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Original Articles

Reviews of Literature in Nursing Research

Methodological Considerations and Defining Characteristics

Silva, Amina Regina MN; Padilha, Maria Itayra PhD; Petry, Stefany MN; Silva E Silva, Vanessa PhD; Woo, Kevin PhD; Galica, Jacqueline PhD; Wilson, Rosemary PhD; Luctkar-Flude, Marian PhD

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doi: 10.1097/ANS.0000000000000418
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Abstract

CURRENTLY, there is an information overload in the scientific literature, with millions of articles being published every year in peer-reviewed journals.1 Although this abundance may signal advances in scientific inquiry, knowledge users in clinical practice and policy development are often overwhelmed by the volume of information available. Thus, different reviews are designed to follow structured and robust methodologies to select, collate, and synthesize existing findings to make evidence more meaningful and accessible.2,3

The primary aims of conducting a review are to identify knowledge gaps, delineate an issue, and clarify concepts that are relevant to a particular question.2 By bringing together a diversity of evidence for comparison, reviews are more reliable and powerful than single studies.2,4 The various reviews are designed to respond to different research questions, and they can be distinguished by the rigor of methodological considerations. In addition, the philosophical stance that researchers embrace while conducting a review will influence the way they assemble, analyze, and interpret the data extracted from a heterogeneous body of literature to produce knowledge from that.5 When there is an inappropriate fit between research question, review methodology, and/or philosophical stance, this can yield inconsistent results and conclusions; therefore, it is important that scholars are aware of the differences when deciding on the review methodology for their study.6

There are several typologies of review, but the most commonly used literature reviews in nursing research are narrative, integrative, and systematic reviews.7–9 In addition, another methodology that has been increasing in popularity and adding to the complexity of typologies of reviews is the scoping review. Currently, there is a lack of studies that assemble a comparative analysis of these 4 methodologies to provide a comprehensive guide for nursing and health care scholars to use when choosing among the different types of literature reviews.9,10 Therefore, the purpose of this article is to contribute to existing knowledge by describing the defining characteristics of narrative, integrative, scoping, and systematic reviews and provide a comparative analysis and decision tree for when each methodology could be appropriate. Finally, by detailing the main characteristics of these reviews, this article is to be used as a starting point for researchers when deciding which type of review could be appropriate for their topic.

Statements of Significance

What is known or assumed to be true about this topic?

Scientific data are published at a rapid rate; thus, literature reviews are increasing in popularity to collate and synthetize the literature and make it more accessible for health care professionals. In nursing research, the most commonly used review methodologies are narrative, integrative, scoping, and systematic reviews. Despite the availability of guidelines about these reviews, the identification of the best approach is not always clear for nurse researchers, which can lead to inconsistencies in the choice of methodology and results. Also, there is a lack of studies approaching and analyzing to these 4 review methodologies together to provide guidance to researchers.

What this article adds:

In this article, we described 4 popular types of literature review in nursing research (narrative, integrative, scoping, and systematic) and provided a discussion around their definition, indication, methodological characteristics, advantages and disadvantages. Although some review methodologies are more rigorous and transparent, each methodology is adequate for a certain type of investigation and research paradigm. Thus, we also provide examples, comparative analysis, and a decision map tree to offer a comprehensive guide to be used by nursing and health care scholars while choosing among the different types of literature reviews.

REVIEWS OF LITERATURE: DEFINING CHARACTERISTICS

In this article, different frameworks used in nursing and health care research are combined to examine, organize, synthesize, and present a discussion around the topic in a comprehensive way. Some examples of the frameworks used to guide our discussion are the Joanna Briggs Institute (JBI) standards for evidence synthesis,3 Whittemore and Knafl,11 Ganong,12 Mendes et al,13 Rozas and Klein,14 and Rother,15 among others.

