example of a literature review on inclusive education

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Inclusive Education: Literature Review

The education of disabled children never received such amount of consideration and special efforts by government and non-government agencies in past as in present days. The attitude of the community in general and the attitude of parents in particular towards the education of the disabled have undergone change with the development of society and civilization.

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vatika sibal

Executive Summary In India, inclusive education for children with disability has only recently been accepted in policy and in principle. In light of supportive policy and legislation, the present paper argues for individual initiative on part of an institution and colleges to implement programmes of inclusive education for children with disabilities in their classrooms. The paper provides guidelines in a generalized mode that institutions can follow to initiate such programmes. In this context, this paper argues for individual initiative on part of institutions to extend facilities for children with disabilities within their regular school settings. The paper further provides guidelines that institutions can adopt to set up inclusive education practices. The guidelines were derived from an empirical study which entailed examining prevalent practices and introducing inclusion in a regular institution setting. It is suggested that institutions can implement inclusive education programmes if they are adequately prepared, are able to garner support of all stakeholders involved in the process and have basic resources to run the programmes. The guidelines also suggest ways in which curriculum adaptations, teaching methodology and evaluation procedures can be adapted to suit needs of students with special needs. Issues of role allocation and seeking support of parents and peers are also dealt with. The recommendations that intuitions can adopt to implement inclusive education programmes for students with special needs within their regular set ups. The recommendations have been presented in a generalized mode to permit institute to interpret, modify and adapt the guidelines based on their individual needs and characteristics. It is pertinent those institutes that initiate such programmes assess their strengths and weaknesses at the outset and ensure adequate cooperation from the school management as well as the administrative and teaching staff. It is important to state here that an inclusive education programme does not require resource overload or elaborate preparations. With policy support, opportunities for training of teachers and cooperation from parents and the peer group, inclusive practices can be effectively adopted by any school. Clarity of vision, commitment to the goal of inclusion, and a perceptible understanding of the nuances involved in such an initiative are central to the success of the programme. Emotional commitment to inclusion emerges when the intellectual understanding of the concept goes through a democratic visioning process involving all the stakeholders expressing their opinions and feelings.

Inclusive Education: children with disabilities - - Background paper prepared for the 2020 Global Education Monitoring Report Inclusion and education 2020

Paula Frederica Hunt

This paper presents the case for inclusive education for children with disabilities as the entry point for policy development and implementation of inclusive education in the broad sense: inclusive, quality education for ALL children. The paper starts by providing a short historical perspective of the education of children with disabilities and continues with a description of the essential elements of an inclusive legislative framework, with a particular focus on General Comment no4 of Article 24 (CRPD). The benefits of inclusive education, as well as financing mechanisms, and required accountability measures for implementation, are also discussed. Then, the paper discusses the foundational basis of curriculum for inclusion, as well as issues related to a transformative teacher education practice. The final chapters describe what an inclusive school might look like, as well as the role of students, families and communities in creating an inclusive education system. It should be noted that this paper is substantiated with selective literature, with attention payed to an equitable geographic coverage.

ankur madan

Research Anthology on Inclusive Practices for Educators and Administrators in Special Education

Shekh Farid

BRAC, a leading international development organization, has been working to ensure the rights of persons with disabilities to education through its inclusive education program. This article discusses the BRAC approach in Bangladesh and aims to identify its strategies that are effective in facilitating inclusion. It employed a qualitative research approach where data were collected from students with disabilities, their parents, and BRAC's teachers and staffs using qualitative data collection techniques. The results show that the disability-inclusive policy and all other activities are strongly monitored by a separate unit under BRAC Education Program (BEP). It mainly focuses on sensitizing its teachers and staff to the issue through training, discussing the issue in all meetings and ensuring effective use of a working manual developed by the unit. Group-based learning and involving them in income generating activities were also effective. The findings of the study would be usefu...

Shonazar Botirov

This article describes the introduction of inclusive education, what it is, about children with disabilities, as well as the positive and negative aspects of inclusive education.

Ikhfi Imaniah

This paper identifies and discusses major issues and trends in special education in Indonesia, including implications of trends for the future developments. Trends are discussed for the following areas: (1) inclusion and integration, issues will remain unresolved in the near future; (2) early childhood and postsecondary education with disability students, special education will be viewed as lifespan schooling; (3) transitions and life skills, these will receive greater emphasis; and (4) consultation and collaboration, more emphasis but problems remain. Moreover, the participant of the study in this paper was an autism student of twelve years old who lived at Maguwoharjo, Yogyakarta. This study was qualitative with case study as an approach of the research. The researchers conclude the autism that has good academic, communication and emotional skill are able to go to integrated school accompanied by guidance teacher. But in practice, inclusive education in Indonesia is inseparable from stakeholders ranging from government and institutions such as schools, educators, school environment, community and parents to support the goal of inclusive education itself. Adequate infrastructure also needs to be given to the school that organizes inclusive education for an efficient and effective students understanding learning-oriented of inclusive education. In short, every child has the same opportunity in education, yet for special education which is aimed at student with special educational needs.

Rajendra KR

Inclusive Education on Children with Learning Disabilities

Arien Arien

ABSTRACT Name : Zahrien Assyifa Nur Palisma NISN : 0002223086 Title : Analysis of Inclusive Education on Children with Learning Disabilities (Case study on 4th Grade of Mutiara Bunda Elementary School, Cilegon Banten Inclusive Education is an approach that aims to change the education system by translating barriers that can accommodate every student to participate fully in education. That is, every child is entitled to a decent education, not to mention children with learning disabilities. Children with learning disabilities are interpreted as children who find it difficult to receive formal and non-formal learning because of certain psychological "disabilities". This study aims to determine how much the effectiveness of inclusive education for children with learning disabilities in Mutiara Bunda Elementary School, Cilegon. The method used by the author is the field research that is carried out on October 6th, 2017 at Bunda Mutiara Elementary School, Street. Boulevard Raya Block A2 Number.6 Taman Cilegon Indah, Sukmajaya, Cilegon Banten.The results obtained from this study are: a. Inclusive Education is the right solution for children with learning disabilities even for all children with disabilities. b. The curriculum used in inclusive schools is similar to the curriculum in public schools. There is little modification in children with learning disabilities as well as some omissions and curriculum substitutions. Keywords: Inclusive Education, Children with Learning Disabilities

Swati Chakraborty

International Journal of …

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Review of Literature: Inclusive Education 

This brief review of relevant literature on inclusive education forms a component of the larger Inclusive School Communities Project: Final Evaluation Report delivered by the Research in Inclusive and Specialised Education (RISE) team to JFA Purple Orange in October, 2020. 

Suggested citation for full evaluation report: 

Jarvis, J. M., McMillan, J. M., Bissaker, K., Carson, K. L., Davidson, J., & Walker, P. M. (2020).  Inclusive School Communities Project: Final Evaluation Report. Research in Inclusive and Specialised Education (RISE), Flinders University. 

https://sites.flinders.edu.au/rise  

Introduction 

Inclusive education has featured prominently in worldwide educational discourse and reform efforts over the past 30 years (Berlach & Chambers, 2011; Forlin, 2006). Inclusive schools are critical to providing a strong foundation for young people with disabilities to access, participate in and contribute to their communities and lead fulfilling lives (Hehir et al., 2016). Schools also represent a key condition for the development of thriving, inclusive communities for all citizens. Yet, as reflected in submissions to the current Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, and consistent with recent South Australian reports (Parliament of South Australia, 2017; Walker, 2017), many students living with disability (and their families) continue to report negative experiences of education. While progress has been made, traditional educational structures and practices often run counter to inclusive goals (Slee, 2013), and inconsistencies occur between theory and policy and the implementation of inclusive principles and practices in schools (Carrington & Elkins, 2002; Graham & Spandagou, 2011). In addition, both preservice and practicing teachers consistently report feeling underprepared to teach students with disabilities and special educational needs (Jarvis, 2019; OECD, 2019). 

