Unveiling the Nexus: Depressive Symptoms and Medication Adherence in Hypertensive Patients' Self-care: A Systematic Review.

Background: Hypertension, a significant public health concern, is frequently linked to emotional disorders like depression. Research shows a reciprocal link between depression and hypertension, potentially influencing patients' adherence to self-care routines. Objective: This systematic review aimed to examine the association between depressive symptoms and aspects of self-care, with a focus on medication adherence in individuals diagnosed with hypertension. Methods: Following PRISMA guidelines, a systematic review was conducted by searching PubMed, PsycINFO and Scopus until March 17, 2023. The included studies involved quantitative primary research conducted in English, focusing on adults (≥18 years) diagnosed with hypertension and experiencing depressive symptoms. Observational studies were assessed using the Newcastle-Ottawa Scale, and randomized controlled trials were evaluated using the revised Cochrane Risk of Bias Tool (RoB 2.0). Due to the great diversity of these studies, a narrative synthesis of the results was undertaken. Results: A total of 18 studies involving 6,131 people with hypertension, that met our eligibility criteria were ultimately included. The reported rates of depressive symptoms ranged from 4% to 43%. Of these studies, nine reported a statistically significant association, showcasing an adverse impact of depressive symptoms on medication adherence. The remaining nine did not confirm the above. Conclusion: This systematic review highlights the diverse body of research exploring depressive symptoms and medication adherence among individuals with hypertension. The review suggests a need for increased attention to self-care practices, particularly in relation to adherence to antihypertensive medication. However, it recommends the conduction of more robust longitudinal studies to comprehensively explore this relationship.

Humor and Quality of Life in Adults With Chronic Diseases: A Systematic Review.

Individuals grappling with chronic ailments often undergo a deterioration in their overall quality of life (QoL), encompassing psychological, social, and physical dimensions of well-being. Acknowledging that humor has demonstrated the potential to engender favorable effects on QoL, this systematic review endeavors to investigate the correlation between humor and QoL among adults contending with chronic health conditions. A comprehensive review of quantitative data was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. PubMed/MEDLINE, PsycINFO, and Cumulative Index to Nursing & Allied Health (CINAHL) were comprehensively searched from the establishment of each database up to June 22, 2023. Furthermore, reference lists of the included datasets and pertinent review articles were scrutinized exhaustively. The Newcastle-Ottawa Scale (NOS) was employed to assess the quality of eligible studies. A total of 18 studies satisfied the inclusion criteria. These studies encompassed a diverse spectrum of chronic disease categories (including cardiovascular diseases, various types of cancer, etc.) and collectively involved a participant cohort comprising 4,325 individuals. Remarkable findings surfaced, indicating a noteworthy association between distinct facets of humor-such as one's sense of humor, coping humor, humor styles, and laughter-and psychological QoL. Nonetheless, the relationship between humor and physical QoL exhibited a more intricate pattern, characterized by mixed outcomes. Despite the limited and inconsistent evidence across studies, humor appears to exhibit a positive association with QoL.

The experience of gender in spousal caregiving: A phenomenological psychological study (Greece).

PURPOSE/OBJECTIVE: To explore how spousal caregivers of older people undergoing rehabilitation experience gender within the Greek community. RESEARCH METHOD/DESIGN: A psychological phenomenological design and analysis were used to illuminate the unique meanings 11 spousal caregivers attribute to their experience of gender by gathering qualitative data via interviews. RESULTS: The data provided an insight into the structure of the experience of gender for the spousal caregivers as a normative diachronic identity in a succession of phases: normative constitution, alienation, and reparation. CONCLUSIONS/IMPLICATIONS: The findings highlight the influence of gender stereotypes on spousal caregivers' self-concept, agency, caregiving evaluations, and practices, emphasizing the importance of adopting an intersectional perspective in future research and interventions, considering various factors such as ethnicity, gender, sexuality, age, power dynamics, and cultural norms. Spousal caregivers experience alienation on entering the caregiving journey, with gender-related vulnerabilities affecting their psychological well-being. Addressing these vulnerabilities can improve caregivers' mental health and foster effective coping strategies. The study emphasizes the moral aspect of caregiving, highlighting the relationship between a sense of obligation, feelings of guilt, gender norms, and motivations calling for challenging self-sacrificial morals and societal norms associated with them to empower caregivers to prioritize their well-being while maintaining their caregiving motivations. This shift in perspective can lead to a more positive and fulfilling caregiving experience. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Patients' Dreams and Unreal Experiences During Intensive Care Unit (ICU) Hospitalization.