Narrative reviews

Narrative reviews, also known as traditional reviews, can be defined as the generic approach used to collate, synthesize, and present an overview of a given subject.15 This approach is the oldest type of review, and it has been widely used to give a synopsis of the evidence related to a certain topic in academic papers, thesis, and other works.14 Narrative reviews are usually used as a source for research ideas and knowledge of practical and theoretical issues. This review can also be used to estimate the prospect of a study and provide specific information to identify research definitions, propositions, limitations, and hypotheses.9,10,16

Methodological and philosophical underpinnings

There are no preestablished standards related to conducting a narrative review, nor specific strategies to be used to formulate the research question (Table 1); the only requirement is having a topic of interest.9 The methodological freedom allows the researcher to conduct the review in accordance with their individual preferences related to the review purpose and inclusion of studies.14 However, narrative reviews do not usually present a methodology that allows the data to be reproduced or verified because of the lack of clarity related to the procedures in the search strategy and study selection.14,17 The philosophical underpinnings can vary widely, but as narrative reviews aim to provide a generic overview of the topic rather than summarize evidence to guide practice, the use of a subjectivist view of the phenomenon is more common.5 The subjectivist epistemology rejects the idea that a single, objective, and measurable truth exists to be discovered; instead, it defends the notion that there is an understanding about reality that is constructed on the basis of individuals' interactions with others and their surroundings.5 Thus, the results of a narrative review are usually based upon an interactive process among researchers, phenomenon, and context.

Table 1. - Types of Research Question According to the Typology of Review
Review Question Type Question Example
Narrative review No preestablished strategy to formulate the research question. It may or may not include a research question, if included, it is usually not well-defined and specific, therefore making it difficult to give reliable examples.
Integrative review PICo (Population, phenomena of Interest, Context)!a How has the use of alternative medicine to treat breast cancer survivors with chronic cancer pain been approached in the literature?
Scoping review PCC (Population, Concept, Context)b What screening assessment tools are available to evaluate chronic cancer pain among breast cancer survivors?
Systematic reviewc
Qualitative evidence
Effectiveness
Text and opinion
Prevalence and incidence
Economic evidence
Etiology and risk
Mixed methods
Diagnostic test accuracy
(1) PICo (Population, phenomena of Interest, Context)
(2) PICO (Population, Intervention, Comparator, Outcome)
(3) PICo (Population, phenomena of Interest, Context)
(4) CoCoPop (Condition, Context, Population)
(5) PICOC (Population, Intervention, Comparator, Outcome, Context)
(6) PEO (Population, Exposure, Outcome)
(7) PICo (Population, phenomena of Interest, Context)
(8) PIRD (Population, Index, test, Reference test, Diagnosis of interest)
(1) What is the experience of chronic cancer pain for breast cancer survivors?
(2) What is the effect of the use of morphine vs tramadol in the treatment of chronic cancer pain among breast cancer survivors?
(3) What are the policy strategies to improve quality of life among breast cancer survivors living chronic pain in Canada?
(4) What is the prevalence of depression in breast cancer survivors with chronic pain?
(5) What is the cost-effectiveness of early vs late treatment of chronic pain among breast cancer survivors in high-income countries?
(6) Are breast cancer survivors who did not smoke at risk of developing chronic pain?
(7) What are the barriers and facilitators to self-management about chronic pain among breast cancer survivors?
(8) What is the diagnostic accuracy of magnetic resonance imaging compared with computed tomography to determine nerve damage among breast cancer survivors experiencing chronic pain?
Abbreviation: JBI, Joanna Briggs Institute.
aNo preestablished strategy to formulate the research question, yet the use of the PICo format is commonly recommended.
bIt may vary depending on the specific topic of investigation (eg, PICo), yet the use of the PCC format is commonly recommended.
cThe numbers 1 to 8 indicate the different types of systematic reviews according to JBI, as well as the respective research question types and examples.

