Hence, the aim of this integrative review is to identify and synthesise literature on podcasting in nursing and midwifery education. The review questions are:
• What effect do podcasts have on learning in nursing and midwifery education?
• What are the perspectives of nursing and midwifery educators, students and practice staff towards using podcasting for learning?
The review is necessary to provide evidence to educators and students regarding the potential benefits this form of eLearning can provide in terms of learning outcomes and resource investment. The review will also pinpoint knowledge gaps for future research and provide recommendations on how to employ podcasting for teaching, learning and assessment across a range of settings.
As the literature on podcasting could include quantitative, qualitative and mixed-method designs, an integrative review approach is needed. This allows for the inclusion of a broad range of studies that employ different methodological approaches and synthesised in a systematic way. The integrative review followed the five stages described by (Whittemore and Knafl 2005) .
A search strategy was developed and a combination of free text keywords and Medical Subject Heading (MeSH) terms for the review population, intervention and outcome were used (see Appendix A). A systematic search was conducted using five online bibliographical databases; PubMed Central, MEDLINE (Ovid), CINAHL (EBSCOHost), Scopus and ERIC.
The search was originally undertaken in June 2016. An update was performed in January 2018 and January 2019. Reference tracking and hand searching a number of nursing and midwifery education journals was also conducted. Mendeley software was used to manage results and remove duplicate citations.
The inclusion criteria for the review were studies with the following attributes. Firstly, they had to contain participants who were nurses or midwives or students undertaking preregistration training in these disciplines. Studies were excluded if participants were other types of health professionals or mixed groups where nurses, midwives or students of these two professions were not clearly identifiable. Secondly, podcasting had to be used as an educational tool. Studies exploring a mixture of educational technologies where podcasting was not a distinct component, those using podcasts or audio recorded stories on a one-off basis, digital resources that were not accessible online or studies examining digital audio feedback were also excluded. Thirdly, studies must have undertaken empirical research, be published in an English language, peer-reviewed journal and have outcomes related to learning. No publication dates were stipulated in the inclusion criteria due to the recent emergence of podcasting as an educational technology. Finally, literature reviews, discussion or opinion articles, theses and conference proceedings were omitted.
Screening was undertaken by two members of the research team working independently. Titles and abstracts were assessed against the inclusion criteria for relevance to the review questions and those that did not meet the inclusion criteria were discarded.
Then, full text screening took place and studies not aligned to the reviews' inclusion criteria were rejected. Any disagreements during the screening process were resolved through consensus discussion with a third team member.
A number of Joanna Briggs Institute (JBI) critical appraisal tools were used to determine the quality of each individual study (http://joannabriggs.org/research/critical-appraisaltools.html) (see Appendix B) . The assessment of quality was undertaken by two researchers working independently. Any disagreements were resolved through consensus discussion.
A constant comparative method was applied to convert extracted data into systematic categories that could be compared and contrasted, enabling an in-depth understanding of podcasting to emerge (Patton 2002) . The five stages of this analytical process were followed (see Figure 1 ). Initially, the included studies were divided into sub-groups based on study design and analysed sequentially, beginning with qualitative studies, then mixed methods and lastly those with quasi-experimental or experimental designs. Data from each of the twentysix included studies were extracted to create an initial matrix. The data included the author,
year and country; research aim, theory and setting; methods such as ethical approval, study design, approaches to data collection and analysis; the type and number of participants; the kind of podcasting intervention such as the devices and software used; and key findings (see Table 1 ). The data display phase encompassed iterative rounds of qualitative coding using N-Vivo QSR 11, until a number of central concepts emerged. Next these concepts were compared and contrasted within sub-groups to determine overarching themes and relationships between them. In the next phase, themes and their relationships were analysed further to identify how different or cohesive they were in helping explain whether nurses, midwives or students of these professions learned via podcasting and how this process works.
Finally, verification involved using a Social Media Learning Model (SMLM) (O' Connor, understanding of learning via podcasting. This learning model centres around three mechanisms; 1) the person, 2) environment, and 3) behaviour that are made up of a number of elements which interact with one another (see Appendix C). It was originally developed from a review of social networking applications, such as Facebook and Twitter, in nursing and midwifery education using Bandura's (Bandura 1977) Social Learning Theory. Hence, it was appropriate to use in this review to undertake the integration and synthesis of the findings on podcasting. This was done by the primary author and discussed periodically with the research team to enhance rigour and reduce bias.
