An overview of the integrative research review by Russell, Cynthia L The integrative literature review has many benefits to the

scholarly reviewer, including evaluating the strength of the scientific evidence, identifying gaps in current research, identifying the need for future research, bridging between related areas of work, identifying central issues in an area, generating a research question, identifying a theoretical or conceptual framework, and exploring which research methods have been used successfully. The 5-stage integrative review process includes (1) problem formulation, (2) data collection or literature search, (3) evaluation of data, (4) data analysis, and (5) interpretation and presentation of results. Maintaining scientific integrity while conducting an integrative research review involves careful consideration to threats to validity. Strategies to overcome these threats are reviewed. The integrative review methodology must involve detailed and thoughtful work, the outcome of which can be a significant contribution to a particular body of knowledge and, consequently, to practice and research. As specialization increases and the volume of completed research expands, the scholarly individual is constantly challenged to possess an accurate and current understanding of information pertinent to his or her area of practice and/or research. Integrative reviews assist in maintaining a current knowledge base in a particular research area.1 An integrative review of the literature is defined as one in which "past research is summarized by drawing overall conclusions from many studies."2(p47) Through the process of systematically analyzing and summarizing the research literature, a well-prepared integrative review can precisely represent the state of the current research literature. The integrative literature review can also be used to evaluate the strength of the scientific evidence, identify gaps in current research, identify the need for future research, build a bridge between related areas of work, identify central issues in an area, generate a research question, identify a theoretical or conceptual framework, and explore which research methods have been used successfully.1 Several terms are closely associated with the integrative review including literature review, systematic review, and meta-analysis. A literature review is "a critical summary of research on a topic of interest, often prepared to put a research problem in context."3(p722) The literature review is frequently found at the beginning of scholarly research articles providing a foundation for the proposed research questions and methods.4 A systematic review is "carefully synthesized research evidence designed to answer focused clinical questions."5(p1) Stevens notes, "systematic reviews are also known as evidence summaries and integrative reviews."5(p1) Finally, a meta-analysis is "a technique for quantitatively combining and thus integrating the results of multiple studies on a given topic."3(p723) In addition, primary research should be differentiated from the integrative review process. Table 1 delineates the similarities and differences. Generally, there are 4 questions that the reviewer answers when a body of knowledge is evaluated using the integrative review technique. (1) What is known? (2) What is the quality of what is known? (3) What should be known? and (4) What is the next step for research or practice? The answers to these questions are discovered through the integrative review process. The reviewer evaluates the current

state of knowledge, judging its quality so that the future directions for research studies in the area are clearer. Definitions The process of conducting an integrative literature review should be approached with the same intensity and scientific rigor used when conducting primary research. Cooper1 conceptualizes the integrative review as occurring in 5 stages: (1) problem formulation, (2) data collection or literature search, (3) evaluation of data, (4) data analysis, and (5) interpretation and presentation of results. To focus the integrative review, the reviewer must begin by defining the purpose,7 the problem,1 and the research questions under study.2,7 The reviewer should ask, "What are the concepts I want to study?"1(p5) The answer to this question facilitates delineating the scope of the review, which also may depend on the history of the research in the area.2 If the research topic has a long history and much research has been conducted in the area, the reviewer must narrow the research question. On the other hand, if the topic is new and little research has been conducted, the research question may need to be broadened so that an adequate amount of information is located. For example, if the reviewer's initial research question is "What interventions are most effective in increasing treatment compliance in liver transplant recipients?" but no intervention studies have been conducted with this population, then the reviewer may need to broaden the research question to, "What interventions are the most effective in increasing treatment compliance in all transplant recipients?" Problem Formulation Cooper1 notes that the problem identification process should include development of conceptual and operational definitions of variables to be examined. The conceptual definition defines how the reviewer abstractly conceives the issue under study. For example, the reviewer interested in evaluating the literature regarding noncompliance must decide whether the concept of noncompliance will include all aspects of treatments (ie, diet, exercise, smoking cessation, appointment keeping, medications) or just one aspect of noncompliance (ie, medication taking). An example of a classic conceptual definition of medication noncompliance is the extent to which the patient's behavior coincides with clinical prescriptions.8 The operational definition defines how the reviewer will measure the concept. To facilitate the integrative review, definitions of conceptual variables must be clearly and concisely delineated by the reviewer. For example, if the reviewer decides to investigate only immunosuppressive medication noncompliance, an operational definition of this concept must be formulated (ie, medication noncompliance is defined as taking less than 80% of the prescribed doses of immunosuppressant measured by an electronic monitoring device). Unlike the primary research process, the reviewer may need to modify the conceptual and operational definitions if the targeted reports utilized broader or narrower definitions.9 For example, if the selected definition of medication noncompliance yields only a few articles, then the reviewer must broaden his or her operational definition. The revised definition would be taking less than 80% of the prescribed doses of immunosuppressive medications as measured by any method not just an electronic monitoring device.