Advantages

Narrative reviews are commonly used as they provide breadth of literature coverage and flexibility to deal with evolving knowledge and are considered valuable depending on the purpose of the review and the resources available.14,17 In addition, the narrative review continues to occupy a prominent place in the synthesis of knowledge and has a fundamental role in advancing knowledge as it provides a reasonably complete overview on a topic, allowing the reader to acquire and update knowledge in a short period of time.14,15,18

Disadvantages

Traditional reviews are criticized as a less reliable approach because the methodology is subjective and carries a high risk of bias.2 The absence of explicit and systematic criteria for searching, extracting, analyzing, and reporting the literature can result in significant methodological issues.9,19 As the methods applied for searching process and study selection are not transparent and replicable, this can lead to bias in the researcher's interpretation and conclusions about the literature extracted, as they may not question the validity of the statements made.2,9,20 In addition, authors may selectively include literature that supports their own argument and exclude evidence that is contradictory to their hypothesis.10

Integrative reviews

Integrative reviews, also known as semi-systematic reviews, aim to collate the results of previous scientific studies with different methodological approaches and are widely used in evidence-based practice for nursing to determine the current knowledge on a specific theme.11 Yet, a key differentiating aspect of integrative reviews is that they aim to integrate the results to develop a new knowledge instead of summarizing and presenting previous findings.18 In addition, the integrative review is particularly useful when the review needs to be conducted using a systematic approach but within a shorter time frame (eg, when compared with systematic/scoping reviews) since its methodological approach involves fewer steps.11,14,18

Methodological and philosophical underpinnings

There are 3 main foci for integrative reviews: methodological (review and analysis of designs and methodologies), theoretical (review of theories on a particular topic), and empirical (review of empirical studies with analysis of results and relationships between variables).11 To formulate the research question for integrative reviews, the PICo (Population, phenomena of Interest, Context) strategy is usually recommended (Table 1). In addition, integrative reviews commonly use a subjectivist view of the phenomenon and an interactive process to provide an overview of a certain topic instead of offering an objective measurable result to guide practice. The process of developing an integrative review is well defined in the literature; however, different authors adopt different ways of subdividing that process, with minor modifications.11–13

Overall, 6 distinct stages are mentioned that must be followed sequentially to guarantee the quality of evidence: (1) elaboration of the guiding question (using a clear strategy, eg, PICo); (2) survey or sampling of the literature (including all of the studies found or just a selection, and clearly stating and justifying the criteria for inclusion); (3) data collection (using a preestablished data extraction instrument); (4) critical analysis of the included studies (using an organized and predefined approach, which may or may not include a quality assessment); (5) discussion of results (interpretation and synthesis of the results); and (6) presentation of the integrative review (it must be clear and complete, integrating results and without omitting any related evidence).11–13

Advantages

Integrative reviews allow the researcher to collate and synthesize scientific literature using different methodological approaches and involve preestablished steps in the process of article searching and selection. The advantage of following a predetermined and well-described process is to ensure transparency and replicability. The model of the integrative review is usually defined as a consistent method for evidence synthesis as it has detailed methods for data collection and extraction.11

Disadvantages

Although integrative reviews have clear methods for data collection and extraction, aspects related to analysis and synthesis can be considered a weakness of this methodology as they are not well established and usually do not include a quality appraisal.11 In addition, the complexity inherent in the combination of several methodologies can contribute to imprecision, prejudice, and a lack of rigor as the results extracted from scientific articles that use different methodologies can result in a large tangle of varied data.2,11,21

Scoping reviews

Scoping reviews can be considered a novelty when compared with other types of reviews.9 Alternative names for scoping reviews are “scoping studies” or “mapping reviews,” and this methodology allows the researcher to ask broader, yet precise, questions to map the literature around a certain topic.22 Scoping reviews are indicated to clarify key concepts or knowledge gaps in the literature, provide a map of a certain topic, guide future research, and identify implications for practice and policy.5,22 Scoping reviews are particularly useful for emerging fields, where the body of literature is relatively unknown or needs to be further and/or widely explored.9

Methodological and philosophical underpinnings

Scoping reviews originated in social sciences and can assemble evidence from different methodological approaches (eg, qualitative, quantitative, gray, and unpublished literature).5 This review usually uses a subjectivist epistemology and is constructed on the basis of the interaction among researchers, phenomenon, and context of study to produce a subjective knowledge of the topic instead of a single objectivist answer.5 Nonetheless, depending on the aim of the review and the results yielded, objective answers can be part of the results of a scoping review.22 To formulate the research question, the PCC (Population, Concept, Context) strategy is usually recommended, although the PICo strategy can also be used (Table 1).

