Background

Skill decay refers to the "loss or decay of trained or acquired skills (or knowledge) after periods of non-use".1^(p.58) Skill decay is therefore different from the cognitive decline associated with aging or disease. Absolute skill decay, defined as loss of skills from a prior baseline, is also different from relative skill decay, defined as stasis in the face of changing scientific knowledge over time.2 While both types of skill decay are important to address in the healthcare setting, it is absolute skill decay that is the focus of this scoping review. Skill decay is widely acknowledged in industry, particularly in fields where automation of processes requires certain skills acquired during initial training to only be utilized in non-routine and infrequent situations,3 such as chemical processing.4 Decay of clinical skills in medical, nursing and allied health professionals is however increasingly being acknowledged in the literature5-7 and may occur for a number of reasons including returning to work after a period of absence, moving between clinical specialisms, and working in a setting where the opportunity to utilize or practice specific skills is rare, such as remote and rural settings. Clinical skills, particularly those used in emergency situations, need to be performed to a high standard to ensure best patient care, irrespective of how often they are required to be utilized. It is therefore important to have an understanding of the extent and nature of clinical skill decay and the effectiveness of approaches designed to prevent or mitigate the decay of clinical skills.

A skill is a well organized performance requiring coordination of perception, cognition and action to achieve a specified goal.8-9 There are numerous clinical skills performed by medical, nursing and allied health professionals, and skill decay may relate to the loss of practical skills such as chest compressions during cardiopulmonary resuscitation,10 temporary catheter insertion11 or competency to conduct procedures such as colonoscopy.12 However, it may also relate to decay of cognitive skills that relate to clinical reasoning and the potential for diagnostic errors to be made.7 Whether in relation to practical or cognitive skills, clinical skill decay is clearly an important issue within health care as the potential consequences for patient care are substantial. There are also potential consequences for clinical teams (in the event that other members have to compensate for an individual's skill decay) and for the healthcare system as a whole (e.g. sub-optimal clinical skills leading to sub-optimal patient management, necessitating increased hospital stay).

Much of the literature on clinical skill decay appears to focus on surgery and emergency medicine,5,12,13 which is not surprising due to the high-risk nature of these clinical environments and requirement for rapid decision making and implementation of skills. There is also an increasing body of literature relating to cardiopulmonary resuscitation and advanced life support performed by a range of healthcare professionals including nurses and paramedics.6,10,14-15 Particular settings may have a higher risk of clinical skill decay than others. For example, decay of specialized surgical skills has been reported in military medical personnel due to periods of non-use when they are performing combat casualty care instead during periods of military deployment,16 and doctors working in rural areas are particularly susceptible to decay of emergency medical skills due to the limited number of times they may be required to utilize them in practice.17 Other remote healthcare practitioners, such as those in the offshore oil and gas sector, will be at similar risk of skill decay, as may practitioners whose roles have expanded to incorporate a wider range of clinical skills than those they were initially trained to deliver.

Several interventions have been developed with the aim of reducing decay of clinical skills, most commonly delivered as refresher training sessions.3 These include simulation-based training,6 experiential learning,18 practice and feedback19 and symbolic rehearsal.4

As there is now a substantial body of literature relating to clinical skill decay, it would be prudent to synthesize that literature to inform the development of appropriate interventions to prevent and/or address clinical skills in particular professional groups and/or healthcare settings. A scoping review in particular is indicated because it is not clear at this stage what specific question/s should be asked in a systematic review. This scoping review will therefore provide a map of the range of available evidence that can be used to inform the specific questions and inclusion/exclusion criteria for a future systematic review.20,21 It is anticipated that the findings of this scoping review will inform future primary research by identifying gaps in the current evidence base.20,21 By identifying which clinical skills and/or professional groups have not been investigated to date, it will be possible to inform primary research studies aimed at exploring and addressing clinical skill decay. As this scoping review will identify the type of literature that has been used to date to inform the topic of clinical skill decay in the medical, nursing and allied health professions, it will also inform whether alternative sources would enhance the evidence base (e.g. qualitative research should the majority of research be of a quantitative nature to date). Ultimately, the new knowledge generated by this scoping review and any subsequent systematic review/s and primary research will inform clinicians and managers regarding effective methods for preventing and addressing clinical skill decay.

