Scaffolding in Health Sciences Education Programmes: An Integrative Review

The complexity of health sciences programmes justifies scaffolding to support students in becoming competent health professionals. This article reports on an integrative review that aimed to describe the application of scaffolding in health sciences programmes. Twenty-nine sources, inclusive of theoretical and empirical studies, were reviewed. The sequencing of educational activities, the application of scaffolding tools or resources, frameworks for applying scaffolding, modelling, and fading represented the application of scaffolding in health sciences programmes. Awareness of the application of scaffolding in health sciences programmes could contribute to enhancing competence development among students when applied across all learning platforms.


Introduction and Background
Students in health sciences programmes should be supported to adapt to the demands of learning complex skills and knowledge in constantly changing platforms, such as dynamic and evolving healthcare systems. Through scaffolding, educators support students' learning by breaking down tasks and providing "just-in-time" strategies to enhance learning [1,2]. Van De Pol et al. [3] define scaffolding as temporary support provided by an educator to aide students in completing a learning task that would prove difficult without such support. The concept has broadened to include scaffolding support that is presented as a designed or preplanned structure applied at macro and meso-curriculum [4,5], in addition to dynamic, contingent, adjustable support commonly described as instructional scaffolding, critical to enhance learning during educator -student(s) interactions [1,6]. Scaffolding is an essential element of student-centred learning approaches [7].
Social constructivism underpins student-centred learning approaches [8], entailing interaction between the students and the educator in creating knowledge. The educator must be aware of students' existing knowledge to design and employ appropriate learning activities that support the students past their zone of proximal development (ZPD), as conceptualised by Vygotsky [9]. Vygotsky [9] defined the ZPD as "the distance between students' actual development as determined by independent problem-solving abilities and the students' potential development as determined by problem solving with the assistance of a more capable peer or instructor". The ZPD is influenced and informed by the curriculum, the educational programme, and the teaching and learning activities. Fading, a gradual withdrawal of educators' support, promotes a seamless transition of students across the ZPD, ultimately enabling the transfer of the responsibility of learning to the student [3]. Modelling, knowledge application, scaffolding, and student achievement of mastery are necessary interventions to achieve internalisation and automatisation of knowledge [6,10]. In health sciences education, problem solving integrates both cognitive strategies and execution of psychomotor skills.
There is global consensus in advocating for the adoption of student-centred approaches for health sciences education [11,12]. The literature over the last decade revealed a general adoption of student-centred approaches to education with variable outcomes [13][14][15][16][17]. Adoption of studentcentred approaches in health sciences education increases the need for scaffolding for competency development [13,14,18]. Additionally, the complexity of the disciplinary knowledge and skills in health sciences education necessitates scaffolding strategies.
Students in health sciences programmes develop competence in various contexts. Literature confirms that classrooms, simulation laboratories, community, and clinical environments are indispensable platforms for effective health sciences education [2,7,[19][20][21][22]. These learning platforms are constantly changing in response to the dynamic and evolving healthcare systems. Students need support in adapting to these continuously changing platforms. Scaffolding as a support strategy has been reported to improve students' comprehension of basic sciences knowledge [7], communication skills [23], evidence-based practice [18], academic literacy [24], clinical reasoning [2,25], psychomotor [26], reflection [27,28], and metacognitive skills [29] that are essential in adapting to dynamic learning platforms.
Literature demonstrates the value of scaffolding in higher education [2,6,[30][31][32]. Student-centred health sciences programmes comprise complex, integrating psychomotor skills applied in various learning platforms. We argue that the complexity of health sciences programmes warrant various approaches to scaffolding. Although much has been written about scaffolding strategies in general, not enough is known about how it is applied in the health sciences. This article reports on an integrative review that describes how scaffolding is applied in health sciences programmes. Insight into the application of scaffolding within health sciences programmes may broaden knowledge about the various approaches to scaffolding and thus guide health sciences educators in applying appropriate scaffolding strategies to support student learning in this dynamic and constantly changing context.

Design
This integrative review answered the question "How is scaffolding applied in health sciences programmes?" The review followed the five integrative review stages described by Toronto and Remington [33] and Whittemore and Knafl [34], namely identification of a problem, the search and selecting the literature, data evaluation, data analysis and data presentation.

