Background: The COVID-19 pandemic had a significant impact on the Swiss health care system, affecting especially vulnerable people, such as patients suffering from dementia. The purpose of this study was to investigate the challenges experienced by dementia patients, their carers, and clinicians during the pandemic in Switzerland. Methods: An online survey was sent to all memory clinics in the German speaking part of Switzerland. Patients diagnosed with dementia and their carers were recruited for semi-structured telephone interviews at the memory clinic of the University Hospital Zurich. Results: A total of 28 clinicians, 17 carers, and seven patients participated in this study. According to the clinicians, all aspects of clinical work were affected by the pandemic. Carers did not perceive a significant role of the pandemic in the disease progression of the patients, despite many challenges faced. Patients described a high level of conscientiousness during the pandemic. Recommendations for future scenarios were provided from all groups. Conclusion: In order to increase the systemic resilience of the Swiss health care system, it is important to consider the experiences and recommendations of vulnerable groups and health care professionals for future public health measures and policies. Dementia is a clinical syndrome resulting from different underlying diseases, for example, Alzheimer’s disease or vascular dementia. The main symptom of dementia is progressive cognitive decline, which goes beyond the average effect of aging and interferes with daily activities of living. Worldwide, dementia is the seventh leading cause of death among all illnesses . In SwitMeasures). Ethics approval was waived by the ethics committee of the canton Zurich (BASEC-Nr. 2022-00502).This study adopted a mixed methods design with both quantitative and qualitative approaches. For the first part, an online survey was designed and sent to all (37) memory clinics in the German speaking part of Switzerland. The survey included both closed as well as open-ended questions about the clinicians’ experiences during the pandemic. For the second part, a semi-structured telephone interview about the patients’ and carers’ experiences during the pandemic was designed. Further information from carers and patients was collected based on questionnaires . Withdrawal from the study at any time without reason or consequences was guaranteed. Informed consent was given verbally via telephone both during the initial screening interview and before the start of data collection.Geriatric depression scale (GDS) and the WHO Quality of Life-question 9 (WHOQoL) was acquired from patients. The Neuropsychiatric Inventory-Questionnaire (NPI-Q), and the Depression, anxiety, and stress scale-21 items (DASS-21) were conducted with the carers.Sociodemographic data was collected from clinicians, patients, and carers. Clinical data and behavioral/neuropsychiatric symptoms based on the The survey was filled out between 05 and 07/2022. Telephone interviews were conducted between 06 and 08/2022 in either Swiss or Standard German. The interviews were recorded to prevent data loss and subsequently transcribed and translated into Standard German. The first version of the transcription was prepared by OS. The transcription was read and verified by EN, based on the audio files. For the preparation of the manuscript, results were translated into English.Conventional content analysis was used for open-ended questions: data was grouped around central, recurring thoughts to form overarching themes. For general closed questions, answers were counted and summarized. If limited information was available or the majority of answers went in a similar direction, answers were also summarized. Non-relevant information  was left out of the analysis. Due to the large amount of available data, only the most relevant results are reported in this manuscript. Quantitative data was analyzed using SPSS Version 28.Fifteen out of the 37 contacted memory clinics responded to our survey (response rate 41%), and a total of 28 clinicians filled out the survey. The sociodemographic characteristics of clinicians are summarized in Answers to the general closed questions are shown in Clinicians reported an impact of the pandemic on several aspects of their work at the memory clinic. First, patient interaction changed: there were more remote consultations and less direct contact with patients; consultations were adjusted ; and communication was more difficult due to mandatory face masks and protective shields. Second, organizational issues emerged: appointments were canceled by patients or by the clinic ; long-term scheduling and planning became more difficult and an increase in bureaucracy and documentation was reported. Third, interactions within the clinicians’ team changed due to difficulties with interdisciplinary exchange , less communication within the team in general , reduced staff due to sickness or taking over other (COVID-19 related) responsibilities within the hospital, and the general psychological burden of the pandemic on team members. Finally, factors relating directly to the patient’s well-being were reported: unaccompanied patients due to the hospital rules; cancelations of cognitive trainings and support groups, and the psychological burden of patients and their families .Clinicians described four general issues with regards to the impact of face masks on their work. First, physical problems (for both the patient and the clinician), for example, pain behind the ears, tiredness, headaches, feeling hot, and a decrease in fluid intake during the day. Second, challenges regarding communication and bonding with patients: lip-reading was not possible for patients with hearing impairments or for non-native speakers; non-verbal and emotional cues were reduced and the physical barrier between patients and clinicians created a less personal and less emotional connection. Third, the assessment of neurological aspects of the face was described to be more difficult with the face masks . Finally, an interruption of the clinical routine was reported, due to numerous reminders for the patient to wear the mask or to place the mask correctly as well as discussion with patients and relatives regarding the necessity of the measures.Clinicians were asked to rank which factor had the greatest negative impact on the diagnostic process during the pandemic. Most frequently (nine times), clinicians stated that the ambiguous cognitive decline of patients was the greatest difficulty during the diagnostic process, that is, it was not clear whether their cognition was deteriorating due to the social isolation or due to a neurodegenerative process. This was followed by cancelations of appointments by patients or by the clinic; missed recognition of symptoms by relatives during the lockdown; and finally, staff shortage due to sickness or newly assigned rules.Four reasons for challenging treatment conditions during the pandemic were outlined by clinicians. First, availability of symptomatic treatment , and external support  was reduced in general. Second, significant delays occurred due to canceled appointments, latencies of referrals, and longer waiting lists for diagnostic measures and appointments at the memory clinic. Third, communication between clinicians, patients, and carers was reduced and information about the diagnosis or the planned treatment was not transferred sufficiently. Finally, the psychological stress of the pandemic on the patient, for example, social isolation and loneliness, fear of infection or confusion about the ongoing situation, affected the treatment process as well.Numerous logistical difficulties were reported: transportation to the memory clinic, organization of COVID-tests or certificates for patients and relatives, checkpoints at entrances, new entrances, access to parking, limited physical space for testing, and frequently changing rules in the hospitals, for example, different forms needed for access. Some hospital rules did not allow accompanying persons, which led to delays, no-shows, and missing information from caregivers.Three themes emerged, when clinicians were asked about positive changes at their memory clinic. First, the possibility to set up virtual conversations or consultation . Second, an increase in solidarity and appreciation within the team; and third, an increase in effectiveness of internal processes, for example, determining the necessity of a personal appointment.The following recommendations for future pandemics were provided by clinicians: first, the importance of direct  contact with relatives was stressed, to ensure mobility and mental health of patients. Moreover, unchanged access to therapies and external assistance was advised. The importance for patients with dementias of having early access to vaccinations and protective material as well as specific recommendations was further highlighted. Additionally, reinforcing remote consultations and programs for social activities  were demanded. Finally, the self-determination of patients, for example, whether or not to wear protective masks, was emphasized.Twenty telephone interviews were held . The behavioral and neuropsychiatric scores of patients at the time of the interview are summarized in Carers themselves scored on average within the normal range on symptoms relating to depression, anxiety, and