In the intensive care unit (ICU), patients often experience fragmented memories, primarily comprising dreams and illusions. These experiences can impact psychosocial well-being, correlating with post-traumatic stress symptoms and heightened anxiety. Understanding these phenomena is crucial for holistic care. To systematically explore patients' perspectives concerning the recollection of dreams and unreal encounters during their stay in the ICU, considering pertinent clinical conditions and potential influencing factors, we conducted a comprehensive search in the PubMed/MEDLINE, Web of Science, and Scopus databases until November 20, 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From an initial pool of 288 records, a thorough screening for eligibility resulted in the inclusion of nine studies for this systematic review. These selected studies underwent evaluation using either the Critical Appraisal Skills Programme (CASP) Qualitative Checklist or the Newcastle-Ottawa Scale (NOS). All studies categorized dreams into three main types: positive, distressing (including nightmares), and neutral experiences. These were further detailed based on aspects such as time, space, senses, emotions, and distinguishing between reality and unreality. Two studies found associations between dreams and conditions like Guillain-Barré syndrome (GBS), mental abnormalities, and delirium. In one study, GBS patients had more vivid dreams, hallucinations, and delusions compared to ICU control group patients; delirious patients tend to report more frequent frightening dreams. Patients in the ICU who recalled dreams often had more severe illness, longer stays, and higher ventilation frequency. Notably, a prolonged ICU stay significantly predicted the likelihood of dream recall, as consistently observed in three other studies. This suggests that patients with prolonged ICU stays, experiencing higher dream recall, underwent extended treatments. This systematic exploration of patients' perspectives on fragmented memories underscores the connections between these experiences, clinical conditions such as GBS and delirium, and extended ICU stays. Recognizing and attending to these psychological aspects in post-ICU care is critical for alleviating the enduring emotional consequences for patients.

Ergophysiological evaluation of heart failure patients with reduced ejection fraction undergoing exercise-based cardiac rehabilitation: A systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aims to explore in heart failure (HF) patients with reduced ejection fraction (EF) undergoing exercise-based cardiac rehabilitation the following: 1) the comparison of temporal changes between peak oxygen uptake (VO2peak) and first ventilatory threshold (VO2VT1), 2) the association of VO2peak and VO2VT1 changes with physiological factors, and 3) the differential effects of continuous aerobic exercise (CAE) and interval training (IT) on VO2peak and VO2VT1. METHODS: A systematic literature search was conducted in PubMed, CENTRAL, and Scopus. Inclusion criteria were 1) original research articles using exercise-based cardiac rehabilitation, 2) stable HF patients with reduced EF, 3) available values of VO2peak and VO2VT1 (in mL/kg/min) both at baseline and after exercise training with comparison between these time points. RESULTS: Among the 30 eligible trials, 24 used CAE, 5 IT, and one CAE and IT. Multivariable meta-regression with duration of exercise training and percentage of males as independent variables and the change in VO2peak as a dependent variable showed that the change in VO2peak was negatively associated with duration of exercise training (coefficient=-0.061, p=0.027), implying the possible existence of a waning effect of exercise training on VO2peak in the long term. Multivariable meta-regression demonstrated that both age (coefficient=-0.140, p<0.001) and EF (coefficient=-0.149, p<0.001) could predict the change in VO2VT1, whereas only age (coefficient=-0.095, p=0.022), but not EF (coefficient = 0.082, p = 0.100), could predict the change in VO2peak. The posttraining peak respiratory exchange ratio, as an index of maximum effort during exercise testing, correlated positively with the change in VO2peak (coefficient=-0.021, p=0.044). The exercise-induced changes of VO2peak (p = 0.438) and VO2VT1 (p = 0.474) did not differ between CAE and IT groups. CONCLUSIONS: Improvement of endurance capacity during cardiac rehabilitation may be detected more accurately with the assessment of VO2VT1 rather than VO2peak.

Older adults' lived experiences of physical rehabilitation for acquired brain injury and their perceptions of well-being: A qualitative phenomenological study.

