types of research studies in education

Please consult the following sources for more information on these types of studies and terminology related to the studies.

• APA Style JARS Supplemental Glossary This webpage provides supplemental information on the terms used in APA Style JARS. This glossary is meant to supplement Chapter 3 of the Publication Manual of the American Psychological Association, Seventh Edition. It is not an exhaustive list of all terms employed in quantitative, qualitative, or mixed methods research, nor does it include all possible definitions for each term; definitions in addition to or different from those reported in this glossary may be found in other sources.
• APA Dictionary of Psychology More than 25,000 authoritative entries across 90 subfields of psychology.
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• Indian J Anaesth
• v.60(9); 2016 Sep

Types of studies and research design

Mukul chandra kapoor.

Department of Anesthesiology, Max Smart Super Specialty Hospital, New Delhi, India

Medical research has evolved, from individual expert described opinions and techniques, to scientifically designed methodology-based studies. Evidence-based medicine (EBM) was established to re-evaluate medical facts and remove various myths in clinical practice. Research methodology is now protocol based with predefined steps. Studies were classified based on the method of collection and evaluation of data. Clinical study methodology now needs to comply to strict ethical, moral, truth, and transparency standards, ensuring that no conflict of interest is involved. A medical research pyramid has been designed to grade the quality of evidence and help physicians determine the value of the research. Randomised controlled trials (RCTs) have become gold standards for quality research. EBM now scales systemic reviews and meta-analyses at a level higher than RCTs to overcome deficiencies in the randomised trials due to errors in methodology and analyses.

INTRODUCTION

Expert opinion, experience, and authoritarian judgement were the norm in clinical medical practice. At scientific meetings, one often heard senior professionals emphatically expressing ‘In my experience,…… what I have said is correct!’ In 1981, articles published by Sackett et al . introduced ‘critical appraisal’ as they felt a need to teach methods of understanding scientific literature and its application at the bedside.[ 1 ] To improve clinical outcomes, clinical expertise must be complemented by the best external evidence.[ 2 ] Conversely, without clinical expertise, good external evidence may be used inappropriately [ Figure 1 ]. Practice gets outdated, if not updated with current evidence, depriving the clientele of the best available therapy.

Triad of evidence-based medicine

EVIDENCE-BASED MEDICINE

In 1971, in his book ‘Effectiveness and Efficiency’, Archibald Cochrane highlighted the lack of reliable evidence behind many accepted health-care interventions.[ 3 ] This triggered re-evaluation of many established ‘supposed’ scientific facts and awakened physicians to the need for evidence in medicine. Evidence-based medicine (EBM) thus evolved, which was defined as ‘the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients.’[ 2 ]

The goal of EBM was scientific endowment to achieve consistency, efficiency, effectiveness, quality, safety, reduction in dilemma and limitation of idiosyncrasies in clinical practice.[ 4 ] EBM required the physician to diligently assess the therapy, make clinical adjustments using the best available external evidence, ensure awareness of current research and discover clinical pathways to ensure best patient outcomes.[ 5 ]

With widespread internet use, phenomenally large number of publications, training and media resources are available but determining the quality of this literature is difficult for a busy physician. Abstracts are available freely on the internet, but full-text articles require a subscription. To complicate issues, contradictory studies are published making decision-making difficult.[ 6 ] Publication bias, especially against negative studies, makes matters worse.

In 1993, the Cochrane Collaboration was founded by Ian Chalmers and others to create and disseminate up-to-date review of randomised controlled trials (RCTs) to help health-care professionals make informed decisions.[ 7 ] In 1995, the American College of Physicians and the British Medical Journal Publishing Group collaborated to publish the journal ‘Evidence-based medicine’, leading to the evolution of EBM in all spheres of medicine.

MEDICAL RESEARCH

Medical research needs to be conducted to increase knowledge about the human species, its social/natural environment and to combat disease/infirmity in humans. Research should be conducted in a manner conducive to and consistent with dignity and well-being of the participant; in a professional and transparent manner; and ensuring minimal risk.[ 8 ] Research thus must be subjected to careful evaluation at all stages, i.e., research design/experimentation; results and their implications; the objective of the research sought; anticipated benefits/dangers; potential uses/abuses of the experiment and its results; and on ensuring the safety of human life. Table 1 lists the principles any research should follow.[ 8 ]

General principles of medical research

Types of study design

Medical research is classified into primary and secondary research. Clinical/experimental studies are performed in primary research, whereas secondary research consolidates available studies as reviews, systematic reviews and meta-analyses. Three main areas in primary research are basic medical research, clinical research and epidemiological research [ Figure 2 ]. Basic research includes fundamental research in fields shown in Figure 2 . In almost all studies, at least one independent variable is varied, whereas the effects on the dependent variables are investigated. Clinical studies include observational studies and interventional studies and are subclassified as in Figure 2 .

Classification of types of medical research

Interventional clinical study is performed with the purpose of studying or demonstrating clinical or pharmacological properties of drugs/devices, their side effects and to establish their efficacy or safety. They also include studies in which surgical, physical or psychotherapeutic procedures are examined.[ 9 ] Studies on drugs/devices are subject to legal and ethical requirements including the Drug Controller General India (DCGI) directives. They require the approval of DCGI recognized Ethics Committee and must be performed in accordance with the rules of ‘Good Clinical Practice’.[ 10 ] Further details are available under ‘Methodology for research II’ section in this issue of IJA. In 2004, the World Health Organization advised registration of all clinical trials in a public registry. In India, the Clinical Trials Registry of India was launched in 2007 ( www.ctri.nic.in ). The International Committee of Medical Journal Editors (ICMJE) mandates its member journals to publish only registered trials.[ 11 ]

Observational clinical study is a study in which knowledge from treatment of persons with drugs is analysed using epidemiological methods. In these studies, the diagnosis, treatment and monitoring are performed exclusively according to medical practice and not according to a specified study protocol.[ 9 ] They are subclassified as per Figure 2 .

Epidemiological studies have two basic approaches, the interventional and observational. Clinicians are more familiar with interventional research, whereas epidemiologists usually perform observational research.

Interventional studies are experimental in character and are subdivided into field and group studies, for example, iodine supplementation of cooking salt to prevent hypothyroidism. Many interventions are unsuitable for RCTs, as the exposure may be harmful to the subjects.

Observational studies can be subdivided into cohort, case–control, cross-sectional and ecological studies.

• Cohort studies are suited to detect connections between exposure and development of disease. They are normally prospective studies of two healthy groups of subjects observed over time, in which one group is exposed to a specific substance, whereas the other is not. The occurrence of the disease can be determined in the two groups. Cohort studies can also be retrospective
• Case–control studies are retrospective analyses performed to establish the prevalence of a disease in two groups exposed to a factor or disease. The incidence rate cannot be calculated, and there is also a risk of selection bias and faulty recall.

Secondary research

Narrative review.

An expert senior author writes about a particular field, condition or treatment, including an overview, and this information is fortified by his experience. The article is in a narrative format. Its limitation is that one cannot tell whether recommendations are based on author's clinical experience, available literature and why some studies were given more emphasis. It can be biased, with selective citation of reports that reinforce the authors' views of a topic.[ 12 ]

Systematic review

Systematic reviews methodically and comprehensively identify studies focused on a specified topic, appraise their methodology, summate the results, identify key findings and reasons for differences across studies, and cite limitations of current knowledge.[ 13 ] They adhere to reproducible methods and recommended guidelines.[ 14 ] The methods used to compile data are explicit and transparent, allowing the reader to gauge the quality of the review and the potential for bias.[ 15 ]

A systematic review can be presented in text or graphic form. In graphic form, data of different trials can be plotted with the point estimate and 95% confidence interval for each study, presented on an individual line. A properly conducted systematic review presents the best available research evidence for a focused clinical question. The review team may obtain information, not available in the original reports, from the primary authors. This ensures that findings are consistent and generalisable across populations, environment, therapies and groups.[ 12 ] A systematic review attempts to reduce bias identification and studies selection for review, using a comprehensive search strategy and specifying inclusion criteria. The strength of a systematic review lies in the transparency of each phase and highlighting the merits of each decision made, while compiling information.

Meta-analysis

A review team compiles aggregate-level data in each primary study, and in some cases, data are solicited from each of the primary studies.[ 16 , 17 ] Although difficult to perform, individual patient meta-analyses offer advantages over aggregate-level analyses.[ 18 ] These mathematically pooled results are referred to as meta-analysis. Combining data from well-conducted primary studies provide a precise estimate of the “true effect.”[ 19 ] Pooling the samples of individual studies increases overall sample size, enhances statistical analysis power, reduces confidence interval and thereby improves statistical value.

The structured process of Cochrane Collaboration systematic reviews has contributed to the improvement of their quality. For the meta-analysis to be definitive, the primary RCTs should have been conducted methodically. When the existing studies have important scientific and methodological limitations, such as smaller sized samples, the systematic review may identify where gaps exist in the available literature.[ 20 ] RCTs and systematic review of several randomised trials are less likely to mislead us, and thereby help judge whether an intervention is better.[ 2 ] Practice guidelines supported by large RCTs and meta-analyses are considered as ‘gold standard’ in EBM. This issue of IJA is accompanied by an editorial on Importance of EBM on research and practice (Guyat and Sriganesh 471_16).[ 21 ] The EBM pyramid grading the value of different types of research studies is shown in Figure 3 .

The evidence-based medicine pyramid

In the last decade, a number of studies and guidelines brought about path-breaking changes in anaesthesiology and critical care. Some guidelines such as the ‘Surviving Sepsis Guidelines-2004’[ 22 ] were later found to be flawed and biased. A number of large RCTs were rejected as their findings were erroneous. Another classic example is that of ENIGMA-I (Evaluation of Nitrous oxide In the Gas Mixture for Anaesthesia)[ 23 ] which implicated nitrous oxide for poor outcomes, but ENIGMA-II[ 24 , 25 ] conducted later, by the same investigators, declared it as safe. The rise and fall of the ‘tight glucose control’ regimen was similar.[ 26 ]

Although RCTs are considered ‘gold standard’ in research, their status is at crossroads today. RCTs have conflicting interests and thus must be evaluated with careful scrutiny. EBM can promote evidence reflected in RCTs and meta-analyses. However, it cannot promulgate evidence not reflected in RCTs. Flawed RCTs and meta-analyses may bring forth erroneous recommendations. EBM thus should not be restricted to RCTs and meta-analyses but must involve tracking down the best external evidence to answer our clinical questions.

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There are no conflicts of interest.

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Original research article, learning scientific observation with worked examples in a digital learning environment.

• 1 Department Educational Sciences, Chair for Formal and Informal Learning, Technical University Munich School of Social Sciences and Technology, Munich, Germany
• 2 Aquatic Systems Biology Unit, TUM School of Life Sciences, Technical University of Munich, Freising, Germany

Science education often aims to increase learners’ acquisition of fundamental principles, such as learning the basic steps of scientific methods. Worked examples (WE) have proven particularly useful for supporting the development of such cognitive schemas and successive actions in order to avoid using up more cognitive resources than are necessary. Therefore, we investigated the extent to which heuristic WE are beneficial for supporting the acquisition of a basic scientific methodological skill—conducting scientific observation. The current study has a one-factorial, quasi-experimental, comparative research design and was conducted as a field experiment. Sixty two students of a German University learned about scientific observation steps during a course on applying a fluvial audit, in which several sections of a river were classified based on specific morphological characteristics. In the two experimental groups scientific observation was supported either via faded WE or via non-faded WE both presented as short videos. The control group did not receive support via WE. We assessed factual and applied knowledge acquisition regarding scientific observation, motivational aspects and cognitive load. The results suggest that WE promoted knowledge application: Learners from both experimental groups were able to perform the individual steps of scientific observation more accurately. Fading of WE did not show any additional advantage compared to the non-faded version in this regard. Furthermore, the descriptive results reveal higher motivation and reduced extraneous cognitive load within the experimental groups, but none of these differences were statistically significant. Our findings add to existing evidence that WE may be useful to establish scientific competences.

