Integration of anatomy and physiology into nursing practice as perceived by undergraduate students and registered nurses: a scoping review

Objective The current study aimed to determine perceptions of registered and student nurses regarding the integration of anatomy and physiology into nursing practice. Methods This scoping review was conducted following the checklist provided in the Reporting Items for Systematic reviews and Meta-Analysis extension for scoping reviews. Articles published in PubMed, ERIC, and CINAL from January 1, 2002 to September 30, 2022 were included. Results A literature review of 20 articles that matched the indicative criteria revealed that both undergraduate student and registered nurses recognized knowledge of anatomy and physiology as important to nursing practice. Student nurses recognized that such knowledge is related to understanding patient pathophysiology, patient observation, treatment selection, and patient safety and forms the basis for nursing practice. Registered nurses who were confident in their knowledge of anatomy and physiology also reported that they were able to explain the rationale for their nursing practice. They also reported that this knowledge is necessary for communication with multiple professions, which promotes patient/family trust in nurses and is the basis for building trusting relationships with patients and their families. Conclusions Although undergraduate student and registered nurses recognized the importance of learning anatomy and physiology, the integration of anatomy and physiology into nursing practice was not the same for all student and registered nurses. This suggests the need to investigate the overall perceptions of nurses regarding the integration of anatomy and physiology into nursing practice and for faculty to discuss how to facilitate critical thinking among students.


Introduction
The exponential growth of information in health care knowledge and the complexity of medical sciences have required clinical nurses to be not only skillful but also knowledgeable on the scientific basis of diseases and treatment [1].Knowledge regarding anatomy and physiology is essential for understanding human beings and is of great importance in nursing practice, especially in clinical decision making [2].A qualitative research study by Van Wissen et al. [3], which sought to determine the impact of studying anatomy and physiology at a postgraduate level by disseminating pre-and post-course semistructured questionnaire for an anatomy and physiology course as part of a Master's Degree Program in Nursing, revealed improvement in confidence, particularly in communication, linking nursing theoretical knowledge to practice, and clinical nursing knowledge.However, with only a few published studies have been available regarding this field of research in undergraduate student nurses [4].The overall view regarding how knowledge of anatomy and physiology relates to nursing practice remains unclear.This leads us to believe that faculty members teaching anatomy and physiology may not have a clearly defined perspective on student achievement goals for their anatomy and physiology courses.Student nurses seem to exhibit better academic performance level when they are well prepared and can understand the relevance of anatomy and physiology in nursing practice [4].However, student nurses have perceived anatomy and physiology courses to be much more difficult than other subjects [5].
Studies have shown the effectiveness of blended learning, flipped learning, and other teaching methods in anatomy and physiology education.Blended learning has been reported to improve nursing students' performance in anatomy and physiology, self-reported learning outcomes, and high levels of satisfaction [6].The benefits of blended learning include flexible study time and improved independent study skills [7].A study on flipped learning showed that the results for the flipped classroom group exceeded those for the traditional lecture group, with 70% of the student nurses reporting satisfaction with the flipped classroom method, indicating that it enhanced their learning and increased their interest in the course [8].However, the primary focus of these teaching methods is not so much on promoting thinking that relates anatomy and physiology knowledge to nursing practice, but rather on how to consolidate anatomy and physiology knowledge.
With the current approach toward anatomy and physiology education, there is a need to examine educational methods that integrate anatomy and physiology knowledge into nursing practice and evaluate the effectiveness of such methods.As such, it is necessary to (1) investigate how students and nurses perceive anatomy and physiology learning and the integration of anatomy and physiology into nursing practice and (2) define the achievement goals of anatomy and physiology education required by students enrolled in a bachelor's program.
The nursing education system in the United Kingdom, Australia, and New Zealand, among other countries, have included anatomy and physiology under bioscience, an umbrella term that includes anatomy, genetics, microbiology, physiology, pharmacology, and pathophysiology [9].However, given that other countries use the term anatomy and physiology, this term was used in the current study.

Scoping review objective
This scoping review aimed to summarize the perceptions of undergraduate student and registered nurses on anatomy and physiology learning and the integration of anatomy and physiology learning and nursing practice.