Despite legislation and policy imperatives related to inclusive education, there remains a lack of consensus in the field about the definition of inclusion and associated models of inclusive practice (Ainscow & Sandill, 2010; Kinsella, 2020). Multiple conceptualisations of inclusion and theoretical approaches to fostering inclusion in schools may contribute to confusion and uncertainty for educators and policymakers. With schools facing growing accountability and teachers expected to educate an increasingly diverse student population (Anderson & Boyle, 2015), it is vital that the concept of inclusive education is demystified for practitioners. Against this backdrop, initiatives such as the Inclusive School Communities (ISC) project that aim to deepen understandings of inclusion and increase the capacity of school communities to provide an inclusive education, are particularly important. 

Inclusive Education 

Inclusive education is based on a philosophy that stems from principles of social justice, and is primarily concerned with mitigating educational inequalities, exclusion, and discrimination (Anderson & Boyle, 2015; Booth, 2012; Waitoller & Artiles, 2013). Although inclusion was originally concerned with ‘disability’ and ‘special educational needs’ (Ainscow et al., 2006; Van Mieghem et al., 2020), the term has evolved to embody valuing diversity among all students, regardless of their circumstances (e.g., Carter & Abawi, 2018; Thomas, 2013). Among interpretations of inclusion, common themes include fairness, equality, respect, diversity, participation, community, leadership, commitment, shared vision, and collaboration (Booth, 2012; McMaster, 2015). The United Nations Convention on the Rights of Persons with Disabilities (CRPD), to which Australia is a signatory, defines inclusive education as:  

. . . a process of systemic reform embodying changes and modifications in content, teaching methods, approaches, structures and strategies in education to overcome barriers with a vision serving to provide all students of the relevant age range with an equitable and participatory learning experience and environment that best corresponds to their requirements and preferences. (United Nations, 2016, para 11)

Consistent with this definition, inclusive education now generally refers to the process of addressing the learning needs of all students, through ensuring participation, achievement growth, and a sense of belonging, enabling all students to reach their full potential (Anderson & Boyle, 2015; Booth, 2012; Stegemann & Jaciw, 2018). Inclusion is concerned with identifying and removing potential barriers to presence (attendance, access), meaningful participation, growth from an individual starting point, and feelings of connectedness and belonging for all students and community members, with a focus on those at particular risk of marginalisation or exclusion (Ainscow et al., 2006; Forlin et al., 2013). 

Critically, the view of inclusion described above moves beyond considerations of the physical placement of a student in a particular setting or grouping configuration. That is, while physical access to a mainstream school environment is essential to maintain the rights of students living with disabilities to access education “on the same basis” as their peers (consistent with legislation and human rights principles), it is not sufficient to ensure inclusion. Rather, inclusion can be considered a multi-faceted approach involving processes, practices, policies and cultures at all levels of a school and system (Booth & Ainscow, 2011). Inclusive education is responsive to each child and promotes flexibility, rather than expecting the child to change in order to ‘fit’ rigid schooling structures. The latter approach reflects integration, and inclusion is also inconsistent with segregation, in which children with disabilities are routinely educated separately from others. 

Considerable research has focused on the implementation of inclusive school processes, practices and cultures that are sustainable over time. Although a number of frameworks to achieve sustainable inclusive practice have been proposed, key elements are consistent across approaches and well supported by research (Booth & Ainscow 2011; Azorín & Ainscow, 2020). These interconnected elements are summarised in Figure 1 and considered fundamental to the process of achieving whole-school (and systemic) cultural change towards more inclusive ways of working. Of particular relevance to the Inclusive School Communities project are the concepts of a whole school approach, leadership, school values and culture, building staff capacity, and multi-tiered models of inclusive practice. 

Inclusion as a Whole School Approach 

Adopting a whole of school approach to inclusive education is fundamental to ensure efficacy and sustainability (Read et al., 2015). The process of developing inclusive schools is complex and multi-faceted, requiring time, commitment, ongoing reflection, and sustained effort. For inclusion to truly take root in schools, changes must be made from the inside out; a strong foundation must be built from inclusive school values, committed leadership, and shared vision amongst staff to support whole school structural reforms to policy, pedagogy, and practice (Ekins & Grimes, 2009). Whilst challenging, “it is necessary to unsettle default modes of operation” in schools (Johnston & Hayes, 2007, p.376), as inclusive education requires new, more efficient and effective ways of supporting student participation and achievement. This is made possible by implementing flexible, planned whole school support structures, such  as multi-tiered systems of support (MTSS), where teachers work collaboratively with specialist staff to identify, monitor, and support students requiring varying levels and types of intervention at different times, and for different purposes (Sailor, 2017; Witzel & Clarke, 2015). This contrasts to the more traditional, ‘categorical’ and segregated approach of general educators referring identified students with additional needs to special educators, to devise and administer further education in isolation from the regular classroom (Sailor, 2017). 

Figure 1. Interconnected elements in sustainable inclusive education, derived from research.

Even at the classroom level, inclusive planning and teaching practices must be supported by school policies, practices, and culture in order to be sustainable (Sailor, 2017). Barriers to inclusive classroom practice can include lack of effective professional learning and support for teachers; teachers’ lack of willingness to include students with particular needs; attitudes that are inconsistent with inclusive practices; teacher education that fails to address concerns about inclusion; and, a lack of accountability for the implementation of inclusive teaching practices (Forlin & Chambers, 2011; Forlin et al., 2008; van Kraayenoord et al., 2014). Addressing each of these relies on targeted, coordinated support. The complexity of embedding inclusive practices such as differentiated instruction or Universal Design for Learning (UDL) into classroom work is often underestimated, and these practices have the greatest chance of becoming embedded when they are reinforced by a shared vision and collaborative effort (McMaster, 2013; Sailor, 2015; Tomlinson & Murphy, 2017). 

Sustainable, whole school change cannot be achieved via focus on a single element of inclusion in isolation, as components do not function in isolation. Rather, the core elements of inclusion including leadership, school culture, building staff capacity, and inclusive practices are parts of an interdependent system. Hence, key elements of inclusion must be considered collectively and accounted for in advanced planning to ensure they function harmoniously and are integrated into the developing inclusive fabric of the school (Alborno & Gaad, 2014). 

Leadership for Inclusion 

The importance of leadership for determining the success of school reforms or changes to practice is well established in the literature (McMaster & Elliot, 2014; Poon-McBrayer & Wong, 2013). Becoming a more inclusive school often requires significant shifts in school values, culture, practices, and organisational systems; thus, leadership is critical to ensuring sustainable inclusive change in schools (Ainscow & Sandill, 2010; McMaster, 2015; Poon-McBrayer & Wong, 2013). School leaders are highly influential figures whose values, beliefs, and actions directly affect the culture of the school, expectations of staff, and school operations (Slater, 2012; Wong & Cheung, 2009). It is critical that school leaders are committed to embodying inclusive principles, establishing and modelling a standard of behaviour that promotes the development of inclusion within the school community. 

Organisational change on the scale often required for inclusion requires leadership across multiple levels (Jarvis et al., 2016; Tomlinson et al., 2008). It is likely to be most effective when facilitated through models of distributed leadership across roles and levels within a school, and when the case for change is underpinned by a broader, shared vision specifically related to student outcomes (Harris, 2013). Research has established the relationship between distributed leadership practices and the implementation of effective, inclusive school practices (Miškolci et al., 2016; Mullick et al., 2013; Robinson et al., 2008; Sharp et al., 2020). Leaders should consider utilising inclusive styles of management, replacing hierarchical structures with leadership teams (Ainscow & Sandill, 2010; McMaster, 2015). Effective school leadership enables shared responsibility, vision, and consistency within the school community, which is vital for the successful implementation of inclusion (Poon- McBrayer & Wong, 2013). 

Fostering Inclusive School Cultures 

Developing an inclusive school culture is a fundamental component of developing sustainable inclusion in schools (Dyson et al., 2004; McMaster, 2013). The culture of a school is made up of the shared values, attitudes, and beliefs of the school community (Booth, 2012). Transitioning to a truly inclusive culture requires close attention to attitudes and general support of the inclusive values being adopted, particularly by staff, but also by students and the broader school community (Dyson et al., 2004; Forlin & Chambers, 2011). 

