest, ERIC, and MEDLINE (EBSCOhost), focusing on English-language articles published between 2018 and 2023. This time frame was chosen to ensure access to the most current litera- ture. Searches were performed using Boolean operators with pre- defined keywords, related synonyms, and Medical Subject Headings (MeSH) terms, with the PubMed database serving as the foundation for developing the MeSH terms. Additionally, trunca- tion and wildcards were applied to some terms. Search terms for nursing students included nursing student, student nurse, pre-licen- sure nursing student and undergraduate nursing student as well as the use of truncation on the words nursing student* and student nurse* For practice readiness, search terms included readiness, practice readiness, readiness for practice, readiness to practice, clinical readiness and practice readiness. Inclusion and exclusion criteria Relevant studies were chosen based on predefined inclusion and exclusion criteria. For these types of reviews, which aim to assess prevalence and incidence data, the JBI (Joanna Briggs Institute) recommends using the CoCoPop mnemonic. CoCoPop stands for Condition, Context, and Population, and is specifically designed to guide the inclusion criteria in reviews that evaluate prevalence and incidence data.16,17 Based on CoCoPop, the inclu- sion criteria for this review are: populations are nursing students, the type of research used is descriptive, cross sectional, cohort and mixed method research, the study focuses on practice readiness or clinical practice readiness in the nursing education phase before or during the professional education phase or before clinical practice in all clinical settings, the country of study was not limited. The search criteria included research publications written in English and published between 2018 and 2023. Exclusion criteria for this study were studies focusing on practice readiness after the profes- sional education phase, involving nurse participants who have completed their education, or those that were not research article. Data extraction Utilizing a self-created extraction matrix, the authors extracted data focusing on study characteristics such as author, country, study objectives, design, sample, data collection and analysis methods, and significant findings. Quality appraisal Critical appraisal (or methodological quality/risk of bias assessment) in this review was conducted by one reviewer. The reviewer evaluated the quality of each study using the JBI Critical Appraisal Tool. Some reviews that assess prevalence and incidence do not include a critical appraisal process, but only include ‘mini- mum criteria’ for inclusion.16,17 The reviewer has a Master’s degree and specializes in pediatric nursing. Data analysis The outcome data from the included studies were compiled and presented as narrative summaries using a thematic synthesis framework. Results Study characteristics A total of 634 articles were found from all databases used, Article [page 735] [Healthcare in Low-resource Settings 2024;12:13014] Non -co mmerc ial us e o nly using predefined keywords. The number of articles from each data- base was 54 studies obtained from PubMed, 233 studies from Scopus, 101 studies from EBSCO, 185 studies from Proquest, 33 studies from ERIC and 28 studies from MEDLINE (EBSCO). From the total number of articles, seven articles that met the inclu- sion criteria were identified and included in the review. The details of the article selection process are outlined in Figure 1. The total sample size of the research articles was 1752 respon- dents, most of whom were female students. The response rate of the overall study results ranged from 40-90% of the target sample size. Supplementary Table 1 presents the features of the studies that were collected. The articles analyzed are studies from coun- tries spread across various continents (Europe, Asia, Australia and Africa) namely Serbia, Italy, Turkey, Oman, Japan and Nigeria. In the study approach, there were five studies that used a cross-sec- tional approach,18-22 study with a cohort approach,23 and one study with a mixed method approach.24 All the articles analyzed had the main objective to determine the practice readiness of nursing stu- dents, in different aspects of practice. Then from each study also has other specific objectives. In two studies the research also intended to compare the readiness levels of nursing students with those of other health students; however, the analysis was limited to the results from two studies involving only the nursing student group.21,24 Instruments/measures of readiness Of the seven studies analyzed in this review, three types of measurement tools were found, where their use was adjusted to the research objectives of each study. The three measuring instruments are the Casey-Fink Readiness for Practice Survey,23 the Readiness for Inter-professional Learning Scale (RIPLS),19-21,24 and measur- ing instruments developed by the researchers themselves.18 Aspects assessed in the research instrument The Casey-Fink Readiness for