Search Methods
An information specialist conducted a literature search in October 2020 using the following search string: "Scaffold* OR Student support*" AND "Program* OR Module* OR Course* AND "Nurs* OR health science* OR health profession*"

Search Outcomes and Selecting Literature
A total of 620 potential records containing titles and abstracts were sourced through the EBSCO host interface of a university library. Through automatic and manual deduplication, 90 records were removed. The three authors independently screened the remaining 530 records for relevance using an inclusion criterion (Fig. 1). Peerreviewed articles and grey literature reporting on scaffolding in health sciences programmes since January 2010 were included. Literature in non-English languages was also excluded. The processes undertaken for identifying relevant publications, screening, and selecting the publications for review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) of 2020 [35], as shown in Fig. 1. The three authors did the screening, as they independently analysed text words contained in the titles and abstracts obtained from the initial search output. Authors held meetings to approve titles, abstracts or articles that met the inclusion criteria. An additional three articles were identified and included for review through an ancestry search of the reference list of accepted full-text articles. Finally, 29 sources were included in this integrative review (see Fig. 1 for more details regarding the selection and screening process).

Article Appraisal
The Johns Hopkins University Research Evidence Appraisal Tools [36] were used to evaluate the methodological rigour of quantitative (n = 16) and qualitative (n = 1) studies included in this review. The remaining 12 articles were appraised using Johns Hopkins University non-research evidence appraisal checklist [36]. We did not eliminate articles secondary to the outcome of the appraisal, but instead, we sought to describe the extent of quality in the evidence on scaffolding obtained from the literature.

Data Charting
A piloted author-generated data charting form was used to extract data from selected sources. The authors extracted characteristics of the sources, including authors names, type of publication, country of origin, study design, purpose of research, type of health sciences programme, methods applied, and the way scaffolding was applied (see Table 1).

Data Analysis
After charting the sources, data was presented in an Excel spreadsheet. Analysis was conducted per characteristic.
Frequencies were calculated for categorical data. Inductive analysis was applied to narrative data as authors read through the extracted data on scaffolding applications in health sciences programmes, analysing content, observing Duplicates removed (n=90)

Abstracts screened for inclusion (n=83)
Full-text articles retrieved and assessed for eligibility for review (n=71) Full-text articles from ancestry-search (n=3) 391 records excluded for not relevant to health sciences scaffolding; 49 described genetic/surgical/tissue engineering scaffolding + 6 reviews + 1 record excluded for non-English language (n=447) Two abstracts were excluded for unavailability of full text; 2 abstracts described teaching strategies/scaffolding; 8 abstracts were excluded for being irrelevant for scaffolding in health sciences (n=12) Full-text articles accepted for review (n=26) Full text excluded describing scaffolding as an outcome; articles described general student support and lacked full texts.  instructional design tips that use cognitive load theory. The scaffolded curriculum seek to move students from low-fidelity, lowcomplexity and high-supportive contexts to competent, independent performance in high-complexity and high-fidelity contexts. As students move from one level of fidelity and complexity to another, adequate support is paramount to decrease cognitive overload and frustrations the Sawyer's "learn, see, practice, prove, do and maintain" framework. The framework fosters the development of medical students' procedural knowledge on venepuncture and PIV insertion. The module guide broke the procedures into 4 phases: planning, preparation, insertion, and post-venepuncture care to further structure and strengthen scaffolding on learning of the skill common trends, and patterns shared. Furthermore, the outcomes of the inductive analysis were synthesised to create themes and subthemes in terms of the application of scaffolding across various learning platforms.

Results
Data analysis and synthesis yielded results on characteristics of the studies and themes regarding the application of scaffolding in health sciences programmes.

Study Characteristics
The majority of the sources were from the USA (n = 16), Australia (n = 6), and the UK (n = 2), while the Netherlands, Norway, Germany, South Africa, and the United Arab Emirates contributed one source each. Seventeen of the sources were studies on scaffolding in nursing and/or midwifery programmes, followed by medicine (n = 5), pharmacy (n = 2), allied health (n = 2), and inter-professional education (IPE) (n = 3). The majority of these sources reported the application of scaffolding in undergraduate programmes (n = 27).
Of the 19 sources that reported on the specific modules where scaffolding was applied, the modules were in the hard sciences (n = 2), clinical skills (n = 9), in discipline-related knowledge (n = 6), and in academic writing, research, and evidence-based practice (n = 2). Nine sources described theoretical studies while the remaining 20 sources presented empirical research. Quantitative research (n = 11), action research (n = 4), qualitative research (n = 1), and designbased research (n = 1) were the research methods used in empirical sources. However, three theoretical studies did not explicitly mention their research design and were included for review.