A whole school approach to inclusion prompts a school to reflect on and embrace values based on inclusive principles, such as equality, diversity, and respect. This process cannot be imposed, but should be a collaborative exercise with school leaders and staff, to ensure any pedagogical philosophies or practices based on outdated ideas or past assumptions are not operating by default (Johnston & Hayes, 2007; Schein, 2004). Evaluating and redefining existing school values also requires professional learning, to facilitate a collective reconceptualisation of inclusion specific to the unique context of the school; the meaning, aims, and expectations of inclusion must be clarified for the school community, to encourage a shared understanding, vision, and responsibility for supporting the inclusive changes unfolding within the school (Horrocks et al., 2008; Symes & Humphrey, 2011). Finally, it is vital that school policies and practices are regularly revised, to ensure that they reinforce the inclusive values and culture of the school; otherwise, they can act as a potential barrier to the development of sustainable whole school inclusion (Dybvik, 2004; McMaster, 2013). 

Building Teachers’ Capacity for Inclusive Practice 

Building the knowledge and capacity of teachers and other school staff is crucial to developing sustainable inclusion in schools. The evolution of an inclusive school culture depends on aligning the attitudes and behaviour of staff (McMaster, 2015). Teachers must be knowledgeable about how inclusive education has progressed over time, particularly how the meaning of inclusion has changed and what it means in their school context. Understanding the concepts and values behind inclusion can help teachers appreciate its significance, prompting reflection of their own practice and how they see their students (Anderson & Boyle, 2015; Skidmore, 2004). This can allow any unhelpful assumptions or beliefs that may have been unconsciously informing their teaching practice, particularly in relation to students living with disability, to be challenged and revised (Ashby, 2012; Ashton & Arlington, 2019). 

While attention to attitudes, values, and broad understandings is fundamental, the goals of inclusion will only be achieved when principles are consistently enacted in daily classroom practice. At the classroom level, inclusion relies on teachers’ willingness and capacity to apply evidence-informed inclusive practices, such as Universal Design for Learning (UDL) and Differentiated Instruction (Van Mieghem et al., 2020). UDL is a planning framework for learning activities designed to maximise curriculum accessibility for all students by offering multiple opportunities for engagement, representation, and action and expression (CAST, 2018; Sailor, 2015). Differentiated Instruction (DI) is a holistic framework of interdependent principles and practices that enables teachers to design learning experiences to address variation in students’ readiness, interests and learning preferences (Tomlinson, 2014). UDL is primarily focused on inclusive task design, although the model has been expanded in recent years to include greater attention to pedagogy. Differentiation encompasses elements of planning (clear, concept-based learning objectives; formative  assessment to inform proactive decision-making for diverse students), teaching (strategies to differentiate by readiness, interest and learning preference; ensuring respectful tasks and ‘teaching up’), and learning environment (flexible grouping, classroom management, establishing an inclusive culture) (Jarvis, 2015; Tomlinson, 2014). 

The application of UDL and DI principles and practices by skilled teachers enables diverse students to access curriculum content in multiple ways (Kozik et al., 2009; McMaster, 2013), at appropriate levels of challenge and support to ensure learning growth, and in ways that support motivation, engagement, and feelings of connection and belonging (Beecher & Sweeney, 2008; Callahan et al., 2015; van Kraayenoord, 2007; Stegemann & Jaciw, 2018). These complementary frameworks apply to all students and define general, flexible classroom practices that also reduce the need for individualised adjustments for students with identified disabilities and specialised learning needs. However, in inclusive classrooms, teachers must also develop the knowledge and skills to make and implement reasonable adjustments and accommodations that enable students with identified disabilities and more complex needs to engage with curriculum and assessment ‘on the same basis’ as their peers, as defined within the Disability Standards for Education (Davies et al., 2016). 

While inclusive teaching and classroom practices are non-negotiable, the challenge for some teachers to master the necessary skills and achieve the significant shift away from traditional teaching practices is often underestimated (Dixon et al., 2014; Tomlinson & Murphy, 2015). It is well-documented that teachers often find it difficult to apprehend both the conceptual and practical tools of DI and to embed differentiated practices into their daily work (Dack, 2019), particularly when they are not adequately resourced or supported to do so (Black-Hawkins & Florian, 2012; Brigandi et al., 2019; Fuchs et al., 2010; Mills et al, 2014). Perhaps related to teachers’ perceived lack of competence and confidence, the past 5-10 years have seen an enormous increase in the employment of teacher aides to work alongside students with disabilities in mainstream classrooms, despite limited evidence for its effectiveness and often in the context of inadequate planning and oversight (e.g., Sharma & Salend, 2016). 

Engagement in targeted professional learning (PL) is fundamental to supporting the shift towards inclusive teaching. Yet, traditional approaches to PL have been criticised for a lack of systematic evaluation and inadequate adherence to principles of effectiveness (Avalos, 2011; Merchie et al., 2018). Research on effective professional learning for teachers has established common principles and practices that are associated with changes in practice, and these also align with teachers’ stated preferences (Walker et al., 2018). These include: 

• professional learning is embedded in teachers’ own work contexts, and requires teachers to engage with content that is highly relevant to their daily practice, and closely linked to student learning (Desimone, 2009; Easton, 2008; Spencer, 2016; Van den Bergh et al., 2014); 
• professional learning enables teachers to learn together with colleagues, such as in communities of practice (Gore et al., 2017; Voelkel & Chrispeels, 2017); 
• professional learning activities are supported by robust school leadership and linked to broader school values and goals (Carpenter, 2015; Frankling et al., 2017; Sharp et al., 2020; Tomlinson et al., 2008; Whitworth & Chiu, 2015); 
• professional learning is provided over extended periods, is led by facilitators with expert knowledge, and includes timely follow up activities such as mentoring and coaching to embed changes in practice (Desimone & Pak, 2017; Grierson & Woloshyn, 2013; Tomlinson & Murphy, 2015). 

Multi-tiered Approaches to Whole School Inclusive Practice 

Multi-tiered system of supports (MTSS) is an overarching term for a whole school inclusive framework that can be used to structure the flexible, timely distribution of resources to support students depending on their level of need (Sailor, 2017). As reflected in the generic depiction of MTSS in Figure 2, models generally utilise three tiers of intervention and teaching, where the intensity of the support is increased with each level or tier (McLeskey et al, 2014; Witzel & Clarke, 2015). Tier 1 includes core differentiated instruction and universal, evidence-based strategies for support that all students in the class receive. Tier 2 provides additional, targeted support to certain students for a specified purpose and period of time, usually in a small group format, while Tier 3 represents the most intensive and individualised support (Webster, 2016). The MTSS approach requires assessing all students regularly to assist in the early identification of needs requiring additional support, to enable prompt delivery of targeted interventions (McLeskey et al., 2014). MTSS is concerned with supporting the holistic development of students, by targeting their academic progress, behaviour, and socio-emotional well- being (McMillan & Jarvis, 2017). 

When implemented with fidelity, MTSS is an effective whole school inclusive framework as teachers, therapists, and other support staff work collaboratively to assess, monitor, and plan interventions to support students (Sailor, 2017). Student progress is frequently monitored and data are evaluated by the support team to determine whether alternative interventions are required. MTSS additionally encourages the use of evidence-based practices to be implemented across the tiers of support. Some common examples of MTSS include Response to Intervention (RTI) and Positive Behaviour Interventions and Supports (PBIS) (Webster, 2016). RTI is focused on supporting students academically, while PBIS is concerned with emphasising behavioural expectations in a positive manner, naturally supporting the social and emotional development of students. MTSS models have also been applied in whole-school mental health promotion, prevention and intervention (McMillan & Jarvis, 2017) and inclusive approaches to academic talent development for more advanced students (Jarvis, 2017). 

MTSS approaches to contemporary inclusive practice stand in contrast to traditional, categorical models whereby students were either ‘in’ or ‘out’ of special education services. The focus is on determining and responding to what students need when they need it, as opposed to focusing on a specific diagnosis or inflexible program options. In the MTSS framework, the tiers do not represent students or their placement, but the flexible suite of supports and interventions that may be provided. The implementation of MTSS approaches fundamentally reconceptualises the role of the classroom teacher, who must work collaboratively with specialist staff and other professionals to define and address individual student needs in ongoing ways, rather than relying on a specialist teacher or even a teacher aide to take responsibility for the education of students with identified special needs. While MTSS requires substantial changes to school operations (and must therefore be supported by leadership and culture in deliberate, coordinated ways), the general framework provides an organisation and structure to support the development of sustainable, contemporary inclusive schools (McLeskey et al., 2014). 