Twenty-six studies were included in the review as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart in Figure 2 . Overall, the quality of included studies was weak, with seventeen rated low quality, eight rated medium and one study rated high quality. The studies on podcasting took place from 2008 to 2018, across five countries. Sixteen articles were from the United States (Forbes and Hickey 2008 , Johnston, Hepworth et al. 2010 , Kardong-Edgren and Emerson 2010 , Kemp, Myers et al. 2010 , Schlairet 2010 , Vogt, Schaffner et al. 2010 , Gipson and Richards 2011 , Greenfield 2011 , Stiffler, Stoten et al. 2011 , Meek, Lee et al. 2012 , Abate 2013 , Lyons 2013 , Blum 2014 , Price, Strodtman et al. 2015 , Blum 2018 , Hargett 2018 , seven from the United Kingdom (McKinney and Page 2009 , Meade, Bowskill et al. 2009 , Clay 2011 , Meade, Bowskill et al. 2011 , Mostyn, Jenkinson et al. 2013 , Fenton 2014 , McSwiggan and Campbell 2017 , and one from Australia (Rogan and San Miguel 2013) , Norway (Foss, Oftedal et al. 2013) and Iran (Abedian, Nosrati et al. 2018 ) (see Table 1 ). The population of learners were mainly undergraduate nursing students, although four studies included graduate nurses (Meade, Bowskill et al. 2009 , Meade, Bowskill et al. 2011 , Stiffler, Stoten et al. 2011 , Meek, Lee et al. 2012 ), one focused on nurse preceptors (Blum 2014), and another had a mixture of preregistration and post-registration nurses (Schlairet 2010) . Two studies centred on the midwifery profession, one focusing on midwives undertaking postgraduate training (Clay 2011) and another on midwifery students (Abedian, Nosrati et al. 2018) . The majority of participants were female, aged between 20 and 40, although thirteen studies did not report gender and twelve did not report age. The ethnicity and socioeconomic status of participants were rarely described (see Appendix D).
The type of technology used to create and host podcasting interventions varied widely and in some studies the podcasts were not described in detail. Software such as Apple's GarageBand, Audacity, Dreamweaver, Final Cut Pro, Microsoft's Movie Maker, VoiceThread and devices such as MP3 players and digital cameras were used to create a range of digital learning resources. These were primarily hosted on virtual learning environments (e.g.
Blackboard, WebCT) but also university websites or YouTube in a few cases. Almost all studies created the podcast content, bar one which used a commercially available podcast Learning outcomes such as knowledge and skills acquisition were measured in several cases (McKinney and Page 2009 , Meade, Bowskill et al. 2009 , Clay 2011 , Gipson and Richards 2011 , Meek, Lee et al. 2012 , Abate 2013 , Lyons 2013 , Rogan and San Miguel 2013 , Blum 2014 , Fenton 2014 , Price, Strodtman et al. 2015 , Abedian, Nosrati et al. 2018 , Blum 2018 , Hargett 2018 and exam grades in others (Johnston, Hepworth et al. 2010 , Kemp, Myers et al. 2010 , Greenfield 2011 . Some studies examined the views of nursing or midwifery students, educators or clinical staff in relation to using podcasts for learning.
Psychometrically tested, valid and reliable tools were generally not used when measuring outcomes. The vast majority of studies used some type of quasi-experimental design such as a questionnaire or survey, while two took purely qualitative approaches using interviews (Meade, Bowskill et al. 2011 ) and focus groups (McSwiggan and Campbell 2017) with nursing students. One study undertook a pilot randomized trial (Abate 2013) and four employed mixed methods i.e. a combination of surveys with focus groups (Johnston, Hepworth et al. 2010 , Clay 2011 , Mostyn, Jenkinson et al. 2013 , Price, Strodtman et al. 2015 . No quantitative studies demonstrated sufficient rigour to determine the efficacy of podcasting on learning.