Scoping review question
What are the perceptions of student and registered nurses on learning anatomy and physiology?What are the perceptions of undergraduate student and registered nurses on the integration of anatomy and physiology learning and nursing practice in undergraduate nursing education?

Protocol and registration
The review protocol for this study was not published.This scoping review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for scoping reviews PRISMA-ScR Checklist [10] and follows the five-strategy review process as identified [11] and later refined by Lavec [12] and Peters [13].

Eligibility criteria
Titles/abstracts and full texts were screened to optimize literature coverage using the eligibility criteria shown in Table 1.
Reviews, brief reports, conference notes/abstracts, and comment articles were excluded.Studies that focused on the perceptions of nurses and student nurses regarding anatomy and physiology learning and those on the perceptions of nurses and student nurses about integrating anatomy and physiology learning into nursing practice were considered eligible.Papers that did not fit these criteria were excluded.

Information sources
An electronic search of PubMed, ERIC, and CINAL was conducted in October 2022.

Search
The search terms used were "nurse, " "nursing, " "anatomy, " "physiology, " "bioscience, " and "student." Using Boolean combinations of the primitives, our final string was (nurse or nursing) AND (anatomy or physiology or bioscience) AND student.
Because nursing education curricula have changed with changing social conditions, in order to analyze the most recent research findings, the period of publication was limited to the last 10 years, and articles were limited to those published between January 1, 2002 and September 31, 2022.Although it is strongly recommended that scoping reviews should not be limited by language selection criteria [11], they were included in the exclusion criteria for this study due to the extreme difficulty of translating and understanding non-English speaking nurse education curricula.The seven excluded articles were in Chinese, Portuguese, and Israeli.

Data charting process and items
Microsoft Excel spreadsheets were used by the lead author to chart the characteristics of all articles.Table 2 was developed to chart the following key information from the selected articles: author(s) and year of publication, sample, objective, methodology, summary of findings, and country.Data from each included article were extracted by an independent researcher and counterevaluated for accuracy or missing information by another researcher.Selected data with counter-information were re-evaluated by the entire team, after which a consensus was reached by the team to regarding the final charted data.

Data synthesis
A scoping review was employed to identify all relevant literature, followed by a narrative synthesis.Due to heterogeneity across studies and even within studies with similar methodologies, metasynthesis for qualitative data was not possible.Instead, studies were combined to summarize the study characteristics, followed by a textual narrative synthesis.This approach helped arrange disparate study types into more homogenous subgroups, thereby aiding in the synthesis of different types of evidence.Study characteristics, context, quality, and findings have been reported according to a standard format, and their similarities and differences have been compared across studies [14].

Search outcomes
Search results were exported to the bibliographic software program EndNote (Clarivate Analytics, Philadelphia, PA, USA).Duplicate articles were removed using the literature management software.Data were extracted from the literature management software to Microsoft Excel.Then, two researchers (MH and TF) independently extracted data from the titles and abstracts based on our eligibility criteria.Any disagreements were resolved through discussion between the two authors.Figure 1 presents the PRISMA flowchart [15] for the study selection process.A total of 2,839 papers were obtained, from which 220 duplicates were eliminated.The number of papers subjected to the title and abstract review was 2619, and the number of papers excluded from title and abstract review was 2571.Further screening of the full text of the remaining 48 articles resulted in the exclusion of 28 articles that were either not original papers or were unrelated to anatomy and physiology education.The excluded papers included 14 nonoriginal reports, 13 cadaveric dissections, and 1 patient simulation.Finally, 20 articles met the inclusion criteria (Fig. 1).
A total of nine studies were from Australia; three from the UK; three from New Zealand; and one each from Norway, Korea, Ireland, Scotland, and the USA.Among the 20 articles reviewed, 3 were qualitative, 11 were quantitative, and 6 were mixed methods studies.The study participants were registered nurses in 7 papers and undergraduate student nurses in 13 papers.