stress (DASS-21).conscientiousness: the majority of patients described a sense of duty to follow the new rules and restrictions, including getting the vaccination, social distancing, and staying informed. One patient commented that “if you follow the rules, everything is alright” and another patient described getting the vaccination as “a contribution to society.” A subtle criticism of people not following the rules was also present, for example, one patient commenting that “there are enough people, who are not careful.” The second theme was labeled unchanged state: in contradiction to the above-described awareness of new regulations, the majority of patients also described that their lives did not change during the pandemic. One patient even said that she “did not notice the pandemic,” while later stating that she adhered to the new rules. The third theme was named fear: negative thoughts and fearful emotions were mentioned by two patients, one of which was battling cancer on top of dementia. The pandemic was described as a “dangerous matter,” especially for those who had suffered a lot already. The importance of not developing a “phobia” of the disease and staying as objective and rational as possible was stressed by another patient.Three general themes emerged when analyzing the effect of the pandemic on the life of patients. The first theme was labeled Most patients reported that they did not observe any effect or only a small effect of the pandemic on their physical health. If an effect was reported, it was related to minor bodily pains due to a decrease in mobility or activity . The majority (five out of seven) patients reported no effect of the pandemic on their mental health. One patient reported a negative effect, that is, being more depressed and thinking more about the “outside world.” One patient’s statement was unclear and not leaning in either direction.Overall, patients were content with the regulations during the pandemic and did not wish for different rules or restrictions. Three aspects were raised, when considering the needs of people living with dementia: first, the importance of direct social contact for example, meeting family members or friends. One patient described her difficulties of staying in touch with people via telephone, due to her hearing aids and language disabilities. Second, it was requested that the rules should be followed by everyone, especially less vulnerable groups. Third, a concern about too many different opinions within the closest circle of family and friends was raised, as this felt counterproductive.Answers to general closed questions are summarized in The majority of carers (12 out of 15) reported no effect of the pandemic on the physical health of patients. Five carers talked about how other effects, such as the progressed dementia, other diseases, medication side effects or the general mindset of patients were so prominent, that the pandemic had no additional influence. For example, one carer said: “she is always stubborn and doesn’t want to -go out for a walk-. She always finds a reason not to.” One carer reported a negative effect of the pandemic on the physical health of his wife, he said it was “one more obstacle” for activities. Two carers described a positive effect of the pandemic on the physical health of patients, mainly due to a calmer daily routine and more time spent on walking. The majority of carers (nine out of 16) described a negative effect of the pandemic on the mental health of patients. For two patients, the negative effect was mainly noticeable in the beginning of the pandemic. Most frequently, loss of activities, loneliness, and boredom was mentioned. Three carers further described an increased anxiety, either unspecific or a fear of getting infected. One carer said: “he lives with the fear, even now that things have calmed down, it is still an issue for him.” Of particular note, one carer described the psychological burden of his wife having to say goodbye to her dying father through a protective glass shield. Seven carers described no effect of the pandemic on the mental health of patients. Three carers of this group further elaborated, that patients did not realize or did not fully understand the pandemic, while two carers pointed out, that the patient was already isolated or depressed before the pandemic.The vast majority of carers (11 out of 16) reported no or only a small influence of the pandemic on their mental health. The general attitude appeared to be pragmatic and realistic, for example, three carers used the phrase “making the best out of the situation.” The missed activities and the inconvenience of wearing masks and following the recommendations and rules was mentioned most frequently among this group, as aspects with potential effect on their mental well-being.Three carers reported a significant negative effect of the pandemic on their mental health, including an increase in worrying and a decrease in patience. Two of these carers stressed the importance of being able to have a “timeout” and putting physical distance between themselves and their home, for example, going for a walk by themselves. Two carers reported a positive effect of the pandemic on their mental health, due to their less stressful schedule.The most frequent recommendation from carers was centered around the isolation of patients during the pandemic, especially in nursing homes. The direct contact to other people was described as “essential,” and one carer recommended that social networks for older people should be strengthened, regardless of the pandemic. Especially for doctors and home carers, caregivers recommended spending more time to explain the ongoing situation and necessary measures to the patients. One carer said: “with dementia it is difficult anyway, if something new happens and suddenly you don’t understand why you have to wear a mask everywhere.” Two carers expressed their wish for more solidarity within the country during the pandemic and less resistance against necessary measures. Finally, home vaccinations as an option were recommended, to decrease the logistic difficulties.Our results demonstrated that based on the clinician’s experience, all aspects of clinical work  were affected by the pandemic. This finding is in line with previous work . HoweverThe high degree of conscientiousness among dementia patients during the pandemic as reported in our study is in line with a previous finding by A novel finding of this study is that according to the carers’ experience, the pandemic did not play a significant role in the progression of the disease. This finding suggests that from the carers’ point of view, the progression of dementia is relatively independent from external factors, such as the challenging situation faced during the lockdown. Alternatively, it could mean that carers do not perceive the influence of external factors on the patients as significant in general. A further novel finding is that most carers did not experience a deterioration of their mental health during the pandemic, despite an increase in worrying about the patients, spending more time informing themselves as well as the general daily challenges, such as patients having difficulties with following the recommended hygienic measures. This finding is further supported by normal scores on symptoms of depression, anxiety, and stress as well as an on average mild carer distress by patients’ neuropsychiatric symptoms. As raised by clinicians and patients, the recommendation to limit isolation of patients was further supported by carers. Social isolation and loneliness are of special importance when discussing dementia. There is evidence, that social isolation is significantly associated with poor cognitive function in later life . FurtherThis study seeks to understand a novel situation based on three different angles: the professional, the direct personal, and indirect personal point of view. Certain limitations of this study are directly linked to our sample. First, some of the patients as well as some of the carers had difficulties with understanding the questions and/or being able to provide an answer. This is partly due to the dementias, but also due to age-related changes such as hearing difficulties or diseases. Second, the majority of patients was diagnosed with Alzheimer’s disease, thus, it is unclear, if patients suffering from other types of dementia experienced the pandemic differently. Third, the sample consists of mainly Swiss nationals. Since some results are connected to cultural aspects, for example, solidarity as an important value in the Swiss culture , the traThe impact of the pandemic on society and the health care system is unprecedented. However, based on mathematical models , there iThe COVID-19 pandemic has exposed weaknesses in the Swiss health care system, that existed before and were exacerbated during the crisis. Many recommendations identified in this study are beneficial to patients and caregivers in general and should be implemented regardless of a possible future pandemic, for example, the use of technology for remote consultations, vaccinations at home, and more time for the professional care of elderly or people with cognitive impairments. These implementations will increase the systemic resilience of the health care system and decrease the burden of individuals and the communities affected by dementias.