In health care research, the JBI framework proposed by Peters et al23 identifies 9 steps to be followed in the conduct of scoping reviews: (1) define and align the objectives and research questions; (2) develop and align the inclusion criteria with the objectives and research questions; (3) describe the evidence behind the approach used for searching strategy, data selection and extraction, and demonstration of evidence; (4) search for evidence; (5) select evidence; (6) extract evidence; (7) analyze evidence; (8) present the results; and (9) summarize the evidence aligned with the purpose of the review, presenting conclusions, and reporting the implication of findings for future practice, policy, and research.23

In addition, another important methodological consideration in the conduct of scoping reviews is the development of a protocol prior to the execution of the review.23 An effective review protocol should give a clear introduction to the topic, key concepts, aims, research questions, inclusion criteria, types of sources, search strategy, information sources, study selection, data extraction, and data presentation, and it can/should be published (for instance, at JBI evidence synthesis or other peer-reviewed journals).22 The protocol guides the review process and is a key aspect in the differentiation of reviews with a systematic approach, such as scoping and systematic reviews, from other less rigorous methodologies, such as narrative and integrative reviews.24 To avoid the conduct of duplicate reviews, the title page and review should also be registered (eg, at JBI, Open Science Framework, or Figshare).

In addition, at least 2 reviewers are required to minimize bias in the data selection and extraction for scoping reviews.3,25 The final report of a scoping review should include any deviation from the protocol and, although scoping reviews are not aimed at reporting implications for practice, this can be included if there are substantial findings.22 Scoping reviews usually do not include a quality appraisal but if relevant to the topic of interest, this step can be justified and included. Finally, the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) should be used to help guide and report scoping review processes.26,27

Advantages

The scoping review is a rigorous and systematic methodology that promotes a broad perspective on a given topic and allows the researcher to include a wide range of literature (eg, opinion papers, articles from peer-reviewed journals, and gray literature).5,9,22 This methodology is iterative instead of linear, as scholars need to be engaged and reflect on each step of the process and, if necessary, repeat the steps to ensure that the literature is covered in a comprehensive way.16

Disadvantages

Scoping reviews can be time-consuming due to the wide range of literature and the broader approach involved. This methodology does not usually include a quality appraisal of the literature, which can result in potential bias in the final report and concluding statements.9,10 In addition, scoping reviews have an exploratory nature and are not aimed at producing a summary finding; consequently, they usually do not directly promote clinical practice changes or guidance, which can limit the applicability of their results.9,10

Systematic reviews

Systematic reviews aim to provide a comprehensive and unbiased review on a given topic using a systematic, rigorous, and transparent methodology to find “all” literature relevant to the purpose of the review by means of a precise research question and an international perspective.28 Systematic reviews involve a narrow and well-established topic of interest and are particularly effective in confirming or refuting the evidence behind a given practice, establishing the quality of practice or evidence, and addressing any level of uncertainty that may occur around a certain topic.3,4,9

Methodological and philosophical underpinnings

Systematic reviews usually use an objectivist view of the phenomena as they are constantly attempting to find an objective truth and use it to guide practice.5,29,30 The objectivist epistemology denies knowledge as a product that interacts or is influenced by social context; instead, it defends the idea that knowledge is an objective truth to be discovered.31 Therefore, findings of systematic reviews aim to synthesize many studies together in a linear, comprehensive, and unbiased way in order to produce a finding summary.5,28

According to JBI, there are 8 different types of systematic reviews: (1) qualitative evidence; (2) effectiveness; (3) text and opinion; (4) prevalence and incidence; (5) economic evidence; (6) etiology and risk; (7) mixed methods; and (8) diagnostic test accuracy.19,28 Each of these review types involves different strategies to formulate the research question (Table 1). Moreover, although there are different types of systematic reviews, the systematic review process generally includes 8 steps: (1) formulate a research question; (2) define inclusion criteria; (3) locate studies through an extensive search; (4) select studies for inclusion; (5) assess the quality of studies; (6) extract the data; (7) analyze and synthesize the data; and (8) present, interpret, and report the results using an evaluation of the certainty evidence (eg, GRADE).3,28