Study of anatomy and physiology
Impressions of undergraduate student nurses on anatomy and physiology were as follows: there was much content to learn [16], it was difficult [16,17], and it required a considerable amount of study time [9,18].In addition, Montayre [19] reported that the perceived difficulty of anatomy and physiology was replaced by positive perceptions in the final year.The impressions of registered nurses on anatomy and physiology were as follows: courses in anatomy, physiology, and pathophysiology  were rated as particularly high priority for learning in the education of student nurses [1].However, 40.5% of registered nurses perceived that their anatomy and physiology classes as students were not compatible with actual nursing practice [20].
Effective learning as perceived by undergraduate student nurses was reported as independent study [17], class attendance [21,22], active participation in class [21], use of office hours [21], and use of core textbooks [22].One study reported that understanding the content was important, not memorizing it [21].Collaborative classes between anatomy and physiology faculty and nursing specialty area faculty [23], as well as collaborative learning opportunities between field placement sites and the university [24], were evaluated highly by the students.Registered nurses agreed that the study of anatomy and physiology should be extended to the final year of undergraduate study [25].
Undergraduate student nurses with high self-efficacy were more science-oriented and had higher expectations for success in the bioscience course than were students with low self-efficacy [26].Several students had anxiety about studying bioscience [16,27].However, Mortimer-Jones [28] reported no significant difference in anxiety scores between bioscience and clinical classes.
Several registered nurses perceived their knowledge as low [29] and considered their anatomy and physiology knowledge inadequate for conducting the nursing process, communicating with other health care professionals, and teaching patients [30].Registered nurses also indicated that they lacked confidence in explaining their knowledge of anatomy and physiology as evidence of nursing practice [25] and wanted to develop more knowledge of these topics [9,25].

Integration of anatomy and physiology into nursing practice
Undergraduate student nurses [18,31] and registered nurses [22,25] recognized that knowledge of anatomy and physiology was important to nursing practice.The students recognized that such knowledge was important for understanding patient pathophysiology, patient observation, treatment selection, and patient safety [31] and that it forms the basis for nursing practice [9].Registered nurses who were confident in their anatomy and physiology knowledge were also capable of explaining the rationale for their nursing practice.They also reported that this promotes patients/family trust in nurses, which they perceived as the basis for building trust with patients and their families [31].In addition, registered nurses' knowledge of anatomy and physiology gave them the confidence to serve as preceptors who influence students' practice [32], and practice instructors with sufficient knowledge were able to provide students with opportunities to integrate that knowledge with their nursing practice [33].

Summary of evidence
This review summarized the perceptions of undergraduate student and registered nurses on anatomy and physiology education in undergraduate nursing programs, as well as their perceptions on the integration of anatomy and physiology into nursing practice.The diversity of assessment methods among the 20 studies, including qualitative, quantitative, and mixed methods, may have affected the aggregated data.

Establishment of anatomy and physiology knowledge
Although undergraduate student nurses initially perceived anatomy and physiology as difficult [16,17], this perception changed for the better in their final year [19] given that clinical practice allowed students to use their knowledge of anatomy and physiology to sharpen their critical thinking skills and clinical judgments [19].
Encouraging class participation [21,22], use of office hours [17], and independent study is important so that students' learning is not hindered by their impression that learning anatomy and physiology is difficult and their learning continues throughout their final year of study [25].With regard to continuity of learning, Spencer [34] believes that continuity of learning, for example, in the training of physicians, will deepen students' understanding of clinical medicine and how anatomy and physiology and specialized subjects are integrated.Additionally, reports have shown the effectiveness of collaborative teaching between faculty teaching anatomy and physiology and those faculty teaching specialized nursing courses [23].Anatomy and physiology are often taught by a diverse group of faculty members, including clinicians, instructors from non-nursing colleges, and instructors with national nursing certifications, several of whom have no experience in clinical nursing practice [35].As such, some classes are taught without an understanding of how anatomy and physiology relate to nursing practice.However, studies have shown that when anatomy and physiology is taught by nationally certified nursing faculty, students' knowledge of anatomy and physiology was insufficient, and that such students would likely not understand basic anatomy and physiology knowledge of diseases and disorders when taking clinically oriented nursing courses [36].Given that anatomy and physiology courses importantly serve as the foundation for nursing practice, collaboration between faculty members in charge of anatomy and physiology courses and those in charge of specialized subjects should be required based on the curriculum of each university.In addition, it is important for faculty members in charge of teaching anatomy and physiology to exchange information with faculty members of other universities in order to share effective methods for teaching the course.