Since the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health.This study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity.This is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care  among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care–related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C).The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort  is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences.This study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions.ClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652RR1-10.2196/49131 The presence of strong primary care systems has been shown to be associated with superior and more equitable health outcomes in the population -6. Core On March 11, 2020, the World Health Organization declared the circulating SARS-CoV-2 as a pandemic. The SARS-CoV-2 pandemic placed a substantial strain on health care services for care of both COVID-19 illness  and non–COVID-19 illness ,21. The Early in the pandemic, there were reductions in visits for chronic condition management ,26,27, pThe onset of the pandemic worsened existing challenges to the prospects of achieving and maintaining an adequate level of comprehensive primary care in Canada. Understanding the ways in which the core functions of primary care -39 were The Canadian Primary Care Sentinel Surveillance Network (CPCSSN ) is a muThis protocol was designed using the RECORD  statement . We willThe study population is all patients who were 18 years and older in 2018, and some analyses will focus on subgroups of patients with specific chronic conditions. We will use the 2-year contact population as recommended previously for defining practice populations for primary care . This mePeople who died during the study period will be included up to the point of death using the death date if captured or the presence of a deceased status with date estimated from the most recent contact in CPCSSN data. Patients who were older than 105 years at the start of the COVID-19 pandemic will be excluded as a possible data error.The primary exposure is the start of the pandemic in March 13, 2020. This date was selected as it marks the beginning of Canadian provincial governments responding to the formal declaration of the pandemic by the World Health Organization on March 11, 2020, by enforcing sweeping public health and safety measures. The prepandemic time frame used is defined as June 22, 2018, through March 12, 2020. The pandemic time frame used in this study runs from March 13, 2020, through December 31, 2022. In addition to comparison between these 2 periods, 30-day interval rates will also be calculated for selected outcomes and indicators where possible.Outcomes were informed by a large primary care trial on improving prevention and management of chronic conditions in primary care , a qualiAccess to the practice will be measured as the overall number of encounters.Comprehensiveness refers to primary care addressing “all problems in the population , except those that are too unusual  for the primary care practitioner or team to treat competently”  vs 3-5 [higher]).t test for continuous variables. Regression models appropriate to outcome distributions will be used to control for potential confounders of age (<70 vs ≥70 years), sex, count of comorbidities , neighborhood income quintile, and CPCSSN network (corresponding to location within Canada). Interactions will be examined in the descriptive analysis and will be considered for inclusion in models if they are found to be relevant. We will present adjusted estimates and 95% CIs for outcomes and parameter estimates for the independent variable and covariates. Analyses will be completed using SAS .We will present the proportions of patients experiencing the outcomes for each time period or mean changes for continuous variables and 95% CIs. Statistical significance of changes from pre to post time period will be assessed using the McNemar test for binary variables, the Wilcoxon signed rank test for original variables, and the paired To examine whether results are biased because of the nonrepresentativeness of the CPCSSN population, we will conduct the analyses on a sample of patients that is representative of the Canadian population based on age, sex, neighborhood socioeconomic status, and rural or urban residence.This study was approved by the Hamilton Integrated Research Ethics Board on April 11, 2022 (project number 14782-C). Because we will be using deidentified data, no consent is required. This study is also registered with ClinicalTrials.gov (NCT05813652).The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. At the time of writing (May 2023), we have finished data cleaning and begun exploratory analyses. As there are known consistencies with CPCSSN data, having a longer exploratory analysis phase has allowed us to liaise with central CPCSSN data managers in order to prepare data for the main analyses. We have now also defined our study cohort: a total of 875,934 individuals between the ages of 18 and 105 years as of 2018 were included.We will attempt to extend our analyses to include the first half of 2022 when data become available if our timelines and resources allow. At the time of writing this protocol (May 2023), data were available up to December 2021. The additional 2022 data will allow us to investigate changes in primary care in the later portion of the COVID-19 pandemic, capturing the Omicron wave, and measure whether any changes identified in the earlier portion of the pandemic were sustained or returned to prepandemic patterns of care.For clinicians, we will create evidence briefs to be shared with the national and provincial colleges of family physicians through social media and our CPCSSN practice-based research network linkages. For researchers and policy and practice decision makers , we will produce peer-reviewed publications and evidence briefs where we will contextualize the new knowledge against recent research relating to pandemic recovery in health care. The 1- to 2-page evidence briefs will be shared with knowledge users involved in the development and implementation of policies and resources related to pandemic recovery. For patients, we will create infographics and a short video that will raise awareness of the issue of chronic condition care gaps and describe patients’ perspectives. These will be circulated via social media and clinical organizations.We plan to share knowledge products for patients and the public with the patient advisory committee being created as part of the David Braley Primary Care Research Collaborative at McMaster University, with whom several authors are affiliated. 1c testing for those with diabetes, number and frequency of visits for monitoring of heart failure, and number of prescriptions for diabetes or heart failure. Potential changes in any of these indicators may indicate that gaps in care are present that may benefit from targeted recovery measures.The aim of this study is to help identify signals of change across several domains of primary care, including access, comprehensiveness, and appropriateness, that may have occurred in response to the COVID-19 pandemic. This will be done by investigating the overall number of primary care encounters during the pandemic compared with prepandemic, as well as potential changes in the number of diagnoses addressed during encounters, number of blood pressure measurements, number of vaccines provided, number of blood tests carried out, and so on. Potential changes in indicators specific to the management of chronic conditions will also be investigated, for example, frequency of HbAHowever, these potential changes in primary care are not inherently negative. For example, many blood tests, examinations, and procedures are considered overused in certain populations and may be conducted more frequently than necessary ,57,58. IThe strengths of this study include the use of a large, multiprovince primary care EMR data source, developed to understand the epidemiology of chronic diseases and care in Canadian primary care. The data set is regularly updated and includes coded information on most aspects of primary care practice. The relative currency, longitudinal format, and comprehensiveness of CPCSSN data are ideal for the study of practice changes, through time, in response to significant environmental imperatives, such as the sweeping public health measures put in place during the pandemic . NumerouThere are limitations in this study. EMR data are collected for clinical and administrative purposes and are not primarily collected for research, which may result in incomplete capture of information. Furthermore, participating sentinel clinics are overrepresented by academic practices , and by This research was initially designed and received funding without patient involvement. When the research team presented the data request to the CPCSSN data access committee (May 2022), a patient advisor on the committee provided input. The advisor noted that the proposal was broad in terms of the scope of chronic diseases to be investigated. In response, we refined our analysis plans to examine diabetes and heart failure in greater detail as exemplar diseases. The advisor also suggested that it would be important to consider the changes in the health care system and behaviors of the public over different phases of the pandemic, especially since the Omicron variant.We anticipate that this study will provide evidence that will inform whether and in what aspects of primary care the COVID-19 pandemic is associated with interruptions that may require attention. It will also highlight gaps or provide reassurance with respect to chronic condition care for populations who were expected to be disproportionately affected by pandemic health care changes such as those who are older or of lower socioeconomic status.


Nursing competency frameworks describe the competencies; knowledge, skills and attitudes nurses should possess. Countries have their own framework. Knowledge of the content of professional competency frameworks in different countries can enhance the development of these frameworks and international collaborations.This study examines how competencies and task divisions are described in the current professional competency frameworks for registered nurses (RNs with a Bachelor’s degree) in the Netherlands, Belgium, the United Kingdom (UK), Canada and the United States (US).Qualitative document analysis was conducted using the most recently published professional competency frameworks for registered nurses in the above-mentioned five countries.All the competency frameworks distinguished categories of competencies. Three of the five frameworks explicitly mentioned the basis for the categorization: an adaptation of the CanMEDS model (Netherlands), European directives on the recognition of professional qualifications (Belgium) and an adapted inter-professional framework (US). Although there was variation in how competencies were grouped, we inductively identified ten generic competency domains: (1) Professional Attitude, (2) Clinical Care in Practice, (3) Communication and Collaboration, (4) Health Promotion and Prevention, (5) Organization and Planning of Care, (6) Leadership, (7) Quality and Safety of Care, (8) Training and (continuing) Education, (9) Technology and e-Health, (10) Support of Self-Management and Patient Empowerment. Country differences were found in some more specific competency descriptions. All frameworks described aspects related to the division of tasks between nurses on the one hand and physicians and other healthcare professionals on the other hand. However, these descriptions were rather