Purpose of Session
Gain clear overview of writing a literature review.
Aid integration of good quality/ quantity research literature into an assignment.
Appreciate the essential task in each section of literature review
Aim of a Literature Review
The whole purpose of a literature review is to uncover new elements of care from contemporary nursing research, then shape these aspects into themes (key findings) or common features of intervention so they can be effectively introduced into practice in order to improve care provision (hence evidence-based practice) (Aveyard 2014, Davis 2016). Only evidence gained in this manner can be truly objective and have genuine clinical credibility. Moreover, a literature review is centrally concerned with learning to read, use and applying NURSING research findings. A literature review has several sections, all of which help to demonstrate the processes involved in seeking evidence-based care (Fig. 1). For a clear example of the literature review process read Rowles and McNaughton (2017) or a brief personal account by Nuttall (2009).
Overview of task.
|Topic – (initial keywords required).|
|Background – justifying need/ reasons/ arguments for change.|
|Search – produce research evidence to support claims for change.|
|Critical examination of the research uncovered.|
|Themes – explain extracted nursing intervention required for future improvements to original topic.|
|Potential Barriers – problems with introduction of suggested new/ alternative nursing intervention.|
|Dissemination – suggested methods of conveying new/ alternative nursing care.|
As with most television news broadcasts it is common to start academic writing with a concise overview of contents. Assignments therefore frequently begin with a paragraph stating the focus, direction and contents. If undertaken it gives the reader/ marker a clear overview of the direction of the paper. Commonly, authors opt for this to be a final task as writing a concise Introduction is challenging.
2) Background/ Rationale
The rationale should justify the need for a change in practice presenting the arguments/ reasons. Many arguments for change can be read in the papers found and used in the assignment. Plus the references supporting such points can be employed alongside cross-referencing although always avoid plagiarism issues! For example, Cleary et al. (2011) stated acute inpatient mental health units are busy and sometimes chaotic settings, with high bed occupancy rates. These settings include acutely unwell patients, busy staff, and an environment characterised by unpredictable interactions and events which can lead to many undesirable incidents. The review therefore aimed to uncover more effective ways to organise care. In a literature review by Sisson (2015) it is recommended during paediatric vaccination, the practice of aspirating during the administration of an intramuscular injection is unnecessary and no clinical reason to suggest these principles may not be applied when using the deltoid, ventrogluteal and vastus lateralis sites. In a comprehensive review by Griffiths et al. (2018) regarding missed care, a link between missed care and staff levels was the aim. The study concluded “Almost all studies found that low nurse staffing levels were related to higher reports of missed care.” (p. 1485). Read a published literature review of interest to view how published authors have undertaken the task.
In addition, it is vital to be able to access sufficient literature on the selected topic. Evidence in the form of descriptive papers, research, literature reviews, policies, NICE guidelines, DH Reports, etc. are all useful to aid the case for change in this section. However, ensure evidence in the Background (and throughout) is not merely NICE guidelines, DH guidelines, Royal Society guidelines, random guidelines from www sites such as National Patient Safety Agency, etc. Such references can be employed sparsely and in a supporting role to nursing research. Crucially, as this is a nursing issue/ assignment, much nursing research should be presented to support the need for change in this section.
3) Question Formation
First, read the eWorkbook for further advice. Always choose a topic of personal interest as this will help sustain attention and be advantageous for future clinical practice. Avoid medically orientated issues (can become quite physiologically or pharmacologically based) and endeavour to remain with nursing-based aspects of care (See FAQ Bb). Choose clear, specific questions that are not too narrow and select one question. Avoid assumptions or leading questions such as “a study into the lack of information provided to patients in the pre-operative period”. Questions must be unambiguous, answerable and realistic in time frame available (Stillwell et al. 2010, Khodabux 2016). Too frequently, students may have an interesting topic although when examining the available literature, far too little research emerges or it is lacking sufficient breadth or quality such as “pre-operative anxiety management and the role of religious beliefs” (Huang et al. 2012, Nigussie et al. 2014). Do not become too concerned with a specific question early in the process, choose an ‘area of interest’ and approach it more broadly.
