An Overview of the Integrative Research Review

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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


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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 theliterature 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 mayneed 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.


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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 aparticular 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 establishinginclusion 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.


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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 greatlyenhances 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. Toaddress 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 ofthe subjects included in the samples.


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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 butless 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


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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 omitimportant 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.


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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. 2001:12:529-

538.

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


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Bibliography for: "An overview of the integrative research review"

Russell, Cynthia L "An overview of the integrative research review". Progress in Transplantation.

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An Overview of the Integrative Research Review

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