Exploring the Role of Nurses in Travel Medicine to Improve Service Performance in Travelers: A Systematic Review

Abstract

Nurses play an important role in travel medicine. However, information about the role of nurses in travel medicine is still limited. This systematic literature review is aimed to exploring the role of nurses in travel medicine to improve service performance in travelers. This study was systematically compiled this review based on a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. The inclusion criteria are articles about travel health nursing, complete original articles, articles written in English and non-review articles. The quality of the studies was also assessed based on the Newcastle Ottawa Scale for observational studies. About 5 out of 257 articles were selected from 3 electronic databases, namely PubMed, Ebsco Host, and Scopus. Analysis of the 5 articles found that the role of travel health caregivers differs from country to country. The primary role of nurses in travel health in the U.S. is to conduct are-travel counseling. Nurses in the Netherlands have the authority to prescribe medicines needed for tourists. In Iris nurses play a role in providing support to the mental health of individual tourists, while in Spain, nurses play a role in emergency care for tourists. Nurses play an important role in the health of travel, including health services for travelers before and during the trip. The results of this review add to the understanding of the role of nurses in travel medicine that contributes to improving nurse performance and tourist welfare.

Keywords

Travel nurses nurse performance travel medicine systematic review

Introduction

The trend of travel has increased which has an impact on developments in the field of travel medicine.¹ Travel medicine is an interdisciplinary specialty that deals with the prevention and management of travel-related health problems.^2,3 Travel medicine can play an important role for travelers in improving travelers’ well-being and quality of life in the long run.³ The number of international tourist arrivals worldwide increased to be 965.31 in 2022.⁴ Based on data reported by the World Tourism Organization (UNWTO)⁵, it is estimated that as many as 975 million (38%) tourists will travel internationally by 2023.

The increase in the number of tourist visits contributes to the economic, environmental, and health sectors.⁶ The high number of tourist arrivals has an impact on the tourism industry such as providing jobs and contributing revenue.^7,8 On the other hand, tourist travel activities also have negative impacts such as carbon emissions on the environment with climate change.^9,10 In addition, the tourism industry also has a negative impact on health. About 22-64% of international travelers reported developing diseases during travel.¹¹ This fact illustrates the need for the role of nurses in handling diseases for tourists.¹²

The high demand for nurses during tourist visits requires increased competence related to travel health.¹³ Nurses’ level of knowledge about travel medicine care is still relatively low.¹⁴ Only a small percentage of nurses report ever taking a short course in travel health.¹⁵ Nurses also reported inconsistency in the implementation of travel standards of care.^16,17 In addition, nurses’ understanding of the role of nurses in travel medicine is also limited. Therefore, an understanding of the role of nurses in travel health is urgently needed.

Until now, publications on the role of nurses in travel medicine are still limited with inconsistent results. Based on the results of pre-existing research, it was found that the role of travel nurses is very important in travel medicine through the provision of health services in various locations.¹⁸ Another researcher found that nurses have a role in providing essential healthcare services and guidance to travelers for safe and healthy journeys.¹⁹ The role of nurses is also shown by providing pre-travel consultations, administer vaccines, and offer health education tailored to travelers’ risks, including occupational health aspects.^20
-22 Nurses also play a role in providing specialized travel care services internationally and contribute to disease prevention and traveler safety.^20,23 Even nurses in travel medicine in the Netherlands are expected to have competence in prescribing the drugs needed during the trip through further education.²⁴

To find out what the roles of nurses are in travel medicine, a literature search is needed. This research is important to provide an understanding of the role of nurses in travel medicine to improve nurse performance. Based on this, this study is aimed at exploring the role of nurses in travel health medicine in improving the performance of travel nurses.

Methods

This study is a systematic review of the role of nurses in travel medicine. The systematic literature review (SLR) method is a research methodology used to collect, identify, and critically analyze available research studies systematically.^25,26 In addition, systematic literature reviews provide a structured approach to evaluating various studies, aiding in evidence-based decision-making, in areas such as healthcare. Using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

Eligibility Criteria

The inclusion criteria used to select articles consist of (1) discussing the roles and responsibilities of nurses in providing travel medicine services, (2) articles that discuss the competence, training, and practices of nurses in providing travel medicine services, (3) complete available articles, and (4) articles written in English. Studies are excluded if the article is a review article, a commentary/perspective piece.