In addition, there are some terms used in the context of systematic reviews, such as “meta-analysis” and “meta-aggregation,” that can cause a certain level of confusion among scholars.28 Meta-analysis refers to the use of a rigorous, quantitative, statistical synthesis that may or may not be included in a systematic review, depending on the review purpose and whether the data allow this type of statistical approach.32 Meta-aggregation (or meta-synthesis) also may or may not be included in a systematic review and refers to the use of a rigorous analysis of qualitative studies to discover the essential elements and translate the primary results into a final product, resulting in (re)conceptualizations of the original conclusions.3,33

Another type of systematic review approach is the umbrella review. Also known as the review of reviews, this methodology uses a systematic analysis approach to provide a comprehensive appraisal of results from other reviews. An umbrella review is particularly indicated for areas of research where there is a large body of literature and high-quality reviews, as the researcher can compare and contrast results from different systematic studies and address quality or the persistence of any uncertainty or variation of practice.34,35

A recommended standard report that can be used to help guide systematic review processes is the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).27 In addition, the conduct of systematic reviews requires a protocol (similar to that required for scoping reviews) and at least 2 reviewers to screen and select the studies, extract and analyze the data, perform an appraisal, and summarize the results.9

Advantages

Systematic reviews strive to uncover all relevant literature on the topic to provide a trustworthy overview of the specific topic of interest and are therefore ranked as the highest level of evidence.3,4,9 This review involves a critical appraisal of the literature using predetermined tools (eg, CAPS, JBI, MMAT), which help endorse the quality of the evidence extracted. In addition, systematic reviews aim to provide a finding summary and orientation for practice, which can confirm or refute the evidence behind a given practice and give clear orientation for health care providers.3,4,9

Disadvantages

The narrow and objectivist approach of systematic reviews can result in limited overviews of the given topic and the loss of information about important outcomes.36 In addition, systematic reviews usually require a substantial period of time and high costs, and, if the methodology is not rigorously followed according to the preestablished criteria of the study and protocol, the data may be collated incorrectly.

REVIEWS OF THE LITERATURE: COMPARATIVE ANALYSIS

The different approaches to conduct reviews of the literature can cause confusion among researchers.9 But related to methodological aspects, there are some defining characteristics that can differentiate the types of reviews. To help clarify and address these main methodological differences, the Search, Appraisal, Synthesis, and Analysis (SALSA) framework has been used.10 The SALSA framework was created in a previous study10 to identify the characteristics of the main phases involved in each review type. These main phases are (1) the searching process, (2) quality appraisal of the evidence, (3) synthesis of the evidence, and (4) the analysis process. The use of the SALSA framework in this article will help scholars easily recognize the similarities of and differences among the steps of each review methodology; these can be found in Table 2.10 Furthermore, because of some similarities in methods, common confusion among health scholars is usually related to the differentiation between narrative and integrative reviews, integrative and scoping reviews, and scoping and systematic reviews; therefore, a comparative analysis that can help clarify these differentiations is presented in the following text.7–10