1 Introduction

Learning in science education frequently involves the acquisition of basic principles or generalities, whether of domain-specific topics (e.g., applying a mathematical multiplication rule) or of rather universal scientific methodologies (e.g., performing the steps of scientific observation) ( Lunetta et al., 2007 ). Previous research has shown that worked examples (WE) can be considered particularly useful for developing such cognitive schemata during learning to avoid using more cognitive resources than necessary for learning successive actions ( Renkl et al., 2004 ; Renkl, 2017 ). WE consist of the presentation of a problem, consecutive solution steps and the solution itself. This is especially advantageous in initial cognitive skill acquisition, i.e., for novice learners with low prior knowledge ( Kalyuga et al., 2001 ). With growing knowledge, fading WE can lead from example-based learning to independent problem-solving ( Renkl et al., 2002 ). Preliminary work has shown the advantage of WE in specific STEM domains like mathematics ( Booth et al., 2015 ; Barbieri et al., 2021 ), but less studies have investigated their impact on the acquisition of basic scientific competencies that involve heuristic problem-solving processes (scientific argumentation, Schworm and Renkl, 2007 ; Hefter et al., 2014 ; Koenen et al., 2017 ). In the realm of natural sciences, various basic scientific methodologies are employed to acquire knowledge, such as experimentation or scientific observation ( Wellnitz and Mayer, 2013 ). During the pursuit of knowledge through scientific inquiry activities, learners may encounter several challenges and difficulties. Similar to the hurdles faced in experimentation, where understanding the criteria for appropriate experimental design, including the development, measurement, and evaluation of results, is crucial ( Sirum and Humburg, 2011 ; Brownell et al., 2014 ; Dasgupta et al., 2014 ; Deane et al., 2014 ), scientific observation additionally presents its own set of issues. In scientific observation, e.g., the acquisition of new insights may be somewhat incidental due to spontaneous and uncoordinated observations ( Jensen, 2014 ). To address these challenges, it is crucial to provide instructional support, including the use of WE, particularly when observations are carried out in a more self-directed manner.

For this reason, the aim of the present study was to determine the usefulness of digitally presented WE to support the acquisition of a basic scientific methodological skill—conducting scientific observations—using a digital learning environment. In this regard, this study examined the effects of different forms of digitally presented WE (non-faded vs. faded) on students’ cognitive and motivational outcomes and compared them to a control group without WE. Furthermore, the combined perspective of factual and applied knowledge, as well as motivational and cognitive aspects, represent further value added to the study.

2 Theoretical background

2.1 worked examples.

WE have been commonly used in the fields of STEM education (science, technology, engineering, and mathematics) ( Booth et al., 2015 ). They consist of a problem statement, the steps to solve the problem, and the solution itself ( Atkinson et al., 2000 ; Renkl et al., 2002 ; Renkl, 2014 ). The success of WE can be explained by their impact on cognitive load (CL) during learning, based on assumptions from Cognitive Load Theory ( Sweller, 2006 ).

Learning with WE is considered time-efficient, effective, and superior to problem-based learning (presentation of the problem without demonstration of solution steps) when it comes to knowledge acquisition and transfer (WE-effect, Atkinson et al., 2000 ; Van Gog et al., 2011 ). Especially WE can help by reducing the extraneous load (presentation and design of the learning material) and, in turn, can lead to an increase in germane load (effort of the learner to understand the learning material) ( Paas et al., 2003 ; Renkl, 2014 ). With regard to intrinsic load (difficulty and complexity of the learning material), it is still controversially discussed if it can be altered by instructional design, e.g., WE ( Gerjets et al., 2004 ). WE have a positive effect on learning and knowledge transfer, especially for novices, as the step-by-step presentation of the solution requires less extraneous mental effort compared to problem-based learning ( Sweller et al., 1998 ; Atkinson et al., 2000 ; Bokosmaty et al., 2015 ). With growing knowledge, WE can lose their advantages (due to the expertise-reversal effect), and scaffolding learning via faded WE might be more successful for knowledge gain and transfer ( Renkl, 2014 ). Faded WE are similar to complete WE, but fade out solution steps as knowledge and competencies grow. Faded WE enhance near-knowledge transfer and reduce errors compared to non-faded WE ( Renkl et al., 2000 ).

In addition, the reduction of intrinsic and extraneous CL by WE also has an impact on learner motivation, such as interest ( Van Gog and Paas, 2006 ). Um et al. (2012) showed that there is a strong positive correlation between germane CL and the motivational aspects of learning, like satisfaction and emotion. Gupta (2019) mentions a positive correlation between CL and interest. Van Harsel et al. (2019) found that WE positively affect learning motivation, while no such effect was found for problem-solving. Furthermore, learning with WE increases the learners’ belief in their competence in completing a task. In addition, fading WE can lead to higher motivation for more experienced learners, while non-faded WE can be particularly motivating for learners without prior knowledge ( Paas et al., 2005 ). In general, fundamental motivational aspects during the learning process, such as situational interest ( Lewalter and Knogler, 2014 ) or motivation-relevant experiences, like basic needs, are influenced by learning environments. At the same time, their use also depends on motivational characteristics of the learning process, such as self-determined motivation ( Deci and Ryan, 2012 ). Therefore, we assume that learning with WE as a relevant component of a learning environment might also influence situational interest and basic needs.

2.1.1 Presentation of worked examples

WE are frequently used in digital learning scenarios ( Renkl, 2014 ). When designing WE, the application via digital learning media can be helpful, as their content can be presented in different ways (video, audio, text, and images), tailored to the needs of the learners, so that individual use is possible according to their own prior knowledge or learning pace ( Mayer, 2001 ). Also, digital media can present relevant information in a timely, motivating, appealing and individualized way and support learning in an effective and needs-oriented way ( Mayer, 2001 ). The advantages of using digital media in designing WE have already been shown in previous studies. Dart et al. (2020) presented WE as short videos (WEV). They report that the use of WEV leads to increased student satisfaction and more positive attitudes. Approximately 90% of the students indicated an active learning approach when learning with the WEV. Furthermore, the results show that students improved their content knowledge through WEV and that they found WEV useful for other courses as well.

Another study ( Kay and Edwards, 2012 ) presented WE as video podcasts. Here, the advantages of WE regarding self-determined learning in terms of learning location, learning time, and learning speed were shown. Learning performance improved significantly after use. The step-by-step, easy-to-understand explanations, the diagrams, and the ability to determine the learning pace by oneself were seen as beneficial.

Multimedia WE can also be enhanced with self-explanation prompts ( Berthold et al., 2009 ). Learning from WE with self-explanation prompts was shown to be superior to other learning methods, such as hypertext learning and observational learning.

In addition to presenting WE in different medial ways, WE can also comprise different content domains.

2.1.2 Content and context of worked examples

Regarding the content of WE, algorithmic and heuristic WE, as well as single-content and double-content WE, can be distinguished ( Reiss et al., 2008 ; Koenen et al., 2017 ; Renkl, 2017 ). Algorithmic WE are traditionally used in the very structured mathematical–physical field. Here, an algorithm with very specific solution steps is to learn, for example, in probability calculation ( Koenen et al., 2017 ). In this study, however, we focus on heuristic double-content WE. Heuristic WE in science education comprise fundamental scientific working methods, e.g., conducting experiments ( Koenen et al., 2017 ). Furthermore, double-content WE contain two learning domains that are relevant for the learning process: (1) the learning domain describes the primarily to be learned abstract process or concept, e.g., scientific methodologies like observation (see section 2.2), while (2) the exemplifying domain consists of the content that is necessary to teach this process or concept, e.g., mapping of river structure ( Renkl et al., 2009 ).

Depending on the WE content to be learned, it may be necessary for learning to take place in different settings. This can be in a formal or informal learning setting or a non-formal field setting. In this study, the focus is on learning scientific observation (learning domain) through river structure mapping (exemplary domain), which takes place with the support of digital media in a formal (university) setting, but in an informal context (nature).

2.2 Scientific observation

Scientific observation is fundamental to all scientific activities and disciplines ( Kohlhauf et al., 2011 ). Scientific observation must be clearly distinguished from everyday observation, where observation is purely a matter of noticing and describing specific characteristics ( Chinn and Malhotra, 2001 ). In contrast to this everyday observation, scientific observation as a method of knowledge acquisition can be described as a rather complex activity, defined as the theory-based, systematic and selective perception of concrete systems and processes without any fundamental manipulation ( Wellnitz and Mayer, 2013 ). Wellnitz and Mayer (2013) described the scientific observation process via six steps: (1) formulation of the research question (s), (2) deduction of the null hypothesis and the alternative hypothesis, (3) planning of the research design, (4) conducting the observation, (5) analyzing the data, and (6) answering the research question(s) on this basis. Only through reliable and qualified observation, valid data can be obtained that provide solid scientific evidence ( Wellnitz and Mayer, 2013 ).

Since observation activities are not trivial and learners often observe without generating new knowledge or connecting their observations to scientific explanations and thoughts, it is important to provide support at the related cognitive level, so that observation activities can be conducted in a structured way according to pre-defined criteria ( Ford, 2005 ; Eberbach and Crowley, 2009 ). Especially during field-learning experiences, scientific observation is often spontaneous and uncoordinated, whereby random discoveries result in knowledge gain ( Jensen, 2014 ).

To promote successful observing in rather unstructured settings like field trips, instructional support for the observation process seems useful. To guide observation activities, digitally presented WE seem to be an appropriate way to introduce learners to the individual steps of scientific observation using concrete examples.

2.3 Research questions and hypothesis

The present study investigates the effect of digitally presented double-content WE that supports the mapping of a small Bavarian river by demonstrating the steps of scientific observation. In this analysis, we focus on the learning domain of the WE and do not investigate the exemplifying domain in detail. Distinct ways of integrating WE in the digital learning environment (faded WE vs. non-faded WE) are compared with each other and with a control group (no WE). The aim is to examine to what extent differences between those conditions exist with regard to (RQ1) learners’ competence acquisition [acquisition of factual knowledge about the scientific observation method (quantitative data) and practical application of the scientific observation method (quantified qualitative data)], (RQ2) learners’ motivation (situational interest and basic needs), and (RQ3) CL. It is assumed that (Hypothesis 1), the integration of WE (faded and non-faded) leads to significantly higher competence acquisition (factual and applied knowledge), significantly higher motivation and significantly lower extraneous CL as well as higher germane CL during the learning process compared to a learning environment without WE. No differences between the conditions are expected regarding intrinsic CL. Furthermore, it is assumed (Hypothesis 2) that the integration of faded WE leads to significantly higher competence acquisition, significantly higher motivation, and lower extraneous CL as well as higher germane CL during the learning processes compared to non-faded WE. No differences between the conditions are expected with regard to intrinsic CL.

The study took place during the field trips of a university course on the application of a fluvial audit (FA) using the German working aid for mapping the morphology of rivers and their floodplains ( Bayerisches Landesamt für Umwelt, 2019 ). FA is the leading fluvial geomorphological tool for application to data collection contiguously along all watercourses of interest ( Walker et al., 2007 ). It is widely used because it is a key example of environmental conservation and monitoring that needs to be taught to students of selected study programs; thus, knowing about the most effective ways of learning is of high practical relevance.

3.1 Sample and design

3.1.1 sample.

The study was conducted with 62 science students and doctoral students of a German University (age M  = 24.03 years; SD  = 4.20; 36 females; 26 males). A total of 37 participants had already conducted a scientific observation and would rate their knowledge in this regard at a medium level ( M  = 3.32 out of 5; SD  = 0.88). Seven participants had already conducted an FA and would rate their knowledge in this regard at a medium level ( M  = 3.14 out of 5; SD  = 0.90). A total of 25 participants had no experience at all. Two participants had to be excluded from the sample afterward because no posttest results were available.

3.1.2 Design

The study has a 1-factorial quasi-experimental comparative research design and is conducted as a field experiment using a pre/posttest design. Participants were randomly assigned to one of three conditions: no WE ( n  = 20), faded WE ( n  = 20), and non-faded WE ( n  = 20).

3.2 Implementation and material

3.2.1 implementation.

The study started with an online kick-off meeting where two lecturers informed all students within an hour about the basics regarding the assessment of the structural integrity of the study river and the course of the field trip days to conduct an FA. Afterward, within 2 weeks, students self-studied via Moodle the FA following the German standard method according to the scoresheets of Bayerisches Landesamt für Umwelt (2019) . This independent preparation using the online presented documents was a necessary prerequisite for participation in the field days and was checked in the pre-testing. The preparatory online documents included six short videos and four PDF files on the content, guidance on the German protocol of the FA, general information on river landscapes, information about anthropogenic changes in stream morphology and the scoresheets for applying the FA. In these sheets, the river and its floodplain are subdivided into sections of 100 m in length. Each of these sections is evaluated by assessing 21 habitat factors related to flow characteristics and structural variability. The findings are then transferred into a scoring system for the description of structural integrity from 1 (natural) to 7 (highly modified). Habitat factors have a decisive influence on the living conditions of animals and plants in and around rivers. They included, e.g., variability in water depth, stream width, substratum diversity, or diversity of flow velocities.