Information Sources

This research is a systematic review using 3 electronic databases, namely PubMed, Ebsco Host, Scopus. A systematic literature search was conducted from 2003 to 2022. The conjunction word, using Boolean logic “AND” and “OR” are used to connect phrases or keywords. The keyword combinations in the search are “Nurses,” OR “registered nurse” AND “travel medicine,” OR “travel health nursing.” The combination of words used is shown in Table 1.

Table 1.

Key Words in Literature Search.

No	Database	Keyword combination with Boolean	Results
1	PubMed	((Nurses) OR (Registered Nurses)) AND (travel medicine) OR (Travel Health Nursing)	208
2	Ebsco Host	TX (Nurses OR Registered Nurses) AND SU Travel Medicine OR Travel Health Nursing	34
3	Scopus	(ALL (“Nurses” OR “Registered Nurses”) AND ALL (“Travel Medicine” OR “travel health nursing”))	15

Literature Search and Selection Process

The selection process begins by determining the research question, namely what is the role of nurses in travel medicine? Furthermore, a web-based search for relevant articles was carried out on the scientific journal databases PubMed, Ebsco, and science Direct using specific keywords. In the search process, 257 articles were found for selection. The selection process consists of 3 stages. The first stage, the article selection process is carried out to issue a double article. This process leaves 179 articles that enter the next selection stage. The selection process in phase 2 is carried out screening of titles and abstracts in the identified articles to determine that the study meets the inclusion criteria. The screening process in phase 2 leaves 27 articles to be continued to stage 3. The stage 3 selection process is carried out to assess the suitability of the available manuscripts. The criteria used for selection include research paper, non-literature review, and non-travel medicine or travel health in nursing. The results of the final selection left 5 articles that met the requirements to enter the data extraction stage and proceed to the study quality assessment. The selection process is shown in Figure 1.

Figure 1.

Prisma flow chart.

Data Collection

The process of collecting data for a literature review on the role of nurses in travel medicine begins with determining the topic and objectives of the research. The research topic studied is the role of nurses in travel medicine, while the purpose of the analysis is to identify and analyze the role of nurses in providing health services for tourists. Articles are collected from scientific article databases such as PubMed, Ebsco, and science direct. The conjunction word, using Boolean logic “AND” and “OR” are used to connect phrases or keywords. The keywords used are such as “nurse,” “travel medicine,” and “tourist health.” The articles obtained are subject to an article selection and evaluation process. Articles that do not meet the inclusion criteria are excluded from the analysis process. Screening is carried out in 3 stages, namely selection of article duplication, selection based on title and abstract, and conformity with the criteria of the journal sought. The process continued by extracting and synthesizing data.

The data collected consisted of author data, year of publication, place of study, title, objectives, research method, results and recommendations. The important data items identified in the study were the settings of travel medicine services by nurses, training and education, the role of nurses, and challenge in implementation in travel medicine. Previous research has focused on the role of nurses in pre-travel health assessments, vaccination strategies, and health education for travelers. However, research that focuses on the role of nurses in travel medicine is still limited

The quality evaluation of the articles used was based on the Newcastle-Ottawa Scale for observational studies (BMJ Open, 2023). In this study, an article with a small number and source of articles was used in connection with the limited number of publications related to the role of nurses in travel medicine, so that there was a bias in the information obtained

Synthesis Methods

The following data were extracted from the eligible studies: author data, year of publication, place of study, title, objectives, research methods, results, and recommendations. The data extracted are data on travel medicine service settings by nurses, training and education, the role of nurses, and challenges in implementation in travel medicine. A shared spreadsheet was used to enter the data, which was independently extracted by 2 authors for analysis (M.NK. and A.LS.). The third reviewer (W.MA.) solves differences in data extraction and reaches consensus in case of disagreement. The quality assessment was carried out by the author (M. NK), who independently assessed the role of nurses in travel medicine. This study only reports results from the number of articles that meet the criteria, so there is a possibility that there are important results from articles that are eliminated that are not reported.