Overall, podcasting as an educational technology appears to have had a positive impact on how nurses, midwives and students of these professions learned. Several outcomes emerged from the synthesis of the review findings, namely knowledge and skills acquisition, and improved confidence (see Table 2 ). However, in a few studies some participants reported not learning anything from listening to podcasts, compared to accessing more traditional forms of education (Johnston, Hepworth et al. 2010 , Kemp, Myers et al. 2010 , Vogt, Schaffner et al. 2010 , Gipson and Richards 2011 , Meek, Lee et al. 2012 . Other studies noted the understanding of nursing students or practice staff improved via podcasting without specifying what knowledge or skills were acquired (Forbes and Hickey 2008 , Schlairet 2010 , Blum 2014 .
Knowledge. The most frequent benefit reported by undergraduate and graduate nursing students was they perceived that they gained a better understanding of subject matter such as pharmacology (Meade, Bowskill et al. 2009 , Meade, Bowskill et al. 2011 
Undergraduate nursing students also reported learning a number of useful skills by listening to podcasts. Communication skills, both verbal and non-verbal, were the most frequently described skill gain through using podcasting (Rogan and San Miguel 2013, Fenton 2014) . Study skills, research, critical thinking and stress management techniques were also noted as being learned by nursing students in a few studies (Greenfield 2011 , Lyons 2013 , McSwiggan and Campbell 2017 , Blum 2018 , Hargett 2018 .
One other outcome identified from using podcasting was improvements in confidence among nursing and midwifery undergraduate and graduate students (Clay 2011 , Meade, Bowskill et al. 2011 , Rogan and San Miguel 2013 , McSwiggan and Campbell 2017 .
For example, first year nursing students in (Rogan and San Miguel 2013) believed they were better prepared to undertake clinical placements from listening to podcasts as they had a better grasp of clinical knowledge or skills that would enable them to work well in 
Several aspects required to deliver podcasting as an educational intervention arose. These were categorised into four themes which were; 1) organisation of social media, 2) digital literacy and e-Professionalism, 3) personal motivation, and 4) flexible access (see Table 2 ).
Organisation of social media. How well podcasting was organised as an educational intervention seemed to affect the level of engagement from students, which could have impacted learning. The awareness of podcasting as a resource among pre-registration nursing students was an issue in some studies (Mostyn, Jenkinson et al. 2013, Rogan and San Miguel 2013) while in others, students suggested having written instructions accompany a podcast as a way to enhance learning (Vogt, Schaffner et al. 2010, Rogan and San Miguel 2013) . In (Meade, Bowskill et al. 2011) , graduate nursing students benefited from IT support.
A handful of studies reported that some undergraduate and graduate nursing students had poor digital literacy skills and struggled to use the software or hardware required to access and play podcasts (McKinney and Page 2009, Meade, Bowskill et al. 2011 ). On the other hand, other studies such as (Fenton 2014) and (Johnston, Hepworth et al. 2010) , reported that no undergraduate nursing students had difficulty with the technology as their technical skills were proficient and they found the podcasts easy to use.
Personal motivation. Whether nursing students were motivated enough to access and listen to podcasts seemed to impact how much they participated in learning. A few studies reported varying levels of motivation and engagement with the technology, which tended to decrease when undergraduate or graduate nursing students were busy and had other priorities such as assessments to complete (Vogt, Schaffner et al. 2010 , Meade, Bowskill et al. 2011 , McSwiggan and Campbell 2017 . ). These issues could detract from students' ability to learn.
Several mechanisms of the learning process were drawn from a number of included studies and synthesised into six themes (see Table 2 ). These were; 1) speed of exchange, 2) social media users, 3) timeframe, 4) quality of information, 5) functionality of social media, and 6) other learning activities.
A few undergraduate nursing students noted there was limited opportunity to ask questions and exchange information quickly with faculty or other students to clarify points of uncertainty when using podcasts, as this is not a function of the technology. This seemed to negatively impact learning (McKinney and Page 2009).
Social media users. Undergraduate nursing students who had a preference for aural learning seemed to enjoy listening to podcasts and took a lot from them (Mostyn, Jenkinson et al. 2013). However, there were undergraduate nursing students some who did not like using the technology or preferred traditional classroom based approaches to learning (Vogt, Schaffner et al. 2010 , Stiffler, Stoten et al. 2011 , McSwiggan and Campbell 2017 . Hence, it may not be useful for all nursing and midwifery students and practice staff given the diversity within these professions. On the other hand, (Kardong-Edgren and Emerson 2010) reported a nursing student with a learning disability seemed to like the podcasts as they helped them learn new knowledge and skills. It also appeared useful for international nursing students whose native language was not English as they could use the audio recordings to improve their pronunciation and vocabulary (Greenfield 2011, Rogan and San Miguel 2013) .