|Truncation (*) avoids repeating the search using nurse, nurses, nursing, separately.|
Quick search example
|Initially, always search in the Abstracts otherwise the search engine will look everywhere.|
|Use of Boolean Operations will help to focus the search.|
Major headings box
For example, violent behaviour in Accident and Emergency may be the focus but the amount/ quality of research evidence available unknown (Ramacciati et al. 2018). A number of hours spent searching the literature may reveal more research undertaken on substance misuse and mental health (Bogstrand et al. 2011), possibly a more simulating area (Fig. 2 & 3). In this manner, Accident and Emergency nursing can remain the issue but not necessarily in the specific area originally intended. After reviewing the available literature and speaking with an academic advisor the question may need to be refined (literature available too vast, too little, unobtainable, limited English papers, too narrow, etc.). To aid the writing of the review section it is advisable to always keep a diary or detailed notes of how and why the research question developed and how it was refined.
- i) Useful tip – when a required reference has be found on CINAHL simply click on the ‘cite’ option to the right side.
- ii) Once ‘cite’ option selected, scroll down to reference style APA and copy/ paste into a Word document. APA6th is the obligatory University referencing style.
iii) Also, do not be concerned about the author alphabetical order in the reference list at this stage. When all references are listed, simply highlight the whole list in Word and click on the ‘A-Z’ option then click ‘OK’. All references will immediately be arranged in first author alphabetical order.
4) Search Strategy
Once papers have been identified, the Abstract in any research paper is a succinct overview of the whole study usually written in 200 – 350 words. However, Abstract word count can be restrictive as it is always governed by the rules of the Journal in which it is published. Nevertheless, each section of the research study is briefly outlined such as background, methodology (how it was done), sample size/ selection, main findings, conclusions and recommendations. This can therefore be read quickly in order to determine whether the whole paper is of value for retrieval. If relevant issues do not appear in the abstract, the paper unlikely to be useful for retrieval and reading.
The search for the literature must be briefly explained in the form of the inclusion and exclusion criteria (read a published literature review). Utilise original nursing research only with no literature reviews or descriptive papers employed in searched evidence. If literature reviews are utilised in the evidence, they must be critically appraised – a task, which differs from normal appraisal of primary research, harder to undertake and not covered in the module. Therefore, easier to use any published literature reviews in the Background information and employ cross-referencing of the papers to uncover more research. Issues of Hierarchy of Evidence (Sackett et al. 1996, Evans 2003) can be stated although it is potentially misleading as it refers mainly to medical studies and therefore a controversial issue as qualitative studies come lower in the Hierarchy (Hawker et al. 2002, McCourt 2005, Noyes 2010, Ingham-Broomfield 2016).
Inclusion/ exclusion flow chart (PRISMA)
Concentrate on qualitative and quantitative nursing research papers with no descriptive studies in the evidence as these mainly contain professional opinions and are therefore not research papers. Descriptive papers are useful in the Background and for cross-referencing purposes, especially if specific to review question. A PRISAM flow diagram can be included (not compulsory as increases word count) stating how the final number of papers in the review were gained (Moher et al. 2009) (Dia 1). The diagram (if used) can be placed in the appendix although it will not be marked. However, it is a good guide for the writer to help increase clarity during the search process.
To some extent, an article can be judge by the journal in which it appears. As a general rule, professional journals accept personal accounts of care/ management, descriptive aspects of intervention whereas the academic journals largely only accept research papers/ literature reviews. Furthermore, the review process for academic journals is generally undertaken in greater detail. However, professional journals do publish some research articles although mainly in a more digestible format. Aveyard (2014) suggests 10 – 20 key studies are required for a review paper at Level 6 BSc (Hons) as it is extremely difficult to establish new elements/ themes/ key findings of care from a small number of studies and thereby expect colleagues to undertake the ‘new’ recommended care. For this module, BSc students are recommended to provide a minimum of n=8 research papers whereas MA students are recommended to provide a minimum of n=10 research papers.