AIM: To explore the experiences of older adults (65+) living with acquired brain injury regarding their sense of well-being during physical rehabilitation within the Greek Healthcare System. BACKGROUND: With the increasing ageing population and the life-changing effects of acquired brain injury, there is a need to focus on care for older people and their potential to live well. Rehabilitation systems deserve greater attention, especially in improving the well-being of those who are using them. DESIGN: A qualitative study design with a hermeneutic phenomenological approach was used. METHODS: Fourteen older adults living with acquired brain injury and undergoing physical rehabilitation in Greece were purposively sampled. Semi-structured interviews were conducted to collect data and were thematically analysed using van Manen's and Clarke and Braun's methods. The COREQ checklist was followed. RESULTS: Four themes emerged from the analysis: (1) Challenges of new life situation, (2) Seeking emotional and practical support through social interaction, (3) Identifying contextual processes of rehabilitation, (4) Realising the new self. CONCLUSIONS: The subjective experiences, intersubjective relations and contextual conditions influence the sense of well-being among older adults living with acquired brain injury, thus impacting the realisation of their new self. The study makes the notion of well-being a more tangible concept by relating it to the degree of adaptation to the new situation and the potential for older adults to create a future whilst living with acquired brain injury. RELEVANCE FOR CLINICAL PRACTICE: Identifying the factors that impact older adults' sense of well-being during rehabilitation can guide healthcare professionals in enhancing the quality of care offered and providing more dignified and humanising care. PATIENT OR PUBLIC CONTRIBUTION: Older adults living with acquired brain injury were involved in the study as participants providing the research data.

Identifying the Relationship Between Economic Prosperity and Quality of Life in Chronic Obstructive Pulmonary Disease Patients.

Background Chronic obstructive pulmonary disease (COPD) places a significant economic burden on national healthcare systems, and the economic effects of diseases have long been known. The study aimed to evaluate the association of parental family financial wealth with current economic prosperity and the combined effect of both on health-related quality of life (HRQOL) in a sample of patients with COPD. The moderating effect of birth order is further investigated. Methods The results of the study are based on a purposive sample of 105 COPD patients at the Larisa University Hospital pulmonology clinic (94 males and 11 females), with an average age of 68.9 (SD = 9.2). The data collection was carried out in the spring and summer of 2020. Participants completed the 36-item Short Form Survey (SF-36) and a sociodemographic questionnaire with self-reported parental and current wealth items. A mediation model with the moderation of the indirect effect of parental wealth on current wealth and the direct effect of parental wealth on HRQOL was applied to test the research hypotheses among the variables studied. Results Parental wealth was found to affect current wealth significantly, and both were involved considerably in HRQOL. Birth order had a significant moderating effect on the relationship between parental wealth and HRQOL. Among parental families with lower financial status, patients who grew up as third or later children had significantly lower HRQOL than the first or second children of these families. Neither age nor COPD duration was related to current wealth or HRQOL. Conclusions An intergenerational transmission of poverty was found in our sample. In addition, a birth order effect can provide further insight into the harsher environment that the later children of a low-income family are exposed to and the long-term implications for their HRQOL.

A Sense of Control and Wellbeing in Older People Living with Frailty: A Scoping Review.

A sense of control is important for supporting older people living with frailty to develop adaptive functioning to optimize wellbeing. This scoping review examined the literature on the sense of control and wellbeing in older people living with frailty within their everyday life and care service use. Nine databases were searched using the timeframe 2000 to 2021 to identify key ideas regarding control and wellbeing in older people with frailty. The review highlighted three major themes: a) Control as conveyed in bodily expressions and daily activities, b) Sense of control and influence of place of residence, and c) Control within health and social care relationships. Maintaining a sense of control is not only an internal feeling but is impacted by physical and social environments. Greater focus is needed on the nature of relationships between older people living with frailty and those who work alongside them, which support control and wellbeing.

Association of Personality Traits and Self-Care Behaviors in People With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis.

