Writing an integrative review

AORN Journal, April, 1998 by Suzanne Beyea, Leslie H. Nichll

Writing an integrative review can fulfill the fantasy of becoming a mystery writer. Identifying and obtaining key references, synthesizing information, and presenting it in written form makes us feel like "research detectives." The work can be a challenge and is sometimes frustrating, but the results of a well-done integrative review on a relevant clinical topic can have a direct impact on quality patient care. Nurses already are familiar with the process of reviewing literature when developing policies and procedures or clinical practice guidelines. An integrative review of research takes this process a step further. The extra work often results in a more substantial contribution to nursing literature and nursing knowledge.

Many people mistakenly use the terms literature review, integrative review, and meta-analysis synonymously. Although there are similarities among the three, they do not mean the same thing. A literature review is an introduction to new data or research findings.(1) In the case of a proposal, a literature review provides the basis for the proposed research questions and methods. Typically, a literature review will be restricted to studies that are directly relevant to the new data or proposed research.

An integrative review summarizes past research and draws overall conclusions from the body of literature on a particular topic. The body of literature comprises all studies that address related or identical hypotheses. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.(2)

A meta-analysis goes beyond critique and integration and conducts secondary statistical analyses on the outcomes of similar studies.(3) An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings. Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted. In that case, an integrative review is an appropriate strategy. In a properly executed integrative review, the effects of subjectivity are minimized through carefully applied criteria for evaluation.

CHOOSING A TOPIC

If you are about to embark on an integrative review, identifying a topic is the first step. Researching and writing an integrative review takes time and considerable effort, and choosing an interesting, well-defined, and appropriately narrow topic makes it easier to expend the energy to complete the review. Sometimes sheer persistence is required to see a project to its conclusion. A meaningful topic that stimulates your intellectual curiosity makes writing an integrative review more like fun than work.

We learned this lesson many times when we conducted an integrative review on the topic of intramuscular (IM) injections.(4) The initial stimulus for this project came from a simple question: "Is an air bubble necessary when giving an IM injection?" As we began our quest to answer the question, our project became much broader and, eventually, developed into a research-based protocol for administering IM injections. Fortunately, we both were interested in the topic and believed our work would address the many inconsistencies that we observed in clinical practice. After reviewing more than 70 research articles and 50 textbooks, we grew even more committed to the topic. Despite sometimes frustrating hours in the library, we became persistent sleuths. We were dedicated to uncovering the answers. Our interest in this subject continued to grow and now, several years later, we continue to lecture and write about this subject.

SEARCHING THE LITERATURE

When you have chosen your topic, it is time to begin the integrative review with a literature search. By using a variety of indexes to start your search, you will be able to identify appropriate references.(5) Expect to retrieve pertinent references from nursing, allied health, and medical literature. At this preliminary stage it is best not to limit your search to only research articles. Include clinical writings, reviews, and other documents, such as editorials and letters to the editor in your investigation.

Reviewing clinical articles can be helpful in identifying and organizing your topic around key issues that need to be addressed. When we reviewed the research on IM injections, we found that clinical articles helped us outline the essential components of the procedure. Our next effort focused on examining the research base for each step of the procedure. In a methodical fashion, we first determined whether there was applicable research that supported a particular practice recommendation. This organizational framework also helped us when we sat down to write our integrative review.

If you have conducted an extensive literature review, you may think you have too many articles. A key element to a properly completed integrative review, however, is an exhaustive search of the literature. It is better to narrow the topic rather than to eliminate articles. For example, after completing the integrative review on IM injections, we decided to tackle subcutaneous (SC) injections; however, as we reviewed the literature, we found the research to be quite divergent. We decided to break up SC injections into two topics: SC injection of heparin and SC injection of insulin.(6) This made the integrative review process more manageable and coherent.