Figure 2. Multi-tiered System of Supports (MTSS) framework. 

Conclusion 

Ultimately, developing sustainable and effective inclusion in schools is a challenging but worthwhile undertaking, requiring shared vision, commitment, ongoing reflection, and patience. Changes in practice, particularly in teachers’ daily planning and pedagogy, take time and will be supported by ongoing, well designed and embedded professional learning in the context of strong leadership and an inclusive school culture. By utilising a whole school approach, key areas including leadership, school values and culture, building staff capacity, and coordinated frameworks for inclusive practice, can be considered collectively and planned for in advance.  

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Inclusive School Communities Project Phone: (08) 8373 8333 Email:  [email protected] Address: 104 Greenhill Road, Unley SA 5061

• Open access
• Published: 14 May 2024

Protocol for a scoping review study on learning plan use in undergraduate medical education

• Anna Romanova   ORCID: orcid.org/0000-0003-1118-1604 1 ,
• Claire Touchie 1 ,
• Sydney Ruller 2 ,
• Victoria Cole 3 &
• Susan Humphrey-Murto 4  

Systematic Reviews volume  13 , Article number:  131 ( 2024 ) Cite this article

Metrics details

The current paradigm of competency-based medical education and learner-centredness requires learners to take an active role in their training. However, deliberate and planned continual assessment and performance improvement is hindered by the fragmented nature of many medical training programs. Attempts to bridge this continuity gap between supervision and feedback through learner handover have been controversial. Learning plans are an alternate educational tool that helps trainees identify their learning needs and facilitate longitudinal assessment by providing supervisors with a roadmap of their goals. Informed by self-regulated learning theory, learning plans may be the answer to track trainees’ progress along their learning trajectory. The purpose of this study is to summarise the literature regarding learning plan use specifically in undergraduate medical education and explore the student’s role in all stages of learning plan development and implementation.

Following Arksey and O’Malley’s framework, a scoping review will be conducted to explore the use of learning plans in undergraduate medical education. Literature searches will be conducted using multiple databases by a librarian with expertise in scoping reviews. Through an iterative process, inclusion and exclusion criteria will be developed and a data extraction form refined. Data will be analysed using quantitative and qualitative content analyses.

By summarising the literature on learning plan use in undergraduate medical education, this study aims to better understand how to support self-regulated learning in undergraduate medical education. The results from this project will inform future scholarly work in competency-based medical education at the undergraduate level and have implications for improving feedback and supporting learners at all levels of competence.

Scoping review registration:

Open Science Framework osf.io/wvzbx.

Peer Review reports

Competency-based medical education (CBME) has transformed the approach to medical education to focus on demonstration of acquired competencies rather than time-based completion of rotations [ 1 ]. As a result, undergraduate and graduate medical training programs worldwide have adopted outcomes-based assessments in the form of entrustable professional activities (EPAs) comprised of competencies to be met [ 2 ]. These assessments are completed longitudinally by multiple different evaluators to generate an overall impression of a learner’s competency.

In CBME, trainees will progress along their learning trajectory at individual speeds and some may excel while others struggle to achieve the required knowledge, skills or attitudes. Therefore, deliberate and planned continual assessment and performance improvement is required. However, due to the fragmented nature of many medical training programs where learners rotate through different rotations and work with many supervisors, longitudinal observation is similarly fragmented. This makes it difficult to determine where trainees are on their learning trajectories and can affect the quality of feedback provided to them, which is a known major influencer of academic achievement [ 3 ]. As a result, struggling learners may not be identified until late in their training and the growth of high-performing learners may be stifled [ 4 , 5 , 6 ].

Bridging this continuity gap between supervision and feedback through some form of learner handover or forward feeding has been debated since the 1970s and continues to this day [ 5 , 7 , 8 , 9 , 10 , 11 ]. The goal of learner handover is to improve trainee assessment and feedback by sharing their performance and learning needs between supervisors or across rotations. However, several concerns have been raised about this approach including that it could inappropriately bias subsequent assessments of the learner’s abilities [ 9 , 11 , 12 ]. A different approach to keeping track of trainees’ learning goals and progress along their learning trajectories is required. Learning plans (LPs) informed by self-regulated learning (SRL) theory may be the answer.

SRL has been defined as a cyclical process where learners actively control their thoughts, actions and motivation to achieve their goals [ 13 ]. Several models of SRL exist but all entail that the trainee is responsible for setting, planning, executing, monitoring and reflecting on their learning goals [ 13 ]. According to Zimmerman’s SRL model, this process occurs in three stages: forethought phase before an activity, performance phase during an activity and self-reflection phase after an activity [ 13 ]. Since each trainee leads their own learning process and has an individual trajectory towards competence, this theory relates well to the CBME paradigm which is grounded in learner-centredness [ 1 ]. However, we know that medical students and residents have difficulty identifying their own learning goals and therefore need guidance to effectively partake in SRL [ 14 , 15 , 16 , 17 ]. Motivation has also emerged as a key component of SRL, and numerous studies have explored factors that influence student engagement in learning [ 18 , 19 ]. In addition to meeting their basic psychological needs of autonomy, relatedness and competence, perceived learning relevance through meaningful learning activities has been shown to increase trainee engagement in their learning [ 19 ].

LPs are a well-known tool across many educational fields including CBME that can provide trainees with meaningful learning activities since they help them direct their own learning goals in a guided fashion [ 20 ]. Also known as personal learning plans, learning contracts, personal action plans, personal development plans, and learning goals, LPs are documents that outline the learner’s roadmap to achieve their learning goals. They require the learner to self-identify what they need to learn and why, how they are going to do it, how they will know when they are finished, define the timeframe for goal achievement and assess the impact of their learning [ 20 ]. In so doing, LPs give more autonomy to the learner and facilitate objective and targeted feedback from supervisors. This approach has been described as “most congruent with the assumptions we make about adults as learners” [ 21 ].

LP use has been explored across various clinical settings and at all levels of medical education; however, most of the experience lies in postgraduate medical education [ 22 ]. Medical students are a unique learner population with learning needs that appear to be very well suited for using LPs for two main reasons. First, their education is often divided between classroom and clinical settings. During clinical training, students need to be more independent in setting learning goals to meet desired competencies as their education is no longer outlined for them in a detailed fashion by the medical school curriculum [ 23 ]. SRL in the workplace is also different than in the classroom due to additional complexities of clinical care that can impact students’ ability to self-regulate their learning [ 24 ]. Second, although most medical trainees have difficulty with goal setting, medical students in particular need more guidance compared to residents due to their relative lack of experience upon which they can build within the SRL framework [ 25 ]. LPs can therefore provide much-needed structure to their learning but should be guided by an experienced tutor to be effective [ 15 , 24 ].

LPs fit well within the learner-centred educational framework of CBME by helping trainees identify their learning needs and facilitating longitudinal assessment by providing supervisors with a roadmap of their goals. In so doing, they can address current issues with learner handover and identification as well as remediation of struggling learners. Moreover, they have the potential to help trainees develop lifelong skills with respect to continuing professional development after graduation which is required by many medical licensing bodies.

An initial search of the JBI Database, Cochrane Database, MEDLINE (PubMed) and Google Scholar conducted in July–August 2022 revealed a paucity of research on LP use in undergraduate medical education (UGME). A related systematic review by van Houten–Schat et al. [ 24 ] on SRL in the clinical setting identified three interventions used by medical students and residents in SRL—coaching, LPs and supportive tools. However, only a couple of the included studies looked specifically at medical students’ use of LPs, so this remains an area in need of more exploration. A scoping review would provide an excellent starting point to map the body of literature on this topic.

The objective of this scoping review will therefore be to explore LP use in UGME. In doing so, it will address a gap in knowledge and help determine additional areas for research.

This study will follow Arksey and O’Malley’s [ 26 ] five-step framework for scoping review methodology. It will not include the optional sixth step which entails stakeholder consultation as relevant stakeholders will be intentionally included in the research team (a member of UGME leadership, a medical student and a first-year resident).