The reviewer should also delineate the relationships between the variables under study. Using a theoretical framework to guide this early phase of the review process will enhance the ability of the reviewer to "fit" the results of the process into the body of developing nursing knowledge. For example, Bandura's Social Cognitive Theory10 may be used as the theoretical framework for a medication compliance study. In this case, self-efficacy and outcome expectancy beliefs are 2 key concepts from this theory that the reviewer may choose to examine in relationship to the health behavior of medication compliance. Threats to Validity Maintaining scientific integrity while conducting an integrative research review involves paying great attention to threats to validity. Several of these threats must be considered during this phase of the integrative review. Cooper1 notes that the reviewer must not define the operational definitions too narrowly because the quality of the findings can be impaired when other definitions are not considered. On the other hand, Cooper warns against defining the operational definitions too broadly because this can lead to overlooking important study details and incorrectly interpreting results. To overcome these 2 threats to validity, Cooper suggests that the reviewer use the broadest conceptual definition possible and pay impeccable attention to the differences in study methodologies. The reviewer must balance the conceptual definition and methods review constantly during this dynamic process. Data Collection or Literature Search The second stage in the integrative review process is the data collection or literature search phase.9 Cooper1 notes that reports of past pertinent research are the data for this review process. Identifying the target and accessible population are 2 key steps in this stage. The target population includes individual or groups the reviewer hopes to represent in the integrative review. Results could be generalized to this population. Examples of target population inclusion criteria are individuals within a particular age range, with a particular diagnosis, who have completed a particular treatment therapy. When conducting an integrative review, there are 2 important components of the target population: (1) all previous published reports on a topic and (2) the population of people within those reports that the reviewer is targeting. For example, the target population for an integrative review may be all studies of adult kidney transplant recipients examining immunosuppressive medication noncompliance. In an integrative review, the accessible population is all published reports related to a topic. The accessible population includes individuals or groups included in the primary research that the reviewer is able to obtain information about. Selected databases, years of publication, and subject headings are examples of accessible population inclusion criteria. During this stage, Ganong7 suggests establishing inclusion criteria for the studies. Given that writing an integrative review involves a circular approach, Ganong believes that inclusion criteria should be tentative. Substantive or methodologic changes should be made if suggested by the findings from the reviewed literature.