5) Summary of the Evidence
An overview of the literature need only be a brief summary of the studies. For example, the following can be used – total number of studies uncovered, number of quantitative studies (survey, cohort/ case control study, experimental), number of qualitative studies (ethnography, phenomenological, grounded theory) common methodology employed, number of countries where studies undertaken, etc.. A ‘Characteristics of Studies Table’ should follow this brief summary. Use the standard format for the Characteristics of Studies table – Author/ Date Origin, Aim, Methodology and Main Findings (See FAQ on Bb). Be succinct with words in the table as word count can increase greatly and always place the studies in first author alphabetical order (Table 1).
Characteristics of Studies Table (medication errors literature review – see Assignment Example)
|Author(s), date and country of origin (STUDIES LISTED IN AUTHOR ALPHABETICAL ORDER)||Aim of
|Examine prevalence and types of medication errors as well as barriers to reporting.||n=500 nurses surveyed using non-validated questionnaire regarding main causes of errors together with barriers in reporting errors.||Error occurrence 17%. Most common errors were administering medications at the wrong time (24%), incorrect dosage (17%), and wrong patient (14%). A heavy workload and high number of patients considered main causes. 45% did not report their errors.|
6) Quality Appraisal
The literature uncovered must be read for the essential elements – what did the researcher’s do, how did they do it, what was found, what are the recommendations for practice, what are the similarities and differences in the studies. Critical appraisal is one of the most important aspects in all assignments from Level 6 and beyond (see Level 6 & 7 grade descriptors). This task demonstrates the ability of the writer to think critically (strengthens and weaknesses identified) and analytically (separation of ‘whole care’ into its parts for greater scrutiny) building a concise ‘picture’ of the research undertaken. Many issues of appraisal are frequently rooted in the research papers’ Methodology section. Keep any description of the research papers succinct, as it is the appraisal of the research that is central. The critical appraisal section can (if desired) have one paragraph for each research paper uncovered. Appraisal of one paper can be undertaken before moving to another paragraph for appraisal of the next paper and so forth. However, some students undertake appraisal of overarching themes such as examining qualitative then quantitative studies, etc. Both methods are acceptable although the second is usually carry out by students who have had previous experience of critical appraisal.
A number of critical appraisal tools are available to help with this task (Hawker et al. 2002, Caldwell et al. 2005, Public Health Resource Unit 2006) (Table 2). However, these tools identify only possible areas for appraisal. It must be determined by the writer when reading individual research papers which one or two points are to be established in the appraisal. Appraisal tools do not need to be used like a shopping list and each point mentioned as word count will not allow and every point may not be relevant to appraise. A number of nursing research textbooks should be used alongside these tools as they contain explanations of many methodological aspects together with the strengths and weaknesses of each approach (Polit and Tantano Beck 2014, Mould et al. 2017, Richardson-Tench et al. 2018). For example, if needing to read about observational studies and their related strengths and weaknesses, Parahoo (2014) Chapter 18 explains all (Salmon 2015).
Hawker et al (2002) appraisal tool
|Abstract and Title||Clear description of the study?||Good Structured abstract with full information and clear title.
Fair Abstract with most of information.
Poor Inadequate abstract.
Very No abstract.
|Introduction and Aims||Good background and clear statement of the aims of the research?||Good Concise background containing contemporary literature review, highlighting gaps in knowledge. Clear statement of aim and objectives including research question(s).
Fair Some background and literature review. Research question(s) outlined.
Poor Some background but no aim/ objectives/ questions, or aims/ objectives plus inadequate background.
Very No mention of aims/ objectives. No background or literature review. Poor
|Method and Data||Method appropriate and clearly explained?||Good Method appropriate and described clearly (eg. Questionnaires included). Clear details of data collection and recording.
Fair Method appropriate, description could be better. Data described.
Poor Questionable if method appropriate. Method described inadequately. Little description of data.
Very No mention of Method and/ or Method appropriate and/ or no details of. Poor data
|Sampling||Sampling strategy appropriate to address the aims?||Good Details (age/ gender/ race/ context) of who was studied and how were recruited. Why this group targeted. Sample size justified for the study. Response rates shown and explained.
Fair Sample size justified. Most information given, but some missing.
Poor Sampling mentioned but few descriptive details.