Step 1—Identifying the research question

The overarching purpose of this study is to “explore the use of LPs in UGME”. More specifically we seek to achieve the following:

Summarise the literature regarding the use of LPs in UGME (including context, students targeted, frameworks used)

Explore the role of the student in all stages of the LP development and implementation

Determine existing research gaps

Step 2—Identifying relevant studies

An experienced health sciences librarian (VC) will conduct all searches and develop the initial search strategy. The preliminary search strategy is shown in Appendix A (see Additional file 2). Articles will be included if they meet the following criteria [ 27 ]:

Participants

Medical students enrolled at a medical school at the undergraduate level.

Any use of LPs by medical students. LPs are defined as a document, usually presented in a table format, that outlines the learner’s roadmap to achieve their learning goals [ 20 ].

Any stage of UGME in any geographic setting.

Types of evidence sources

We will search existing published and unpublished (grey) literature. This may include research studies, reviews, or expert opinion pieces.

Search strategy

With the assistance of an experienced librarian (VC), a pilot search will be conducted to inform the final search strategy. A search will be conducted in the following electronic databases: MEDLINE, Embase, Education Source, APA PsycInfo and Web of Science. The search terms will be developed in consultation with the research team and librarian. The search strategy will proceed according to the JBI Manual for Evidence Synthesis three-step search strategy for reviews [ 27 ]. First, we will conduct a limited search in two appropriate online databases and analyse text words from the title, abstracts and index terms of relevant papers. Next, we will conduct a second search using all identified key words in all databases. Third, we will review reference lists of all included studies to identify further relevant studies to include in the review. We will also contact the authors of relevant papers for further information if required. This will be an iterative process as the research team becomes more familiar with the literature and will be guided by the librarian. Any modifications to the search strategy as it evolves will be described in the scoping review report. As a measure of rigour, the search strategy will be peer-reviewed by another librarian using the PRESS checklist [ 28 ]. No language or date limits will be applied.

Step 3—Study selection

The screening process will consist of a two-step approach: screening titles/abstracts and, if they meet inclusion criteria, this will be followed by a full-text review. All screening will be done by two members of the research team and any disagreements will be resolved by an independent third member of the team. Based on preliminary inclusion criteria, the whole research team will first pilot the screening process by reviewing a random sample of 25 titles/abstracts. The search strategy, eligibility criteria and study objectives will be refined in an iterative process. We anticipate several meetings as the topic is not well described in the literature. A flowchart of the review process will be generated. Any modifications to the study selection process will be described in the scoping review report. The papers will be excluded if a full text is not available. The search results will be managed using Covidence software.

Step 4—Charting the data

A preliminary data extraction tool is shown in Appendix B (see Additional file 3 ). Data will be extracted into Excel and will include demographic information and specific details about the population, concept, context, study methods and outcomes as they relate to the scoping review objectives. The whole research team will pilot the data extraction tool on ten articles selected for full-text review. Through an iterative process, the final data extraction form will be refined. Subsequently, two members of the team will independently extract data from all articles included for full-text review using this tool. Charting disagreements will be resolved by the principal and senior investigators. Google Translate will be used for any included articles that are not in the English language.

Step 5—Collating, summarising and reporting the results

Quantitative and qualitative analyses will be used to summarise the results. Quantitative analysis will capture descriptive statistics with details about the population, concept, context, study methods and outcomes being examined in this scoping review. Qualitative content analysis will enable interpretation of text data through the systematic classification process of coding and identifying themes and patterns [ 29 ]. Several team meetings will be held to review potential themes to ensure an accurate representation of the data. The PRISMA Extension for Scoping Reviews (PRISMA-ScR) will be used to guide the reporting of review findings [ 30 ]. Data will be presented in tables and/or diagrams as applicable. A descriptive summary will explain the presented results and how they relate to the scoping review objectives.

By summarising the literature on LP use in UGME, this study will contribute to a better understanding of how to support SRL amongst medical students. The results from this project will also inform future scholarly work in CBME at the undergraduate level and have implications for improving feedback as well as supporting learners at all levels of competence. In doing so, this study may have practical applications by informing learning plan incorporation into CBME-based curricula.

We do not anticipate any practical or operational issues at this time. We assembled a team with the necessary expertise and tools to complete this project.

Availability of data and materials

All data generated or analysed during this study will be included in the published scoping review article.

Abbreviations

• Competency-based medical education

Entrustable professional activity

• Learning plan
• Self-regulated learning
• Undergraduate medical education

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This study will be supported through grants from the Department of Medicine at the Ottawa Hospital and the University of Ottawa. The funding bodies had no role in the study design and will not have any role in the collection, analysis and interpretation of data or writing of the manuscript.

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AR designed and drafted the protocol. CT and SH contributed to the refinement of the research question, study methods and editing of the manuscript. VC designed the initial search strategy. All authors reviewed the manuscript for final approval. The review guarantors are CT and SH. The corresponding author is AR.

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AR is a clinician teacher and Assistant Professor with the Division of General Internal Medicine at the University of Ottawa. She is also the Associate Director for the internal medicine clerkship rotation at the General campus of the Ottawa Hospital.

CT is a Professor of Medicine with the Divisions of General Internal Medicine and Infectious Diseases at the University of Ottawa. She is also a member of the UGME Competence Committee at the University of Ottawa and an advisor for the development of a new school of medicine at Toronto Metropolitan University.

SH is an Associate Professor with the Department of Medicine at the University of Ottawa and holds a Tier 2 Research Chair in Medical Education. She is also the Interim Director for the Research Support Unit within the Department of Innovation in Medical Education at the University of Ottawa.

CT and SH have extensive experience with medical education research and have numerous publications in this field.

SR is a Research Assistant with the Division of General Internal Medicine at the Ottawa Hospital Research Institute.

VC is a Health Sciences Research Librarian at the University of Ottawa.

SR and VC have extensive experience in systematic and scoping reviews.

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Supplementary Information

Additional file 1. prisma-p 2015 checklist., 13643_2024_2553_moesm2_esm.docx.

Additional file 2: Appendix A. Preliminary search strategy [ 31 ].

Additional file 3: Appendix B. Preliminary data extraction tool.

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Romanova, A., Touchie, C., Ruller, S. et al. Protocol for a scoping review study on learning plan use in undergraduate medical education. Syst Rev 13 , 131 (2024). https://doi.org/10.1186/s13643-024-02553-w

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Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

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Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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Acknowledgements

We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Cross-Education of Muscular Endurance: A Scoping Review

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• Jun Seob Song 1 ,
• Yujiro Yamada 1 ,
• Ryo Kataoka 1 ,
• William B. Hammert 1 ,
• Anna Kang 1 &
• Jeremy P. Loenneke 1  

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It is well established that performing unilateral resistance training can increase muscle strength not only in the trained limb but also in the contralateral untrained limb, which is widely known as the cross-education of strength. However, less attention has been paid to the question of whether performing unilateral resistance training can induce cross-education of muscular endurance, despite its significant role in both athletic performance and activities of daily living.

The objectives of this scoping review were to provide an overview of the existing literature on cross-education of muscular endurance, as well as discuss its potential underlying mechanisms and offer considerations for future research.

A scoping review was conducted on the effects of unilateral resistance training on changes in muscular endurance in the contralateral untrained limb. This scoping review was conducted in PubMed, SPORTDiscus, and Scopus.

A total of 2000 articles were screened and 21 articles met the inclusion criteria. Among the 21 included studies, eight studies examined the cross-education of endurance via absolute ( n  = 6) or relative ( n  = 2) muscular endurance test, while five studies did not clearly indicate whether they examined absolute or relative muscular endurance. The remaining eight studies examined different types of muscular endurance measurements (e.g., time to task failure, total work, and fatigue index).

The current body of the literature does not provide sufficient evidence to draw clear conclusions on whether the cross-education of muscular endurance is present. The cross-education of muscular endurance (if it exists) may be potentially driven by neural adaptations (via bilateral access and/or cross-activation models that lead to cross-education of strength) and increased tolerance to exercise-induced discomfort. However, the limited number of available randomized controlled trials and the lack of understanding of underlying mechanisms provide a rationale for future research.