limited and often imprecise.Although ten generic domains could be identified when analysing and comparing the competency frameworks, there are country differences in the categorizations and the details of the competencies described in the frameworks. These differences and the limited attention paid to the division of tasks might lead to cross-country differences in nursing practice and barriers to the international labour mobility of Bachelor-educated RNs.The online version contains supplementary material available at 10.1186/s12912-023-01514-3. Since the late 19th century, the nursing profession in the Netherlands and many other Western countries, like the United Kingdom and the United States of America, has become a paid profession with specific nursing training . NursingExternal factors that influence professional development include demographic and epidemiological developments. For instance, the increase in patients with chronic conditions and high-aged people with multimorbidity requires nurses to be able to provide complex care and support across multiple  domains . Also, hInternal factors also influence the nursing profession. Internal factors concern, for instance, the continuing academic development in nursing. The number of university departments of nursing science is growing in Western countries, as is the number of nursing scholars; this is associated with the increased attention paid to evidence-based nursing practice , 16. AnoIt can be expected that such internal and external factors, and their influence on the nursing profession, are reflected in the professional competency frameworks for nurses. Equally, up-to-date professional competency frameworks influence the nursing profession. In this paper, we define a professional competency framework as a document describing the competencies a nurse must have. ‘Competencies’ are the knowledge, skills and attitudes, and the ability to perform tasks successfully within the professional context , 24.Professional competency frameworks are often developed and/or authorized by national professional nursing associations , 24. TheUp-to-date professional competency frameworks are important as they provide guidance to nursing practice, but also reflect the required core competencies of the nursing profession in a specific country. Under the influence of internal and external factors, the content of the nursing profession evolves in a dynamic institutional process. This means that professional competency frameworks have to be revised regularly. For instance, in the Netherlands and Belgium, nursing associations are currently preparing a new competency framework for nurses. For the development of future professional competency frameworks, it is relevant to know the content of professional frameworks in other countries: what competencies and tasks performed by nursing staff do they describe? By comparing them, developers of professional competency frameworks in one country can learn from other countries.This document analysis therefore describes the competencies and task divisions between nurses and other professionals in the current professional competency frameworks for Bachelor-educated registered nurses (RNs) in five countries: the Netherlands, Belgium, the United Kingdom (UK), Canada and the United States (US). First, the choice for the Netherlands is based on the motherland of the authors, and Belgium is chosen as an interesting neighbouring country that has similarities with the Netherlands culturally, geographically and in terms of its language . The three Anglo-Saxon countries  were selected because they have strongly influenced the global development of the nursing profession. This is particularly the case for the UK which initiated modern nursing through the pioneering role of Florence Nightingale, which first spread to Canada and the US as two countries that are historically and culturally strongly related to the UK. In these three countries, the nursing profession progressed rapidly in the second half of the 20th century due to factors such as advanced academic education for nurses and federal funding and support for nursing research , 29. TheThe following research questions were answered:In each country, what is the educational model and/or base for the categorizations of the key competencies described in the professional competency frameworks for registered nurses ?What are the competencies described in the professional competency frameworks, and how do these differ or agree between the countries analysed?How do the professional competency frameworks address the division of tasks between nurses and other healthcare professionals?In addressing these research questions, we chose to focus on nurses with a Bachelor of Science/in Nursing, because that is the level of education that is most comparable between countries .We performed a qualitative document analysis, a systematic procedure for reviewing or evaluating documents , of profbe a national professional competency framework for registered nurses with a Bachelor of Science in Nursing. If there was no separate competency framework for Bachelor-educated nurses, the framework for registered nurses in general was eligible for inclusion.be from the Netherlands (NL), Belgium (BE), Canada (CA), the United Kingdom (UK) or the United States (US).concern a general competency framework covering nursing in various healthcare sectors and various patient groups.be developed by or in collaboration with a national or international nursing association.be published in Dutch or English.be the most recent competency framework.Documents focusing solely on education or nursing specializations (e.g. intensive-care nursing) or specific settings (e.g. community nursing) were excluded.We identified five relevant professional competency frameworks (one for each selected country) between November 2021 and March 2022 through website searches of professional nursing associations and government sites. Our search for nationwide professional frameworks and nursing associations revealed only one nationwide general professional competency framework for registered nurses with a bachelor’s degree in each respective country.RW and AF independently reviewed the documents against the inclusion criteria. Then the documents were checked to see whether they were the most recent versions by contacting experts  in the different countries.The competency frameworks were analysed using a qualitative document analysis . All comTo ensure the internal validity of the findings, both the pre-definitive results section and the schematic overview of the results  was developed in collaboration with the Nursing Association in the Netherlands (V&VN) . This coIn Belgium (BE), in addition to higher education, there is also vocational training available for nurses. However, the existing framework does not have a separate framework or distinct section for nurses holding a Bachelor’s degree. The Belgian competency framework was published in 2016 and authorized by the Federal Council for Nursing . This frThe frameworks for the UK and Canada were both published in 2018, by the Nursing & Midwifery Council (NMC) and the Canadian Council of Registered Nurse Regulators (CCRNr) respectively , 35. In The US framework was published in 2021 by the American Association of Colleges of Nursing (AACN) . It consThree of the five professional competency frameworks mentioned explicitly what their point of departure was for the categorization of the competencies into specific domains: an adaptation of the CanMEDS model (NL), European directives on the recognition of professional qualifications (BE) and an adapted inter-professional framework (US).In the UK competency framework, no reference was provided concerning the origin of the categories of the competencies. The Canadian framework does not mention the point of departure of the categorization of competencies either, but the categorization looks similar to the domains of the CanMEDS model.Although the original categorization and description of competencies differed between the countries, through the document analysis (see Methods) we were able to extract and distinguish ten ‘generic’ domains of competencies that are addressed in all competency frameworks  Education;Technology and e-Health;Support of Self-Management and Patient Empowerment.As can also be seen in Appendix Furthermore, the generic domain ‘Support of Self-Management and Patient Empowerment’ is not described in any framework as a separate domain (with a similar title), although all competency frameworks present this as a core element of nursing and pay substantial attention to the need to support the self-management and empowerment of patients.All competencies described in the professional competency frameworks fit in one or other of the ten generic domains.The first generic domain concerns Professional Attitude. This is defined in our study as the willingness and ability to act professionally as a nurse complying with laws and regulations, evidence-based knowledge and ethical standards. This domain can be found as a separate domain in all frameworks, with the term ‘professional’ in the heading  and ‘Collaborator’ . The Belgian framework refers to competencies regarding communication and collaboration under ‘Communicating professionally with clarity’  and ‘Cooperation’ . Additionally, one specific competency was found under another heading, namely building a culture of collegiality, respect and professional relationships. In the UK framework, communication and collaboration competencies are grouped under ‘Leading and managing nursing care and working in teams’  and ‘Coordinating care’ . Furthermore, three competencies were identified in other domains. In the Canadian framework, competencies are described under ‘Communicator’  and ‘Collaborator’ . In the US competency framework, RNs’ communication and collaboration competencies are grouped under ‘Inter-professional partnerships’ , while the competencies ‘communicating effectively with individuals’ and ‘promoting collaboration by clarifying responsibilities’ are described under other headings.The generic competency domain Health Promotion and Prevention concerns health promotion and prevention by RNs, both directed at individual persons and public health in general. It is described in all frameworks as a separate domain, but under varying headings , demonstrating professional leadership by participating in activities aimed at guiding policy and health services, making services more accessible, and organizational leadership. These competencies are described in different parts of the competency framework. In the UK competency framework, relevant competencies are described under the heading ‘Leading and managing care and working in teams’. The competency framework describes RNs’ leadership competencies in coordinating the care, acting as a role model and understanding the principles of effective leadership. Under the heading ‘Leader’, the Canadian competency framework describes RNs’ role as leaders who influence and inspire others, enhance the quality of a professional and safe practice environment and demonstrate self-awareness. In the US competency framework, competencies are grouped under the heading ‘Personal, professional and leadership development’. The competencies in this section include demonstrating commitment to personal health and wellbeing, showing professional maturity and developing leadership capacity.The generic domain Quality and Safety of Care is described as a separate domain for all countries except Canada, where it is covered extensively under other headings  Education encompasses lifelong learning for nurses and providing or assisting in education. It is