Results

A summary of the 5 selected articles is shown in Table 2. The quality of the included studies was assessed on the Newcastle-Ottawa Scale. It was found that 2 cross-sectional studies met 4 of the 7 points on the Newcastle-Ottawa Scale, 1 cross-sectional study met 3 of the 7 points on the Newcastle-Ottawa Scale, while the remaining 2 articles with a qualitative study design met 9 of the 10 criteria for a qualitative study based on The Newcastle-Ottawa scale.

Table 2.

Characteristics of the Selected Studies.

Number	1
Study	Bauer et al²³
Country	Australia, Japan, UK
Judul	Providing travel health care - the nurses’ role: An international comparison
Tujuan	To examine the role and challenges of nurses in travel healthcare in Australia, Japan and the UK
Sample	474
Study design	Online survey
Method analisis	Analisis Kuantitaif dan kualitatif dengan metode Survey Monkey’s statistical dan thematic content analysis.
Finding	Travel health nursing service settings in Australia include general practitioner practice areas, community health services, university health services, and travel business health services; in the UK includes general practitioner practice, school medical center; and in Japan, namely in quarantine and occupational health departments. Most nurses in the 3 countries have received training/education related to travel health, including general training related to vaccination The main role of nurses in travel health includes providing vaccines for tourists, prevention of malaria and consultation, and information and education for tourists. In Australia and Japan, most vaccine prescribing is done by doctors, while in the UK vaccine administration is based on patient group direction (PGD) and patient specific direction (PSD) guidelines. For advice related to malaria and anti-malarial in Japan and the UK can be given by nurses, but for anti-malarial prescriptions in the 3 countries, most are signed by doctors. Information is provided to tourists in the 3 countries mainly using the internet. The biggest challenge in implementing travel health; time with travelers, time allocation to meet with travelers; educate and provide advice to travelers according to procedures. Traveler risk assessment is important in consultation because there is no record of traveler’s immunization status. Another challenge is that travel health nursing must continue to update its knowledge of world health issues and the availability of nursing resources. In some cases, there may also be conflicts between nurses and doctors, especially in matters of authority.
Recomendation	Future research is expected to conduct research on nurses in areas that have recently been exposed to travel health nursing.
Number	2
Study	Sofarelli et al²⁰
Country	USA
Title	Standardized Training in Nurse Model Travel Clinics
Tujuan	To describe the travel-clinic model in maintaining professional services to reduce the spread of cross-world diseases
Sample	Not availabile
Study design	Descriptive study by implementing a pre-travel health program
Finding	Nurses provide pre-travel consultations including necessary nutritional intake, assessment of travel needs based on geographic conditions, duration of travel, age, and health condition of tourists. Pre-travel counseling also emphasizes the necessary vaccines related to the conditions of the area to be visited, education about diarrhea and prescriptions for common medicines. Tourists are also given a “Healthy Traveler” booklet. In filling out documents related to travel health nursing, several things that are often not optimal in filling out the form are the purpose and duration of the trip, drug allergies, medical history. In addition, negligence is also related to providing information to tourists such as the risk of malaria or yellow-fever, and the need for vaccinations for tourists.
Recomendation	It is expected to conduct research to determine the effectiveness of this standard on tourist populations around the world.
Number	3
Study	Overbosch et al²⁴
Country	Dutch
Tittle	Dutch Travel Health Nurses: Prepared to Prescribe?
Tujuan	To find out whether travel health nurses are willing and feel competent in prescribing (supplementary) medications and what kind of training they want.
Sampel	274 nurses
Study design	Descriptive study with a survey using a questionnaire on nurses.
Finding	Most nurses want to have authority over prescribing medication. A minority of nurses who do not want to have authority in prescribing drugs because they are not sufficiently educated, are comfortable with the current way of providing travel health and have a preference that the final responsibility lies with the doctor The results also show that nurses have a positive response in terms of competency in prescribing drugs for the following reasons: educational qualifications, support from national guidelines and being involved according to the protocol. The results show that when nurses are given the authority to prescribe, nurses need education in pharmacology and medicine in general
Recomendation	It is necessary to evaluate the prescription of drugs given by travel health nurses after being given authority.
Number	4
Study	O’Sullvian et al²⁷
Country	Irish
Title	The role and activities of the Traveler mental health liaison nurse: Findings from a multi-stakeholder evaluation
Tujuan	Provides an overview of the role of the Traveler Mental Health Liaison Nurse (TMHLN) after a thorough evaluation of various stakeholders
Sample	34 informants
Study design	A Qualitative descriptive with dept-interview and focus group discussion.
Finding	After conducting individual and group interviews with 34 stakeholders, 2 major themes were obtained, namely the context of the role and the specific activities of the role. Experience and understanding of local issues and understanding of services are keys that must be possessed in the context of roles, such as using the right language, being able to build trusting relationships, creating experiences (metaphorical), and having physical strength at work. Specific activities of the role include providing individual mental health support, providing educational/training sessions to tourists and service providers, building partnerships with specialist services, integrating services with various Institutions, and promoting cultural competence. The results showed that the role of nurses prioritizes the use of recovery technology that emphasizes psychosocial interventions and self-care and focuses less on biomedical technology, signs and symptoms, and clinical outcomes.
Recomendation	No Available
Number	5
Study	Granero-Molina et al²⁸
Country	Spain
Title	Nurses’ experiences of emergency care for undocumented migrants who travel by boats
tujuan	To describe and understand the experiences of nurses providing emergency care to undocumented migrants
Sample	17 nurses
Study design	Qualitative descriptive study through dept-interview
Finding	Nurses are expected to be able to perform comprehensive emergency care. The nurse’s actions range from triage, communication with tourists, nursing assessments, teamwork, and overcoming the psychological problems of tourists who do not have documents. The nurse becomes a key member of the multidisciplinary care team. The nurse coordinates tourists/patients with the rescue team and police as well as being a cultural mediator. In addition, nurses also guarantee continuous care, namely by accompanying patients, administrative problems with hospital transfers, police detention, psychological problems and stigma experienced. In terms of service, it becomes an opportunity to improve services (dilemmas, differences in language, culture, and clashes between the security and health sectors) in emergency wards, especially for migrants whose documents are incomplete.
Recomendation	Not Available