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1 Introduction

Resistance training leads to improvements in strength and muscular endurance [ 1 , 2 , 3 ]. When resistance training is performed on one side of the body only (i.e., unilateral resistance training), increased muscle strength has been observed not only in the trained limb but also in the contralateral untrained limb, which is widely known as the cross-education (or cross-transfer) of strength [ 4 , 5 ]. The cross-education of strength was first reported in the scientific literature as early as the late nineteenth century [ 6 ], and thereafter it has been studied and reviewed extensively over the years [ 4 , 5 , 7 , 8 , 9 ]. Although its underlying mechanisms are not entirely understood, there is a general consensus within the cross-education literature that the transfer of strength to the untrained limb is mediated primarily by neural mechanisms and likely not by mechanisms at the local muscle level (e.g., changes in muscle fiber type and cross-sectional area) as these changes appear to occur within the trained limb only [ 4 , 7 , 10 , 11 ]. In contrast to cross-education of strength, considerably less attention has been paid to the question of whether performing unilateral resistance training can increase muscular endurance in the contralateral untrained limb (i.e., cross-education of muscular endurance).

Muscular endurance refers to the ability of muscles to perform successive contractions at a submaximal load, and it is considered as an important physical fitness component not only for athletic performance in sports but also for activities of daily living that require repetitive work [ 12 ]. Muscular endurance can be further specified into absolute and relative muscular endurance [ 13 ]. Absolute muscular endurance involves performing a maximal number of repetitions with a given absolute load regardless of changes in maximal strength (e.g., using 60% of pretraining 1RM at pre- and posttesting) [ 14 ]. In contrast, relative muscular endurance involves an individual performing a maximal number of repetitions with a load corresponding to a specific relative intensity or percentage of the individual’s current 1RM (e.g., using 60% of pretraining and posttraining 1RM at pre- and posttesting, respectively) [ 14 ]. In addition, muscular endurance has been measured in several other ways when using different types of testing (e.g., isometric, isokinetic), such as time to task failure or total work during repeated isokinetic contractions [ 15 , 16 ]. There is evidence that resistance training can increase strength as well as induce positive mitochondrial and microvascular adaptations (e.g., mitochondrial respiratory capacity, capillary to fiber ratio), which may help explain muscular endurance adaptations in the trained limb [ 17 , 18 , 19 ]. However, it remains unclear whether these mechanisms can also explain the changes in muscular endurance in the contralateral untrained limb. Therefore, the purpose of this paper was to provide an overview of the existing literature on cross-education of muscular endurance following unilateral resistance training and to discuss its potential underlying mechanisms.

A scoping review was conducted to evaluate the cross-education of muscular endurance. The current study was conducted and reported in accordance with the Preferred Reporting for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) [ 20 ].

To identify relevant articles for the current scoping review, systematic literature searches were conducted from inception through April 2023, using PubMed, SPORTDiscus, and Scopus. Relevant studies were identified with the following search terms: “cross education” OR “cross transfer” OR “contralateral effect” OR “contralateral transfer” OR “interlimb transfer” OR “bilateral transfer” AND “endurance.” An additional search was carried out by examining the references of the included articles. Following the removal of duplicates, articles were screened first by title and abstract, followed by full text screening for eligibility. The study selection process is summarized using the PRISMA flow diagram (Fig.  1 ). In the present scoping review, broad inclusion criteria were used to provide an overview of the existing literature on cross-education of muscular endurance. To be included within the scoping review, studies were required to fulfill the following criteria: (1) original article was written in English language; (2) included a unilateral resistance exercise training intervention (regardless of strength training type and training load); (3) measured muscular endurance (e.g., number of repetitions at an absolute or relative load, time to task failure, total work) in the contralateral untrained limb at pre- and posttesting; and (4) was performed in humans with no restrictions on age and training status. One reviewer (JSS) completed literature searches and extraction of data. The following information was extracted: characteristics of participants, unilateral resistance training intervention (exercise type, sets, repetitions, load), frequency, duration, and main outcomes (cross-education of strength and muscular endurance). Two reviewers (JSS and JPL) checked the studies that only reported within-group changes (i.e., pre- to posttest) for each group, and back-calculated the p -value of between-group differences when possible.

Study selection process as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)

3.1 Search Results

The systematic search provided 2000 articles (PubMed = 860, Scopus = 535, SPORTDiscus = 605), of which 377 were duplicates, leaving 1623 for screening. After title/abstract screening, 1516 articles were excluded and the remaining 107 articles were assessed for eligibility via full-text screening. Ninety-six articles were omitted following the full-text assessment, and 10 additional studies were included by reference checking. In total, 21 studies met the aforementioned criteria and were included in the review.

3.2 Study Characteristics

The present review included both randomized controlled trials and nonrandomized controlled trials. Of the 21 articles included in the review (Table  1 ), 10 studies were randomized controlled trials (including a nontraining control group) [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ] and 11 studies were nonrandomized controlled trials [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. Of note, this review focused more on randomized controlled trials, as it allows determination of whether changes in muscular endurance in an untrained limb (i.e., cross-education of muscular endurance) are solely due to the training interventions.

Among the 21 included studies, nine studies employed unilateral exercise training in the lower body (3 randomized controlled trials and 6 nonrandomized controlled trials) [ 21 , 23 , 24 , 31 , 33 , 35 , 36 , 37 , 39 ], nine studies in the upper arm (7 randomized controlled trials and 2 nonrandomized controlled trials) [ 22 , 25 , 26 , 27 , 28 , 29 , 30 , 40 , 41 ], and three studies used handgrip (3 nonrandomized controlled trials) [ 32 , 34 , 38 ]. For the muscular endurance measurements, absolute muscular endurance (i.e., number of repetitions with the same given load at pre- and postintervention, regardless of changes in maximal strength) was assessed in six studies [ 21 , 22 , 25 , 30 , 39 , 41 ], and relative muscular endurance (i.e., number of repetitions with a load corresponding to a specific relative intensity or percentage of individual’s current 1RM) was measured in two studies [ 26 , 27 ]. Of note, five studies did not provide enough detail to determine whether absolute or relative muscular endurance was examined for testing [ 23 , 29 , 32 , 38 , 40 ]. The remaining eight studies used several different types of muscular endurance measurements including: time to task failure (using absolute or relative load) [ 28 , 31 , 34 , 36 , 37 ], total work performed [ 24 , 33 ], and fatigue index (e.g., difference in work between the first three reps and the last three reps) [ 35 ]. Among the 21 included studies, five studies were conducted in untrained individuals [ 23 , 24 , 31 , 33 , 38 ], whereas the remaining 16 studies did not clearly describe the training status of the participants (e.g., physically active, college students from physical education program) [ 21 , 22 , 25 , 26 , 27 , 28 , 29 , 30 , 32 , 34 , 35 , 36 , 37 , 39 , 40 , 41 ].

4 Discussion

4.1 findings from nonrandomized controlled trials.

Several nonrandomized controlled trials reported changes in muscular endurance in the untrained limb following unilateral exercise training interventions. For example, 3 weeks of unilateral knee extension training increased absolute muscular endurance (i.e., maximal number of repetitions using 8.2 kg) in the contralateral untrained leg from pre- to posttest [ 39 ]. Similarly, 12 weeks of unilateral leg press exercise training increased relative muscular endurance [i.e., time to task failure during sustained isometric knee extension at relative 50% maximum voluntary isometric contraction (MVIC)] in the untrained leg from pre- to posttest [ 31 ]. In addition, four studies observed an increased muscular endurance (i.e., maximal number of repetitions and time to task failure) in the untrained limb (i.e., pre- to posttest) following 4–6 weeks of unilateral handgrip exercise training [ 32 , 34 , 38 ] and 6 weeks of unilateral isometric leg press training [ 37 ]. In those studies, however, it was unclear whether they used an absolute or relative muscular endurance test [ 32 , 34 , 37 , 38 ]. In one study, an increase in total work (i.e., during 30 maximum isokinetic knee extension) from pre- to posttest was observed in the untrained leg following 4 weeks of unilateral isokinetic knee extension and flexion [ 33 ]. However, these findings were not consistent throughout the literature. For example, no changes (i.e., pre- to posttest) in muscular endurance (i.e., absolute and/or relative, fatigue index) were observed in the contralateral untrained limb following unilateral knee extension training interventions [ 35 , 36 ], or following unilateral elbow flexion training interventions [ 40 , 41 ]. Of note, however, these findings should be interpreted with caution as it is not possible to know whether the changes in muscular endurance are due to the exercise training intervention or other factors outside of the training intervention. In other words, to determine whether the cross-education of muscular endurance is solely due to the training interventions, a time-matched nontraining control group is required (i.e., randomized controlled trials).