Very No details of sample.
|Data Analysis||Description of data analysis sufficiently rigorous?||Good Clear description of how analysis done. Qualitative studies; Description of how themes derived/ respondent validation or triangulation. Quantitative studies: Reasons for tests selected hypothesis driven/ numbers add up/ statistical significance discussed.
Fair Qualitative: Descriptive discussion of analysis. Quantitative: Some explanation regarding findings and manner significant results achieved.
Poor Minimal details about analysis.
Very No discussion of analysis.
|Ethics and Bias||Ethical issues been addressed and what was necessary ethical?||Good Where necessary issues of confidentiality, sensitivity, and consent were addressed. Bias: Researcher was reflexive and/ or aware of own bias.
Fair Limited concern for above (i.e., issues just acknowledged).
Poor Brief mention of issues.
Very No mention of issues.
|Results||Clear statement of the findings?||Good Findings explicit, easy to understand, logical progression. Tables explained in text. Results relate directly to aims. Sufficient data presented to support findings.
Fair Findings mentioned but more explanation could be given. Data presented relates directly to results.
Poor Findings presented haphazardly, not explained, and do not progress logically.
Very Findings not mentioned or do not relate to aims.
|Transferability or Generalizability||Findings transferable (generalizable) to a wider population?||Good Context and setting described sufficiently to allow comparison with other contexts and settings, plus high score in Sampling measure.
Fair Some context and setting described, but more needed to replicate or compare with other studies plus fair score or higher in Sampling measure.
Poor Minimal description of context/ setting.
Very No description of context/ setting.
|Implications and Usefulness||Importance of findings to policy and practice?||Good Contributes new and/ or difference in terms of understanding/ insight/ perspective. Suggests ideas for further research. Suggests implications for policy and/ or practice.
Fair Two of the above (states what is missing).
Poor Only one of the above.
Very None of the above.
This is the part of the assignment where the clinical importance and possible need for a change in practice can be explained (Davis 2016). The focus for the themes or key findings are an individual matter and rest with the writer (Aveyard 2014). Therefore, select the themes/ key findings deemed to be most important/ prominent. However, it must be demonstrated these are gained solely from the evidence provided within the research papers and not the personal opinions on a given issue or a description of the issues encounter in practice or issues read in a descriptive paper (Wakefield 2015). References can overlap between themes as frequently good research papers make a number of recommendations. In this way, a number of essential aspects of academic study are demonstrated i) the quality and quantity of the literature reviewed by the writer, and ii) the ability of the writer to formulate pertinent debate and discussion.
The literature uncovered and the main themes/ key findings constructed, must be considered in relation to practice (specific to the themes uncovered in the review). Frequently, contemporary research papers can help with this task as they provide sections on ‘Implications for Practice’. Issues of recommendation and implementation need to be succinct but importantly be linked to the research evidence uncovered in the review. A number of articles explaining aspects of dissemination can be referenced during this section (Oermann et al. 2010, Gelling 2014, Timmins 2015).
Publication in academic or professional journals provide the means of reporting to a wide audience, even an international audience (Alspach 2004, Bourne 2005, Happell 2012). Generally, professional journals accept personal accounts of care, management issues, descriptive aspects of intervention and current news/ debates (Gennaro 2012). The academic journals largely only accept research papers. However, professional journals do publish some research although in a more ‘easy read’ format. Presenting research at a conferences, workshops, Trust seminars journal clubs, research interest groups, can help to disseminate findings quicker than in publications (Alexandrov and Hennerici 2013). Wood and Morrison (2011) state several reasons why presenting at a conference is personally advantageous – developing a reputation and name associated with a specific area of research being uppermost. Most national and international conferences are organised 12 months or more in advance, allowing much time for abstracts and posters to be submitted and peer-reviewed (Paliadelis et al. 2011).
A poster presentation for the clinical environment can be of value in an easy-to-read format, informative and well-designed (Bingham and O’Neal 2013). Viewing posters around the Trust or the Higher Education Institute (HEI) helps to judge what appears effective (McCulloch 2010). Both Healthcare Trusts and Higher Education Institute (HEI) may offer poster production at a reasonable cost. Providing the author’s name, job description and contact details on posters is advantageous as interested people can make contact. Increasing in prominence is the use of toilet posters (Corkill 2012) although has anyone seen conference calls asking for toilet poster submissions? Toilet posters have been used in pubs and clubs effectively for decades therefore their appearance in healthcare premises may be on the horizon – who knows!