Discussion

The literature discussing travel health nursing is still limited. However, although limited, several studies have shown that nurses play an important role in travel health.

Pre-Travel Assessment Phase

In general, travel health nurses can provide nursing services before the trip either in person or through social media (including telephone or electronic messages) Travel health nurses provide pre-travel services like risk assessment, immunizations, health counseling, referrals, and screenings for conditions.²⁹ The target of this service can come from various groups, both individuals, 1 family or several families in the form of groups. Most tourists will seek travel nursing services in preparation for domestic or international travel.^30,31

In the initial phase, the travel health nurse will conduct an assessment regarding the general health history of tourists. This is done to identify the health risks of these tourists during the trip.^32
-34 The documented factors are divided into 2. The first is individual factors (tourists), which include, among other things, age, possibility of pregnancy (if the tourist is a woman), history of allergies, history of chronic diseases. unstable medical and psychiatric conditions requiring special attention, history of previous vaccinations, history of illnesses related to previous travel, and history of medication or use of personal medical aids. Other tourist risk factors that may also be assessed include: penchant or tendency to engage in risks related to sexual behavior, use of illegal drugs (narcotics), or extreme sports, travel health insurance, and status as immigrants or refugees if any.^31,34 Next, the second is travel-related risk factors. These factors consist of the date of departure, the specific order of countries to be visited (if visiting more than 1 country including transit), duration of visit in each country (especially if more than 1 month), season, climate, and altitude in the area or country purpose, type of accommodation, purpose or motivation for traveling, specific activities that may or will be carried out in the country of travel destination, and the mode of transportation used.^31,35