Practice Survey measures four subscale factors, namely clinical problem solving, learning tech- niques, professional identity, and trials and tribulations. The RIPLS measuring instrument measures five main things, namely teamwork and collaboration, professional identity, respect for other roles, active and interactive learning and social responsibili- ty.25 Meanwhile, the measurement tools developed by the authors are aimed at assessing students’ readiness to conduct clinical prac- tice during the COVID-19 pandemic and readiness to treat COVID-19 patients.18,22 Students’ readiness for practice In a study that used the Casey-Fink Readiness for Practice Survey,23 the readiness score was rated as high, between 85-99%. The findings detailed those participants felt secure in their profes- sional duties and believed they had sufficiently prepared for their roles, and they also affirmed their confidence in their communica- tion abilities. In four studies that used the RIPLS measurement tool assessed readiness in the context of nursing students’ readiness to conduct interprofessional education (IPE).19-21,24 Where learning related to IPE is obtained in the clinical practice phase. Of the four studies, the total RIPLS score of nursing students was in the range of 69.78 - 82.2. The highest RIPLS score was obtained in a study of nursing students in Japan, namely 82.2 ± 0.69.24 This score illustrates that in general nursing students, with the current curriculum, are ready and willing to participate in IPE practices during clinical practice. In two studies,18,22 readiness was assessed in the context of stu- dents’ readiness to conduct clinical practice during the COVID pandemic and readiness to care for COVID patients. In both stud- ies, researchers used self-composed tools, developed based on a literature review. The measurement results in this instrument are not calculated using scoring, but in the form of a final categoriza- tion with the categories ready and not ready. The assessment results in the study stated that 61.7% of students reported feeling prepared for clinical practice during the pandemic, only a small percentage (30.7%) of students stated that they were ready to treat corona virus patients.18 Meanwhile, in one of the research, stated that most students expressed their unpreparedness to carry out clin- ical practice during a pandemic (66.79%),22 which means the same as the research, at that time not many students felt ready to treat COVID-19 patients, due to various factors.18 Discussion The studies included in this review represent several countries around the world. Some similar studies were not captured in the search, because they did not meet several criteria, including the scope of research years limited to the last five years of study, could not be accessed in full text and the purpose/method of research did not match the purpose of the search. Most of the studies related to readiness to practice with the keyword readiness are more in the population of students who have graduated from education to see readiness to practice after graduation and in the transition phase to become a new nurse, not in nursing students who will do clinical practice as students. From the seven studies analyzed in this review, in general, nursing students are considered ready to do clinical practice. Except during the COVID-19 pandemic, espe- cially in the early phase, there are many factors that affect student readiness, both internal and external factors. Research by Joolaee Article [Healthcare in Low-resource Settings 2024;12:13014] [page 736] Figure 1. PRISMA flow diagram. Non -co mmerc ial us e o nly et al indicated that nursing students may not be psychologically prepared to enter the clinical environment due to certain factors.26 This condition can affect the quality of their learning and their readiness to learn in the field. Therefore, paying attention to the level of readiness of students, including their needs and psycholog- ical conditions before entering the clinical practice setting, can help improve students’ competence and readiness when doing clin- ical practice placements. In this study, nursing students were dominated by the female student population, this is indeed because in general, there are more female nurses than male nurses. Regarding gender differ- ences in practice readiness, female students have been shown to be more prepared to work in teams and collaborate than male stu- dents.27 In many countries the choice to become a nurse is mostly chosen by women, due to gender traditions,28 but today more and more men are choosing the nursing profession as social changes and changes in gender views or due to cultural factors such as in Arabia. 