Collaboration with clinical nursing instructors
Integration of anatomy and physiology into nursing practice is best achieved through clinical practice experiences.Furthermore, studies have reported that students' thought processes are enhanced in clinical practice settings wherein the clinical instructor has sufficient knowledge of anatomy and physiology [24].For students to learn effectively, the cooperation of not only the faculty but also the practicum supervisor is essential [24].Evidence suggests that clinical nurses also want to further develop their knowledge of anatomy and physiology [9,25].Nurses who are confident in their knowledge of anatomy and physiology have a positive influence on the clinical practice of students [32].We believe that providing clinical nurses with opportunities to study anatomy and physiology in the future will facilitate the continuous improvement of student nurses' practical skills.Future studies need to verify the effectiveness of clinical practice initiatives and new education systems on campus to facilitate the integration of anatomy and physiology knowledge into nursing practice.Research physicians who specialize in basic science or clinically oriented basic science play an important role in bridging the gap between basic specialty and clinical disciplines [34].Perhaps inviting more such educators to participate in nursing student education could help integrate anatomy and physiology into nursing practice.

Integration of anatomy and physiology and nursing practice
Apart from acquiring systemic knowledge, it is necessary to visualize how this knowledge is connected to nursing practice and evaluate students' academic achievement.
Studies have suggested that knowledge of anatomy and physiology is associated with patient safety [31], decision making, and building trust [32].However, given the limited research reports on these perspectives, there is a need to understand the overall picture in the future and visualize how knowledge of anatomy and physiology is specifically linked to nursing practice.To link knowledge of anatomy and physiology to nursing practice, it is important to clarify the goals within each subject while considering the curriculum of each university, so that students themselves are aware of what they should learn.The use of clinical material created for medical students' anatomy and physiology courses increases the relevance of the course to students and improves students' knowledge retention [34].
In the future, research will need to facilitate thinking that enhances the effectiveness of learning and integrates it with nursing practice, examine educational content and methods, and evaluate their effectiveness.Therefore, appropriate evaluation of the achievement objectives for anatomy and physiology is necessary to clarify how learning anatomy and physiology facilitates nursing practice and determine how to promote sufficient learning among students.

Limitations
For this scoping review, database searches were limited to studies pertaining to education in anatomy, physiology, and biological sciences, and keywords such as "pathophysiology" and "microbiology" were not used.National nursing school designations vary, and curricula are uniquely developed by each training school.Because the design of anatomy and physiology courses (i.e., textbooks, time, teaching methods, and examination methods) varied among schools, a critical evaluation was not conducted.Because this aimed to identify perceptions regarding the integration of anatomy and physiology learning into nursing practice, the quality of each literature review was not evaluated.The student and nurse perceptions in this study may have been influenced by differences in the course design.

Conclusions
Regarding perceptions on integrating anatomy and physiology into nursing practice, students reported that anatomy and physiology knowledge was important for patient safety and understanding the patient's condition, whereas nurses reported that such knowledge was related to explaining the rationale of nursing practice, building trust, and effective practice teaching.In the future, research needs to clarify the attainment goals related to the integration of anatomy and physiology into nursing practice for students enrolled in a bachelor's program.It is also necessary to establish an anatomy and physiology education system that connects anatomy and physiology with nursing practice and to examine the effectiveness of such an education system.

Fig. 1
Fig. 1 PRISMA flow diagram for the study search and selection process (diagram based on that of Page et al. [15])

Table 1
Inclusion and exclusion criteria that they lack the confidence to explain their knowledge of A&P.They are been to improve their knowledge and agree that A&P coursework should be extended up to the final year of undergraduate study.Moreover, they believe that it is important to relate A&P knowledge to nursing practice.

Table 2
Student' and Nurses' perceptions of anatomy and physiology (A&P) learning and integrating A&P learning into nursing practice