a separate domain in Canada and the US, but is described in the frameworks of the other three countries as well . In the other countries it is covered throughout the framework under various headings.In the Netherlands, competencies include digital literacy, reporting digitally and working with electronic patient files, utilizing social media, remote care and e-health technologies. For Belgium, relevant competencies concern using technology and ICT to store, access and record data for improved healthcare access and patient outcomes. The framework refers to clear digital communication and digital literacy for RNs. According to the UK competency framework, RNs need numeracy, literacy, digital and technological skills to meet the needs of people in their care and to ensure safe and effective nursing practice. They should be able to utilize digital technologies for accessing information, recording vital signs, and interpreting data. The Canadian competency framework refers to using social media and ICT to uphold public trust in nurses. It also includes competencies for ICT communication, assisting patients with ICT, strengthening nursing informatics and identifying and analysing technologies that may change. In the US, technology and e-health competencies are bundled under ‘Informatics and healthcare technologies’. This includes the competencies to gather  data, describe information and use communication technology tools for care delivery and documentation support.The generic domain Support of Self-Management and Patient Empowerment is addressed in all the competency frameworks but not as a separate domain. The domain includes competencies aimed at enabling self-management by patients and empowering patients to take control of their health and to be involved in decisions about care and care interventions. In the Netherlands, Belgium and the UK, Support of Self-Management and Patient Empowerment is described in the introduction to the competency framework as a ‘core value’ of nursing. From that perspective, it is logical that the domain is not found under a separate heading but is discussed throughout the competency framework. References to self-management support and empowerment in Canada and the US are found under headings like: ‘Support and empower clients in making informed decisions about their health care’ and ‘Promote self-care management’.Professional competency frameworks not only refer to competencies, but also outline some tasks and may highlight aspects of the task division between RNs and other professionals. All five frameworks discuss at least one aspect of the division of tasks between RNs and other healthcare professionals. Most of the time, no details are given about healthcare professionals in terms of their discipline or whether they are other nursing staff with specific educational levels. Some competency frameworks mention delegating tasks from RNs to other healthcare professionals  while others emphasize the coordination and organization of care or the delegation of tasks to other nursing staff (Netherlands). The UK framework mentions both delegating tasks and coordinating/organizing care. However, the specifics of task division and delegation are often unclear, with limited descriptions. For instance, one competency framework (Canada) only states that RNs must have knowledge of the delegation process. Information might partially overlap with the competencies described under the generic domain Communication and Collaboration.voorbehouden handelingen’), the Bachelor-educated RN can have independent authority (in Dutch ‘zelfstandige bevoegdheid’), provided that the RN has the competency for the specific restricted action. If the RN has the required competency, the RN also has the authority to determine the indication for the restricted action, to perform the action herself, and to give orders to another healthcare professional  to perform the restricted procedure. Details are not given in the framework about who the other healthcare professionals can be, what the specific restricted actions with independent authority are or what the required competencies are. Regarding the independent authority there is a footnote stating that some medicines may be prescribed by specific groups of specialized nurses which is further explained in the appendix part of the document. In other restricted actions, the RN has functional independence (in Dutch ‘functionele zelfstandigheid’), which means that a competent RN can perform these without supervision but only after being instructed to do so by a doctor or other authorized healthcare professional. These restricted actions concern injections, catheterization of the bladder, insertion of a tube or drip and venipunctures.In the Netherlands the division of tasks was described in the general description of the field of expertise of an RN with a Bachelor of Science in Nursing. This part describes the direction, organization, and coordination of the care process, including shared decision-making with the patient and other healthcare professionals, without specifying the disciplines of these other professionals. In addition, the Dutch competency framework states that for several restricted actions  over all the actions of RNs related to medical treatments.The competency framework for the UK describes task division firstly in relation to the RN’s competencies to safely and effectively lead and manage the nursing care of a group of people, demonstrating appropriate prioritization, delegation and assignment of care responsibilities to others involved in providing care. Secondly, task division is discussed in relation with the RN’s competency to show leadership as a role model in delivering high-quality nursing care. They are responsible for managing nursing care and are accountable for the appropriate delegation and supervision of care provided by team members and lay carers. RNs need to provide clear information and instructions when delegating or handing over care responsibilities. They should also demonstrate effective supervision, teaching, and performance appraisal by using clear instructions and explanations.In the Canadian competency framework, task division is discussed is addressed under ‘Coordinator’ focussing on RNs’ competency in understanding the delegation process. No other references to task division were found in the professional competency framework. Moreover, this framework does not give any information on which tasks can be delegated and to which types of professional.The US competency framework pays attention to the delegation of tasks, firstly in relation to RNs’ competency to delegate appropriately to team members and, secondly, their ability to delegate work based on team members’ roles and competencies. However, the framework does not specify the professional backgrounds of team members, which specific tasks can be delegated, or who has jurisdictional control over those tasks.Three of the five professional competency frameworks included in this document analysis explicitly identify their point of departure in categorizing the competencies of RNs, namely the CanMEDS model (NL), European directives on the recognition of professional qualifications (BE) or an adapted inter-professional framework (US). The point of departure was not mentioned in the competency frameworks for the UK and Canada. In addition, one competency framework (BE) made no distinction between Bachelor-educated nurses and registered nurses with a vocational qualification.Since there is no ‘golden standard’ for creating a professional competency framework for nurses, it is only to be expected that the categorizations and descriptions of competencies will differ between countries. However, variation in competency frameworks might be a barrier to the international exchange of the developing body of nursing knowledge and make it harder for nurses to work abroad. Within the European Union, there are minimum requirements for the training of general nurses in terms of content, placements, and time spent in clinical practice to facilitate the free movement of EU citizens , 39. TheAround the world, shortages of skilled healthcare workers are high, but the need is more urgent in some countries than in others –43. The Although the underlying model or base of the categorizations varied between countries, there were similarities in the competencies. We identified ten generic competency domains. These generic competency domains reflect the core of nursing and what is considered essential in today’s healthcare and in society in a broader sense. In particular the generic competency domains (4.) Health Promotion and Prevention, (9.) Technology and e-Health and (10.) Support of Self-Management and Patient Empowerment reflect the current focus of policymakers and practitioners on disease prevention, the use of ICT, and the promotion of patients’ self-reliance and autonomy. These developments are partly driven by the increasing shortages of nursing staff.Although these three generic domains are addressed in all the included competency frameworks, there are also differences. Support of Self-Management and Patient Empowerment received less attention in the competency frameworks of Canada and the US than in frameworks for the Netherlands, Belgium, and the UK. Future international empirical research can show whether these differences are also found in daily nursing practice.All professional competency frameworks address the division of tasks between nurses and other healthcare professionals but to a varying extent. Relatively most attention is paid to task division in the competency frameworks of the Netherlands and Belgium. These frameworks address the question of responsibility for medical actions carried out by the RNs, with both competency frameworks referring to legislation.Only the Dutch and Belgian competency frameworks explicitly mention physicians regarding the division of tasks or task delegation, although all competency frameworks mention ‘other professionals’ in general when discussing task divisions or task delegation. The lack of clarity and explicitness regarding the specific tasks involved in the division of tasks is striking, especially as we have indications from previous research that task shifts, e.g. when prescribing medication or monitoring chronic conditions, occur increasingly in nursing practice . This isThe fact that our document analysis concerned ‘generic’ professional competency frameworks that transcend care settings and patient groups may partly explain why so little attention is paid to registered nurses’ specific tasks and why they are often described in imprecise terms. It is expected that more specific information on task division will be found in, for instance, competency frameworks for RNs specialized in the care for a specific patient group or nurses with a Master’s degree in Advanced Nursing Practice since they may have a more specific role within the nursing staff and also in relation to physicians.A limitation of this document analysis concerns the selection of the five countries. Although a deliberate decision was made to include these specific countries, this does have consequences for the generalizability of the findings to the competency frameworks for RNs in other countries. For future research, it is recommended to extend this document analysis to include the professional competency frameworks of more countries.Another limitation is that only the latest versions of the professional competency frameworks were included. As a result, we have not been able to identify possible changes over time. Some countries, like the Netherlands and Belgium, are currently revising the professional competency frameworks for RNs. When new