Themes on the Application of Scaffolding in Health Sciences Programmes
Content analysis on scaffolding application in health sciences programmes produced four themes: "Sequencing the educational activities", "Tools and resources used for scaffolding", "Frameworks for applying scaffolding", and "Modelling and fading to scaffold learning".

Sequencing the Educational Activities
Reviewed studies reported how health sciences programmes designed and sequenced curricula content and teaching-learning activities to enhance the scaffolding of the learning process. Dawn et al. [37] defines sequencing of educational activities as a deliberate structuring of related content, teaching-learning activities, and assessments to enhance students' comprehension and performance of targeted competencies. Three sub-themes reflect the sequencing of educational activities, namely (1) sequencing of the content, (2) sequencing the complexity of the task, and (3) sequencing the learning environment.
Sequencing of the Content Lauerer et al. [38] applied scaffolding in sequencing the content on behavioural health concepts, while Frantz and Rhoda [39] and Zook et al. [40] sequenced content related to IPE. Coombs [41] and Duff et al. [42] sequenced content on community and oral health and started with patient assessments before functional knowledge on diagnosing pathologies, planning, and implementing interventions to solve identified problems. Enquirybased learning [43] and presentations [37,44] were also presented as approaches to sequencing content.
Sequencing the Complexity of the Task Educators meticulously structured learning tasks focusing on mastery of single or simple tasks or part of a task to complex real-life cases that demanded integration of knowledge drawn from diverse sources [45,46]. Duff et al. [42] designed an oral health midwifery module starting with activities that aim to foster comprehension of oral cavity anatomy and physiology before mapping simulations and actual clinical practice activities that required the application and integration of knowledge on oral health pathologies. To assist nurses in learning new work-related software skills, Luo and Kalman [47] sequenced procedural steps that built on each other in facilitating students to complete tasks independently. Miller et al. [46] utilised a scaffolded sequence of writing assignments to overcome academic writing exertions. Students constructed foundational knowledge on IPE [40], behavioural health concepts [38] and community health [41] before engaging in intra-or inter-professional teams [38,40,41]. Frantz and Rhoda [39] designed an IPE curriculum following scholarships of teaching, application, integration, and discovery, while Coombs [41] assigned students to work on patient assessments skills before creating a care plan. Various student-centred instructional techniques, such as case studies, group projects [37], and demonstrations [48,49], were also used in sequencing tasks.

Sequencing the Learning Environment
The reviewed studies showed that scaffolding in health sciences programmes was applied in various learning environments, such as the classroom, virtual space, clinical skills laboratory, the clinical setting, and the community. Modules were designed by structuring and sequencing learning to start from the either the face-to-face classroom or an online classroom, flipped classrooms [50] through simulated environments [44] and ending with learning in the clinical or community contexts [39][40][41][42]. An example was that of a multi-semester module that was designed to start with classroom learning of related IPE principles and core domains before assigning students to online IPE learning activities and communities to manage virtual or real-case problems requiring inter-professional teamwork and collaborative care [40]. Similarly, Duff et al. [42] explained how they deliberately increased learning of oral health from low to high fidelity by assigning students to engage in classroom activities before engaging in simulation laboratory activities. Concept-based simulations were deliberately structured and sequenced to alternate with theoretical classes following Benner's novice-expert competency framework [51] to encourage nursing students to simulate simple concepts before intermediate and complex skills [52]. Clinical and physical assessment skills learning was facilitated through intertwining classroom and practical sessions [48,49]. Students had an opportunity to apply newly acquired knowledge immediately, which aided their understanding and performance of relevant professional competencies [48,49]. The authors reported that students were assigned to work on authentic clinical cases, presenting to class, self-evaluation, self-critique to nurture metacognition skills essential for competency development [37,43,53].

Tools and Resources Used for Scaffolding
Both paper-based and computer-based tools were used for scaffolding. Paper-based, technologic, or computer-based scaffolds offer structure and support to demonstrate relevant aspects and processes required to complete a task [54].