29 In various studies, gender differences are not actually the causal factor that distinguishes readiness in practice, but there are many other factors both internally and externally from the student. Assessment of student readiness can also include assessment of theoretical knowledge, professional attitudes, and practical experience. Evaluation of these students can include cognitive, psychomotor, and affective aspects. This evaluation is not only to see students’ clinical abilities, but also to assess their psychological and emotional aspects, as in Joolaee et al. study which reviewed the psychological aspects of students.26 Assessment of practice readiness can also be done based on settings, conditions, and cases in the field. This evaluation is very important to determine the extent to which nursing students have prepared themselves and the extent to which they have been prepared to enter the clinical envi- ronment and provide care to patients safely and effectively. Evaluating nursing students’ readiness for practice varies in context and objectives across different studies. Therefore, the measuring instrument used must be adjusted to the purpose of measuring each aspect in the study. In Jamieson et al study, the Casey-Fink Readiness for Practice Survey was utilized as the measuring instrument.23 This instrument measures nursing stu- dents’ readiness to enter clinical practice by exploring four sub- scale factors, specifically, clinical problem-solving, learning strategies, professional identity, and trials and tribulations. Results in this questionnaire are presented for each subscale.30 The Casey- Fink Readiness for Practice Survey has been utilized as a measure- ment tool in several studies to evaluate students’ readiness in man- aging patient care tasks and in communicating with doctors. Multiple studies employing the Casey-Fink Readiness for Practice Survey have revealed that nursing students encounter significant challenges in managing patient care tasks, communicating with doctors, and caring for critically ill patients. In addition, students also need further assistance and guidance in developing clinical competencies, role development, and career planning during clini- cal practice from their seniors.12 In addition to being used to explore students’ readiness before clinical placement, this instru- ment has also been used in various research studies. The study used the Readiness for Interprofessional Learning Scale (RIPLS) to assess nursing students’ readiness for interprofes- sional practice. Four studies in this review assessed readiness in the context of nursing students’ readiness to conduct Interprofessional Education (IPE).19-21,24 Where learning related to IPE is obtained in the clinical practice phase. The main things assessed in the scale are Teamwork and Collaboration, Professional Identity, Respect for Other Roles, Active and Interactive Learning and Social Responsibility.25 In addition, two studies developed their own measurement tools, as done by Nweke et al and Basso et al in their study to evaluate nursing students’ readiness to practice during the COVID-19 pandemic.18,22 These tools can be used separately or in combination to assess student preparedness more comprehensively. Academic preparation is an important part of the readiness process for nursing students before clinical practice. The goal is to alleviate nursing students’ fear and anxiety before they enter the clinical setting. In addition, Efforts are needed to close the gap between theory and clinical practice by providing all the necessary materials for field practice during the academic process. Educational institutions should also identify areas for improve- ment in nursing education programs and ensure that students are prepared to work as professional nurses after graduation. Thus, thorough academic preparation and appropriate strategies in link- ing theory and clinical practice can help improve nursing students’ readiness and competence in clinical practice. All of the studies analyzed provided clues about several learn- ing strategies that can improve nursing students’ practice readi- ness. The first strategy is the development of clinical skills through structured and measurable learning approaches, by providing diverse and contextually appropriate practice experiences. Second, interprofessional education and collaborative practice approaches can help nursing students work in teams with other health profes- sionals. Third, the development of an inclusive nursing education curriculum and self-development and professionalism programs. It’s also important to consider the latest advancements in the health sector and the evolving requirements for health worker qualifica- tions due to changes in global situations and conditions. Self- development and professionalism programs can also help nursing students to continue learning and develop the skills needed in the future. It is hoped that by integrating these learning strategies, nursing students can become competent health workers. Conclusions Assessment of readiness for practice in nursing students has many aspects, so it is necessary to have an appropriate measure- ment tool to evaluate each aspect of student readiness. Educational institutions need to make efforts to develop learning strategies, such as clinical skills workshops and visiting hospitals before entering the clinical environment. 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