3.2.2 Materials

On the field trip days, participants were handed a tablet and a paper-based FA worksheet (last accessed 21st September 2022). 1 This four-page assessment sheet was accompanied by a digital learning environment presented on Moodle that instructed the participants on mapping the water body structure and guided the scientific observation method. All three Moodle courses were identical in structure and design; the only difference was the implementation of the WE. Below, the course without WE are described first. The other two courses have an identical structure, but contain additional WE in the form of learning videos.

3.2.3 No worked example

After a short welcome and introduction to the course navigation, the FA started with the description of a short hypothetical scenario: Participants should take the role of an employee of an urban planning office that assesses the ecomorphological status of a small river near a Bavarian city. The river was divided into five sections that had to be mapped separately. The course was structured accordingly. At the beginning of each section, participants had to formulate and write down a research question, and according to hypotheses regarding the ecomorphological status of the river’s section, they had to collect data in this regard via the mapping sheet and then evaluate their data and draw a conclusion. Since this course serves as a control group, no WE videos supporting the scientific observation method were integrated. The layout of the course is structured like a book, where it is not possible to scroll back. This is important insofar as the participants do not have the possibility to revisit information in order to keep the conditions comparable as well as distinguishable.

3.2.4 Non-faded worked example

In the course with no-faded WE, three instructional videos are shown for each of the five sections. In each of the three videos, two steps of the scientific observation method are presented so that, finally, all six steps of scientific observation are demonstrated. The mapping of the first section starts after the general introduction (as described above) with the instruction to work on the first two steps of scientific observation: the formulation of a research question and hypotheses. To support this, a video of about 4 min explains the features of scientific sound research questions and hypotheses. To this aim, a practical example, including explanations and tips, is given regarding the formulation of research questions and hypotheses for this section (e.g., “To what extent does the building development and the closeness of the path to the water body have an influence on the structure of the water body?” Alternative hypothesis: It is assumed that the housing development and the closeness of the path to the water body have a negative influence on the water body structure. Null hypothesis: It is assumed that the housing development and the closeness of the path to the watercourse have no negative influence on the watercourse structure.). Participants should now formulate their own research questions and hypotheses, write them down in a text field at the end of the page, and then skip to the next page. The next two steps of scientific observation, planning and conducting, are explained in a short 4-min video. To this aim, a practical example including explanations and tips is given regarding planning and conducting scientific for this section (e.g., “It’s best to go through each evaluation category carefully one by one that way you are sure not to forget anything!”). Now, participants were asked to collect data for the first section using their paper-based FA worksheet. Participants individually surveyed the river and reported their results in the mapping sheet by ticking the respective boxes in it. After collecting this data, they returned to the digital learning environment to learn how to use these data by studying the last two steps of scientific observation, evaluation, and conclusion. The third 4-min video explained how to evaluate and interpret collected data. For this purpose, a practical example with explanations and tips is given regarding evaluating and interpreting data for this section (e.g., “What were the individual points that led to the assessment? Have there been points that were weighted more than others? Remember the introduction video!”). At the end of the page, participants could answer their before-stated research questions and hypotheses by evaluating their collected data and drawing a conclusion. This brings participants to the end of the first mapping section. Afterward, the cycle begins again with the second section of the river that has to be mapped. Again, participants had to conduct the steps of scientific observation, guided by WE videos, explaining the steps in slightly different wording or with different examples. A total of five sections are mapped, in which the structure of the learning environment and the videos follow the same procedure.

3.2.5 Faded worked example

The digital learning environment with the faded WE follow the same structure as the version with the non-faded WE. However, in this version, the information in the WE videos is successively reduced. In the first section, all three videos are identical to the version with the non-faded WE. In the second section, faded content was presented as follows: the tip at the end was omitted in all three videos. In the third section, the tip and the practical example were omitted. In the fourth and fifth sections, no more videos were presented, only the work instructions.

3.3 Procedure

The data collection took place on four continuous days on the university campus, with a maximum group size of 15 participants on each day. The students were randomly assigned to one of the three conditions (no WE vs. faded WE vs. non-faded WE). After a short introduction to the procedure, the participants were handed the paper-based FA worksheet and one tablet per person. Students scanned the QR code on the first page of the worksheet that opened the pretest questionnaire, which took about 20 min to complete. After completing the questionnaire, the group walked for about 15 min to the nearby small river that was to be mapped. Upon arrival, there was first a short introduction to the digital learning environment and a check that the login (via university account on Moodle) worked. During the next 4 h, the participants individually mapped five segments of the river using the cartography worksheet. They were guided through the steps of scientific observation using the digital learning environment on the tablet. The results of their scientific observation were logged within the digital learning environment. At the end of the digital learning environment, participants were directed to the posttest via a link. After completing the test, the tablets and mapping sheets were returned. Overall, the study took about 5 h per group each day.

3.4 Instruments

In the pretest, sociodemographic data (age and gender), the study domain and the number of study semesters were collected. Additionally, the previous scientific observation experience and the estimation of one’s own ability in this regard were assessed. For example, it was asked whether scientific observation had already been conducted and, if so, how the abilities were rated on a 5-point scale from very low to very high. Preparation for the FA on the basis of the learning material was assessed: Participants were asked whether they had studied all six videos and all four PDF documents, with the response options not at all, partially, and completely. Furthermore, a factual knowledge test about scientific observation and questions about self-determination theory was administered. The posttest used the same knowledge test, and additional questions on basic needs, situational interest, measures of CL and questions about the usefulness of the WE. All scales were presented online, and participants reached the questionnaire via QR code.

3.4.1 Scientific observation competence acquisition

For the factual knowledge (quantitative assessment of the scientific observation competence), a single-choice knowledge test with 12 questions was developed and used as pre- and posttest with a maximum score of 12 points. It assesses the learners’ knowledge of the scientific observation method regarding the steps of scientific observation, e.g., formulating research questions and hypotheses or developing a research design. The questions are based on Wahser (2008 , adapted by Koenen, 2014 ) and adapted to scientific observation: “Although you are sure that you have conducted the scientific observation correctly, an unexpected result turns up. What conclusion can you draw?” Each question has four answer options (one of which is correct) and, in addition, one “I do not know” option.

For the applied knowledge (quantified qualitative assessment of the scientific observation competence), students’ scientific observations written in the digital learning environment were analyzed. A coding scheme was used with the following codes: 0 = insufficient (text field is empty or includes only insufficient key points), 1 = sufficient (a research question and no hypotheses or research question and inappropriate hypotheses are stated), 2 = comprehensive (research question and appropriate hypothesis or research question and hypotheses are stated, but, e.g., incorrect null hypothesis), 3 = very comprehensive (correct research question, hypothesis and null hypothesis are stated). One example of a very comprehensive answer regarding the research question and hypothesis is: To what extent does the lack of riparian vegetation have an impact on water body structure? Hypothesis: The lack of shore vegetation has a negative influence on the water body structure. Null hypothesis: The lack of shore vegetation has no influence on the water body structure. Afterward, a sum score was calculated for each participant. Five times, a research question and hypotheses (steps 1 and 2 in the observation process) had to be formulated (5 × max. 3 points = 15 points), and five times, the research questions and hypotheses had to be answered (steps 5 and 6 in the observation process: evaluation and conclusion) (5 × max. 3 points = 15 points). Overall, participants could reach up to 30 points. Since the observation and evaluation criteria in data collection and analysis were strongly predetermined by the scoresheet, steps 3 and 4 of the observation process (planning and conducting) were not included in the analysis.

All 600 cases (60 participants, each 10 responses to code) were coded by the first author. For verification, 240 cases (24 randomly selected participants, eight from each course) were cross-coded by an external coder. In 206 of the coded cases, the raters agreed. The cases in which the raters did not agree were discussed together, and a solution was found. This results in Cohen’s κ = 0.858, indicating a high to very high level of agreement. This indicates that the category system is clearly formulated and that the individual units of analysis could be correctly assigned.

3.4.2 Self-determination index

For the calculation of the self-determination index (SDI-index), Thomas and Müller (2011) scale for self-determination was used in the pretest. The scale consists of four subscales: intrinsic motivation (five items; e.g., I engage with the workshop content because I enjoy it; reliability of alpha = 0.87), identified motivation (four items; e.g., I engage with the workshop content because it gives me more options when choosing a career; alpha = 0.84), introjected motivation (five items; e.g., I engage with the workshop content because otherwise I would have a guilty feeling; alpha = 0.79), and external motivation (three items, e.g., I engage with the workshop content because I simply have to learn it; alpha = 0.74). Participants could indicate their answers on a 5-point Likert scale ranging from 1 = completely disagree to 5 = completely agree. To calculate the SDI-index, the sum of the self-determined regulation styles (intrinsic and identified) is subtracted from the sum of the external regulation styles (introjected and external), where intrinsic and external regulation are scored two times ( Thomas and Müller, 2011 ).

3.4.3 Motivation

Basic needs were measured in the posttest with the scale by Willems and Lewalter (2011) . The scale consists of three subscales: perceived competence (four items; e.g., during the workshop, I felt that I could meet the requirements; alpha = 0.90), perceived autonomy (five items; e.g., during the workshop, I felt that I had a lot of freedom; alpha = 0.75), and perceived autonomy regarding personal wishes and goals (APWG) (four items; e.g., during the workshop, I felt that the workshop was how I wish it would be; alpha = 0.93). We added all three subscales to one overall basic needs scale (alpha = 0.90). Participants could indicate their answers on a 5-point Likert scale ranging from 1 = completely disagree to 5 = completely agree.

Situational interest was measured in the posttest with the 12-item scale by Lewalter and Knogler (2014 ; Knogler et al., 2015 ; Lewalter, 2020 ; alpha = 0.84). The scale consists of two subscales: catch (six items; e.g., I found the workshop exciting; alpha = 0.81) and hold (six items; e.g., I would like to learn more about parts of the workshop; alpha = 0.80). Participants could indicate their answers on a 5-point Likert scale ranging from 1 = completely disagree to 5 = completely agree.

3.4.4 Cognitive load

In the posttest, CL was used to examine the mental load during the learning process. The intrinsic CL (three items; e.g., this task was very complex; alpha = 0.70) and extraneous CL (three items; e.g., in this task, it is difficult to identify the most important information; alpha = 0.61) are measured with the scales from Klepsch et al. (2017) . The germane CL (two items; e.g., the learning session contained elements that supported me to better understand the learning material; alpha = 0.72) is measured with the scale from Leppink et al. (2013) . Participants could indicate their answers on a 5-point Likert scale ranging from 1 = completely disagree to 5 = completely agree.

3.4.5 Attitudes toward worked examples

To measure how effective participants rated the WE, we used two scales related to the WE videos as instructional support. The first scale from Renkl (2001) relates to the usefulness of WE. The scale consists of four items (e.g., the explanations were helpful; alpha = 0.71). Two items were recoded because they were formulated negatively. The second scale is from Wachsmuth (2020) and relates to the participant’s evaluation of the WE. The scale consists of nine items (e.g., I always did what was explained in the learning videos; alpha = 0.76). Four items were recoded because they were formulated negatively. Participants could indicate their answers on a 5-point Likert scale ranging from 1 = completely disagree to 5 = completely agree.

3.5 Data analysis

An ANOVA was used to calculate if the variable’s prior knowledge and SDI index differed between the three groups. However, as no significant differences between the conditions were found [prior factual knowledge: F (2, 59) = 0.15, p  = 0.865, η 2  = 0.00 self-determination index: F (2, 59) = 0.19, p  = 0.829, η 2  = 0.00], they were not included as covariates in subsequent analyses.

Furthermore, a repeated measure, one-way analysis of variance (ANOVA), was conducted to compare the three treatment groups (no WE vs. faded WE vs. non-faded WE) regarding the increase in factual knowledge about the scientific observation method from pretest to posttest.

A MANOVA (multivariate analysis) was calculated with the three groups (no WE vs. non-faded WE vs. faded WE) as a fixed factor and the dependent variables being the practical application of the scientific observation method (first research question), situational interest, basic needs (second research question), and CL (third research question).

Additionally, to determine differences in applied knowledge even among the three groups, Bonferroni-adjusted post-hoc analyses were conducted.

The descriptive statistics between the three groups in terms of prior factual knowledge about the scientific observation method and the self-determination index are shown in Table 1 . The descriptive statistics revealed only small, non-significant differences between the three groups in terms of factual knowledge.

Table 1 . Means (standard deviations) of factual knowledge tests (pre- and posttest) and self-determination index for the three different groups.