Paper-Based Tools and Resources
Paper-based tools, such as the vocabulary worksheets, self-monitoring rubrics, question prompts, self-assessments, guided notes, checklists, worked exemplars, procedure guides [37, 48-50, 53, 55], clinical reasoning scaffolds [43], peer coaching tools [56], the Graduated Descriptors Competency Tool [57], and the playbook [58], were used to support the learning of stated outcomes. The tools mainly focused on providing structural guidance on clinical practice learning, academic writing, and critical thinking and reflection [56][57][58]. Peinhardt and Hagler [56] demonstrate how a peer-coaching tool structures assignments to improve reliability, relevance, and evidence-based practice. Similarly, the Graduated Descriptors Competency Tool [57] maps the expected competencies of pharmacy students at every stage of their clinical development with corresponding support strategies to scaffold their development. The tool aids students to reflect on their performances and scaffolds them in identifying areas for improvement [57]. The playbook presents multiple semesters of disorienting dilemmas scaffolded to improve the learning of clinical reasoning [58]. Application of these tools resulted in the learning of physical assessment [48], clinical skills [49], clinical reasoning, and problem solving [43,53].

Computer-Based Tools and Resources
Four technologic and computer-based tools were used to create virtual interactive platforms of learning. The tools and resources were the SlideTutor intelligent tutoring system [59], the SIDNIE (Scaffolded Interviews Developed by Nurses in Education) virtual platform [60], e-Support4U [61], and the CASUS electronic learning environment [62]. The SlideTutor has pedagogic models to scaffold students' diagnostic reasoning skills. The system was automated to identify corrective actions and errors and to provide prompt hints depending on the students' accuracy in diagnosing dermatopathology [59]. Similarly, the SIDNIE virtual platform was designed to provide adaptable scaffolding hints according to a student's performance in interviewing a virtual patient [60,63]. The SIDNIE and Slide tutors have built-in cognitive systems to enhance customising and adjusting feedback and support provided to students depending on the accuracy of their individual performances [59,60]. The e-Support4U platform was structured to scaffold learning of academic writing skills through interactive e-tivities [61]. e-Support4U tools provide a rich array of supports that make learning of complex writing skills practical [61]. E-tivities enhance students' collaboration in organising resources, content, and contributions towards completing assignments [61]. The CASUS system was designed to infuse case representation scaffolds that guide students in developing appropriate clinical reasoning skills and diagnostic pathways [62]. Additionally, Bingen et al. [50] and Lauerer et al. [38] report infusing principles of blended learning pedagogy and tools to facilitate and support learning the human physiology module and primary healthcare behavioural health concepts. Computer-based tools and virtual platforms promote the customised scaffolding of many students at one goal, a feat almost impossible when using human instructors.

Modelling and Fading to Scaffold Learning
Scaffolding strategies used during class engagements allowed the educator and students to change roles on multiple occasions during the learning journey. Initially, the educator took an active role by conducting introductory sessions on the fundamentals of physical examination [48], principles of literature evaluation and text organisation [37], and foundational content related to a clinical skill [49]. The educator's role then progressed to include modelling problem-solving processes [43,48,53], demonstrating physical assessment, clinical skills, and information retrieval processes [37,48,49,55]. The educator's roles gradually lessened in later stages through fading. Both physical and virtual support faded as students individually or collaboratively took over the responsibility to complete complex tasks, such as a critical appraisal of clinical literature [37], managing ill-structured problems [53], conducting a physical assessment [48], and performing relevant clinical skills [49].