Data collection should involve several strategies. Cooper9 delineates informal, primary, and secondary channels. Informal channels include (1) personal research findings; (2) the invisible college, which includes reviewers conducting similar research sharing information with each other; (3) sharing between students and professors; and (4) attendance at professional meetings and conferences. Primary channels include review of journals, and the ancestry approach that involves finding research articles by examining the reference lists of other articles. secondary channels include research bibliographies and government documents (eg, Government Printing Office works), research registers (eg, Computer Retrieval of Information on Scientific Projects), and reference databases (eg, CINAHL, MEDLINE). All available methods should be used to obtain information for the review. Finally, a data collection tool should be developed. Characterizing the data to be collected is an important part of the integrative review.7 Common study characteristics include sample size, group assignment methods, measurement of variables, attrition, data analysis methods, conceptual framework used, and significance of findings. Table 2 contains an example of a completed data collection tool. Additional examples of data collection tools are available.1 Ganong7 suggests using tables to organize data in a clear and concise format. Using a concise format for data collection greatly enhances the reviewer's ability to ascertain consistent information from all information sources. Threats to Validity The first threat to validity in the data collection stage is inadequate sampling.9 The reviewer considers how the collected studies could be different from all studies. Realistically, it is difficult for the reviewer to obtain all possible studies for review. The reviewer must identify which studies were not able to be included, describe why they were not included, and then discuss how they might have shown different results from those selected. The second threat to validity is discrepancy between collected studies and the target population. To address the second threat to validity, the reviewer must determine how the elements contained in the collected studies might be different from the target population. Cooper1 notes that comprehensive integrative reviews contain articles conducted at different times; in different places; with different samples; of different ages, genders, and race, while using different methodologies. This approach increases generalizability because the target population is often better represented in the reviewed articles. Cooper1 suggests 4 strategies to enhance validity in this stage including: (1) conducting an exhaustive data collection strategy; (2) clearly delineating in the review information about data collection such as sources, years, and keywords; (3) presenting all selection biases; and (4) summarizing demographics of the subjects included in the samples.

Data Evaluation The third stage in the integrative review process is the data evaluation phase. During this phase, the reviewer critically judges whether the data element or result is worthy of remaining in the study data set.1 This can be decided a priori, in which case the decision to include or exclude certain articles is made before data collection, or a posteriori, in which case the decision is made to include all articles but less weight is then given to the poorer (ie, less scientifically rigorous) articles.1 The reviewer evaluates the data for unreliable values, which might include whether the findings from one study are too different from the other studies to be considered, and whether data recording errors exist. The reviewer also must evaluate the reliability of each study's findings, both in and of itself and in comparison with all of the other studies included in the review.1 Threats to Validity One threat to validity in the data evaluation phase is the tendency to positively evaluate research that is congruent with the reviewer's own beliefs and negatively evaluate those studies that are not. The reviewer must also evaluate each study's methodology to determine whether the findings are valid. Cooper1 offers several suggestions for enhancing objectivity in methodology evaluation. One approach is to score each study's methods using a list of threats to validity. Methodologic evaluation lists can also be used. Additional information about rating the quality of studies is available.12-15 Unfortunately, there is no universally accepted model for use. Data Analysis Analysis and interpretation are included in the fourth stage of the integrative review process. Cooper1(p104) defines this stage as "reducing the separate data points collected by the inquirer into a unified statement about the research problem." Depending on the goal of the integrative review, analysis may involve statistical tests. For example, if a review of the development of the concept medication noncompliance is the goal of an integrative review, then statistical tests would not be required. Historically, there has been sparse use of statistical techniques for analysis of integrative review data.1 Meta-analysis, defined as application of statistical procedures to a group of research report findings, is an appropriate statistical technique which could be used.1 Cooper1 notes that with recent increases in research results, quantitative reviewing techniques have been utilized more frequently. For example, if a review of the predictors of medication noncompliance is the goal of an integrative review, then a meta-analysis would be appropriate. Threats to Validity Threats to the analysis and interpretation stage are several. The first threat involves reviewers not following appropriate rules of inference.1 The assumptions for statistical tests may not always be clearly delineated. If additional secondary analyses are undertaken, the reviewer may have to assume that the primary researcher interpreted rules of inference correctly. The second threat is inferring causality that is inappropriate when examining research review data. Cooper1(p155) notes, "study-based evidence is capable of establishing causal precedence among variables while review-based evidence is always purely