Timeframe. The frequency and duration of podcasting use was not always reported.
However, being able to control the pace of learning seemed to help undergraduate and graduate nursing students refresh existing knowledge. It also enabled them to remember material missed during class or catch up if a class was skipped, as podcasts could be listened too as often and as long as needed (Meade, Bowskill et al. 2009 , Schlairet 2010 , Meade, Bowskill et al. 2011 , Stiffler, Stoten et al. 2011 . (Greenfield 2011) also reported nursing students who were non-native English speakers were able to focus more in class as they were not under pressure to take notes because podcasts of the lecture content were available when required. This enabled students to make the best use of time available for learning. However, 
This integrative review provides the first rigorous synthesis of the current evidence on podcasting in nursing and midwifery education. It identifies key learning outcomes, namely new knowledge and skills, that students appeared to attain through the use of podcasts which were relevant to professional practice. In a few instances, the technology seemed particularly helpful for international students and those with learning disabilities and appeared to improve confidence among some students. Notably, a Social Media Learning Model (O'Connor, Jolliffe et al. 2018) helped to conceptualise the use of this digital tool in nursing and midwifery education. From this, key elements of the learning process such as the speed of exchange, timeframe, quality of information and functionality of social media among others were uncovered. Several aspects needed to deliver podcasting also emerged such as how well it was organised, the accessibility of the technology, digital literacy skills of staff and students, and whether students were motivated to learn. The application of the learning model to podcasting demonstrated that this type of social media is slightly different to social networking applications, as a number of mechanisms in the original model such as 'Virtual interaction', 'Student-centred setting', 'Social support', and 'Role modelling' were not present in this review. However, several mechanisms were similar and a new one 'Other learning activities' emerged from the findings of this review, revealing podcasts may have a unique property that could enhance learning. Hence, a refined version of the Social Media Learning Model for podcasting based on the results of this review is suggested (see Figure 3 ).
This review has a number of strengths including a robust approach to the integrative method by employing an established process and the use of best practice guidelines such as PRISMA to improve reporting. The further development of a Social Media Learning Model to aid our understanding of how nursing and midwifery students learn via podcasting technology also strengthens the findings. Yet a number of limitations are present such as the exclusion of grey literature, conference proceedings, theses and studies in languages other than English which means some relevant articles may have been missed. The studies are primarily based in high income countries which may introduce some cultural and other bias as educational settings and students could be different in low-and middle-income nations. Furthermore, many of the included studies were low in quality, had poor descriptions of the participant characteristics, key stakeholders such as nursing and midwifery educators and practice staff were largely overlooked, and weak study designs were used. The features of the podcasting interventions were also poorly explained in many studies, meaning an in-depth comparison between different types was not feasible limiting the utility of the findings. Hence, the review results should be interpreted with caution.
The review showed that nursing and midwifery students seemed to learn new knowledge and skills by utilising podcasts and in some cases their confidence also improved. 
Podcasting is becoming established as a popular social media tool to help educate nurses, midwives and students of these professions in higher and continuing education. In the future, it is likely to be used more regularly or it may become compulsory that all teaching resources are available via podcasts, vodcasts or audiobooks to give students more diverse material and methods through which to learn, particularly during the current coronavirus pandemic where students must be taught remotely (Williamson, Eynon et al. 2020 ). More research that employs robust experimental approaches to establish if podcasts improve learning is needed, so educators know investing in this technology is worthwhile. Richer descriptions of student populations and podcasting interventions would also be beneficial to enhance transparency, replicability and the generalisability of future research, as the diversity of students, technologies and educational resources could affect learning in different ways. Research that explores educators' views on podcasting and those of other key stakeholders such as qualified nursing and midwifery staff, leaders and managers in academic and clinical settings, learning technologists and policy makers would also be welcome to ensure this technology can be developed and deployed appropriately across higher and continuing education.
As more novel technology comes on-stream podcasting may be eclipsed by virtual and augmented reality, serious gaming, avatars or chatbots that enable students to learn via more visual and interactive means (Bayne 2015, Irwin and Coutts 2015, O'Connor 2019), or it could be integrated with these to extend the usefulness of this rather simplistic digital tool.