The results of the ANOVA revealed that the overall increase in factual knowledge from pre- to posttest just misses significance [ F (1, 57) = 3.68, p  = 0.060, η 2  = 0 0.06]. Furthermore, no significant differences between the groups were found regarding the acquisition of factual knowledge from pre- to posttest [ F (2, 57) = 2.93, p  = 0.062, η 2  = 0.09].

An analysis of the descriptive statistics showed that the largest differences between the groups were found in applied knowledge (qualitative evaluation) and extraneous load (see Table 2 ).

Table 2 . Means (standard deviations) of dependent variables with the three different groups.

Results of the MANOVA revealed significant overall differences between the three groups [ F (12, 106) = 2.59, p  = 0.005, η 2  = 0.23]. Significant effects were found for the application of knowledge [ F (2, 57) = 13.26, p  = <0.001, η 2  = 0.32]. Extraneous CL just missed significance [ F (2, 57) = 2.68, p  = 0.065, η 2  = 0.09]. There were no significant effects for situational interest [ F (2, 57) = 0.44, p  = 0.644, η 2  = 0.02], basic needs [ F (2, 57) = 1.22, p  = 0.302, η 2  = 0.04], germane CL [ F (2, 57) = 2.68, p  = 0.077, η 2  = 0.09], and intrinsic CL [ F (2, 57) = 0.28, p  = 0.757, η 2  = 0.01].

Bonferroni-adjusted post hoc analysis revealed that the group without WE had significantly lower scores in the evaluation of the applied knowledge than the group with non-faded WE ( p  = <0.001, M diff  = −8.90, 95% CI [−13.47, −4.33]) and then the group with faded WE ( p  = <0.001, M diff  = −7.40, 95% CI [−11.97, −2.83]). No difference was found between the groups with faded and non-faded WE ( p  = 1.00, M diff  = −1.50, 95% CI [−6.07, 3.07]).

The descriptive statistics regarding the perceived usefulness of WE and participants’ evaluation of the WE revealed that the group with the faded WE rated usefulness slightly higher than the participants with non-faded WE and also reported a more positive evaluation. However, the results of a MANOVA revealed no significant overall differences [ F (2, 37) = 0.32, p  = 0.732, η 2  = 0 0.02] (see Table 3 ).

Table 3 . Means (standard deviations) of dependent variables with the three different groups.

5 Discussion

This study investigated the use of WE to support students’ acquisition of science observation. Below, the research questions are answered, and the implications and limitations of the study are discussed.

5.1 Results on factual and applied knowledge

In terms of knowledge gain (RQ1), our findings revealed no significant differences in participants’ results of the factual knowledge test both across all three groups and specifically between the two experimental groups. These results are in contradiction with related literature where WE had a positive impact on knowledge acquisition ( Renkl, 2014 ) and faded WE are considered to be more effective in knowledge acquisition and transfer, in contrast to non-faded WE ( Renkl et al., 2000 ; Renkl, 2014 ). A limitation of the study is the fact that the participants already scored very high on the pretest, so participation in the intervention would likely not yield significant knowledge gains due to ceiling effects ( Staus et al., 2021 ). Yet, nearly half of the students reported being novices in the field prior to the study, suggesting that the difficulty of some test items might have been too low. Here, it would be important to revise the factual knowledge test, e.g., the difficulty of the distractors in further study.

Nevertheless, with regard to application knowledge, the results revealed large significant differences: Participants of the two experimental groups performed better in conducting scientific observation steps than participants of the control group. In the experimental groups, the non-faded WE group performed better than the faded WE group. However, the absence of significant differences between the two experimental groups suggests that faded and non-faded WE used as double-content WE are suitable to teach applied knowledge about scientific observation in the learning domain ( Koenen, 2014 ). Furthermore, our results differ from the findings of Renkl et al. (2000) , in which the faded version led to the highest knowledge transfer. Despite the fact that the non-faded WE performed best in our study, the faded version of the WE was also appropriate to improve learning, confirming the findings of Renkl (2014) and Hesser and Gregory (2015) .

5.2 Results on learners’ motivation

Regarding participants’ motivation (RQ2; situational interest and basic needs), no significant differences were found across all three groups or between the two experimental groups. However, descriptive results reveal slightly higher motivation in the two experimental groups than in the control group. In this regard, our results confirm existing literature on a descriptive level showing that WE lead to higher learning-relevant motivation ( Paas et al., 2005 ; Van Harsel et al., 2019 ). Additionally, both experimental groups rated the usefulness of the WE as high and reported a positive evaluation of the WE. Therefore, we assume that even non-faded WE do not lead to over-instruction. Regarding the descriptive tendency, a larger sample might yield significant results and detect even small effects in future investigations. However, because this study also focused on comprehensive qualitative data analysis, it was not possible to evaluate a larger sample in this study.

5.3 Results on cognitive load

Finally, CL did not vary significantly across all three groups (RQ3). However, differences in extraneous CL just slightly missed significance. In descriptive values, the control group reported the highest extrinsic and lowest germane CL. The faded WE group showed the lowest extrinsic CL and a similar germane CL as the non-faded WE group. These results are consistent with Paas et al. (2003) and Renkl (2014) , reporting that WE can help to reduce the extraneous CL and, in return, lead to an increase in germane CL. Again, these differences were just above the significance level, and it would be advantageous to retest with a larger sample to detect even small effects.

Taken together, our results only partially confirm H1: the integration of WE (both faded and non-faded WE) led to a higher acquisition of application knowledge than the control group without WE, but higher factual knowledge was not found. Furthermore, higher motivation or different CL was found on a descriptive level only. The control group provided the basis for comparison with the treatment in order to investigate if there is an effect at all and, if so, how large the effect is. This is an important point to assess whether the effort of implementing WE is justified. Additionally, regarding H2, our results reveal no significant differences between the two WE conditions. We assume that the high complexity of the FA could play a role in this regard, which might be hard to handle, especially for beginners, so learners could benefit from support throughout (i.e., non-faded WE).

In addition to the limitations already mentioned, it must be noted that only one exemplary topic was investigated, and the sample only consisted of students. Since only the learning domain of the double-content WE was investigated, the exemplifying domain could also be analyzed, or further variables like motivation could be included in further studies. Furthermore, the influence of learners’ prior knowledge on learning with WE could be investigated, as studies have found that WE are particularly beneficial in the initial acquisition of cognitive skills ( Kalyuga et al., 2001 ).

6 Conclusion

Overall, the results of the current study suggest a beneficial role for WE in supporting the application of scientific observation steps. A major implication of these findings is that both faded and non-faded WE should be considered, as no general advantage of faded WE over non-faded WE was found. This information can be used to develop targeted interventions aimed at the support of scientific observation skills.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

Ethical approval was not required for the study involving human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants in accordance with the national legislation and the institutional requirements.

Author contributions

ML: Writing – original draft. SM: Writing – review & editing. JP: Writing – review & editing. JG: Writing – review & editing. DL: Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2024.1293516/full#supplementary-material

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Walker, J., Gibson, J., and Brown, D. (2007). Selecting fluvial geomorphological methods for river management including catchment scale restoration within the environment agency of England and Wales. Int. J. River Basin Manag. 5, 131–141. doi: 10.1080/15715124.2007.9635313

Wellnitz, N., and Mayer, J. (2013). Erkenntnismethoden in der Biologie – Entwicklung und evaluation eines Kompetenzmodells. (Methods of knowledge in biology - development and evaluation of a competence model). Z. Didaktik Naturwissensch. 19, 315–345.

Willems, A. S., and Lewalter, D. (2011). “Welche Rolle spielt das motivationsrelevante Erleben von Schülern für ihr situationales Interesse im Mathematikunterricht? (What role does students’ motivational experience play in their situational interest in mathematics classrooms?). Befunde aus der SIGMA-Studie” in Erziehungswissenschaftliche Forschung – nachhaltige Bildung. Beiträge zur 5. DGfE-Sektionstagung “Empirische Bildungsforschung”/AEPF-KBBB im Frühjahr 2009 . eds. B. Schwarz, P. Nenninger, and R. S. Jäger (Landau: Verlag Empirische Pädagogik), 288–294.

Keywords: digital media, worked examples, scientific observation, motivation, cognitive load

Citation: Lechner M, Moser S, Pander J, Geist J and Lewalter D (2024) Learning scientific observation with worked examples in a digital learning environment. Front. Educ . 9:1293516. doi: 10.3389/feduc.2024.1293516

Received: 13 September 2023; Accepted: 29 February 2024; Published: 18 March 2024.

Reviewed by:

Copyright © 2024 Lechner, Moser, Pander, Geist and Lewalter. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Miriam Lechner, [email protected]

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1.9: Types of Research Studies and How To Interpret Them

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• Alice Callahan, Heather Leonard, & Tamberly Powell
• Lane Community College via OpenOregon

The field of nutrition is dynamic, and our understanding and practices are always evolving. Nutrition scientists are continuously conducting new research and publishing their findings in peer-reviewed journals. This adds to scientific knowledge, but it’s also of great interest to the public, so nutrition research often shows up in the news and other media sources. You might be interested in nutrition research to inform your own eating habits, or if you work in a health profession, so that you can give evidence-based advice to others. Making sense of science requires that you understand the types of research studies used and their limitations.

The Hierarchy of Nutrition Evidence

Researchers use many different types of study designs depending on the question they are trying to answer, as well as factors such as time, funding, and ethical considerations. The study design affects how we interpret the results and the strength of the evidence as it relates to real-life nutrition decisions. It can be helpful to think about the types of studies within a pyramid representing a hierarchy of evidence, where  the  studies at the bottom of the pyramid usually give us the weakest evidence with the least relevance to real-life nutrition decisions, and the studies at the top offer the strongest evidence, with the most relevance to real-life nutrition  decisions .

The pyramid also represents a few other general ideas. There tend to be more studies published using the methods at the bottom of the pyramid, because they require less time, money, and other resources. When researchers want to test a new hypothesis , they often start with the study designs at the bottom of the pyramid , such as in vitro, animal, or observational studies. Intervention studies are more expensive and resource-intensive, so there are fewer of these types of studies conducted. But they also give us higher quality evidence, so they’re an important next step if observational and non-human studies have shown promising results. Meta-analyses and systematic reviews combine the results of many studies already conducted, so they help researchers summarize scientific knowledge on a topic.

Non-Human Studies: In Vitro & Animal Studies

The simplest form of nutrition research is an in vitro study . In vitro means “within glass,” (although plastic is used more commonly today) and these experiments are conducted within flasks, dishes, plates, and test tubes. These studies are performed on isolated cells or tissue samples, so they’re less expensive and time-intensive than animal or human studies. In vitro studies are vital for zooming in on biological mechanisms, to see how things work at the cellular or molecular level. However, these studies shouldn’t be used to draw conclusions about how things work in humans (or even animals), because we can’t assume that the results will apply to a whole, living organism.

Animal studies are one form of in vivo research, which translates to “within the living.” Rats and mice are the most common animals used in nutrition research. Animals are often used in research that would be unethical to conduct in humans. Another advantage of animal dietary studies is that researchers can control exactly what the animals eat. In human studies, researchers can tell subjects what to eat and even provide them with the food, but they may not stick to the planned diet. People are also not very good at estimating, recording, or reporting what they eat and in what quantities. In addition, animal studies typically do not cost as much as human studies.

There are some important limitations of animal research. First, an animal’s metabolism and physiology are different from humans. Plus, animal models of disease (cancer, cardiovascular disease, etc.), although similar, are different from human diseases. Animal research is considered preliminary, and while it can be very important to the process of building scientific understanding and informing the types of studies that should be conducted in humans, animal studies shouldn’t be considered relevant to real-life decisions about how people eat.