associational." Cooper suggests the following methods for reviewers to preserve validity: (1) assumptions should be made clear by the reviewer when discussing results and inferences, (2) important interpretation rules should be identified, and (3) evidence that is single study-based should be clearly delineated from that which is review-based. Interpretation and Presentation The interpretation and presentation phase is the fifth and final stage of the integrative review as identified by Cooper.1 Dissemination of the findings from an integrative literature review is paramount to the development of our knowledge base. Cooper notes that there is no one accepted template for reporting integrative research reviews. Several journals do offer guidelines, but they are inconsistent. Cooper suggests a format for integrative review reporting that is similar to primary research, which includes introduction, methods, results, and discussion sections. Threats to Validity Several threats to validity exist when writing the integrative review. First, the reviewer might omit important details and information about how the integrative review was conducted.1 This omission could affect the availability of information about the relationships between variables under study. Second, the ability to reproduce review findings is impaired if details of the study methods and moderators of relationships are not stated. Suggestions to reduce these threats include giving much attention to all possible details of the report. In reporting integrative reviews the reviewer must be so explicit that another reviewer could follow the same strategy without difficulty. Summary In summary, the integrative literature review has many benefits to the scholarly reviewer including evaluating the strength of the scientific evidence, identifying gaps in current research, identifying the need for future research, bridging between related areas of work, identifying central issues in an area, generating a research question, identifying a theoretical or conceptual framework, and exploring which research methods have been used successfully.1 This review methodology must involve detailed and thoughtful work, the outcome of which can be a significant contribution to a particular body of knowledge and, consequently, to practice and research. References 1. Cooper HM. Synthesizing Research: A Guide for Literature Reviews. 3rd ed. Thousand Oaks, Calif: Sage Publications; 1998. 2. Broome ME. Integrative literature reviews for the development of concepts. In: Rogers B, Knafl K, eds. Concept Development in Nursing. Philadelphia, Pa: WB Saunders; 2000:231-250.

3. Polit DF. Beck CT. Nursing Research: Principles and Methods. 7th ed. Philadelphia. Pa: JB Lippincott Co; 2004. 4. Beyea SC, Nicoll LH. Writing an integrative review. AOKN. 1998;67:H77-880. 5. Stevens K. Systematic reviews: the heart of evidence-based practice. AACN Clin Issues. 2001:12:529538. 6. American Psychological Association. American Psychological Association Publication Manual. 5th ed. Washington, DC: The American Psychological Association; 2001. 7. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987; 10:1-11. 8. Sackett DL, Haynes RB. Compliance With Therapeutic Regimens. Baltimore. Md: Johns Hopkins University Press; 1976. 9. Cooper HM. Integrating Research: A Guide for Literature Reviews. 2nd ed. Newbury Park, Calif: Sage; 1989. 10. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs. NJ: Prentice-Hall; 1986. 11. Chisholm MA, Vollenweider LJ, Mulloy LL, et al. Renal transplant patient compliance with free immunosuppressive medications. Transplantation. 2000:70:1240-1244. 12. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. J Epidemiol Comm Health. 1998:52:377-384. 13. Evidence Report/Technology Assessment: No. 47. Systems for Rating the Quality of Individual Articles. AHCPR Web site. Available at: http://www.ahcpr.gov/clinic/epcsums/ strengthsum.htm#Rating. Accessed April 24, 2004. 14. Evidence ReportATechnology Assessment: No. 47. Systems for Rating the Quality of Individual Articles: Summary. AHCPR Web site. Available at: http://www.ahcpr.gov/clinic /epcsums/strength2.htm. Accessed April 24, 2004. 15. Estabrooks C. Goes V, Thiel E, Pinfold P. Sawka C, Williams I. Decision aids: are they worth it? A systematic review. J Health Serv Res Policy. 2001 ;6:170-182. Cynthia L. Russell, RN, PhD University of Missouri-Columbia, Columbia, Mo Copyright North American Transplant Coordinators Organization Mar 2005 Provided by ProQuest Information and Learning Company. All rights Reserved

Bibliography for: "An overview of the integrative research review" Russell, Cynthia L "An overview of the integrative research review". Progress in Transplantation. FindArticles.com. 01 Sep, 2011. http://findarticles.com/p/articles/mi_qa4117/is_200503/ai_n13476203/