frameworks are published, it would be interesting to compare them with the current version to see how the COVID-19 pandemic, for example, has affected the required competencies and tasks, e.g., in relation to the increasing use of e-health and online communication between RNs and patients.The last limitation is that we only addressed the required competencies and task divisions as described in the competency frameworks. This research did not examine whether the framework is implemented in practice or is legally binding. For instance, in the Netherlands the professional competency framework is published but has not been anchored in the law or national regulations. Together with the variation in health systems between countries this could also be a possible explanation for the differences we found.A strength of this document analysis is that it is the only known international study to date that compares current competency frameworks in different Western countries. This is especially interesting for nurses and nursing associations that develop new professional competency frameworks for RNs in collaboration with other stakeholders . This analysis can also serve as input for the future alignment of competency frameworks between countries.Another strength of this research is the involvement of experts from the respective countries, who were consulted both when retrieving the current competency frameworks and during the validation of the results for their respective countries.Ten generic domains were identified during the analysis and comparison of the professional competency frameworks. However, there are differences across countries in how the competencies of Bachelor-educated RNs are categorized and described in the frameworks. Moreover, limited information is available regarding the division of tasks between nurses, physicians and other healthcare professionals, particularly in Canada and the US. These variations and gaps in information may result in differences in nursing practice among countries and could impede the cross-border labour mobility for RNs.Below is the link to the electronic supplementary material.Supplementary Material 1


This article has been written in honor of the late professor emeritus Kazuo Tanne, who passed away on 4 March 2023. During his career as dean of and professor at the Hiroshima University Graduate School of Biomedical Sciences, he greatly influenced and contributed to my now comprehensive understanding of the mechanism behind mandibular condylar resorption and deformation. Moreover, for researchers around the world, he was a great inspiration with great perseverance. I hereby express my gratitude for his efforts and pray that his soul will rest in peace.During growth, the long bones increase in length via epiphyseal cartilaginous growth and in size via periosteal growth due to new bone apposition via subperiosteal and subendoseum osteoblasts. The mandibular condylar cartilage is the primary growth center of the mandible, and bone formation in the mandibular condyle causes the mandibular rami to grow upward and backward, moving the entire mandible in the opposite directions, namely, downward and forward. This also results in an increase in the intercondylar width corresponding to the lateral growth of the cranial base . Thus, tIdiopathic condylar resorption (ICR), on the other hand, is defined as a condition in which the mandibular condyle is specifically and progressively resorbed, accompanied by a marked reduction in mandibular ramus height; this reduction is affected by mandibular retraction and, subsequently, an anterior open bite, resulting in an imbalance between the occlusal and musculoskeletal systems . Since IThe purpose of this article is to present the risk factors associated with the development of ICR based on previous studies and propose criteria for the diagnosis of ICR and the timing of treatment initiation.The local factors of ICR include TMJ osteoarthritis, ischemic necrosis, infection, and trauma to the head, neck, and jaws ,4,5. TheIn our clinico-statistical survey of orthodontic patients under 25 years of age who visited the orthodontic clinic of Tokushima University Hospital, a total of 12 patients with ICR were identified among 1735 participants with various malocclusions; the prevalence rate was 0.7%, and the male-to-female ratio was 1:5 . The aveICR appears most commonly in women in their teens or early twenties, with a sex ratio of 1:9 to 1:16 . Gunson Like other synovial joints in the human body, the TMJ is a widely recognized load-bearing structure, and the application of a mechanical load to the mandibular condyle is essential for its growth, development, and maintenance . A healtAbnormal or excessive mechanical loading of the mandibular condyle during orthodontic treatment is thought to be one of the risk factors contributing to the development of ICR. Although the relationship between ICR and orthodontic treatment is still unknown, it should not be ignored that many patients with ICR have undergone orthodontic treatment, even though the occurrence of ICR is extremely rare . For exaPatients with ICR often have a history of maxillofacial trauma, especially forms related to the TMJ. Direct or indirect trauma of the mandibular condyle is thought to cause a partial loss of mandibular cartilage through laceration, resulting in bony condylar lysis of the mandible due to decreased nutritional supply and weakened tissue resistance ,14. ReduAmong children of elementary to junior high school age, the biomechanical environment in the tissues surrounding the TMJ dramatically changes in size with skeletal growth. Thus, even if the TMJs are subjected to relatively large stress during the growth period, children are relatively adaptable to environmental changes and often remain asymptomatic. Parafunctional habits and bad posture have been identified as risk factors for detrimental effects on the TMDs . For exaTMD symptoms such as joint sounds, pain, and trismus are commonly presented by patients with ICR. TMJ disc disorders are also the most common signs of TMDs, and some are developed through bony changes in the mandibular condyle, while others develop without bony changes ,13,15. TIn 2009, the Japan Intractable Diseases Information Center declared ICR to be an intractable disease, and little new information is available on the diagnostic criteria for ICR. The factors of the development of ICR are also unknown, and ICR patients are likely to visit dentists and orthopedic surgeons after an anterior open bite emerges due to a reduction in mandibular ramus height and mandibular retraction caused by progressive condylar resorption. Therefore, it is highly likely that important symptoms or signs that may be risk factors for ICR are hidden in these pathogenic factors.As mentioned above, osteogenesis in the growing condyle causes the mandibular ramus to grow upward and backward, resulting in the entire mandible moving forward and downward . Thus, tIf age-related skeletal changes are incomprehensive, findings from clinical and intraoral examination and radiography are key to the diagnosis of ICR ,5,8. ThrWhen patients present the above findings before or during treatment and are diagnosed as suffering from ICR based on radiographic findings, all treatment procedures should be interrupted at once. If necessary, splint and/or physical therapy may be applied to relieve pain, but no effective modalities for modulating the progression of ICR have been developed, and no basic studies on the development of new effective modalities for ICR have been reported. In order to determine when to initiate or resume treatment, it is essential to confirm via CT or other radiological examination that the progression of mandibular condylar resorption has ceased.ICR is still an unknown disease both in terms of its pathogenesis and risk factors, and no diagnostic criteria allowing for the early detection of this disease have been established. Little information is available on the best treatment to apply after ICR has developed. On the other hand, osteoarthritis of the knee and hip joints has been shown to be a multifactorial genetic and lifestyle-related disease caused by the interaction of genetic and environmental factors, and the genetic factors for osteoarthritis, or disease-related genes, include Asporin, Growth Differentiation Factor 5 (GDF5), and double von Willebrand factor A domains (DVWA) ,20,21. T


Learning in virtual museum can transcend the limits of time and space. The virtual museum that combines expertise in different disciplines provides a virtual learning environment for college students, but how to intervene in museum learning has been unclear. Targeted at this question, this study selected 2030 majors in clinical medicine from a certain university and the final results exhibited four types of learners who are of high, medium, low and absent museum immersion, respectively. When the learners visited the virtual museum, their behavior data were collected backstage and later used as data source. The method of fuzzy c clustering analysis was utilized to test the behavior recognition results of virtual museum learning, and lag sequential analysis (LSA) was used to carry out sequential transformation of learning behaviors in virtual museum. In this study, the four types of learners were subsumed under two broad categories of middle & high museum immersion and low & absent museum immersion. The importance of behavior was identified with random forest algorithm, and the intervention mechanism of museum teaching was designed according to the analysis results. Specifically, such strategies as museum support, voice guidance, video guidance, sub-museum ordering, rewards points on the list, etc. were used to study the museum learners in need of intervention. The results showed that the learning state of some learners was significantly improved. With the advantages of technology, virtual museums are more widely distributed and less costly than physical museums, and learners have access to them whenever and wherever they want, making it more convenient to serve the needs of informal learning. Martín et al. created virtual museums as an effective learning tool for teaching manufacturing engineering courses . CarolinAs developed through literature research, research on museum learning behaviour is scarce and focused on physical museum learning. in order to improve the mobile wizard system in museum learning, Sung et al. considered it important to explore the actual patterns of learner access and behaviour in museum learning; to this end, they coded and analysed the learning behaviour of 65 primary school students to identify patterns of behavioural interaction in museum learning, following which derive the characteristics and limitations of the different types of instruction, with higher levels of interaction and more active discussion found in the problem-solving mobile wizard group; and conclude with relevant recommendations for teachers, researchers and instructional system developers . StartinIn summary, this study concludes that research related to virtual museum learning has received some attention and development, with research directions mostly focused on the design and application of virtual museums, with less attention to learner behaviour, especially less research on university students’ professional learning in virtual museums, and even less research on interventions for university students’ museum learning behaviour, and the existing research fails to give, through behavioural analysis The existing studies have failed to provide reasonable solutions to address the problem through behavioural analysis. Therefore, research on learning