This would require nurse educators to upskill in these technologies and further investment in hardware, software, learning spaces and technical support would be necessary to deliver more advanced digital learning tools (Farra, Smith et al. 2018 , Pront, Müller et al. 2018 . Some considerations should also be made for nursing and midwifery students whose digital literacy, computer or mobile equipment, or Internet access may be poor as this could hinder their engagement with and learning from podcasts. Hence, additional resources could be provided by educators for this. Co-creating podcasting content with students or availing of good quality commercial or freely available podcasts may also help nursing or midwifery educators overcome some of the limitations of producing teaching material for this educational technology (Hennig 2017, Phillips 2017). Faculty may also support open access education initiatives by making podcasts accessible online for free, as has been done in some areas of medical and social work education (Fronek, Boddy et al. 2016 , Lin, Joshi et al. 2016 . Further theoretical development of the Social Media Learning Model would also be useful to help explain the complex processes by which students learn when using podcasts and other types of social media. This educational framework could help to create, deliver and evaluate better quality pedagogical interventions that support a diverse range of students.
This integrative review has provided the first rigorous synthesis of podcasting in nursing and midwifery education, which aids our understanding of this pedagogical tool. Tentative evidence that podcasts could improve learning emerged as the technology appeared to enhance knowledge and skills, in particular for international students and those with special learning needs. The review identified various podcasting interventions and their application in nursing and midwifery training which may benefit both educators and students when planning and operationalising learning. A Social Media Learning Model was also employed to elicit the fundamental components of developing and delivering podcasting in higher and continuing education. However, further research that robustly tests the efficacy of podcasts and objectively measures improvements in learning outcomes among more diverse groups of students and settings is needed. This would help clarify the value of this technology in nursing and midwifery education, so it could be used to positively influence professional practice and patient care. Educators who are going to use podcasting may wish to consider Of those who used anatomy and physiology podcasts 26% of students rated them as very good and 32% as good learning tools. These results were similar for the microbiology podcasts. However, 30% of students did not use the podcasts, which was the highest nonusage % of all the eight learning tools available in the e-compendium. Design: not explicitly stated. Data collection: Combination of exam results and questions posed to six ESL students was used. Analysis: not described.
Non-native Englishspeaking (ESL) nursing students (n=6) taking a medical-surgical course.
Developed: by faculty. Podcasts were recorded using a digital MP3 player. Content: Medical-surgical lectures and case study discussions were audio recorded. Duration: 10-15minute podcasts of a 90-minute class. Access: posted on Blackboard the online course management system.
Some non-ESL students had slight improvements in their grades after using the podcasts. Students used podcasts to review lecture material, as revision for exams and they helped students to concentrate more in class as they knew they would not miss anything as the lecture was recorded. Students liked the flexibility in learning that podcasts provided and it saved them valuable time.
Hargett (2018), USA Aim: Evaluate commercially prepared podcasts to improve students' critical thinking abilities. Theory: None reported. Setting: Academic. Quality: Low.
Design: pilot study. Data collection: online survey. Analysis: not described.
First-year undergraduate bachelor of science in nursing programme (n=20). Nine students responded to the survey.
Developed: self-select one instructorselected podcast episode of a commercially prepared podcast (This American Life, Radiolab) to utilise in an assignment. Content: nursing ethics.
All students (100%) reported that the podcasting assignment sparked learning and/or inspired critical thinking or reflection on the topic. Six students (66.6%) reported that they would recommend podcasting assignments be utilised in future courses.
Johnston, Hepworth et al. Design: exploratory qualitative pilot study. Data collection: four focus groups. Analysis: framework approach underpinned by the theoretical framework put forward by Self-Efficacy Theory.
Purposive sample of third-year undergraduate nursing students (n=18).
Developed: by faculty. Content: podcasts to help students understand assessment guidance and feedback in relation to a scenario-based summative examination.
Podcasts appeared to strengthen self-efficacy by providing readily accessible support and by helping students convert intentions into action. Students with high self-efficacy in relation to preparing for assessment were more likely to engage with feedback, whereas those with low self-efficacy tended to overlook opportunities to access feedback due to feelings of helplessness and futility.
Meade, Bowskill et al. 