For this assessment I have to undertake an integrative literature review, which also considers important issues of practice change. It’s a research project of 6,000 words on a topic of my choice. I have chosen to do my research on obesity. I have to identify a review question that is relevant to child nursing. I was thinking along the lines of ‘How effective is education in reducing obesity in adolescence?’, however, this question can be subject to change as I have yet to start my research. My review should include:

Abstract – (100-150 words) Title, aim, background, method, results and conclusion

Introduction, including a methods section – (750-1000 words) Rational for and importance of the study (supportive literature and personal context), overview of subject area and a summary of the main research in the area using key references

Method – (250-500 words) Clear search strategy and databases used, inclusion and exclusion criteria, how I identified my themes and document how literature was critiqued (using the relevant CASP tool)

Results – (2000 words) Incorporate the main themes/results identified from the literature, provide table in the appendix to demonstrate how I extracted information and critiqued literature and identify similarities and inconsistencies in the data

Recommendations for change – (150-200 words) Evaluate findings in the results section, identify focus of practice change and discuss rationale for chosen area of practice change

Considering change in clinical practice – (1500-2000 words) Use the PARIHS framework to: critically consider the influence of the evidence on practice change, critically consider the influence of the clinical context on practice change and critically consider the influence of facilitation on practice change

Recommendations and Conclusions – (250-500 words) Set my results in context by acknowledging limitations of my review, make realistic recommendations based on my findings and briefly reflect on my experiences as a developing researcher in conducting the review

Steps in the Review Process: overview

There are three types of information that will have to be search for, read, analysed and discussed.

1. Information that provides background reading and gives a rationale for the clinical importance of the study. The literature for this element of the study can be wide-ranging and not necessarily research-based.

2. Information that provides answers to your review question. The review will require you to identify 10-12 focused articles which are research (evidence) -based (primary or secondary evidence only) that provide answers to your review question. Your answers will be presented and formalised in themes.

3. Information that provides insight into issues of changing practice. The literature use for this element of the study can be wide-ranging and not necessarily research-based.

Expected to use primary and secondary sources only. This is important as a key module learning outcome is to assess ability to understand the value and relevance of primary and secondary evidence to clinical practice. Both Qualitative and Quantitative methods are primary research methods which collect original information. For the review you can also identify and include secondary sources of research-based evidence – if the secondary source provides answers for the review question. Therefore, could include other reviews (Systematic Reviews, Integrative Reviews, Narrative Reviews).

Introduction

The overall purpose of the introduction is to set the scene for the review, and establish the importance of the review question. In this section need to:

Explain why the question is important to you and your branch of nursing.

Establish background information: What is the importance of your review question? Why is this question important for clinical practice and to the profession? In what clinical context is the review question important?

Document how you arrived at your review question. This might be through reading different literature or talking to clinical and academic experts.

Who influenced the development of your research question?

Justify why a review of the literature is important rather than another research method.

At this stage the aim is to collate a wide-range of literature which establishes the review question. Some of this literature will be research-based (primary and secondary), some will be policy documents (national/local guidelines) or opinion based literature. Some of this background literature may also eventually form one or more of the research-based articles for the results of the review.

Write the Review Methods

All good literature reviews follow a method. For example, high quality Systematic Reviews follow established methodological guidelines, such as the Preferred Reporting of Systematic Reviews and Meta-Analysis (PRISMA) to enhance rigour in the reporting of this type of review (Moher et al, 2008).

Similarly, Integrative reviews have a recognised design which should be adhered to, to uphold rigour (Aveyard, 2010). In the review will be expected to uphold the reporting of the integrative review in four key areas:

1. Search Strategy: how and where you accessed and searched literature

2. Study selection: on what basis did you select studies?

3. Critical Appraisal: how you plan to appraise the literature

4. Synthesis of Findings: how you plan to make sense of the research-based literature as integrated results for your review question

 
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Reporting Your Search Strategy

The aim is to demonstrate how you undertook a systematic approach to your searching; included in the report you should consider:

Which electronic databases did you search? Are these appropriate?

Are you going to include only published literature, or unpublished (grey) literature?

Are you going to hand-search for literature?

How did you apply search terms (from review question) into each database?

Provide an example of your electronic search strategy from one database

State the Inclusion and exclusion criteria for either including or excluding studies

Identify strengths and weaknesses in your search strategy

Reporting how you intend to select literature (for the Results Section)

Use a variety of literature in different sections of the review. For example, when writing the introduction can use a range of research-based and non-research based literature, in which will rationalise the importance of the review question.Similarly, will use a variety of literature in the discussion and recommendations section to establish the importance of review findings.

However, the literature selected for the results section must be research-based, which can include either primary and secondary evidence, or a mixture of both. Must select evidence which clearly addresses the research question, thus the aim is to describe and defend why selected certain studies and not others. Studies therefore must be relevant and address the review question. The report must:

-Describe inclusion criteria

-Describe exclusion criteria

-Indicate the quality of studies you intend to include

-Indicate the quality of studies you will not include (opinion, low level of evidence)

-Identify the 10-12 studies selected to provide answers to your research question

Reporting how you intend to Critically Appraise the Literature (for the analysis of evidence in the results section)

A key part of the Integrative Review Process is assessing the quality of studies.