4.2 Findings from Randomized Controlled Trials

Among ten randomized controlled trials [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ], three studies reported a cross-education of muscular endurance [ 23 , 30 ]. In male children (aged 10–13 years), for example, 8 weeks of unilateral leg press training increased not only strength but also muscular endurance (i.e., number of unilateral leg press repetitions with 60% of 1RM until failure) of the contralateral untrained leg compared with a nontraining control group [ 23 ]. In that study, however, it was not clear whether 60% of pre- or posttraining 1RM was used at the posttesting (i.e., absolute or relative muscular endurance) [ 23 ]. In healthy young males, 3 weeks of unilateral elbow flexion exercise training increased absolute muscular endurance (i.e., maximal number of unilateral elbow flexion repetitions with 6.4 kg) in the contralateral untrained arm compared with a nontraining control group [ 30 ]. In five randomized controlled trials, only within-group changes (i.e., pre- to posttest) in muscular endurance were reported [ 24 , 25 , 26 , 27 , 29 ]. For example, increases in muscular endurance (i.e., total work performed during 25 maximal isokinetic contractions and work performed during the last 5 repetitions) were observed in the contralateral untrained leg from pre- to posttest in a group that performed 7 weeks of isokinetic and isometric knee extension training, whereas no within-group changes were observed in a time-matched nontraining control group [ 24 ]. Similarly, increases in absolute and relative [ 25 , 26 ] muscular endurance from pre- to posttest were observed in the untrained arm following 6 weeks of unilateral elbow flexion training, while no changes were observed in a nontraining control group. In contrast, one study found no within-group changes (pre- to posttest) in either the training (i.e., 4 weeks of unilateral elbow flexion training) group or the nontraining control group [ 29 ]. Although some studies reported increases in muscular endurance only in the training groups and not in the control groups, this does not indicate that there was cross-education of muscular endurance. To determine whether a cross-education of muscular endurance is present, the changes in muscular endurance of the training groups should be directly compared with those of the control group. In one study, although only within-group changes (i.e., pre- to posttest) were reported for training and control groups, we were able to directly compare those two groups by back-calculating the p -value of between-group differences [ 27 ]. The calculation showed that the changes in relative muscular endurance in the untrained arm following 6 weeks of unilateral elbow flexion training were significantly greater compared with a control group, indicating a cross-education of relative muscular endurance [ 27 ]. Three randomized controlled trials did not observe cross-education of muscular endurance [ 21 , 22 , 28 ]. For example, no changes in absolute muscular endurance were observed in the contralateral untrained limb following 5 weeks of unilateral knee extension training [ 21 ] and following 5 weeks of unilateral elbow flexion training [ 22 ] when compared with a nontraining control group. Similarly, no changes in time to failure (i.e., sustaining at 100% MVIC until force drop below 50% MVIC) were observed in the untrained arm following 6 weeks of unilateral isometric elbow flexion training when compared with a nontraining control group [ 28 ].

Taken together, there is very limited evidence to suggest that performing unilateral resistance training can increase muscular endurance in the contralateral untrained limb (i.e., cross-education of muscular endurance). For example, there have been only three randomized controlled studies (out of 10 studies) that demonstrated evidence for cross-education of muscular endurance. Among these three studies, one showed increased absolute muscular endurance, another showed increased relative muscular endurance, and the third study showed increased muscular endurance (unclear whether absolute or relative). In contrast, the remaining seven studies either did not find or could not provide supporting evidence. These discrepancies in the cross-education of muscular endurance may be due to the differences in training interventions (e.g., contraction type, intensity, duration) and/or muscular endurance measurements (e.g., maximal number of repetitions and time to task failure using absolute or relative load). The current body of literature does not provide sufficient evidence to draw a clear conclusion on whether cross-education of muscular endurance is present, and thus requires further investigation.

4.3 Potential Underlying Mechanisms

There have been several mechanisms proposed to explain the increase in muscular endurance in the trained limb following resistance training, such as increased muscle capillarity [ 17 ] and mitochondrial respiratory capacity/function [ 42 , 43 ]. Although these proposed mechanisms may explain training-induced increases in muscular endurance in the trained limb, these would be unlikely to explain the changes in the contralateral untrained limb. The following section will discuss potential mechanisms that might contribute to the cross-education of muscular endurance.

4.3.1 Increases in Muscle Strength (Cross-Education of Strength)

One potential adaptation that could improve absolute muscular endurance in the contralateral untrained limb following unilateral resistance training is increased strength in the untrained limb via cross-education (i.e., cross-education of strength). According to the size principle, motor units are recruited in an orderly manner from the smaller motor units (i.e., low threshold) to the larger motor units (i.e., high threshold) as required force increases or muscle fatigues [ 44 ]. Based on this, increases in strength following resistance training may require fewer motor units to lift an absolute submaximal load for the same number of repetitions, which may delay the involvement of larger motor units and reserve them to be recruited subsequently for sustaining the required force as fatigue develops [ 14 , 45 ]. This hypothesis is partially supported by Ploutz et al. [ 45 ] who showed that less muscle was recruited to lift the same submaximal load in the untrained leg following 9 weeks of unilateral knee extension training [ 45 ], which may reserve larger motor units to be recruited later on and consequently allow for better performance on the absolute muscular endurance test in the untrained limb. However, this should be interpreted with caution since there was no time-matched control group, which makes it difficult to know whether the changes in muscle recruitment in the untrained limb were due to the unilateral training or some other factor [ 45 ]. The potential role of changes in strength on absolute muscular endurance may be also partially supported by a secondary analysis that examined if the changes in 1RM strength mediate changes in absolute muscular endurance (i.e., maximal number of repetitions using 42.5% pretraining 1RM) following high-load (i.e., 70% 1RM) training compared with low-load training interventions (i.e., 15% 1RM with or without blood flow restriction) [ 18 ]. In that study, it was found that training-induced increases in strength mediated the changes in muscular endurance in the high-load training group relative to the low-load training groups, suggesting that the differences in muscular endurance between high-load and low-load training groups may be explained by changes in strength. However, it is of note that the mediation analysis in that study only compared between training groups and not with a time-matched control group, meaning that the results can only explain the differences between training groups (i.e., high load versus low load). To clearly demonstrate whether the change in strength is an underlying mechanism for changes in muscular endurance, it may be more appropriate to compare training groups to a nonexercise control group in the mediation analysis. Furthermore, that analysis was on the changes in the trained limb, and thus it remains unknown whether increased strength from cross-education can also be translated to improved absolute muscular endurance in the untrained limb. One of the included studies reported concurrent increases in strength and muscular endurance in the untrained limb [ 23 ], whereas other studies showed that the cross-education of strength is not always accompanied by the cross-education of absolute muscular endurance [ 21 , 22 ]. Of note, simply assessing whether there were concurrent cross-education of strength and absolute muscular endurance may not be an appropriate approach to determine whether cross-education of strength can be translated to cross-education of absolute muscular endurance. A more appropriate approach might be using a mediation analysis to examine if the increases in strength from cross-education mediate the changes in absolute muscular endurance in the untrained limb [ 46 , 47 ]. It is of note that some previous studies have shown that unilateral low-load (or low-intensity) training does not increase strength in the opposite untrained limb (i.e., no cross-education of strength) [ 48 , 49 ]. However, this does not necessarily mean that unilateral low-load (or low-intensity) exercise would not induce cross-education of muscular endurance. It is plausible that cross-education of muscular endurance can occur in the absence of strength gain via different mechanisms.