Intervention Phase

After all initial assessments have been made, the travel health nurse will begin planning the implementation of preventive measures. These precautions are intended to manage possible health risks associated with tourists and travel that have been assessed previously.³⁶ This implementation can be in the form of non-pharmacological or pharmacological interventions.^31,34

Non-pharmacologically, the interventions that can be carried out by travel health nurses are in the form of pre-travel counseling, coordination of care with other health providers, referrals for additional evaluations (if needed) and provision of health management guidelines during the trip (eg, by giving the “Healthy Traveler” booklet to potential tourists).²⁰ Pre-travel counseling is generally related to providing advice about food intake and needs during the trip which is adjusted to the duration of the trip and the geographical conditions of the travel destination.²⁰ This will also be based on the age and current health condition of the tourists concerned. In addition, this consultation will also emphasize providing information related to vaccinations,²⁰ diseases that may be encountered during the trip at the destination area such as traveler’s diarrhea, vector-related infections (eg, malaria, Aedes disease [such as dengue fever], Zika, and yellow fever), rabies, STIs, motor vehicle accidents, aviation hazards (eg, deep vein thrombosis [DVT]),³⁷ jet lag, respiratory infections, and climate hazards. It should be ensured that potential travelers are aware of all routine immunizations required for prevention and have been offered additional and booster vaccines depending on the risks identified at the destination of the trip.³¹ pharmacology is carried out by direct administration of immunizations and administration of drugs, either with or without a doctor’s prescription.^30,31

Emergency Services

Research by Granero-Molina et al,²⁸ published in 2022, discusses the experiences of nurses in providing emergency care for undocumented migrants in Spain. In this study, the provision of emergency care to migrants requires not only clinical knowledge, but also an understanding of migrant life. In terms of clinical management, nurses assist in assessment, initial diagnosis, and emergency treatment followed by determining triage, so that patients with cases with a higher triage level or more serious cases can be immediately taken to the hospital for further assistance.

The triage system used is a quick assessment of acute conditions, trauma, wounds, and burns, coupled with possible chronic diseases (eg, diabetes mellitus, asthma, or tuberculosis). Because the objects of first aid are undocumented migrants, upon arrival these migrants generally feel dazed and confused. This is where nurses play a role in helping them understand the information provided by gaining the trust of migrants who become their patients. In addition, the nurses document the patient’s symptoms and vital signs, and provide limited emergency care in the absence of the doctor. This treatment is limited because nurses in Spain have not been able to prescribe their own medicine without a doctor’s intervention.²⁸

Mental Health Services and Assistance

In an article about the role of travel health nursing in the mental health of tourists, it was stated that Ireland introduced the Traveler Mental Health Liaison Nurse (TMHLN) in its health system.²⁷ The TMHLN has a role in managing and carrying out referrals related to mental health cases to primary care services. In addition, together with the tourist health project that has been formed in Ireland, TMHLN carries out activities aimed at raising awareness around mental health issues. In addition, TMHLN assists the professional development of institutions/organizations so that they can refer tourists in need to primary and mental health services themselves. Furthermore, TMHLN also plays a role in supporting the development of tourists’ skills in the field of mental health with the aim that in their own communities, tourists can become independent resources.²⁷

Furthermore, Granero-Molina et al²⁸ showed that nurses are important members of the multidisciplinary health care effort for undocumented migrants. Nurses help coordinate tourists/patients with rescue teams and police as well as become cultural mediators. In addition, nurses also guarantee continuous care, namely by accompanying patients, administrative problems with hospital transfers, police custody, psychological problems, and the stigma experienced as undocumented migrants.