Observational Studies

Observational studies  in human nutrition collect information on people’s dietary patterns or nutrient intake and look for associations with health outcomes. Observational studies do not give participants a treatment or intervention; instead, they look at what they’re already doing and see how it relates to their health. These types of study designs can only identify  correlations  (relationships) between nutrition and health; they can’t show that one factor  causes  another. (For that, we need intervention studies, which we’ll discuss in a moment.) Observational studies that describe factors correlated with human health are also called  epidemiological studies . 1

One example of a nutrition hypothesis that has been investigated using observational studies is that eating a Mediterranean diet reduces the risk of developing cardiovascular disease. (A Mediterranean diet focuses on whole grains, fruits and vegetables, beans and other legumes, nuts, olive oil, herbs, and spices. It includes small amounts of animal protein (mostly fish), dairy, and red wine. 2 ) There are three main types of observational studies, all of which could be used to test hypotheses about the Mediterranean diet:

• Cohort studies follow a group of people (a cohort) over time, measuring factors such as diet and health outcomes. A cohort study of the Mediterranean diet would ask a group of people to describe their diet, and then researchers would track them over time to see if those eating a Mediterranean diet had a lower incidence of cardiovascular disease.
• Case-control studies compare a group of cases and controls, looking for differences between the two groups that might explain their different health outcomes. For example, researchers might compare a group of people with cardiovascular disease with a group of healthy controls to see whether there were more controls or cases that followed a Mediterranean diet.
• Cross-sectional studies collect information about a population of people at one point in time. For example, a cross-sectional study might compare the dietary patterns of people from different countries to see if diet correlates with the prevalence of cardiovascular disease in the different countries.

Prospective cohort studies, which enroll a cohort and follow them into the future, are usually considered the strongest type of observational study design. Retrospective studies look at what happened in the past, and they’re considered weaker because they rely on people’s memory of what they ate or how they felt in the past. There are several well-known examples of prospective cohort studies that have described important correlations between diet and disease:

• Framingham Heart Study : Beginning in 1948, this study has followed the residents of Framingham, Massachusetts to identify risk factors for heart disease.
• Health Professionals Follow-Up Study : This study started in 1986 and enrolled 51,529 male health professionals (dentists, pharmacists, optometrists, osteopathic physicians, podiatrists, and veterinarians), who complete diet questionnaires every 2 years.
• Nurses Health Studies : Beginning in 1976, these studies have enrolled three large cohorts of nurses with a total of 280,000 participants. Participants have completed detailed questionnaires about diet, other lifestyle factors (smoking and exercise, for example), and health outcomes.

Observational studies have the advantage of allowing researchers to study large groups of people in the real world, looking at the frequency and pattern of health outcomes and identifying factors that correlate with them. But even very large observational studies may not apply to the population as a whole. For example, the Health Professionals Follow-Up Study and the Nurses Health Studies include people with above-average knowledge of health. In many ways, this makes them ideal study subjects, because they may be more motivated to be part of the study and to fill out detailed questionnaires for years. However, the findings of these studies may not apply to people with less baseline knowledge of health.

We’ve already mentioned another important limitation of observational studies—that they can only determine correlation, not causation. A prospective cohort study that finds that people eating a Mediterranean diet have a lower incidence of heart disease can only show that the Mediterranean diet is correlated with lowered risk of heart disease. It can’t show that the Mediterranean diet directly prevents heart disease. Why? There are a huge number of factors that determine health outcomes such as heart disease, and other factors might explain a correlation found in an observational study. For example, people who eat a Mediterranean diet might also be the same kind of people who exercise more, sleep more, have higher income (fish and nuts can be expensive!), or be less stressed. These are called confounding factors ; they’re factors that can affect the outcome in question (i.e., heart disease) and also vary with the factor being studied (i.e., Mediterranean diet).

Intervention Studies

Intervention studies , also sometimes called experimental studies or clinical trials, include some type of treatment or change imposed by the researcher. Examples of interventions in nutrition research include asking participants to change their diet, take a supplement, or change the time of day that they eat. Unlike observational studies, intervention studies can provide evidence of cause and effect , so they are higher in the hierarchy of evidence pyramid.

The gold standard for intervention studies is the randomized controlled trial (RCT) . In an RCT, study subjects are recruited to participate in the study. They are then randomly assigned into one of at least two groups, one of which is a control group (this is what makes the study controlled ). In an RCT to study the effects of the Mediterranean diet on cardiovascular disease development, researchers might ask the control group to follow a low-fat diet (typically recommended for heart disease prevention) and the intervention group to eat a Mediterrean diet. The study would continue for a defined period of time (usually years to study an outcome like heart disease), at which point the researchers would analyze their data to see if more people in the control or Mediterranean diet had heart attacks or strokes. Because the treatment and control groups were randomly assigned, they should be alike in every other way except for diet, so differences in heart disease could be attributed to the diet. This eliminates the problem of confounding factors found in observational research, and it’s why RCTs can provide evidence of causation, not just correlation.

Imagine for a moment what would happen if the two groups weren’t randomly assigned. What if the researchers let study participants choose which diet they’d like to adopt for the study? They might, for whatever reason, end up with more overweight people who smoke and have high blood pressure in the low-fat diet group, and more people who exercised regularly and had already been eating lots of olive oil and nuts for years in the Mediterranean diet group. If they found that the Mediterranean diet group had fewer heart attacks by the end of the study, they would have no way of knowing if this was because of the diet or because of the underlying differences in the groups. In other words, without randomization, their results would be compromised by confounding factors, with many of the same limitations as observational studies.

In an RCT of a supplement, the control group would receive a placebo—a  “fake” treatment that contains no active ingredients, such as a sugar pill. The use of a placebo is necessary in medical research because of a phenomenon known as the placebo effect. The placebo effect results in a beneficial effect because of a subject’s belief in the treatment, even though there is no treatment actually being administered.

Blinding is a technique to prevent bias in intervention studies. In a study without blinding, the subject and the researchers both know what treatment the subject is receiving. This can lead to bias if the subject or researcher have expectations about the treatment working, so these types of trials are used less frequently. It’s best if a study is double-blind , meaning that neither the researcher nor the subject know what treatment the subject is receiving. It’s relatively simple to double-blind a study where subjects are receiving a placebo or treatment pill, because they could be formulated to look and taste the same. In a single-blind study , either the researcher or the subject knows what treatment they’re receiving, but not both. Studies of diets—such as the Mediterranean diet example—often can’t be double-blinded because the study subjects know whether or not they’re eating a lot of olive oil and nuts. However, the researchers who are checking participants’ blood pressure or evaluating their medical records could be blinded to their treatment group, reducing the chance of bias.

Like all studies, RCTs and other intervention studies do have some limitations. They can be difficult to carry on for long periods of time and require that participants remain compliant with the intervention. They’re also costly and often have smaller sample sizes. Furthermore, it is unethical to study certain interventions. (An example of an unethical intervention would be to advise one group of pregnant mothers to drink alcohol to determine its effects on pregnancy outcomes, because we know that alcohol consumption during pregnancy damages the developing fetus.)

VIDEO: “ Not all scientific studies are created equal ” by David H. Schwartz, YouTube (April 28, 2014), 4:26.

Meta-Analyses and Systematic Reviews

At the top of the hierarchy of evidence pyramid are systematic reviews and meta-analyses .  You can think of these as “studies of studies.” They attempt to combine all of the relevant studies that have been conducted on a research question and summarize their overall conclusions. Researchers conducting a  systematic review  formulate a research question and then systematically and independently identify, select, evaluate, and synthesize all high-quality evidence that relates to the research question. Since systematic reviews combine the results of many studies, they help researchers produce more reliable findings. A  meta-analysis  is a type of systematic review that goes one step further, combining the data from multiple studies and using statistics to summarize it, as if creating a mega-study from many smaller studies . 4

However, even systematic reviews and meta-analyses aren’t the final word on scientific questions. For one thing, they’re only as good as the studies that they include. The  Cochrane Collaboration  is an international consortium of researchers who conduct systematic reviews in order to inform evidence-based healthcare, including nutrition, and their reviews are among the most well-regarded and rigorous in science. For the most recent Cochrane review of the Mediterranean diet and cardiovascular disease, two authors independently reviewed studies published on this question. Based on their inclusion criteria, 30 RCTs with a total of 12,461 participants were included in the final analysis. However, after evaluating and combining the data, the authors concluded that “despite the large number of included trials, there is still uncertainty regarding the effects of a Mediterranean‐style diet on cardiovascular disease occurrence and risk factors in people both with and without cardiovascular disease already.” Part of the reason for this uncertainty is that different trials found different results, and the quality of the studies was low to moderate. Some had problems with their randomization procedures, for example, and others were judged to have unreliable data. That doesn’t make them useless, but it adds to the uncertainty about this question, and uncertainty pushes the field forward towards more and better studies. The Cochrane review authors noted that they found seven ongoing trials of the Mediterranean diet, so we can hope that they’ll add more clarity to this question in the future. 5

Science is an ongoing process. It’s often a slow process, and it contains a lot of uncertainty, but it’s our best method of building knowledge of how the world and human life works. Many different types of studies can contribute to scientific knowledge. None are perfect—all have limitations—and a single study is never the final word on a scientific question. Part of what advances science is that researchers are constantly checking each other’s work, asking how it can be improved and what new questions it raises.

Attributions:

• “Chapter 1: The Basics” from Lindshield, B. L. Kansas State University Human Nutrition (FNDH 400) Flexbook. goo.gl/vOAnR , CC BY-NC-SA 4.0
• “ The Broad Role of Nutritional Science ,” section 1.3 from the book An Introduction to Nutrition (v. 1.0), CC BY-NC-SA 3.0

References:

• 1 Thiese, M. S. (2014). Observational and interventional study design types; an overview. Biochemia Medica , 24 (2), 199–210. https://doi.org/10.11613/BM.2014.022
• 2 Harvard T.H. Chan School of Public Health. (2018, January 16). Diet Review: Mediterranean Diet . The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/healthy-weight/diet-reviews/mediterranean-diet/
• 3 Ross, R., Gray, C. M., & Gill, J. M. R. (2015). Effects of an Injected Placebo on Endurance Running Performance. Medicine and Science in Sports and Exercise , 47 (8), 1672–1681. https://doi.org/10.1249/MSS.0000000000000584
• 4 Hooper, A. (n.d.). LibGuides: Systematic Review Resources: Systematic Reviews vs Other Types of Reviews . Retrieved February 7, 2020, from //libguides.sph.uth.tmc.edu/c.php?g=543382&p=5370369
• 5 Rees, K., Takeda, A., Martin, N., Ellis, L., Wijesekara, D., Vepa, A., Das, A., Hartley, L., & Stranges, S. (2019). Mediterranean‐style diet for the primary and secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews , 3 . doi.org/10.1002/14651858.CD009825.pub3
• Figure 2.3. The hierarchy of evidence by Alice Callahan, is licensed under CC BY 4.0
• Research lab photo by National Cancer Institute on Unsplas h ; mouse photo by vaun0815 on Unsplash
• Figure 2.4. “Placebo effect example” by Lindshield, B. L. Kansas State University Human Nutrition (FNDH 400) Flexbook. goo.gl/vOAnR

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5 Popular Education Beliefs That Aren’t Backed by Research

Making adjustments to these common misconceptions can turn dubious strategies into productive lessons, the research suggests.

Not every learning myth requires teachers to pull up stakes and start all over again—at least not entirely. There are some commonly-held misconceptions that contain a nugget of wisdom but need to be tweaked in order to align with the science of learning.

Sometimes, in other words, you’re already halfway there. Here are five mostly-myths, from the power of doodling to the motivating role of grades, that educators can quickly adjust and turn to their advantage.

1. Doodling Improves Focus and Learning

When we write about the power of drawing to learn, we often hear from readers who feel compelled to defend an old habit: “See, I told you that when I was doodling I was still paying attention!” But doodling—which is commonly defined as “an aimless or casual scribble or sketch” and often consists of marginalia like cartoon characters, geometric patterns, or pastoral scenes—is distinct from what researchers call “task-related drawing.” And doodling, in this sense, is not associated with improvements in focus or academic outcomes.

In fact, both cognitive load theory and experimental studies are generally downbeat on doodling. Students who sketch complicated scenes or designs as they try to process a lesson on plate tectonics, according to the first theory, are engaging in competitive cognitive tasks and will generally underperform on both. Doodling, like all drawing, is cognitively intensive, involving complex feedback loops between visual, sensorimotor, attentional, and planning regions of the brain and body. Because our ability to process information is finite, drawing and learning about different things at the same time is a simple question of too much.

Research confirms the theory. A 2019 study pitted off-task doodling against typical learning activities like “task-related drawing” and writing. In three separate but related experiments, task-related drawing and writing beat out doodling in terms of recall—by margins as large as 300%. How to fix it: Sketching what you are actually learning—from representational drawings of cells or tectonic boundaries to the creation of concept maps and organizational drawings—is, in fact, a powerful learning strategy (see research here , here , and here ), and that applies “regardless of one’s artistic talent,” a 2018 study confirms. Try to harness a student’s passion for doodling by allowing them to submit academic sketches as work products. To get even more bang for your buck, ask them to annotate their drawings, or talk you through them—which will encode learning even more deeply, according to research .