Diabetes self-care is critical for individuals with type 2 diabetes mellitus (T2DM), and exploring the impact of personality traits on this domain remains pivotal. This study aimed to investigate the association between personality traits and various dimensions of self-care in people with T2DM. A Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA)-guided systematic review with meta-analysis was conducted. Two reviewers independently screened articles, extracted data, and assessed the risk of bias. Estimates were pooled using random-effects meta-analysis. Twenty-three studies, that met our inclusion criteria, revealed distinct associations between certain personality traits and various aspects of self-care. Notably, traits such as openness, conscientiousness, and agreeableness showed associations with improved foot care compliance (odds ratio (OR) = 2.53, 95% CI = 1.49-4.28; OR = 1.84, 95% CI = 1.10-3.08; and OR = 2.07, 95% CI = 1.23-3.48, respectively). Openness was also linked to better overall self-care behaviors (OR = 2.00, 95% CI = 1.17-3.41), while conscientiousness correlated with reduced smoking (OR = 0.96, 95% CI = 0.93-0.99), and agreeableness was associated with improved medication adherence (OR = 1.68, 95% CI = 1.34-2.31). Conversely, traits like extraversion and neuroticism showed associations with decreased medication adherence (OR = 0.77, 95% CI = 0.61-0.96 and OR = 0.51, 95% CI = 0.40-0.65, respectively), with neuroticism additionally linked to lower overall self-care behaviors (OR = 0.67, 95% CI: 0.55-0.81). This study emphasizes the intricate role of personality traits in shaping self-care practices in individuals with T2DM, underscoring the significance of factoring these traits into tailoring and improving diabetes self-care strategies. Nevertheless, establishing definitive causal relationships mandates further in-depth longitudinal investigations and broader meta-analyses to achieve a more conclusive understanding.

Prolonged QT Interval in Athletes: Distinguishing between Pathology and Physiology.

BACKGROUND: The physiological QT prolongation in athletes is expected to widen the gray zone between physiology and pathology of QT, increasing the diagnostic challenges encountered in athletes with QT prolongation. SUMMARY: According to international recommendations for electrocardiogram in athletes, further evaluation for long QT syndrome (LQTS) is indicated in male athletes with corrected QT (QTc) ≥470 ms and in female athletes with QTc ≥480 ms. Apart from QTc ≥500 ms, diagnostic challenges arise in borderline cases of QTc prolongation, where further clinical investigations are needed to be performed to clarify whether LQTS exists. Clinical diagnostic investigations, including exercise testing, are more readily available, convenient, and easily interpretable, as well as less costly than genetic testing for LQTS. The main findings on exercise testing that are suggestive of LQTS can be the paradoxical prolongation of QTc during exercise and QTc ≥480 ms at fourth min of recovery. KEY MESSAGES: Exercise testing appears to have an important role in the diagnostic evaluation of athletes with prolonged QT interval, when genetic testing is not available.

Impact of the COVID-19 pandemic on the mental health of hospital staff: An umbrella review of 44 meta-analyses.

BACKGROUND: Hospital staff is at high risk of developing mental health issues during the coronavirus (COVID-19) pandemic. However, the literature lacks an overall and inclusive picture of mental health problems with comprehensive analysis among hospital staff during the COVID-19 pandemic. OBJECTIVES: To ascertain the prevalence of anxiety, depression and other mental health outcomes as reported in original articles among hospital staff during the COVID-19 pandemic. DESIGN: A PRISMA 2020 and MOOSE 2000 compliant umbrella review of published meta-analyses of observational studies evaluating the prevalence of mental health problems in hospital staff during the pandemic. REVIEW METHODS: Systematic searches were conducted in PubMed/Medline, CINAHL, EMBASE, and PsycINFO from December 1st, 2019, until August 13th 2021. The random effects model was used for the meta-analysis, and the I2 index was employed to assess between-study heterogeneity. Publication bias using Egger test and LFK index was examined. Data was analyzed using STATA 17.0 software. AMSTAR-2 was applied for the quality assessment of systematic reviews, while we used GRADE to rate the quality of evidence. RESULTS: Forty-four meta-analyses from 1298 individual studies were included in the final analysis, encompassing the prevalence of 16 mental health symptoms. One-third of hospital workers reported anxiety (Prevalence: 29.9%, 95% CI:27.1% to 32.7%) and depression (Prevalence: 28.4%, 95% CI:25.5% to 31.3%) symptomatology, while about 40% (95% CI: 36.9% to 42.0%) suffered from sleeping disorders. Fear-related symptoms, reduced well-being, poor quality of life, and acute stress symptoms had the highest prevalence among hospital staff. However, the quality of evidence in these areas varied from low to very low. Nurses suffered more often from sleep problems and symptoms of anxiety and depression than doctors, whereas doctors reported a higher prevalence of acute stress and post-traumatic disorders. The burden of anxiety, depression, and sleep disorders was higher among female employees than their male counterparts. Remarkably, acute stress and insomnia affected more than half of first-line medical staff. CONCLUSIONS: The prevalence of mental health problems among hospital staff during the COVID-19 pandemic is generally high, with anxiety, depression and insomnia symptoms representing the most robust evidence based on a large dataset of prevalence meta-analyses. However, there is no strong confidence in the body of evidence for each outcome assessed. REGISTRATION: Not registered. TWEETABLE ABSTRACT: The COVID-19 pandemic is having a major impact on the mental health of hospital staff. The need for support must be different for nurses and doctors @eldi12345.