behaviour in virtual museums needs to be further explored and enriched; whereas research on learners’ online learning behaviour has been more mature, with most researchers carrying out analysis of learning behaviour sequences and construction of models. In addition, it is not difficult to find that lagged sequence analysis is a common method for learning behaviour sequence analysis, which can achieve the identification and mining of learners’ potential learning behaviour . Based oBased on this this study will use methods such as fuzzy C clustering analysis, lagged sequence analysis and random forest algorithm to identify the importance of museum behaviours to address the problem of poor learning outcomes for low immersion and stray students in virtual museums, aiming to improve the poor learning outcomes in virtual museums. In this study, 2030 clinical medicine learners from a university in northeast China were selected for the experiment, and the behavioural data collected in the background when learners participated in virtual museums were used as the data source, and methods such as cluster analysis with fuzzy C were used to examine the results based on the identification of virtual museum learning behaviours, as well as behavioural transformation of virtual museum learning behaviours based on lagged sequence analysis, resulting in four types of learners. museum high immersion type, museum medium immersion type, museum low immersion type and museum stray type. In this study, the four types of learners were divided into two categories: medium-high immersion type and low stray type, and the behavioural importance was identified through the random forest algorithm. The study then explores how to conduct learning behaviour interventions in virtual museums in order to facilitate learners’ improved learning status and learning outcomes.Research Hypothesis 1 The importance of learning behaviour in museums can be identified through the random forest algorithmResearch Hypothesis 2 Effective learning behaviours promote students’ learning outcomes in the museumIn order to prove the hypothesis of this study, experimental research related to virtual museum learning behaviour was carried out using lagged series analysis and data analysis. The lagged series analysis method was used to transform the learning behaviour of the virtual museums to obtain four types of learners: high immersion type, medium immersion type, low immersion type and stray type. The Fuzzy C algorithm and Random Forest algorithm were used for the data analysis method, where Fuzzy C was used to cluster the visiting behaviour of the museum and Random Forest algorithm was used to identify the importance of the behaviour. The intervention mechanism and intervention strategies were designed through the identified important behaviours, so that the intervention effects could be verified whether the important and effective learning behaviours could promote the students’ learning effectiveness in the museum.The experimental material is a virtual museum titled Museum of Human Life Sciences which was designed and developed independently by our research team. In combination with the discipline characteristics of human life science in colleges and universities, the entire learning museum is composed of six sub-museums. Students can learn professional expertise in the museum after login. Before the experiment, the teacher informed students of the total duration of the experiment, that is, 30 minutes, and students were required to complete the learning tasks within the specified time. The technologies applied in museum construction is shown in Selecting the 2030 clinical medicine majors from a medical university in Northeast China, this study collected the backstage data of these students in the experimental museum of “Museum of Human Life Sciences” to investigate their learning behaviors within 30 minutes per round. After eliminating the 30 students whose data were invalid , the data set of this study was formed. All students who participated in the virtual museum experiment signed an informational letter that specified the following: the purpose of the study, the process of the study, the significance of the study, and the considerations for participation in the study and post-study remuneration. The students were informed and volunteered to participate in this study.Through the backstage supporter of the museum, teachers can fully investigate students’ use traces in the virtual museum and make a statistical analysis of certain basic data. On the museum page, relevant data like daily visitors and the total visitors can be displayed; personal usage data  can be collected and further displayed altogether in the module of “My Museum”. More data can also be collected and docked on the teaching management cloud platform to conduct the statistical analysis of Big Data. Such data include user information  and more learners’ behaviors . Through the backstage supporter of the museum, teachers can know about students’ learning situation in the virtual museum, so that targeted measures can be put forward to improve teaching. The existing research framework of learners’ behavioral engagement in online and offline learning environments provides a reference for the study of that in virtual museums. In traditional teaching, the research framework of learning behavioral engagement was widely adopted. Li Shuang et al.  divided After analyzing the behavior data transferred from the museum backstage supporter, this study summarized the 13 possible museum learning behaviors of the tested students, which were further classified into 6 types of learning behaviors and non-learning behaviors and coded respectively. The specific coding results are shown in The method of fuzzy c-means (FCM) clustering is used in this study. In most cases, the objects in a data set can not be separated as distinct clusters since errors are prone to generate if an object is assigned to a specific cluster. In that sense, each object and each cluster should be given a weight value to indicate the extent to which the object belongs to the cluster. Surely, methods based on probability can offer such weight values, but sometimes it is difficult to determine a suitable statistical model. Therefore, the adoption of FCM which boasts natural and non-probabilistic characteristics is a good choice to conduct clustering analysis of the visiting behaviors in the museum. After several iterative processing of the changes in the clustering center, this study divided the browsing behaviors of 2000 visiting students into four categories, as shown in After analyzing the behavior sequences of the four clustering groups, this study has the following discoveries: ①the transformation of behavior sequences in Clustering 1 ranks the highest in type and average times. It means that the visiting students in this group have the best learning effect who in other words, are of the high immersion type of museum learning. Specifically, while visiting the museum, these visiting students show more autonomous learning behaviors and strong subjective initiatives; ②there is a slight difference in the transformation type of behavior sequences between Clustering 2 and Clustering 1, indicating that students in Clustering 2 mainly listen to lectures and answer questions, and seldom make comments. They have relatively good learning effect, belonging to the medium immersion type of museum learning; ③the transformation times of behavior sequences in Clustering 3 is significantly less than that in the first two clustering groups and the transformation is relatively simple. It is worth noting that students in this clustering concentrate more frequently on “browsing the museum→recording form” and “browsing the museum→ listening to knowledge” than those in other clustering, which reveals that students in this clustering acquire knowledge mostly through listening and belong to the low immersion type of museum learning; ④the transformation times of behavior sequences in Clustering 4 is less than that in the previous clustering groups, and most visitors just “browse the museum→ record forms”, suggesting that the visiting students in this clustering only clock in to finish the tasks, lack learning motives and have weak self-control ability, thus belonging to the absent immersion type of museum learning.Based on the theory of learning behavioral engagement, this study classified the behavior into 4 immersions types, as shown in With data processing flow as the analysis framework, this study designed a recognition model of learning behavior patterns  based onThe LSA method can lend itself to the sequential transformation of learning behaviors . With thThe sequential transformation of learning behaviors of visitors who belong to the high immersion type in museum learning is continuous, and the length of learning behavior sequence is the longest, indicating that the high-immersion learners performed well in museum learning. The relatively thickest lines for LK-LC represent the greatest salience, i.e. such students are more likely to engage in human-computer interaction learning after listening to the lecture. Meanwhile, the sequential transformation of their learning behaviors is more concentrated and highly structural without independently absent behaviors, suggesting that they have good learning habits.The length of learning behavior sequence by visitors of medium immersion type in museum learning is the second, demonstrating that the medium-immersion learners have good learning habits. At the same time, significant sequential transformation of independent learning behaviors was manifested in them and no other significant learning behaviors appeared after the sequential transformation of the two learning behaviors of LK (listening to knowledge) and AT (answer test), which indicates that they are more inclined to autonomous learning. Future research will focus on the self-regulated learning of such learners.The sequential transformation of learning behaviors of visitors belonging to the low immersion type in museum learning is rather scattered compared with that of the first two types of visitors. The sequential transformation of independent learning behaviors was relatively large in number. There appeared no other significant learning behaviors after the sequential transformation of the two learning behaviors of AT (answer test) and CC (comment the content), suggesting that they may just follow the visitors and carry out shallow learning according to the study form. This indicates that such learners are only following shallow learning based on the learning form and that no deep learning phenomena such as problem solving and skill development are taking place.The sequential transformation of learning behaviors of visitors belonging to the type of absent immersion in museum learning is scattered the most among the four types of visitors. The three behaviors of BM (browsing the museum), PM (playing music and videos) and LK (listening to knowledge) frequently occurred on them, but the rest behaviors were fairly scattered, indicating that they were passive learners’ in museum learning, or to be more straightforward, they were just finishing the learning tasks without deep learning.The combination of the 13 kinds of learning behaviors originating from the 2000 visitors can produce 156 behavior sequences. The 2000 visitors were classified into the four types, among which the high and medium immersion of museum learning were set as 1, and the low and absent immersion of museum learning as 0. The target variables were set as binary variables  and the Finally, to effectively evaluate the performance that the established random