2. Reading Aloud In Turn Improves Fluency

Often called “round robin reading” (RRR), I resorted to it when I taught years ago—and it appears that it’s still frequently used, judging from a 2019 blog by literacy expert Timothy Shanahan, and comments on a 2022 Cult of Pedagogy post on the topic. Teachers deploy it for good reasons: Arguably, the practice encourages student engagement; gives teachers the opportunity to gauge oral reading fluency; and has a built-in classroom management benefit as well. Students are generally silent and (superficially) attentive when a peer is reading.

But according to Shanahan, and the literacy professors Katherine Hilden and Jennifer Jones, the practice has long been frowned upon. In an influential 2012 review of relevant literature , Hilden and Jones cut straight to the point: “We know of no research evidence that supports the claim that RRR actually contributes to students becoming better readers, either in terms of their fluency or comprehension.”

In fact, RRR has plenty of problems. Individual students using RRR may accumulate less than three hours of oral reading time over the course of a year, according to Shanahan—and Hilden and Jones say that students who are following along during the activity tend to “subvocalize” as they track the reader, reducing their own internal reading speed unnecessarily. RRR also has the unfortunate effects of stigmatizing struggling readers; exposing new readers to dysfluent modeling; and failing to incorporate meaningful comprehension strategies. 

How to fix it: Yes, reading out loud is necessary to teach fluency, according to Shanahan, but there are better methods. Pairing kids together to “read sections of the text aloud to each other (partner reading) and then discuss and answer your questions,” is a good approach, he says, especially if teachers circulate to listen for problems. 

More generally, reading strategies that model proper reading speed, pronunciation, and affect—while providing time for vocabulary review, repeated exposure to the text, and opportunities to summarize and discuss—can improve both fluency and comprehension.

A 2011 study , for example, demonstrated that combining choral reading—teachers and students read a text in unison (similar to echo reading )—with other activities like vocabulary review, teacher modeling, and follow-up discussion improved students’ decoding and fluency.

3. Talent Beats Persistence

It’s a common trap: Observers tend to rate people who appear to be naturally gifted at something more highly than those who admit they’ve worked hard to achieve success. Researchers call this the “ naturalness bias ,” and it shows up everywhere, from teachers evaluating students to bosses evaluating employees.

In reality, the opposite is more often true. “Popular lore tells us that genius is born, not made,” writes psychologist and widely-cited researcher of human potential K. Anders Ericsson for the Harvard Business Review . “Scientific research, on the other hand, reveals that true expertise is mainly the product of years of intense practice and dedicated coaching.”

Experimental studies extend the point to academics: An influential 2019 study led by psychologists Brian Galla and Angela Duckworth, for example, found that high school GPA is a better predictor than the SAT of how likely students are to complete college on time. That's because "grades are a very good index of your self-regulation—your ability to stick with things, your ability to regulate your impulses, your ability to delay gratification and work hard instead of goofing off," said Duckworth in a 2020 interview with Edutopia .

How to fix it: All kids—even the ones who already excel in a discipline—benefit when teachers emphasize the importance of effort, perseverance, and growth. Consider praising students for their improvement instead of their raw scores; have students read about and then discuss the idea of neural plasticity; and consider assigning reports on the mistakes and growing pains of accomplished writers, scientists, and artists.

Try to incorporate rough-draft thinking in class and think about taking risks yourself: The renowned writing teacher Kelly Gallagher, author of Readicide , regularly composes in front of his class to model his own tolerance for errors and redrafting.

4. Background Music (Always) Undermines Learning

It’s a fascinating and complex question: Can students successfully learn while background music is playing?

In some cases, it appears, background music can be a neutral to positive influence; in other scenarios, it’s clearly distracting. There are several factors at play in determining the outcomes.

A 2021 study clarifies that because music and language use some of the same neural circuitry—a finding that appears as early as infancy —“listening to lyrics of a familiar language may rely on the same cognitive resources as vocabulary learning,” and that can “lead to an overload of processing capacity and thus to an interference effect.” Other features of the music probably matter, too: Dramatic changes in a song’s rhythm, for example, or transitions from one song to the next , often force the learning brain to reckon with irrelevant information. A 2018 research review confirms the general finding: Across 65 studies, background music consistently had a “small but reliably detrimental effect” on reading comprehension.

In some cases, however, music may aid learning. Neuroscience suggests that catchy melodies, for example, can boost a student’s mood—which might lead to significant positive effects on learning when motivation and concentration are paramount, a 2023 study found.

How to fix it: Basically, “music has two effects simultaneously that conflict with one another,” cognitive psychologist Daniel Willingham told Edutopia in 2023 —one distracting, and the other arousing.

“If you’re doing work that’s not very demanding, having music on is probably fine”—and likely to motivate students to keep going, Willingham says . In those cases, try to stick to music that’s instrumental or familiar, in order to decrease the cognitive resources needed to process it. “But if you’re doing work that’s just somewhat difficult, the distraction is probably going to make music a negative overall,” Willingham adds.

5. Grades Are Motivating

Teachers are well aware that grading, as a system, has many flaws—but at least grades motivate students to try their hardest, right? Unfortunately, the research suggests that that’s largely not the case.

“Despite the conventional wisdom in education, grades don’t motivate students to do their best work, nor do they lead to better learning or performance,” write motivation researcher Chris Hulleman and science teacher Ian Kelleher in an article for Edutopia . A 2019 research review , meanwhile, revealed that when confronted by grades, written feedback, or nothing at all—students preferred the latter two to grades, suggesting that A-F rankings might actually have a net negative impact on motivation.

In another blow to grades, a 2018 analysis of university policies like pass/fail grading or narrative evaluations concluded that “grades enhanced anxiety and avoidance of challenging courses” but didn’t improve student motivation. Providing students with specific, actionable feedback, on the other hand, “promot[ed] trust between instructors and students,” leading to greater academic ambition.

How to fix it: While grades are still mandatory in most schools—and some form of rigorous assessment remains an imperative—educators might consider ways to de-emphasize them.

Some teachers choose to drop every student’s lowest grade , for example, allow students to retake a limited number of assessments each unit, or periodically give kids the discretion to turn in “their best work” from a series of related assignments. 

At King Middle School in Portland, Maine , educators delay their release of grades until the end of the unit, an approach backed by a 2021 study which found that delayed grading—handing back personalized feedback days before releasing number or letter grades—can boost student performance on future assignments by two-thirds of a letter grade.

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8 Time Management Tips for Students

Don't let a hectic schedule get the better of you with these time management tips.

Lian Parsons

College can be a stressful time for many students and time management can be one of the most crucial — but tricky — skills to master.

Attending classes, studying for exams, making friends, and taking time to relax and decompress can quickly fill up your schedule. If you often find yourself wishing there were more hours in the day, this guide will offer time management tips for students so you can accomplish what you need to get done, have fun with your friends, and gain back some valuable time for yourself. 

1. Create a Calendar

Don’t be caught by surprise by an important paper due two days from now or a dinner with your family the same night you planned for a group study session. Create a calendar for yourself with all your upcoming deadlines, exams, social events, and other time commitments well in advance so you can see what’s coming up. 

Keep your calendar in a place where you can see it every day, such as in your planner or on your wall above your desk. If you prefer a digital calendar, check it first thing every day to keep those important events fresh and top-of-mind. For greater efficiency, make sure you can integrate it with your other tools, such as your email.

Digital calendar options include: 

• Google Calendar 
• Outlook Calendar
• Fantastical

2. Set Reminders

After you’ve created your calendar, give yourself periodic reminders to stay on track such as to complete a study guide in advance or schedule a meeting for a group project. Knowing deadlines is important; however, staying on top of the micro tasks involved in meeting those deadlines is just as important. You can set an alarm on your phone, write it down in a physical planner, or add an alert to your digital calendar. The reminders will help to prevent things from slipping through the cracks during particularly hectic days.

Make sure you’ve allotted enough time to study for that big test or write that final paper. Time management is all about setting yourself up for success in advance and giving yourself the tools to accomplish tasks with confidence. 

Read our blogs, Your Guide to Conquering College Coursework and Top 10 Study Tips to Study Like a Harvard Student , for more suggestions.

3. Build a Personalized Schedule

Each person’s day-to-day is different and unique to them, so make sure your schedule works for you. Once you’ve accounted for consistent commitments such as classes or your shifts at work, add in study sessions, extracurriculars, chores and errands, and social engagements.

Consider your personal rhythm. If you typically start your day energized, plan to study or accomplish chores then. If you fall into an afternoon slump, give yourself that time to take a guilt-free TV break or see friends.

Having a schedule that works for you will help maximize your time. Plus, knowing exactly when your laundry day is or when your intramural volleyball practice is every week will help you avoid trying to cram everything in one day (or running out of clean socks!)

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4. Use Tools That Work For You

Just like your calendar and schedule, the tools you use to keep you organized should be the right fit for you. Some students prefer physical planners and paper, while some prefer going totally digital. Your calendar can help you with long-term planning, but most of these tools are best for prioritizing from day to day.

Explore what best suits your needs with some of the following suggestions:

Planners can help you keep track of long-term deadlines, such as important essay deadlines, upcoming exams, and appointments and meetings. They often provide a monthly overview each month, as well as day-to-day planning sections, so you can stay ahead. 

• Papier – Offers a 20% student discount 

If your schedule is jam-packed and you have trouble figuring out what to do and when, scheduling day by day—and sometimes even hour by hour—can help you slot in everything you need to do with less stress.

• Structured app

Note Taking

From class to study sessions to errands, keeping track of everything can feel overwhelming. Keeping everything in one place, whether on the go or at your desk, can help keep you organized.

• Bullet journals

5. Prioritize

Sometimes there really is too much to do with too little time. In these instances, take just a few minutes to evaluate your priorities. Consider which deadlines are most urgent, as well as how much energy you have. 

If you are able to complete simple tasks first, try getting them out of the way before moving on to tasks that require a lot of focus. This can help to alleviate some of the pressure by checking a couple things off your to-do list without getting bogged down too early.

If you are struggling to fit everything in your schedule, consider what you can postpone or what you can simply say no to. Your friends will likely understand if you have to meet them for coffee another time in order to get in a final library session before a challenging exam. 

6. Make Time to Have Fun — And For Yourself

Time management isn’t just about getting work done. It’s also about ensuring that you can put yourself and your mental wellbeing first. Consistently including time for yourself in your schedule helps to keep your mental health and your life in balance. It can also be helpful to have things to look forward to when going through stressful periods.  

Whether it’s going for a bike ride along the river, spending time with your friends and family, or simply sleeping in on a Sunday, knowing you have space to relax and do things you enjoy can provide better peace of mind. 

7. Find Support 

Preparation and organization can sometimes only get you so far. Luckily, you have plenty of people rooting for your success. Keep yourself and your classmates on task by finding an accountability partner or study buddies. Remind your roommates when you need extra space to work on a paper. 

Your school’s academic resource center is also there to support you and point you in the right direction if you need additional help. Getting—and staying—organized is a collaborative effort and no one can do it on their own. 

8. Be Realistic and Flexible 

Sometimes unforeseen circumstances will come up or you simply may not be able to get to everything you set out to do in a given day. Be patient with yourself when things don’t go exactly to plan. When building your calendar, schedule, and priorities list, be realistic about what you can accomplish and include buffer time if you’re unsure. This can help to reduce obstacles and potential friction.

Time management isn’t just about sticking to a rigid schedule—it’s also about giving yourself space for change.

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About the Author

Lian Parsons is a Boston-based writer and journalist. She is currently a digital content producer at Harvard’s Division of Continuing Education. Her bylines can be found at the Harvard Gazette, Boston Art Review, Radcliffe Magazine, Experience Magazine, and iPondr.

Managing Stress in High School

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• Open access
• Published: 29 March 2024

Access to continuous professional development for capacity building among nurses and midwives providing emergency obstetric and neonatal care in Rwanda

• Mathias Gakwerere 1 ,
• Jean Pierre Ndayisenga 2 , 3 ,
• Anaclet Ngabonzima 4 ,
• Thiery Claudien Uhawenimana 2 ,
• Assumpta Yamuragiye 5 ,
• Florien Harindimana 6 &
• Bernard Ngabo Rwabufigiri 7  

BMC Health Services Research volume  24 , Article number:  394 ( 2024 ) Cite this article

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Nurses and midwives are at the forefront of the provision of Emergency Obstetric and Neonatal Care (EmONC) and Continuous Professional Development (CPD) is crucial to provide them with competencies they need to provide quality services. This research aimed to assess uptake and accessibility of midwives and nurses to CPD and determine their knowledge and skills gaps in key competencies of EmONC to inform the CPD programming.