A systematic review of the qualitative literature on older individuals' experiences of care and well-being during physical rehabilitation for acquired brain injury.

AIMS: To acquire an in-depth understanding of how older individuals diagnosed with acquired brain injury (ABI) experience their well-being and care when undergoing physical rehabilitation. DESIGN: Systematic literature review. DATA SOURCES: The electronic databases of PubMed, CINAHL, APA PsycInfo, ASSIA and SCOPUS were searched from 2005 to 2020. Extensive reference checking was also conducted. REVIEW METHODS: A systematic review was conducted following PRISMA guidelines, including predominantly qualitative studies. Studies' quality was appraised using the critical apraisal skills programme (CASP) tool. RESULTS: Seventeen studies met the inclusion criteria. Following methods of thematic synthesis, four overarching interpretive themes were identified: (a) Rehabilitation processes and their impact on older individuals' well-being; (b) Identity and embodiment concerns of older individuals during rehabilitation; (c) Institutional factors affecting older individuals' care and well-being experiences; and (d) Older individuals' participation in creative activities as part of rehabilitation. CONCLUSION: Organizational and structural care deficiencies as well as health disparities can adversely impact older individuals' autonomous decision-making and goal-setting potentials. The discrepancy between older individuals' expectations and the reality of returning home along with the illusionary wish to return to a perceived normality, can further negatively affect older individuals' sense of well-being. Constructive communication, emotional support, family involvement in rehabilitation and creating a stimulating, enriching social environment can humanize and facilitate older individuals' adjustment to their new reality following ABI. IMPACT: There is a lack of qualitative research on older individuals' ABI rehabilitation experiences, especially traumatic brain injury incidents. Further study should consider patients' concerns over their involvement in decision-making and goal setting about their care. Overall, this review reveals the need to examine further the significance of humanizing care and the factors that affect older individuals' sense of well-being.

Gendered experiences of providing informal care for older people: a systematic review and thematic synthesis.

BACKGROUND AND PURPOSE: The caregiving's impact on informal carers' quality of life and gender-based stereotypes make older individuals' informal care a complex process for which our knowledge is still limited. The purpose of this review is to identify how gender relates to informal carers' experiences of providing care for people aged 60 years and over with mental and physical health needs by synthesising the available empirical data published between 2000 to 2020. DESIGN AND METHODS: The systematic method for reviewing and synthesising qualitative data was performed using the PRISMA checklist and ENTREQ statement. The CASP tool was used to examine the quality of the included papers. Thematic synthesis was used as the methodological framework. RESULTS: This review produced two analytical themes, the impact of gender on the caregivers' labour and negotiating gender identity with self, society, and cultural norms. While informal caregivers share motivators, a linkage between traditional gender stereotypes impacts caregiving burden and coping strategies. Informal carers' experiences entail a constant pursuit of self-agency after acquiring the caregiver role. Cultural values and their intersection with gender appear to influence caregivers' healthy adjustment into their new caregiving identities. The flexibility to move beyond gender boundaries could mediate caregivers' negotiations between self and society on developing their new caregiving identity. Providing intensive informal primary care to older people affects both men's and women's mental and physical health. Gender ideals of the feminine nurturing role further disadvantage women as they determine the caregiving arrangements, the strategies and resources to sustain the caring burden, and the adaptability to experience their new caregiving role positively. Men appear more flexible to debate their hegemonic masculinity and defend their existence in the caregiving role. CONCLUSION AND IMPLICATIONS: Transgressing gender lines and expanding gender possibilities can ease the caregiving burden and strengthen caregivers coping potentials. Health professionals can empower informal careers to challenge gender binaries and expand gender possibilities by intentionally injecting the language of diversity in caring information and caring processes. The review findings outline a path for research on gender identity development in older people's care.

Exploring the Impact of Shame on Health-Related Quality of Life in Older Individuals.