Journal Clubs have been used for many years but are now growing in popularity (Honey and Baker 2011). Such clubs have been defined as ‘arranged meetings where nurses convene to discuss the use of research knowledge in practice’. (Mattila et al. 2013) or just discuss a certain research paper. Hattoy et al. (2015) propose journal clubs to be more effective when discussing research relevant to the practice site or in the interests of the group. To help establish such groups, Steele-Moses (2009) recommends gaining help and support from the Trust librarian, senior nurses, medical staff, etc.. Journal clubs have been so successful that online clubs have been advocated (Chan et al. 2015). A significant difference in knowledge concerning evidence-based practice was gained by online group members during multi-disciplinary journal club sessions (Wilson et al. 2015). Although technically more difficult to establish, it is suggested online clubs using social media sites such as Twitter as a platform can reach a far wider audience. Moreover, a ‘host site’ can be utilised as a base for the club (eg International General Surgery Journal Club – @igsjc) and wider educational use of social media demonstrated (Lewis and Rush 2013). The American Operating Room Nurses’ Journal (AORN) already run an online discussion group for research, quality improvements and systematic review papers via their site (Baker 2013). Virtual Journal clubs can quickly educate nurses about best practice, current research and impending practice changes (Lehna et al. 2010).
9) Barriers to Implementation
Historically, nursing decisions concerning patient care have emerged from ritual, tradition, communication with fellow nurses, knowledge gained in Schools of Nursing, seeking medical advice and the preferences of senior medical staff (Thompson et al. 2001). However, for a number of years the increasing complexity of clinical nursing has required more informed decision making to ensure the employment of effective and safe practices (Curtis et al. 2017). Essentially, this means the need for staff to make greater use of research findings (Parsonage 2010, Mitchell and Phillips 2015). Campbell et al. (2010) advise implementing evidence-based practice requires the use of change-management strategies, local ownership of the changes, clinical practice guidelines and regular evaluation. However, numerous studies have repeatedly identified three main barriers to the implementation of research findings – education (Marsh et al. 2001, Hawranik and Thorpe 2008, Christie et al. 2012), culture (Cummings et al. 2007, Bohman et al. 2013) and clinical management (Hutchinson and Johnston 2006, Akerjordet et al. 2012, Veeramah 2016a; 2016b). These are general points and issues pertinent to individual key findings hindering application must be considered.
The concluding paragraph needs to be succinct. As a ‘rule of thumb’ in academic writing, this brief section should reiterate the main points from each of the sections. Again, as with many television news broadcasts, this helps to demonstrate awareness of essential issues in each section. It is often advantageous to reiterate theses main points using slightly differing terms/ language as it helps to clarify possible omissions and perhaps simplify the main points to aid a final comprehensive summary of the writer’s central arguments. Only include this section if the word count permits.
References and Further Reading
Akerjordet, K., Lode, K. and Severinsson, E. (2012) Clinical nurses’ attitudes towards research, management and organisational resources in a university hospital: Part 1. Journal of Nursing Management. Vol.20 No.6 p.814 – 823.
Alexandrov, A. V. and Hennerici, M. G. (2013) How to prepare and deliver a scientific presentation. Cerebro-vascular Diseases. Vol.35 No.3 p.202 – 208.
Alspach, G. (2004) The No1 secret to getting published. Critical Care Nurse. Vol.24 No.6 p.8 – 11.
Aveyard, H. (2014) (3rd Ed) Doing a Literature Review in Health and Social Care: A Practical Guide. Maidenhead: Open University Press.
Baker, J. D. (2013) Journal club as a resource for practice. American Operating Room Nurses Journal. Vol.98 No.2 p.102 – 106.
Bingham, R. and O’Neal, D. (2013) Developing great abstracts and posters. Nursing for Women’s Health. Vol.17 No.2 p.131 – 138.