Discussion
The purpose of this integrative review was to describe the application of scaffolding in health sciences programmes. High-income countries such as the USA and Australia dominated the number of sources included in this review, possibly due to limited uptake of student-centred education approaches in low-income settings [70,71]. Student-centred approaches necessitate the application of scaffolding. As expected, nursing, midwifery and medicine reported the most on scaffolding in their programmes because they generally have more students than other disciplines in health sciences [72,73]. This review integrated data from theoretical and empirical studies whose quality was generally good. Four themes reflected the application of scaffolding in health sciences programmes.
Sequencing of the educational content, learning tasks and learning environments followed increasing complexity to enhance students' progress in competency development. Scaffolding has been described as both a design of content and a process of delivering such content to support meaningful learning [41]. Educators arranged content to begin with foundational sciences forming a basis for decisionmaking in clinical practice [50,59,68], a view supported by the work of Dickinson et al. [74] as well as Grande [75]. The sequencing of the content and learning tasks promoted learning built on prior knowledge [38,47]. Learning tasks were scaffolded by focusing on single, small successive chunks of foundational concepts before complex situations that demand knowledge integration [40,45,69]. Similar programme design principles related to task scaffolding were described as requirements for enhancing the learning of complex skills, such as scaffolding metacognition, diagnostic reasoning, clinical reasoning, psychomotor skills, inter-professional practice, academic writing, and designing treatment plans [76][77][78]. In scaffolding learning platforms, students were first exposed to theory in classrooms, then moved to applying the theory in simulation before work-integrated learning [40,42,45]. This approach to sequencing learning platforms promoted building cognitive bridges between theoretical knowledge and experiential learning among students [79]. Sequencing content, tasks and learning platforms allowed students to engage with learning material and experiences, promoting knowledge internalisation and automatisation.
Various scaffolding tools were used during face-to-face and virtual engagement with learning materials, such as the playbook [58] and e-tivities [61]. These student-centred tools provided "just-in-time" scaffolds, such as prompts, hints, examples, and checklists, to ease students' cognitive processing and reduce their cognitive load [45]. According to the saw-tooth model, presentation of supportive information or "just-in-time" scaffolds increase students' chances of completing the required task [80]. Computer-based tools, such as virtual simulations, software systems, digital tools, and other technological advancements, were used to provide optimum learning support [56,57,[59][60][61][62]. Although there is a risk of "blanket scaffolding" [54], tools offer structure and multimodal scaffolding support for students to complete a learning task with ease [4,54,81]. The recent growth in technology inadvertently supported the adoption of technological scaffolding innovations in higher education [4,25,82,83]. Hence, exploitation of opportunities presented by improvements in technology is a remedy for programmes with large student cohorts. The design of computer-mediated systems with cognitive and metacognitive functions assisted in providing dynamic scaffolding for learning essential clinical skills, such as diagnostic reasoning and communication, which are usually learnt during patient interactions [59,62]. The adaptive capacity, dynamism, contingency, and fading witnessed in computer systems used in health sciences programmes improved the limitations of cultural tools described in the work of Malik [84].
Frameworks were applied to structure the process of learning and the design of learning activities [85]. The authors applied frameworks in structuring learning activities in progressive steps built on one another [66][67][68], and students learnt through applying clinical pathways in practice [65,69]. Frameworks are essential in enhancing transferability and standardisation of scaffolding interventions across platforms and contexts allowing for vertical scaffolding in programmes [65,86].
In the initial stages of learning a concept, educators play an active role including modelling of expected outcomes and facilitation of learning. The educator's engagement faded as students became independent as evidenced by knowledge internalisation and automatisation. Van Merriënboer and Sweller [80] argue that the processes of modelling and fading need to be repeated with each subsequent learning outcome to build competence.

Study Limitations
The search string was in English, which excluded studies published in other languages. Therefore, the outcome of this review is biased towards Anglophone populations. The use of a single university database interface may have influenced the literature search outputs limiting the representativeness of this review. The inconsistency in the definition and application of the concept of scaffolding in the literature may have influenced the inclusion and exclusion of studies for review.

Suggestions for Further Research
Studies included in this review reported the application of scaffolding mostly in single modules or learning platforms. Holistic programme-wide scaffolding strategies should be developed and implemented within student-centred health sciences programmes. Future research could investigate the consistent use of frameworks and models related to scaffolding across all health sciences programmes and in different settings and contexts.

Conclusion
The complexity of health sciences programmes justifies scaffolding to support students in becoming competent health professionals. This integrative review summarises the application of scaffolding in health sciences programmes. The sequencing of educational activities, tools or resources used in scaffolding, frameworks for applying scaffolding, and instructional strategies such as modelling and fading represented the application of scaffolding in health sciences programmes. The reviewed studies demonstrated the deliberate design of educational activities aligned with the students' zone of proximal development. Such activities supported students' transition from low fidelity and low complexity with high support to become independent tasks performers in complex environments with faded or no support from the educator. Educators should include scaffolding during instructional design and teaching-learning interactions. Scaffolding in health sciences should address various learning platforms, including simulation, clinical learning platforms and also goes beyond face-to-face interactions. Therefore, health sciences programmes need multifaceted, systematic, and programmatic approaches to scaffolding that begin with meticulous planning, design, and sequencing of curricula to build up necessary learning experiences for students.