The study applied a quantitative, cross-sectional, and descriptive research methodology. Using a random selection, forty (40) health facilities (HFs) were selected out of 445 HFs that performed at least 20 deliveries per month from July 1st, 2020 to June 30th, 2021 in Rwanda. Questionnaires were used to collect data on updates of CPD, knowledge on EmONC and delivery methods to accessCPD. Data was analyzed using IBM SPSS statistics 27 software.

Nurses and midwives are required by the Rwandan midwifery regulatory body to complete at least 60 CPD credits before license renewal. However, the study findings revealed that most health care providers (HCPs) have not been trained on EmONC after graduation from their formal education. Results indicated that HCPs who had acquired less than 60 CPD credits related to EmONC training were 79.9% overall, 56.3% in hospitals, 82.2% at health centres and 100% at the health post levels. This resulted in skills and knowledge gaps in management of Pre/Eclampsia, Postpartum Hemorrhage and essential newborn care. The most common method to access CPD credits included workshops (43.6%) and online training (34.5%). Majority of HCPs noted that it was difficult to achieve the required CPD credits (57.0%).

The findings from this study revealed a low uptake of critical EmONC training by nurses and midwives in the form of CPD. The study suggests a need to integrate EmONC into the health workforce capacity building plan at all levels and to make such training systematic and available in multiple and easily accessible formats.

Implication on nursing and midwifery policy

Findings will inform the revision of policies and strategies to improve CPD towards accelerating capacity for the reduction of preventable maternal and perinatal deaths as well as reducing maternal disabilities in Rwanda.

Peer Review reports

Continuous professional development (CPD) for capacity building is critical for health workers for enabling them to continually update their competencies to ensure they are able to meet client needs and adapt to constant changes in the practice environment [ 1 ]. CPD has been defined as any kind of education that professionals receive after completing their basic education of professional entry [ 2 ]. It is highly recommended that professionals in practice keep regularly updated about new protocols and refresh their knowledge for better continuity of care [ 3 ]. In emergency obstetric and neonatal care (EmONC), CPD is necessary to allow health care providers (HCPs) to feel confident and ready to deliver quality maternal and newborn health services [ 4 ]. Nurses and midwives, as essential providers of EmONC services, need to update their knowledge to enhance the quality of EmONC service delivery. EmONC encompasses all care provided to address emergent complications that occur during pregnancy, labor, and childbirth [ 4 ].

Globally, the maternal mortality ratio (MMR) is still unacceptably high; on average every day approximately 810 women lose their lives while giving birth [ 5 ]. Most of these deaths could be prevented if quality EmONC is provided by skilled health care professionals [ 5 , 6 ]. The leading causes of maternal deaths include hemorrhage, hypertensive disorders, especially pre-eclampsia/eclampsia, sepsis, embolism and complications of unsafe abortions. Sub-Saharan Africa remains the region with the highest burden of maternal mortality and morbidities with an MMR of 542 per 100,000 live births, which is higher than the ratio of 216 per 100,000 live births globally [ 5 ]. According to the Sustainable Development Goal (SDG) 3.1, every country is expected to reduce the MMR to less than 70 per 100,000 live births and no country should have more than 140 maternal deaths per 100,000 live births by 2030 [ 7 , 8 ]. To achieve this target, evidence-based high impact interventions should be implemented at scale and with the highest quality. The WHO has developed policies and guidelines for antenatal, intrapartum, and postpartum care, but the implementation of these guidelines and policies could be difficult if HCPs are not updated through CPDs [ 9 ].

In Rwanda, several health system-wide interventions such as community-based health programs, performance-based financing, community health insurance, and mentorship initiatives have been implemented to reduce the Maternal Mortality Ratio (MMR) [ 6 ]. Currently, the MMR in Rwanda is 203 per 100,000 live births [ 10 ]. However, despite the progressive improvement in reducing the maternal mortality ratio, there is still a need to triple efforts if the country is to achieve the SDG goal 3 target 1. The country is putting increased effort into training health care professionals in EmONC. Continuous Professional Development was formally introduced in 2013 with the adoption of the National CPD policy and since then EmONC has been one of main focus areas. Health Professional bodies were mandated to assess, validate and regulate the provision of CPD across the countries and every health provider is required to earn 60 CPD credits annually before renewing his/her professional license. This strategy enabled the Ministry of Health to keep health professionals’ knowledge and skills up to date hence improving the quality of maternal health services [ 11 ]. However, these CPD trainings were provided randomly without prior assessment of training needs of nurses and midwives in EmONC and maternity care.

Accordingly, the aim of this study is to assess uptake, accessibility to CPDs and knowledge and skills gaps on EmONC among midwives and nurses in Rwanda. Specifically, this study assessed the basic knowledge of these health cadres in EmONC, the areas in which nurses feel confident, how often nurses and midwives receive training, and finally, the ways they prefer to get the CPDs to renew their license to practice. Furthermore, since the country is progressing toward using technologies across the health system, the study assessed the familiarity of midwives and nurses to use Information Technology (IT) for learning purposes. The findings could provide evidence on the status of uptake of CPDs by nurses and midwives, describe challenges and best practices to inform revision of strategies to further improve CPD programs for midwives and nurses in Rwanda. In addition, the results could help to explore and deploy cost-effective training delivery models for nurses and midwives in Rwanda and in other similar contexts.

Study setting

Rwanda’s health system has been built on the administrative scheme with referral, provincial, district, and sub-district health facilities (public and private) and, overall, has 1,695 health facilities [ 10 ]. Forty (40) of the 444 health facilities that conducted at least 20 deliveries per month from July 1st, 2020 to June 30th, 2021 nationwide were randomly selected for the study.

Study design

A cross-sectional study design was used to collect data at the selected health facilities. The study was conducted across selected facilities nationwide, selection was done randomly from a list of health facilities arranged per region and district to ensure equitable representation.

Study population

Within the randomly selected health centers, up to four HCPs (midwives and nurses) who are assigned in maternity participated in the study. In total, 93% of the targeted HCPs from the 40 Health Facilities were recruited and participated in this study. Selected health posts had only one nurse providing health care services instead of four planned for the survey. This research excluded all participants with experience less than six months at a given health facility as they may not yet have been familiar with the facility systems and various training opportunities for EmONC.

Sample size and sampling strategy

A random sampling method was used to enroll 40 health facilities in the study. After getting permission/authorization from District Health Offices, the recruitment was done through directors/gatekeepers of selected health facilities. The support letter from Ministry of Health was secured and was presented at each health facility chosen. Using this support letter, the researchers approached selected health facilities’ leaders (gatekeepers), including medical directors, directors of nursing and head of health centers. They asked them to assist in identifying the potential and eligible participants. Those gatekeepers did the first contact with potential participants. Data collectors ensured that each participant meet the eligibility criteria before enrolling him/her in the study to avoid selection biases.

Data collection process

The data collection tool was piloted/tested in one health facility one week prior to data collection. Two nurses and two midwives were selected to respond to the questionnaire for testing and validation purposes. This informed the revision and finalization of the questionnaire by the research team.

The research team deployed two enumerators per each selected health facility to collect data using the validated questionnaire. Data collection began by an introduction of enumerators to potential respondents per the head of the health facility. Those potential respondents were provided with information about the research study including its objectives and they were given an official consent form requesting him/her to participate in this study if s/he agrees. After consenting, a questionnaire was administered to collect quantitative data related to the study objectives. The electronic questionnaire was developed and uploaded in the KoBo toolbox. KoBo toolbox is an open-source tool for collecting data using mobile phones. The questions were accessed via a web application link. The collected data were uploaded onto a password-protected Data were collected from 22 November 2021 to 26 November 2021.

Data Analysis

Data analysis was preceded by data quality assurance which was done regularly throughout the data collection period. This was enabled by the KoBo toolbox which would push real time data into a national server. Study questions and related data were organized, collected and analyzed according to study objectives. Data set was accessed via a web application link. The collected data were stored onto a password-protected server for confidentiality and ethical purposes. Data were analyzed using IBM SPSS statistics 27 software. The analysis generated standard descriptive and frequencies on the key assessment indicators on uptake of CPDs, accessibility to CPDs and knowledge and skills gaps on EmONC among nurses and midwives. Data are presented using tables and graphs.

Ethical consideration

Ethical clearances from the Rwanda National Ethical Committee was granted to researchers to conduct this study (Approval Notice: No. 984/RNEC/2021). In addition, an authorization of the health facility to collect data was secured prior to conducting interviews. Data collectors adhered to principles of confidentiality and ethics in data collection. No person’s name (except for the identification of the data collector) was recorded on any of the interviews. Permission to enter each facility, interview the different employees, and review registers was requested from the director or staff in charge of the health facility at the beginning of each visit. The data collection teams carried with them official letters of cooperation from the Ministry of Health and district level offices. Interviewees were requested to read an information note and sign a consent form before proceeding with the interview. No incentives were provided to participants hence the participation was voluntary. Respondents were able to withdraw their participation anytime during the interview. The information notes, and consent forms are added as annexes for easy reference.

Demographic characteristics of the respondents

The study was carried out across 40 health facilities and 149 health care providers (HCP) participated in the study (Annex 1). Of them, 99 (64.4%) were female and 50 (33.6%) were male. The highest proportion of the HCP who participated in the study were less than 30 years of age, 38 (25.5%). The majority of the participants were nurses, 104 (69.8%), while the remaining 45 (30.2%) were midwives. Among the nurses, 21 (20.2%) had a high school diploma, 74 (71.1%) had an advanced diploma, and 9 (8.7%) had a bachelor’s degree. Among midwives, 42 (93.3%) of them had advanced diplomas and 3 (6.7%) had bachelor’s degrees in midwifery. The highest proportion of the HCP who participated in the study had been working in maternity services for more than 5 years and were 96 (64.4%). The detailed results are shown in Table  1 below.

Respondents’ obstetric experience and skills in EmONC

Overall, the predominant number of births that the HCPs conduct themselves per week was between one and five (71.1%). Broken down by the type of health facility, a large number of the respondents said that they perform between 5 and 10 (50%) for the hospitals, between one and five (74.4%) for the health centers and between one and five (75.0%) for the health posts. The majority of the HCPs felt confident in performing a birth-related diagnosis on their own (89.9%): all the HCPs from the hospitals felt confident, while 91.5% felt confident at the health centers and none felt confident at the health posts. Similarly, those who felt confident in performing births on their own was 89.9% overall, with all of the HCP from the hospitals feeling confident, and 89.9% from the health centers and 25% from the health posts. Across all the types of facility, the majority of the HCPs agreed that birth complications while performing deliveries sometimes happen, specifically as follows: overall (90.6%), hospital (93.8%), health center (90.7%) and health post (75.0%). In terms of diagnostic and management, the majority of the HCP agreed that they feel less confident with pre-eclampsia, with 67.1% overall, 31.3% at the hospitals, 71.3% at the health centers and 75.0% at health posts. Among the newborn health concerns, the majority of the HCP were less confident in immediate care after delivery for baby who does not cry, mainly 74.5% overall, 37.5% in hospitals, 78.3% in health centers and 100% in health posts were less confident on immediate care after delivery for baby who does not cry. Table  2 shows the results in details.

Respondents’ previous training on EmONC related topics

Overall, the majority of the HCPs reported having never being trained on EmONC after graduation from their formal education. Apart from the hospitals, where most of the HCP were trained, in the two years (37.5%) and within 2 and 5 years (37.5%), at health centers and health posts, the majority of the HCP had never been trained on EmONC after graduation from their formal education. Among the relevant EmONC competencies, the overall majority of the HCP had been trained on B EmONC while 28.8% had not been trained on any of the topics. The proportion of HCP who were not trained on any topics is 12.5% for the hospitals, 30.2% for the health centers and 50% for the health posts. Of all the HCP, 63.1% had benefited from a mentorship program on EmONC after graduation. The Table  3 below details the findings.

Ways respondents accumulate CPD credits

Normally, every nurse or midwife is required to complete at least 60 credits to be able to renew his / her license. This study revealed that the HCP who had acquired less than 60 CPD credits related to EmONC training were the most predominant, with 79.9% overall, 56.3% at the hospitals, 82.2% at the health centers and 100% at the health posts. The most common way of delivering the CPD credits was through workshops (43.6%) and online training (34.5%). Most of the HCP noted that it was hard for them to achieve the required CPD credits (57.0%). The detailed results are presented in Table  4 below.