Remember you are writing a „critical review‟ which involves a critical evaluation of the arguments presented in the body of evidence. Will need to explain how you intend to identify the individual strengths and weaknesses of each study to be appraised in the results section.

Use CASP Tools to:

Identify the appropriate CASP Tools for each piece of evidence

Identify which areas of the CASP Tools you intend to apply to your research-based articles

Remember to highlight both strengths and weaknesses of each research-based article

Summarise the results of your critical appraisal in the data extraction table

Reporting the Synthesis of findings

Another key stage of the integrative review process is finding original answers to the review question. There are many types of synthesis processes used for a variety of research studies, which include meta-analysis, meta-ethnography and meta-study. These synthesis are quite complex and drawn out. Therefore, we will be using a more straight-forward approach to synthesis of the literature. The end process of synthesis is the identification of themes. Should complete this process at the end of the next step.In the methods section of the review, just need to provide a brief explanation as to the synthesis process used.

Data Extraction Table

In the review, the details of each research-based article (each one of the 10-12 research-based studies) will be presented in a Data Extraction Table.

The purpose of presenting the detail of each research-based article in a table is to help familiarise yourself with each article, and to identify how you interpreted key findings from each article.

Identifying themes from the table

The starting point for generating themes is to enter the details of each of your 10-12 research-articles into a table. Once you have identified and entered the details of each article into the data extraction table, you can then focus on developing your themes.

The themes will represent the different viewpoints and different perspectives of the review question. These collated perspectives provide the themed results of the review. Thus each of the 10-12 articles should in some way inform or provide answers to the review question. The main outcomes (or message) in each article is found in the results or conclusions section; the main outcomes may also be reported in the abstract.

The activity of constructing themes should be viewed as a process:

Step 1: Identify and record the main finding/result from each individual study

Step 2: Assign a name /code to the result (this will be your interpretation)

Step 3: Group together similar names/codes

Step 4: Provide a label/name for each group, this will be the theme.

The name of the theme (for each group) should help provide different perspectives in addressing the review question. This process is very similar to reviewing findings in primary research – in classical qualitative research this is known as a „comparative analysis‟ of the findings (Guba and Lincoln, 1985). Should aim to develop 2-4 themes from the 10-12 articles.

 
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Summary of Theme Generation Process

1. Enter information of each study into the table: Title, Aim, Type of Source, Sample and Data Collection Method, Strengths and Weaknesses, Main Findings, Code and theme.

2. Look at the main findings in each study, and apply a code. Count how many times you have assigned the same code (or collection of words) to different studies. This will give you an indication of the themes emerging from the information (Aveyard, 2007).

3. Group the studies with similar codes (findings) together to make one theme (you may find there are slight differences of opinion within each theme) this is normal and will help support your analysis and debate when writing up your results.

4. Repeat this process to identify a minimum of 2 and maximum 4 themes.

Identification and development of themes is an essential stage to the integrative literature review process and importantly it is this process that makes the literature review unique. Essentially interpreting what the IMPORTANT ISSUES ARE FOR THE REVIEW QUESTION.Thus, developing new knowledge and insight into the review question.

Some important points to note from the activities in this section:

Presenting results in a table will help identify and then develop themes.

Some themes will have more studies than others; this depends on the findings. In theme one may have 6 studies, theme two 3 studies and theme three 3 studies. If from the 10-12 studies you have three distinctly different findings then these will be the 3 themes.

Must critically appraise the evidence in each individual study and identify strengths and weaknesses.

Write results section

Must write in a critical style; thus must be able to identify strengths and weaknesses of the 10-12 research-based articles and discuss implications for this. Must not simply describe the methods and results of included research-based studies.

In writing the results section should move beyond a straightforward description of the papers towards an integration and interpretation of what the papers mean as a whole, taking into account any similarities and inconsistencies (Aveyard 2010).

Critical Integration and discussion of Results of studies in one theme

1. What does it say about the theme? (main finding)?

2. What are the main points of view? Article 1

3. What is the quality of the research-evidence?

4. How are the results presented – what do the results mean?

1. What does it say about the theme (main finding)?

2. What are the main points of view?

3. What is the quality of the research-evidence?

4. What is the comparative viewpoint to the previous Article 2article? What is the relationship?

5. How are the results presented – what do the results mean?

In summary, the purpose of the results section is to establish the following in each theme:

1. What does each article say about the theme?

2. What are the differences in points of view between each article?

3. What is the quality of each article?

4. How are statistical/clinical results presented – what do these mean?

5. What is the overall quality of research?

Other key points to consider in writing up results:

Discuss the best available evidence in each theme first

Analyse each study for quality (areas of bias you feel confident in reporting i.e. recruitment, sampling, data collection)

Compare the quality of evidence in each study (in each theme) and how well each study addresses each theme.