Bogstrand, S. T., Normann, P. T., Rossow, I., Larsen, M., Mørland, J. and Ekeberg, O. (2011) Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department. Drug & Alcohol Dependence. Vol.117 No.2/3 p.132 – 138.
Bohman, D. M., Ericsson, T. and Borglin, G. (2013) Swedish nurses’ perception of nursing research and its implementation in clinical practice: A focus group study. Scandinavian Journal of Caring Sciences. Vol.27 No.3 p.525 – 533.
Bourne, P. E. (2005) Ten simple rules for getting published. PLoS Computational Biology. Vol.1 No.5 p.341 – 342.
Caldwell, K., Henshaw, L. and Taylor, G. (2005) Developing a framework for critiquing health research. Journal of Health, Social and Environmental Issues. Vol.6 No.1 p.45 – 54.
Campbell, S., Hancock, H. and Lloyd, H. (2010) Implementing Evidence-Based Practice. In: K Gerrish and A Lacey (Eds.) (6th Ed) The Research Process in Nursing. Blackwell: Oxford.
Chan, T. M., Thoma, B., Radecki, R., Topf, J., Woo, H. H., Kao, L. S., Cochran, A., Hiremath, S. and Lin, M. (2015) Ten steps for setting up an online journal club. Journal of Continuing Education in the Health Professions. Vol.35 No.2 p.148 – 154.
Christie, J., Hamill, C. and Power, J. (2012) How can we maximize nursing students’ learning about research evidence and utilization in undergraduate, preregistration programmes? A discussion paper. Journal of Advanced Nursing. Vol.68 No.12 p.2789 – 2801.
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Curtis, K., Fry, M., Shaban, R. Z. and Considine, J. (2017) Translating research findings to clinical nursing practice. Journal of Clinical Nursing. Vol.26 No.5-6 p.862 – 872.
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Fathi, A., Hajizadeh, M., Moradi, K., Zandian, H., Dezhkameh, M., Kazemzadeh, S. and Rezaei, S. (2017) Medication errors among nurses in teaching hospitals in the west of Iran: what we need to know about prevalence, types, and barriers to reporting. Epidemiology and Health. Vol.39 No.e2017022
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Hattoy, S. L., Childress, B.-C., Jett, A. and Montney, J. (2015) Enhancing experiential education: Implementing and improving the journal club experience. Currents in Pharmacy Teaching and Learning. Vol.7 No.3 p.389 – 394.
Hawker, S., Payne, S., Kerr, C., Hardey, M. and Powel, J. (2002) Pearls, pith, and provocation. Appraising the evidence: Reviewing disparate data systematically. Qualitative Health Research. Vol.12 No.9 p.1284 – 1299.
Hawranik, P. and Thorpe, K. M. (2008) Helping faculty enhance scholarship. The Journal of Continuing Education in Nursing. Vol.39 No.4 p.155 – 163.
Hoe, J. and Hoare, Z. (2012) Understanding quantitative research: Part 1. Nursing Standard. Vol.27 No.15/ 17 p.52 – 57.
Honey, C. P. and Baker, J. A. (2011) Exploring the impact of journal clubs: A systematic review. Nurse Education Today. Vol.31 No.8 p.825 – 831.
Huang, C.-Y., Hsu, M.-C. and Chen, T.-J. (2012) An exploratory study of religious involvement as a moderator between anxiety, depressive symptoms and quality of life outcomes of older adults. Journal of Clinical Nursing. Vol.21 No.5/ 6 p.609 – 618.
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Khodabux, R. (2016) Identifying and defining research questions. Nursing Times. Vol.112 No.3/4 p.16 – 19.
Lehna, C., Berger, J., Truman, A., Goldman, M. and Topp, R. (2010) Virtual journal club connects evidence to practice: An analysis of participant responses. Journal of Nursing Administration. Vol.40 No.12 p.522 – 528.
Lewis, B. and Rush, D. (2013) Experience of developing Twitter-based communities of practice in higher education. Research in Learning Technology. Vol.21 No.18598 http://www.researchinlearningtechnology.net/index.php/rlt/article/view/18598
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