Respondents’ digital literacy and access to digital devices

The most common electronic device owned by the HCP was a smartphone (98.7%). Overall, there were no significant differences between the places where the HCP usually accessed the internet. However, accessing the internet at work was most frequent for the hospitals (43.7%) and health centers (46.5%), and least frequent for the health posts (0.0%). The majority of the HCP, agreed to be comfortable using a computer (57.0%), a normal feature phone (83.2%) and smartphone (86.6%) as tools that facilitate eLearning. Similarly, being comfortable with eLearning was predominant overall (51.0%), at the hospitals (75.0%) and health centers (48.8%), however majority of the heath posts HCP agreed to be somewhat comfortable with eLearning (50.0%). Furthermore, the HCP aged less than 40 years are the ones being more comfortable with Electronic-Learning. The details are provided below in Table  5 .

Uptake of E-learning

Of all the HCP, 72.5% use their computer or smartphone to access eLearning. Of these, a proportion (23.1%) dedicated more than 30 min per day to self-training in EmONC using their phone. However, at the hospitals, a larger proportion would dedicate a few minutes in a week (30.0%) and more than an hour in a week (30.0%). Overall, more HCP had not used eLearning as a teaching-learning method in the past two years (37.3%). However, those who had never used it are more at the health centers (39.5%) and health posts (75.0%) but the eLearning utilization is high at the hospitals with 43.8% who have used it more than four times in the past two years. Supplemental knowledge/skills in existing areas was the predominant (80.5%) expectation from the phone delivered eLearning EmONC modules, while learning new learning and teaching methods was the least expectation (51.0%). At the health centers, 55.8% of the HCP would be able and willing to self-support for their personal remote training. Inconsistently, 43.8% at the hospitals as well as 100% at the health posts would not be able and willing to self-support for their personal remote training. Table  1 in the annex shows the findings in detail.

Respondents’ basic knowledge on EmONC

While assessing the basic information on EmONC, specifically by assessing what aspect should be given special attention during abdominal examination of an at-term pregnant mother, the majority of the HCP agreed that all elements (fundal height, descent of the presenting part, fetal heart tones and frequency and duration of contractions) should be given special attention. However, at the health centers and health posts, there were some HCP who believe that not all of those elements should be given special attention (for example: 17.1% of the HCP from health centers agreed that only fundal height should be given special attention). In addition, the majority of the HCP defined postpartum hemorrhage as vaginal bleeding of more than 500 mL after vaginal birth, 95.3% overall, 100% at the hospitals, 84.6% at health centers and 100% at the health posts. Table  2 in the annex summarizes the findings.

The purpose of the study was to assess the progress of uptake and accessibility of midwives and nurses to CPD and determine their knowledge and skills gaps in key competencies of EmONC in Rwanda. Generally speaking, the study findings revealed a low to moderate progress of uptake of CPDs among nurses and midwives’ health cadres due to lack of opportunity or difficult access. The study also revealed knowledge and skills gaps in critical competencies for EmONC; which calls for a particular focus on EmONC during CPD programming. The study findings indicated that the majority of nurses have never received any formal training on EmONC after graduation from their formal education. The proportion of HCP who were not trained on any topics is 12.5% for the hospitals, 30.2% for the health centers and 50% for the health posts. This calls for more investments in CPDs opportunities tailored to the needs of individual health care providers practicing EmONC in a given health facility. Whichever delivery method is used, CPD are important to keep practitioners updated and enhance their practice [ 12 ]. According to Gray et al. [ 1 ] adult learners need a structured teacher guided approach compared to the youngest clinicians who can comply with different modes of teaching, including self-directed learning. Similarly, the study revealed small progress of uptake of mentorship on EmONC with only 63.1% health providers mentored on EmONC after graduation. Small coverage of mentorship is another important missed opportunity because mentorship proved to be a cost effective approach to transfer skills between the most experienced professional to less experienced one in a more sustainable manner [ 13 , 14 , 15 ]. This might have been due to various factors including lack of systematic plan for mentorship scale up and financial constraints .

As such, this form of training could complement the continuous professional development delivered through traditional training. Similar strategies have been implemented in other countries with similar contexts. For example, a cascade type mentorship for health workers has been implemented in Uganda and demonstrated tremendous results in terms of maternal and neonatal health outcomes. Nevertheless, given the nature and complex set of practical skills required for better management of obstetric complications, clinical mentorship for EmONC should remain erratic, dynamic and always adapted to the case in hand and to the competencies and skills gaps of the health care provider [ 13 , 16 , 17 ].

Despite the fact that Pre/Eclampsia and Postpartum hemorrhage remain among the main killers of women during delivery at global level and in Rwanda, this study revealed knowledge and skills gaps in management of both critical obstetric conditions among nurses and midwives. Nurses and midwives reported feeling less confident in some aspects of EmONC, including management of eclampsia, and care of newborn after birth especially when babies don’t cry immediately [ 5 ]. Organizing CPDs trainings in management of these life threatening conditions could probably make health providers feel confident to provide effective quality EmONC services thus contribute to acceleration of reduction of preventable maternal and neonatal deaths in Rwanda towards achieving the SDG goals and targets [ 18 , 19 , 20 ].

These findings correlate also with another study conducted in Australia where participants suggested more training in the management of eclampsia [ 21 ]. Moreover, the skill gaps in management of key obstetric complications could be explained by a mismatch between the CPDs and the needs on the field. CPDs opportunities are limited in Rwanda and they are not always aligned to the felt need of nurses and midwives on ground. Similar mismatches between CPD needs and supply has been reported by Feldacker et al. [ 22 ] in a study conducted in Malawi, Tanzania and South Africa due to lack of evidence-based planning and effective coordination. The Ministry of Health of Rwanda has put in place incentives to motivate health care providers to invest in lifelong learning. One of them is an instruction to earn at least 60 CPD credits before renewing the license to practice nursing and midwifery in Rwanda [ 23 ]. However, more than 79.9% face the challenges of having necessary credits when planning to renew their license to practice, depending on the working place across the health system. The study findings indicate that among respondents who reported facing challenges to earn the required minimum of CPDs credits 56.3% were from the hospitals, 82.2% from the health centers and 100% from the health posts. The most common way of delivering the CPD credits was through workshops (43.6%) and online training (34.5%). Most of the HCPs noted that it was hard for them to achieve the required CPD credits (57.0%), suggesting a need for an organizational culture that supports CPDs. For participants who received training, common methodologies were face-to-face and online teaching. Regarding the common devices participants use for online training, the majority use their smartphones, while others use a computer. Since internet connectivity is a challenge, respondents in the study mentioned using those devices mostly at the working places to benefit internet connectivity at work [ 24 ]. Similarly, Addae et al. [ 25 ] reported in a study conducted in Ghana on online learning experience for nurses and midwives’ students that the lack of internet connectivity was one of the major challenges that impeded the programme. These findings highlight untapped potential of using advanced information technological systems to deliver CPDs courses in a more cost-effective manner as virtual training represents only 34.5% due to small coverage and cost of using the internet by the health worker’s community. This calls for more investment in IT infrastructures such as optic fibers and other cost-effective means of expanding internet coverage across the country. In the meanwhile, tools such as safe delivery app [ 26 ] that provide nurses and midwives evidence-based and up-to-date clinical guidelines could be used as these don’t require internet when successfully downloaded. Findings from this study correlate with a study on the use of blended learning in nursing where poor IT skills and lack of organizational support were identified as weakness to CPD provision among nurses and midwives [ 27 , 28 , 29 ].

The study findings call for more investment in enhancement of skills and capacities of human resource for health using more predictable and sustainable approaches such as CPDs and mentorship. This will require integration of these interventions in health sector policies and strategies, allocation of finances and strong monitoring and evaluation of the impact of these interventions on health service delivery and quality of care. Moreover, the study revealed challenges in the use of e-learning as a tool to sustain CPDs due to the limited internet connectivity. No one would deny the potential of technology in health care delivery and more lessons and best practices have been gathered during the COVID-19 pandemic era. This calls for the Government of Rwanda to continue strengthening ICT infrastructure and deploy strategies to ease the finance burden for the user.

Strength and limitations

This study has been conducted using a random sampling from all facilities with significant obstetric activity across the country arranged per region and district to ensure equitable representation.

This enabled researchers to collect information from reliable sources while minimizing biases hence with increased validity and generalizability. However, since the study relied on self-assessment/reporting of knowledge and skills, the research team acknowledged some of the limitations of the study including respondent bias as participants might have reported what he/she felt could meet the expectations of the researchers. In addition, due to financial constraints, the study sample covered 40 out of 444 health facilities which could have affected the generalizability of the findings. Besides the general survey related limitation, evidence suggests that increased knowledge for healthcare professionals does not automatically translate into improvements in clinical practice or patient outcomes. Nevertheless, literature supports CPD in terms of accumulation and how clinicians apply the knowledge gained in practice [ 30 ]. Therefore, there is a need for more studies to explore and evaluate how the CPD straining translates in actual change in practices and its overall impact on reduction of preventable maternal and neonatal deaths in Rwanda.

The main purpose of this study was to assess the CPD program for nurses and midwives in the context of EmONC in Rwanda. The findings highlight a modest progress of the program due to lack of systematic policy and strategic approach for its implementation. This resulted in skills and knowledge gaps in management of 3 critical and life threatening obstetric conditions namely Pre/Eclampsia, PPH, essential newborn care. The study revealed that Nurses and midwives face challenges to accumulate the number of credits required to renew their licenses to practice due to limited opportunities for CPDs. Online teaching was identified as an alternative methodology for CPD training delivery. However, participants mentioned internet access as a barrier to effective online learning. Therefore, the study findings are a call for policy makers to integrate CPDs for nurses and midwives in policies and strategies and allocate enough resources to ensure systematic implementation. These will require a multisector approach to ensure CPDs are prioritized and financed as well as an infrastructure system is put in place to facilitate uptake of CPDs in a cost-effective manner.

Data Availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The authors express heartfelt gratitude to each individual health provider and institution that participated in this research. The authors would like to commend the Ministry of Health and the Ministry of Education for having created an enabling environment and operational framework that facilitated the conduct of this research. Any opinions stated within this document reflect those of the authors and not necessarily of the United Nations Population Fund.

Costs related to this study were covered by voluntary contribution of authors themselves.

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Regional Office for East and Southern Africa, United Nations Population Fund, 09 Simba Road, Sunninghill, Johannesburg, South Africa

Mathias Gakwerere

School of Nursing and Midwifery, College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda

Jean Pierre Ndayisenga & Thiery Claudien Uhawenimana

Arthur Labatt Family School of Nursing, Western University, London, Canada

Jean Pierre Ndayisenga

JSI Research & Training Institute, Inc, International Division, Washington, DC, USA

Anaclet Ngabonzima

School of Health Sciences, University of Rwanda, Kigali, Rwanda

Assumpta Yamuragiye

United Nations Population Fund, KG 7 Ave, Kigali, Rwanda

Florien Harindimana

College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda

Bernard Ngabo Rwabufigiri

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Contributions

MG conceptualized the study, developed the protocol and data collection tools, coordinated the study implementation, analyzed the data, and drafted the manuscript. CTU contributed to the study design, data analysis and revision of the manuscript. AY was involved in manuscript drafting, data analysis and contributed to the revision of the paper. AN was involved in the study design, refinement of data collection tools, analysis of data and contributed substantially to the review of the manuscript. FH was involved in data analysis and reviewed the manuscript. Contributed to the study design, supported the analysis of the data and review of the manuscript. BRN was involved in research tools development, supervised the data collection. JPN was involved in the study design and the overall supervision of the study and critically reviewed the manuscript. All authors have read and approved the final version of manuscript for submission. All authors reviewed the manuscript.

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Correspondence to Mathias Gakwerere .

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Ethical clearance was obtained from CMHS-IRB of the University of Rwanda (Approval Notice:No 984 RNEC/2021 and the research was also permitted by the management of the study hospitals and health centers. All methods were performed in accordance with the relevant guidelines and regulations. All those nurses and midwives were above 18 years old and informed consent was obtained from all subjects. All subjects were allowed to withdraw from the research at any time during the research period.

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Gakwerere, M., Ndayisenga, J.P., Ngabonzima, A. et al. Access to continuous professional development for capacity building among nurses and midwives providing emergency obstetric and neonatal care in Rwanda. BMC Health Serv Res 24 , 394 (2024). https://doi.org/10.1186/s12913-023-10440-8

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Received : 05 May 2023

Accepted : 05 December 2023

Published : 29 March 2024

DOI : https://doi.org/10.1186/s12913-023-10440-8

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