Must critically appraise the collective evidence in each theme (CASP Tools)

Must try and make sense (compare and contrast) how well the studies in each theme address the theme

Must summarise the collective evidence in each theme in a final paragraph at the end of each theme.

Make recommendations for practice change based upon empirical evaluation of the evidence

The purpose of this section is to bring together the findings of all themes in the context of the importance of the study (established in the introduction). will be expected to provide recommendations for an area of practice change.

Need to:

1. Consider which theme is most informative and why?

2. Consider which themes are least informative and why?

3. On what basis are themes most informative or least informative? What is the quality of the research in each theme?

4. As an overview, consider the weight and quality of literature across all themes, how does the literature inform the research question? What are the implications for practice based on this analysis?

5. Must identify a key problem or outcome you want to explore as a focus of change.

Exploring potential influences on practice change

Enquiry into nursing practice should bring together findings from research and clinical practice, hence the activity of „Academic and Practice Enquiry‟.

In this section of the review goal is to identify a problem, intervention or outcome (identified in themes generated in your review) and evaluate the readiness for change in a specific clinical area. To help guide this evaluation should use a contemporary change management framework called the PARiHS (Promoting Action on Research Implementation in Health Services) framework.

The basic premise is that each of these elements positions on a continuum from weak to strong with regard to the support for an implementation project. Successful implementation is most likely to occur when (Kitson et al, 1998):

1. Scientific evidence is viewed as sound and fitting with professional and patient beliefs.

2. The healthcare context is receptive to implementation in terms of supportive leadership, culture, and evaluative systems.

3. There are appropriate mechanisms in place to facilitate implementation.

 
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Evaluating the location of ‘Evidence’ as a readiness for change

In line with the PARiHS Implementation framework, to identify the position and influence of the „evidence‟  need to focus on at least one of the following areas (one must include patient preferences and experiences):

Research Evidence

Clinical Experience

Patient Preferences and experiences

Local Information

Research Evidence

In the review should have by this stage established the quality of the research evidence (empirical evidence) in relation to the outcome interested in implementing. Can refer to these empirical findings to re-iterate the strength of the research-based evidence, as either strong or weak, and to compare the influence of evidence to other areas in this section in the summary.

Clinical Experience

In the evaluation of clinical experience need to construct a discussion which:

1. Outlines the principal importance of clinical judgement and opinion in changing practice

2. Identifies the position of clinical experience as either weak (expert opinion divided) or strong (consensus of opinion)

3. Discuss the impact of clinical experience as a source of evidence for changing practice

Patient Preferences and experiences

In the evaluation of patient preferences and experiences need to construct a discussion which:

1. Outlines the principal importance of patient preferences and experiences in changing practice

2. Identifies the position of patient preferences and experiences as either weak (patients not involved) or strong (partnerships with patients)

3. Discusses the impact of preferences and experiences as a source of evidence for changing practice

Local Information

In the evaluation of local information need to construct a discussion which:

1. Outlines the principal importance of local information (audits, local research, pilot projects) in changing practice

2 Identifies the status of local information as either weak (no local experience, or experiences are not consistent with the practice to be implemented) or strong (local information matches the practice to be implemented)

3. Discusses the impact of local information as a source of evidence for changing practice

Evaluating the location of clinical context as a position for Implementation

In line with the PARiHS Implementation framework, to identify the position and influence of the „evidence‟ you need to focus on one of the following areas:

Culture

Leadership

Evaluation

Culture

In the evaluation of culture need to construct a discussion which:

1. Outlines the principal importance of culture (attitudes and beliefs about health care, organisational morale) in changing practice

2. Identifies the position of culture as either weak (weak support for implementation, task driven settings with low morale) or strong (strong support for implementation in learning, innovation, and where patient-centred approaches are valued)

3. Discusses the impact of culture as a source of evidence for changing practice

Leadership

In the evaluation of leadership need to construct a discussion which:

1. Outlines the principal importance of leadership (organisational support for implementation) in changing practice

2. identifies the position of leadership as either weak (weak support for implementation, unclear roles) or strong (strong support for implementation, effective organisational structure and clear roles)

3. Discusses the impact of leadership as a source of evidence for changing practice

Evaluation

In considering evaluation you need to construct a discussion which:

1. Outlines the principal importance of evaluation (Audit and Feedback) in changing practice

2 Identifies the position of evaluation as either weak (absence of audit and feedback) or strong (strong support for implementation, with routine evaluation and feedback)

3. Discusses the impact of evaluation as a source of evidence for changing practice

Evaluating the location of Facilitation as a position for Implementation

In line with the PARiHS Implementation framework, to identify the position and influence of „facilitation‟ you need to focus on one of the following areas:

Characteristics of the facilitator

Role

Style

Characteristics of the facilitator

In the evaluation of the role of the „facilitator‟ need to construct a discussion which:

1. Outlines the principal importance of facilitation (being respectful, credible, motivational) in changing practice

2. Identifies the position of facilitation as either weak (low respect, credibility and empathy