forest model exhibited in the diagnosis of students with learning difficulties, the ten-fold cross-verification method was utilized in this study to analyze the accuracy. The four indices of accuracy rate, recall rate, precision rate and F-measure were analyzed with the model, so that a comprehensive evaluation and comparison of the distinction effectiveness based on random forest can be carried out between students with medium or above immersion and those with low or below immersion in museum learning . The binAccuracy rate: the percentage of correctly predicted results in the total samples. The formula is: Accuracy rate = (TP+TN)/(TP+TN+FP+FN).Precision rate: the probability of actually positive samples in all samples predicted to be positive. The formula is: Precision rate = TP/(TP+FP).Recall rate: the probability of samples predicted to be positive in the actually positive samples. The formula is: Recall rate = TP/(TP+FN). The higher recall represents higher probability that actually negative users can be predicted.TP: The sample was retrieved positive and it was actually positive. (correct identification)FP: The sample was retrieved positive, but it was actually negative. (primary wrong identification)FN: The sample was not retrieved positive, but it was actually positive. (secondary wrong identification)TN: The sample was not retrieved positive, and it was actually negative. (correct identification)The data were distributed to the training group and verification group in the proportion of 7 to 3. The model training was conducted through the data in the training group, and the verification set was verified with the model after training. The result data of the confusion matrix is shown in According to the analysis of the confusion matrix which is about the model verification results in the above table, it is found that in the verification samples, there are 206 samples of actually medium and high immersion, of which 177 samples are correctly predicted; there are 395 samples of low and below immersion, of which 345 are correctly predicted. Based on the confusion matrix, the evaluation indicators of the model are calculated, as shown in That the recall and precision rates in the above table are 86.1% and 78.0% respectively indicates that the identification effect of the model is so satisfactory that it can effectively identify medium and high immersion students and students of low immersion level.To explore the relationship between learners’ behavior sequences and their academic performance, this study analyzes the importance degree of the variables in random forest model. According to the importance data, the 17 behavior sequences of superior importance are selected, as shown in the following table. The larger importance number signals closer correlation between the two variables, indicating that all the behavior sequences in Intervention in all behaviors are rather likely to make learners weary of learning, so when teachers consider intervening, the behaviors that highly influence academic performance should be sifted out . AccordiWhen such behaviors as PM-TC (playing music and videos-giving thumbs-ups), BM-CS (browsing the museum-communication & sharing), RS-OT (recording study form-other behaviors), BM-BP (browsing the museum-browsing pictures), BM-RS (browsing the museum-recording study form) and BM-LK (browsing the museum-listening to knowledge) are way too many, timely intervention in museum teaching is also necessary. In the above-mentioned key behaviors, more behaviors of browsing the museum and those have nothing to do with learning tasks occupy students’ time for completing learning tasks. The emergence of other behaviors indicates that learners are liable to low immersion and absent-mindedness in museum learning, so intervention in museum teaching should be launched as soon as possible.After analyzing the sequential transformation of learning behaviors of four different types of learners, this study finds out that except for learners of high immersion type, learners of the other three types have certain problems regarding learning and those of the types of absent and low museum immersion especially need teaching intervention. Hence, centered on the museum data-based recognition model of learning behavior patterns, this study has designed a teaching intervention mechanism based on problematic learning behaviors, as shown in When museum learners are grouped into high, medium, low and absent immersion types, the mechanism quickly determines and identifies the learners who need intervention. The teachers take teaching intervention measures, including voice prompts, help manuals, peer assistance, teachers’ guidance and others, to help them with learning so that they can concentrate and understand the museum knowledge more easily, thereby improving learning effect.This study designed the following virtual museum intervention strategies based on the behaviors in need of key intervention and the characteristics of virtual museum learning tasks: (1) Museum support: dominated by texts, images and hyperlinks, the first two of which were intended to be triggered by learners who therefore, could be stimulated to discover and actively solve problems; hyperlinks were mainly linked to the museum learning manuals or help manuals on other websites. With museum support, learners can complete the tasks with more clear hints. (2) Voice guidance: a countdown was designed in every virtual museum learning task. Specifically, if operational instructions from learners were not received when time was due, the voice guidance prompts would be started automatically, and a voice guidance button was provided for students in the intervention experiment, so they could also turn on voice guidance in advance. The content of voice guidance corresponded to the hints for learners’ current operating steps, contributing to their understanding of task flows and solutions. (3) Sub-museum ordering: learners were allowed to preview the themes and difficulty degrees of the 6 sub-museums in advance , and willingly chose the appearance order of sub-museums before entering the intervention experiment. The familiar answering habits made for their more positive performance in the museums. (4) Rewards points on the list: the strategy of rewards points can lend itself to the intervention of all important behaviors. Answer tests were designed at the connecting door between two sub-museums and the tests were about expertise of the current sub-museum. The strategy of rewards points on the list was used as an incentive measure and every successful pass of the test would be displayed in the eye-catching position of the virtual museum that “Your Rewards Points Have Been Accumulated on the List”. Positive incentive of rewards points would motivate learners to study, further promoting the completion of museum learning tasks. (5) Video guidance: when museum support and voice guidance failed to be commonly accepted by learners, video guidance could be started autonomously. The content of video guidance was displayed in the form of pop-up videos, where the teachers, acting as operators, interpreted the operation steps of the current task, thus assisting learners with their learning tasks more intuitively. That video guidance was last activated among all the strategies since it was the most direct intervention strategy could impel learners to autonomous learning.Psychologist Albert Bandura believed that learning is the imitation of specific peer behaviors . By obseIntervention subjects: learners of the absent and low museum immersion after the first round of experiment. The museum learning materials which were of the same layout and difficulty degrees as the “Museum of Human Life Sciences” in the first experiment were used to do the intervention experiment. The duration of the experiment was 30 minutes.The intervention result analysis is shown in Figs This study verifies hypothesis 1: the Random Forest algorithm can identify the importance of the learning behaviour of the museum. After extracting the learning behaviour data of virtual museum learning, a scientific method is needed to cluster and identify the importance of the behaviour, so this research innovation uses the fuzzy C clustering algorithm and the random forest algorithm after experimental verification, the random forest algorithm is stable and tolerant to outliers and noise, to derive the importance of the behaviour and based on the analysis to derive the museum teaching intervention mechanism. The research hypothesis 2 was also verified: effective learning behaviours can promote students’ learning outcomes in the museum. Using strategies such as museum scaffolding, voice guided learning, video guided learning, sub museum sequencing, points on the list and video guided learning, the intervention study was conducted on the museum learners who needed the intervention. The results of the intervention showed that the learning status of some learners improved significantly, and from Figs This study conducted an experimental research to explore how to solve the wandering phenomenon that learners are prone to in virtual museums, and how to conduct museum teaching interventions. The 2030 learners of clinical medicine in a university in Northeast China were selected, and the behavioral data collected in the background when the learners visited the virtual museum was used as the data source, and methods such as cluster analysis of fuzzy C were used to examine the results based on the identification of learning behaviors in the virtual museum, while the sequence transformation of learning behaviors in the virtual museum was carried out based on the lagged sequence analysis method, so as to obtain four types of learners: high immersion type in the museum, medium immersion type in the museum, low immersion type in the museum and stray type in the museum. The high immersion learners are more self-regulated and do not need to participate in subsequent intervention experiments. In this study, the four categories of learners were divided into two types of learners: medium-high immersion and low-loafing, and the importance of their behaviour was identified through the random forest algorithm. The results showed that the learning status of some learners improved significantly, especially the stray learners got more than 80% improvement, which is important to improve the overall field learner effectiveness of students and lay the foundation for future research on deep learning in the field. Teachers should identify learning behavior patterns as early as possible to determine corresponding interventions, so as to improve their learning effect. The builders of virtual museums should provide learners with personalized learning experience by combining the characteristics of both virtual and brick-and-mortar museums.This study also has some limitations. Due to the pandemic of COVID-19, cycle experiment can not be carried out. The scope and quantity of experimental subjects are affected by many factors. Specifically, this experiment was only performed in a university in Northeast China and the data of students’ learning within 30 minutes were used for analysis and research. In future study, the experimental research areas and sample number should be expanded. Moreover, the state of learners also changed with the passage of time, so the follow-up study of our experimental team will perform several cycle experiments according to learners’ learning cycles with the aim to explore whether the passage of time and the enhancement of learners’ relevant knowledge reserve can influence learning effect . In thisVirtual museums boast high immersion and are not limited by time and space , so our