Prescribing Authority

In Australia and Japan, most vaccine prescribing is done by doctors, while in the UK vaccine administration is based on PGD (patient group direction) and PSD (patient specific direction) guidelines. For advice related to malaria and anti-malarial in Japan and the UK can be given by nurses, but for anti-malarial prescriptions in the 3 countries, most are signed by doctors.²³

Most nurses in the Netherlands want to have authority over prescribing drugs. The remaining small proportion do not want authority in prescribing drugs because they are not sufficiently educated, are comfortable with the current way of providing travel health services and have a preference that the final responsibility lies with the doctor. The results also show that nurses have a positive response in terms of competence in prescribing drugs for the following reasons: educational qualifications, support from national guidelines and already involved according to the protocol. The results of a study in the Netherlands showed that when nurses were given the authority to prescribe, nurses needed education in pharmacology, medicine in general and pharmacology.²⁴

The role of nurses in travel medicine contributes to quality service by ensuring patient safety, providing medical care, and meeting evolving patient expectations in healthcare.³⁸ The results of this study show that nurses have a very important role in the provision of quality health services. Nurses have a role in pre-travel health risk assessments, mental health services, emergency services, and pre-travel vaccinations. Nursing services provided in accordance with tourism nursing standards can increase a sense of security and comfort as well as satisfaction.^18,38 Although the role of nurses is very important in improving the quality of tourism health services, the number of nurses who have awareness of tourism nursing is still limited. The knowledge and skills of nurses in the provision of travel medicine services also still need to be improved through education. High-quality employee training is needed for the success of travel services, especially for international tourists.²⁰ Nurses should be knowledgeable about travel and routine vaccines able to provide health advice for travelers about destination-specific disease risks, prescribe chemoprophylaxis and self-medication regimens, and be aware of travel drug resources.³⁹ In addition, the provision of tourism nursing service standards is still limited in certain countries such as the United States.⁴⁰ Nursing professionals discuss the challenges to the availability of consistent training and standards of care.¹⁶ The provision of tourism nursing service standards can ensure the quality of travel medicine services through the fulfillment of tourism nurse competencies. This study suggests the provision and application of tourism nursing standards to improve the quality of travel medicine services.

This study has limitations from the number and sources of articles analyzed. The articles used are only sourced from reputable databases, so they ignore articles that may be valuable but are not published. For this reason, it is recommended to expand the search sources to include gray literature (such as reports, theses, and conferences) as well as search for literature from diverse databases.

Conclusion

Despite limitations in the source of the article, the study concludes that nurses play an important role in improving the quality of travel health services, namely in health services for travelers before the trip (which consists of an assessment phase and an intervention phase) and during the trip (including emergency services and mental health-related services). Nurses’ authority in prescribing vaccines and prophylactic drugs has begun to receive special attention in several countries. The results of this study contribute to nurses’ awareness of the importance of maintaining the performance of tourist welfare through the provision of nursing services in accordance with travel nursing standards and the improvement of nurses’ knowledge and competence. So, it is recommended to improve the knowledge and skills of nurses about health trips. In addition, to obtain consistency of results, it is recommended to re-examine the role of nurses in travel health with a wider scope.

Supplemental Material

sj-pdf-1-jpc-10.1177_21501319241287454 – Supplemental material for Exploring the Role of Nurses in Travel Medicine to Improve Service Performance in Travelers: A Systematic Review

Supplemental material, sj-pdf-1-jpc-10.1177_21501319241287454 for Exploring the Role of Nurses in Travel Medicine to Improve Service Performance in Travelers: A Systematic Review by Komang Matalia Gandari, Luh Seri Ani and I Made Adi Wirawan in Journal of Primary Care & Community Health

Supplemental Material

sj-pdf-2-jpc-10.1177_21501319241287454 – Supplemental material for Exploring the Role of Nurses in Travel Medicine to Improve Service Performance in Travelers: A Systematic Review

Supplemental material, sj-pdf-2-jpc-10.1177_21501319241287454 for Exploring the Role of Nurses in Travel Medicine to Improve Service Performance in Travelers: A Systematic Review by Komang Matalia Gandari, Luh Seri Ani and I Made Adi Wirawan in Journal of Primary Care & Community Health

Footnotes

Author Contributions

MG: Do conceptualization, validation, and writing original draft. LSA: Writing original draft, review & editing. IMAW: review and editing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

ORCID iD

Luh Seri Ani

Supplemental Material

Supplemental material for this article is available online.

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