An initial search of the JBI Database of Systematic Reviews and Implementation Reports (JBISRIR), Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination (CRD) Database, MEDLINE and CINAHL failed to identify any scoping reviews (published or in progress) on this topic.

Inclusion criteria

Types of participants

The current scoping review will consider all studies that focus on addressing absolute decay of clinical skills in the medical, nursing and allied health professions. Therefore, we will include studies that focus on doctors, nurses, paramedics and allied health professionals (e.g. radiographers, occupational therapists, physiotherapists and prosthetists/orthotists). Allied health professionals will include those listed by the United Kingdom Health and Care Professions Council as having protected title status22 and their international equivalents. Studies concerning support staff without formal professional qualifications will be excluded from this review (e.g. technicians, auxiliary staff and assistants). Absolute skill decay will be defined as loss of skills from a prior baseline2 and therefore does not include interventions solely aimed at keeping professionals up to date with changing scientific knowledge.

Concept

The current scoping review will consider studies that focus on methods of addressing skill decay of clinical skills. Any method of addressing skill decay will be considered including, but not limited to, simulation-based training, experiential learning, practice and feedback and refresher training sessions. A wide range of clinical skills will be considered, including emergency and non-emergency skills, including but not limited to, chest compressions, catheterizations and procedures such as colonoscopy.

Context

The current scoping review will consider studies that include medical, nursing and allied health professionals working in any healthcare sector (e.g. primary care, secondary care, occupational health, public and private healthcare sectors) and any geographical location (e.g. urban, rural and remote) in any country.

Types of studies

The current scoping review will consider quantitative and qualitative research studies and systematic reviews on the topic of addressing clinical skills fade in the medical, nursing and allied health professions. In addition, this scoping review will consider reports from professional bodies and networks, for example, clinical skill networks, and medical, nursing and allied health profession regulators and professional bodies.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review, as well as studies published in other languages where the review team can arrange for translation through their respective professional networks and collaborations. Studies published in any year will be considered for inclusion in this review to comprehensively map the clinical skills and approaches that have been used, and due to initial searching indicating that the volume of literature would be feasible to include.

The databases to be searched include: MEDLINE, CINAHL, Embase, AMED, ERIC, Cochrane Library (controlled trials; systematic reviews), JBISRIR and CRD Database.

The search for unpublished studies will include: Google Scholar, OpenDOAR, EThOS and OATD.

The search for reports will include websites of clinical skills networks and medical, nursing and allied health professions regulators and professional bodies, accessed via Google. These will include the General Medical Council (UK), Health and Care Professions Council (UK), Nursing and Midwifery Council (UK), Resuscitation Council (UK; European), American Physical Therapy Association and equivalents from other countries. The review team will compile a comprehensive list prior to commencing the review.

Initial keywords to be used will be: skill decay, skill retention, knowledge retention, nursing staff, medical staff and allied health personnel.

Two reviewers will independently screen studies for inclusion at title/abstract and full-text screening stages. A third reviewer will be consulted in the event of disagreement. Authors of primary studies or systematic reviews will be contacted for further information, should it be deemed relevant by the review team.

Data extraction

Data will be charted in a logical manner to provide the reader with a descriptive summary of the results in relation to each review question.20^(p.14),21 A draft charting table has been created (Appendix I); however, it is anticipated that it will be further refined during the review process. Therefore, in keeping with scoping review recommendations,20 it will be piloted by two reviewers independently on the first three studies to be included in the review, following which the review team will decide whether it should be further refined to ensure the inclusion of all relevant data. Authors of primary studies or systematic reviews will be contacted for further information at this stage also, should it be deemed relevant by the review team.

Presentation of the results

The results of the scoping review will be presented using tabular and narrative summaries. A draft table is presented in Appendix II. It is anticipated that a table will be presented for each clinical skill identified from the literature as having been the topic of study. However, similar to data extraction, the results tables will be further refined during the review process.

Appendix I: Data extraction instrument

Appendix II: Results table

References