PURPOSE: To explore the relationship between shame, ageing, physical disease, and quality of life in Greek older people. DESIGN AND METHODS: A cross-sectional design using a stratified random cluster sample of older adults from Open Care Centers for the Elderly in the region of Epirus, Greece. Data were collected using (a) the Short Form-36 Health Survey, (b) the Other As Shamer Scale, and (c) the Experience of Shame Scale. Data were analyzed using SPSS software. RESULTS: Internal shame was positively correlated with external shame (Pearson's r(177) =, p < .01), with negative effect on the mental component in both men and women (effect on women bW = -0.173, pW = .004, effect on men bM = -0.138, p​M = .047), b = path analysis beta coefficient and with a significant negative effect on the physical health component for men. External shame was found to have a significant negative effect on women's mental health (b = -0.266, p = .002) and a nonsignificant effect on the physical health component. Age was negatively related with the physical health component in both groups (bW = -0.392, pW = .002 and bM = -0.384, pM = .003), while the presence of a bodily disease corresponded with a lower physical health component score for men (b = -4.267, p = .033). CONCLUSION: Shame in older individuals is present in both sexes. Older males suffering from a physical disease displayed a greater decline of the health-related quality of life on physical health components, leading to greater internal shame. Older females suffering from a physical disease displayed a greater decline of health-related quality of life on mental health components, leading to greater external shame. CLINICAL RELEVANCE: These results indicate the need for developing assessment and care plans for older individuals that incorporate in them the concept of shame as a factor in dealing with and adapting to physical disease.

The impact of The Florence Network in advancing nursing and midwifery in Europe.

Diversity of the nursing workforce and multiculturalism of European cities have mandated the need for culturally sensitive nurses and midwives able to provide effective, engaging, high quality and socially just healthcare. The Florence Network is a professional network that aims to bring together like-minded professionals and to cultivate relationships amongst nurses and midwives from different European Union (EU) countries to create synergies on matters of common interest by transcending national and cultural barriers. A qualitative study based upon a focus group interview was conducted with six former Presidents and one present President of the Florence Network, each with a tenure of two years. The study explored the impact of the Florence Network in advancing cultural awareness and promoting educational, research and professional synergies. The outcome of the study identified that from the Presidents perspectives networks create awareness of cultural diversity, enable the delivery of multicultural nursing care and develop future leaders regarding global health-related issues. Furthermore, professional networks contribute to the refining of educational curricula, in developing applicable research evidence, and in sharing formal and informal professional knowledge.

Competence evaluation processes for nursing students abroad: Findings from an international case study.

BACKGROUND: Assessing clinical competence in nursing students abroad is a challenge, and requires both methods and instruments capable of capturing the multidimensional nature of the clinical competences acquired. OBJECTIVES: The aim of the study was to compare the clinical competence assessment processes and instruments adopted for nursing students during their clinical placement abroad. DESIGN: A case study design was adopted in 2015. SETTING AND PARTICIPANTS: A purposeful sample of eight nursing programmes located in seven countries (Belgium, Denmark, Greece, Norway, Poland, Portugal and Italy) were approached. METHODS: Tools as instruments for evaluating competences developed in clinical training by international nursing students, and written procedures aimed at guiding the evaluation process, were scrutinised through a content analysis method. FINDINGS: All clinical competence evaluation procedures and instruments used in the nursing programmes involved were provided in English. A final evaluation of the competences was expected by all nursing programmes at the end of the clinical placement, while only four provided an intermediate evaluation. Great variability emerged in the tools, with between five and 88 items included. Through content analysis, 196 items emerged, classified into 12 different core competence categories, the majority were categorised as 'Technical skills' (=60), 'Self-learning and critical thinking' (=27) and 'Nursing care process' (=25) competences. Little emphasis was given in the tools to competences involving 'Self-adaptation', 'Inter-professional skills', 'Clinical documentation', 'Managing nursing care', 'Patient communication', and 'Theory and practice integration'. CONCLUSIONS: Institutions signing Bilateral Agreements should agree upon the competences expected from students during their clinical education abroad. The tools used in the process, as well as the role expected by the student, should also be agreed upon. Intercultural competences should be further addressed in the process of evaluation, in addition to adaptation to different settings. There is also a need to establish those competences achievable or not in the host country, aiming at increasing transparency in learning expectations and evaluation.