Table 2. - Defining Characteristics of Narrative, Integrative, Scoping, and Systematic Reviews
Type of Review Description Search Appraisal Synthesis Analysis
Narrative Generic approach used to collate and synthesize evidence from different types of sources, to present the “state-of-the-art” on a given subject of interest from a theoretical point of view with no rigorous, preestablished standards related to the review approach, only a topic of interest.10,14,15,17 Does not include a transparent and peer-reviewed search strategy, neither the use of a research protocol.10,14,15,17 Does not include quality appraisal of the literature.10,14,15,17 Does not include the use of a standardized data extraction form for evidence synthesis.10,14,15,17 Aims to provide an overview of the topic but not a summary finding.10,14,15,17
Integrative Approach used to collate and analyze studies with different methodologies, and it has meticulous methods for data collection and extraction, but aspects related to analysis and synthesis can be considered a weakness of this methodology.11,12 Does include a transparent search strategy, which may or may not be peer-reviewed, but does not include the use of a research protocol.11,12 May or may not include a quality appraisal of the literature.11,12 Should include the use of a standardized data extraction form for evidence synthesis.11,12 Aims to provide an overview of the topic, and it may or may not include a summary finding.11,12
Scoping Approach used to clarify key concepts or knowledge gaps in the literature, provide a map of a certain topic, or guide future research using allowing the researcher to include a wide range of literature and it follows a structured flow of steps for all stages of the review.3,9,25,37 Does include a transparent and peer-reviewed search strategy, and the use of a research protocol3,9,25,37 May or may not include a quality appraisal of the literature.3,9,25,37 Does include the use of a standardized data extraction form for evidence synthesis.3,9,25,37 Aims to provide an overview of the topic, and it may or may not include a summary finding.3,9,25,37
Systematic Approach aimed at providing a comprehensive and unbiased review on a given topic using a systematic, rigorous, and transparent methodology to find “all” literature relevant to the specific purpose of the review.3,9 Does include a transparent and peer-reviewed search strategy, and the use of a research protocol.3,9 Includes a mandatory quality appraisal of the literature.3,9 Does include the use of a standardized data extraction form for evidence synthesis.3,9 Aims to provide an overview of the topic, summary finding, and guidance for practice.3,9

Narrative versus integrative reviews

Narrative and integrative reviews usually use a subjectivist view of the phenomenon in order to provide an overview of the topic rather than summarize evidence to guide practice. However, the methodology of both types of reviews can be easily differentiated, as narrative reviews do not use an organized and transparent search method as do integrative reviews. In addition, narrative reviews collate studies within specific topics of interest to provide an overview while integrative reviews collate and analyze the results of studies on the same topic to trace an interpretation of its meaning and importance, providing an integrated new knowledge as a result.

Integrative versus scoping reviews

Both of these review types have similar research indications, which may include providing an overview of the literature and even signaling potential gaps. As well, they share similar research paradigms that include a subjectivist view of the phenomenon. Integrative and scoping reviews include a systematic and organized method of searching and extracting research results; yet, the scoping review has a more rigorous process of search strategy development and is guided by a preestablished protocol. Moreover, integrative reviews include only published scientific material while scoping reviews accept published literature and nonscientific and unpublished reports. Finally, scoping reviews group the data to present the results but do not integrate and synthesize the data to produce a new knowledge as do integrative reviews.

Scoping versus systematic reviews

Authors who conduct scoping reviews do not necessarily perform a critical appraisal of the included studies, nor do they provide a summary finding, whereas both are required for systematic reviews.3 In addition, scoping reviews ask broader questions and are more useful for topics where the literature needs to be uncovered to provide a map, clarify concepts or knowledge gaps, or even guide future researchers.3,9,22 In contrast, systematic reviews ask more precise and specific questions, looking to uncover “all” literature on a certain topic using an international perspective and providing a summary of findings focused on an objective truth.9,22,28 Therefore, one could say that scoping reviews provide a macroscopic lens through a subjectivist epistemology on a given topic while systematic reviews provide a microscopic lens with an objectivist epistemology of the topic.3,5

The decision tree

To help authors decide the most appropriate review type according to the purpose of the study, a fundamental decision tree has been developed. The decision tree is presented in the Figure and should be combined with other considerations (eg, paradigm of research, resources available, and desired outcomes) to facilitate the choice of the appropriate methodology of review.

F1
Figure.:
Decision tree to facilitate the choice of review methodology. This figure is available in color online (www.advancesinnursingscience.com).

CONCLUSION

Reviews of literature are essential to summarize evidence, provide a more comprehensive and synthesized literature for health care professionals, and facilitate the interpretation of research used in clinical practice. Even with the existence of guidelines for the different types of reviews, deciding the best approach is not straightforward. Although some methodologies are more rigorous and transparent, it would be inaccurate to say that one methodology is preferable over the others. Instead, each methodology of review is appropriate for a certain type of investigation and research paradigm. Therefore, in choosing the best option among narrative, integrative, scoping, and systematic reviews, researchers should consider the different types of review against the purpose of their study and the resources available.

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Keywords:

nursing; nursing methodology research; review literature; systematic review

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