4.3.2 Bilateral Access and Cross-Activation Model

Cross-education of relative muscular endurance likely cannot be explained by increased strength in the contralateral limb as relative muscular endurance is scaled to current maximal strength. Two main theoretical models, which may not be mutually exclusive, have been proposed to explain the cross-education of strength and skills: “bilateral access” and “cross-activation” models [ 50 ]. Although speculative, these two models may also explain the cross-education of muscular endurance. The “bilateral access” model involves the development of a motor engram during unilateral resistance training, which can be accessed not only by the trained limb, but also by the untrained limb for the control and execution of movements [ 50 , 51 ]. A widely used example is the “callosal access” hypothesis, in which the motor engrams developed in the trained hemisphere may be accessed by the opposite untrained hemisphere via the corpus callosum during motor tasks in the untrained limb [ 50 , 51 ]. In this model, it has been hypothesized that performing unilateral resistance training may develop an effective muscle recruitment pattern for maximum force production (i.e., muscle strength), such as coordination of synergists and inhibition of antagonists, which can be stored in neural circuits and accessed by the untrained hemisphere [ 4 ]. Although speculative, this hypothetical model may also play a role in the cross-education of muscular endurance. In other words, performing unilateral resistance training may create a motor engram of the motor output necessary to effectively perform repeated submaximal contractions, leading to cross-education of muscular endurance. However, further research is needed to determine whether or not the “bilateral access” model plays a role in the cross-education of muscular endurance in a similar way as cross-education of strength. In the “cross-activation” model, it is proposed that performing unilateral resistance training could induce bilateral cortical activation, potentially leading to concurrent neural adaptations in both trained and untrained hemispheres [ 50 , 52 , 53 , 54 , 55 ]. For example, it was previously found that unilateral resistance training increased corticospinal excitability in both the trained and untrained primary motor cortex [ 55 ]. Furthermore, decreases in interhemispheric inhibition [ 56 ], short-interval intracortical inhibition [ 52 , 57 ], and cortical silent period [ 58 , 59 ] were also observed in both the trained and untrained side following unilateral resistance training. However, whether or not these neural adaptations can explain the cross-education of muscular endurance is currently not known, and further research is needed.

4.3.3 Increase in Tolerance to Exercise-Induced Discomfort

Increases in tolerance to exercise-induced discomfort may in part play a role in the cross-education of muscular endurance. For example, previous studies have suggested that the cross-education of muscular endurance may be due to repeated exposures to uncomfortable exertions during a training intervention, which allows individuals to accommodate greater exercise-induced discomfort, pain, and/or fatigue sensation [ 23 , 27 , 30 , 32 ]. Although it is not directly related to exercise-induced discomfort perception, previous cross-sectional studies have demonstrated that athletes typically have higher pain tolerance when compared with nonathlete control individuals [ 60 , 61 ]. In addition, increased pain tolerance has been observed following aerobic and combined (aerobic + resistance) exercise training in healthy young adults [ 62 ]. It has been proposed that the higher pain tolerance observed in trained individuals may be due to enhanced pain coping strategies, developed through repeated exposure to physical and psychological stress during exercise [ 60 , 63 ]. This is further supported by a previous study in which 6 weeks of high-intensity interval training increased not only ischemic pain tolerance but also exercise tolerance (i.e., time to exhaustion) when compared with volume-matched moderate-intensity continuous training [ 64 ]. In that study, it was suggested that the improvement in pain tolerance is likely due to repeated exposure to high metabolic stress and exercise-induced noxious stimuli, which might partly explain the improvement in exercise tolerance [ 64 ]. Based on these findings, it is possible that repeated exposure to discomfort from unilateral resistance training can lead to increased tolerance, resulting in increased muscular endurance in the contralateral untrained limb. This proposed mechanism is unlikely to play a role in the cross-education of muscular endurance if the training intervention only induces very low levels of discomfort or pain (e.g., low repetition with low load). However, since this proposed mechanism is based on a study that implemented aerobic training intervention, it needs to be further examined with resistance training intervention.

4.4 Future Considerations

There has been extensive work on the cross-education of strength, but far less attention has been paid to the cross-education of muscular endurance. For example, there is a lack of randomized controlled studies, which makes it difficult to draw clear conclusions on the cross-education of muscular endurance. The inclusion of a time-matched nonexercise control group allows researchers to confidently conclude that the increase in muscular endurance in the untrained limb is due to the unilateral resistance training and not to some other factor. Thus, time-matched control groups are always recommended for future studies. In addition, it is common to see studies reporting within-group changes (i.e., pre- to posttest) for each training and control group, and when significant changes are observed only in the training group and not in the control group, it is often concluded that there is cross-education of muscular endurance. However, this interpretation is problematic since the change scores are not directly compared between groups (e.g., intervention group versus control group). In other words, it is important to test the group × time interaction or directly compare the change scores between the groups if the goal is to examine whether the changes in muscular endurance in the untrained limb differ between the groups [ 65 , 66 , 67 ].

Several included studies in the present review did not clearly indicate how they measured the cross-education of muscular endurance. For example, a number of studies measured the maximal number of repetitions using a certain percentage of maximum strength (e.g., 30% of 1RM); however, they did not clearly indicate whether an absolute or relative load/intensity was utilized at posttesting. This lack of clarity makes it difficult to compare results across the literature and to replicate the data in future works. Therefore, future studies should clearly state within their methodology whether muscular endurance was measured via an absolute or relative muscular endurance test. In addition to absolute/relative muscular endurance, several other types of outcome variables have been also examined to test muscular endurance (e.g., total work during a certain number of repetitions, time to task failure). This discrepancy in methodology may partially explain the inconsistent findings observed in the existing literature. At present, it remains unclear which outcome variable is the most appropriate way to test an individual’s muscular endurance, and thus further research is warranted. Of note, in the cross-education of strength literature, it has been suggested that the changes in strength in the contralateral untrained limb are the greatest when it is tested with the same movement task performed by the trained limb (training specificity; e.g., test and train dynamically) [ 4 ]. Based on this, it may be reasonable to test the cross-education of muscular endurance with the same movement task used for the training intervention. However, the question of whether the cross-education of muscular endurance follows the principle of specificity requires further investigation.

Future studies might examine other markers of endurance capacity (e.g., mitochondrial density, muscle capillarization) to provide better support for the idea that the mechanism underlying cross-education of muscular endurance may not be local per se, but potentially via neural adaptations. A final consideration for future studies, especially for those attempting to address potential underlying mechanisms, may be the use of mediation analysis. In the present review, we suggested a number of potential underlying mechanisms including changes in strength in the untrained limb (for absolute muscular endurance). In one of the included studies, for example, concurrent increases in strength and muscular endurance were observed in the untrained limb (i.e., cross-education of strength and muscular endurance) [ 23 ]. However, because there was concurrent cross-education of strength and absolute muscular endurance, this does not necessarily indicate that the cross-education of muscular endurance was driven by the cross-education of strength. One statistical approach to understanding the potential role of strength changes in cross-education of muscular endurance may be using a mediation analysis [ 46 , 47 ]. Mediation analysis can quantify the effect of the third (mediating) variable (e.g., changes in strength in untrained limb) on the relationship between the independent variable (e.g., intervention groups) and dependent variable (e.g., changes in absolute muscular endurance in untrained limb). This approach may help future studies with identifying the potential underlying mechanisms that contribute to the cross-education of muscular endurance (if it exists).

5 Conclusions

Performing unilateral resistance training has been shown to increase strength not only in the trained limb but also in the contralateral untrained limb (i.e., cross-education of strength). However, less attention has been paid to the question of whether performing unilateral resistance training can also increase muscular endurance in the contralateral untrained limb (i.e., cross-education of muscular endurance). The current body of the literature does not provide sufficient evidence to draw clear conclusions on whether a cross-education of muscular endurance is present. Therefore, further research with a nonexercise control group (i.e., randomized controlled trials) is necessary to draw a strong conclusion. Furthermore, some potential underlying mechanisms (i.e., increased strength, bilateral access model, increased tolerance) are discussed in the present review; however, the proposed ideas currently lack experimental evidence and require further research.

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Jun Seob Song, Yujiro Yamada, Ryo Kataoka, William B. Hammert, Anna Kang & Jeremy P. Loenneke

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JSS carried out the systematic scoping review. YY, RK, WBH, AK, and JPL contributed to the manuscript writing. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.

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Song, J.S., Yamada, Y., Kataoka, R. et al. Cross-Education of Muscular Endurance: A Scoping Review. Sports Med (2024). https://doi.org/10.1007/s40279-024-02042-z

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Accepted : 30 April 2024

Published : 17 May 2024

DOI : https://doi.org/10.1007/s40279-024-02042-z

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