what is a literature review nursing

Nursing: Literature Review

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Good Place to Start: Citation Databases

Interdisciplinary Citation Databases:

A good place to start your research  is to search a research citation database to view the scope of literature available on your topic.

TIP #1: SEED ARTICLE Begin your research with a "seed article" - an article that strongly supports your research topic.  Then use a citation database to follow the studies published by finding articles which have cited that article, either because they support it or because they disagree with it.

TIP #2: SNOWBALLING Snowballing is the process where researchers will begin with a select number of articles they have identified relevant/strongly supports their topic and then search each articles' references reviewing the studies cited to determine if they are relevant to your research.

BONUS POINTS: This process also helps identify key highly cited authors within a topic to help establish the "experts" in the field.

Begin by constructing a focused research question to help you then convert it into an effective search strategy.

• Identify keywords or synonyms
• Type of study/resources
• Which database(s) to search
• Asking a Good Question (PICO)
• PICO - AHRQ
• PICO - Worksheet
• What Is a PICOT Question?

Seminal Works: Search Key Indexing/Citation Databases

• Google Scholar
• Web of Science

TIP – How to Locate Seminal Works

• DO NOT: Limit by date range or you might overlook the seminal works
• DO: Look at highly cited references (Seminal articles are frequently referred to “cited” in the research)
• DO: Search citation databases like Scopus, Web of Science and Google Scholar

Web Resources

What is a literature review?

A literature review is a comprehensive and up-to-date overview of published information on a subject area. Conducting a literature review demands a careful examination of a body of literature that has been published that helps answer your research question (See PICO). Literature reviewed includes scholarly journals, scholarly books, authoritative databases, primary sources and grey literature.

A literature review attempts to answer the following:

• What is known about the subject?
• What is the chronology of knowledge about my subject?
• Are there any gaps in the literature?
• Is there a consensus/debate on issues?
• Create a clear research question/statement
• Define the scope of the review include limitations (i.e. gender, age, location, nationality...)
• Search existing literature including classic works on your topic and grey literature
• Evaluate results and the evidence (Avoid discounting information that contradicts your research)
• Track and organize references
• How to conduct an effective literature search.
• Social Work Literature Review Guidelines (OWL Purdue Online Writing Lab)

What is PICO?

The PICO model can help you formulate a good clinical question. Sometimes it's referred to as PICO-T, containing an optional 5th factor. 

Search Example

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Nursing: How to Write a Literature Review

• Traditional or Narrative Literature Review

Getting started

1. start with your research question, 2. search the literature, 3. read & evaluate, 4. finalize results, 5. write & revise, brainfuse online tutoring and writing review.

• RESEARCH HELP

The best way to approach your literature review is to break it down into steps.  Remember, research is an iterative process, not a linear one.  You will revisit steps and revise along the way.  Get started with the handout, information, and tips from various university Writing Centers below that provides an excellent overview.  Then move on to the specific steps recommended on this page.

• UNC- Chapel Hill Writing Center Literature Review Handout, from the University of North Carolina at Chapel Hill.
• University of Wisconsin-Madison Writing Center Learn how to write a review of literature, from the University of Wisconsin-Madison.
• University of Toronto-- Writing Advice The Literature Review: A few tips on conducting it, from the University of Toronto.
• Begin with a topic.
• Understand the topic. 
• Familiarize yourself with the terminology.  Note what words are being used and keep track of these for use as database search keywords. 
• See what research has been done on this topic before you commit to the topic.  Review articles can be helpful to understand what research has been done .
• Develop your research question.  (see handout below)
• How comprehensive should it be? 
• Is it for a course assignment or a dissertation? 
• How many years should it cover?
• Developing a good nursing research question Handout. Reviews PICO method and provides search tips.

Your next step is to construct a search strategy and then locate & retrieve articles.

•  There are often 2-4 key concepts in a research question.
• Search for primary sources (original research articles.)
• These are based on the key concepts in your research question.
• Remember to consider synonyms and related terms.
• Which databases to search?
• What limiters should be applied (peer-reviewed, publication date, geographic location, etc.)?

Review articles (secondary sources)

Use to identify literature on your topic, the way you would use a bibliography.  Then locate and retrieve the original studies discussed in the review article. Review articles are considered secondary sources.

• Once you have some relevant articles, review reference lists to see if there are any useful articles.
• Which articles were written later and have cited some of your useful articles?  Are these, in turn, articles that will be useful to you? 
• Keep track of what terms you used and what databases you searched. 
• Use database tools such as save search history in EBSCO to help.
• Keep track of the citations for the articles you will be using in your literature review. 
• Use RefWorks or another method of tracking this information. 
• Database Search Strategy Worksheet Handout. How to construct a search.
• TUTORIAL: How to do a search based on your research question This is a self-paced, interactive tutorial that reviews how to construct and perform a database search in CINAHL.

The next step is to read, review, and understand the articles.

• Start by reviewing abstracts. 
• Make sure you are selecting primary sources (original research articles).
• Note any keywords authors report using when searching for prior studies.
• You will need to evaluate and critique them and write a synthesis related to your research question.
• Consider using a matrix to organize and compare and contrast the articles . 
• Which authors are conducting research in this area?  Search by author.  
• Are there certain authors’ whose work is cited in many of your articles?  Did they write an early, seminal article that is often cited?
• Searching is a cyclical process where you will run searches, review results, modify searches, run again, review again, etc. 
• Critique articles.  Keep or exclude based on whether they are relevant to your research question.
• When you have done a thorough search using several databases plus Google Scholar, using appropriate keywords or subject terms, plus author’s names, and you begin to find the same articles over and over.
• Remember to consider the scope of your project and the length of your paper.  A dissertation will have a more exhaustive literature review than an 8 page paper, for example.
• What are common findings among each group or where do they disagree? 
• Identify common themes. Identify controversial or problematic areas in the research. 
• Use your matrix to organize this.
• Once you have read and re-read your articles and organized your findings, you are ready to begin the process of writing the literature review.

2. Synthesize.  (see handout below)

• Include a synthesis of the articles you have chosen for your literature review.
• A literature review is NOT a list or a summary of what has been written on a particular topic. 
• It analyzes the articles in terms of how they relate to your research question. 
• While reading, look for similarities and differences (compare and contrast) among the articles.  You will create your synthesis from this.
• Synthesis Examples Handout. Sample excerpts that illustrate synthesis.

Regis Online students have access to Brainfuse. Brainfuse is an online tutoring service available through a link in Moodle. Meet with a tutor in a live session or submit your paper for review.

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What is a Literature Review?

Key questions for a literature review, examples of literature reviews, useful links, evidence matrix for literature reviews.

• Annotated Bibliographies

The Scholarly Conversation

A literature review provides an overview of previous research on a topic that critically evaluates, classifies, and compares what has already been published on a particular topic. It allows the author to synthesize and place into context the research and scholarly literature relevant to the topic. It helps map the different approaches to a given question and reveals patterns. It forms the foundation for the author’s subsequent research and justifies the significance of the new investigation.

A literature review can be a short introductory section of a research article or a report or policy paper that focuses on recent research. Or, in the case of dissertations, theses, and review articles, it can be an extensive review of all relevant research.

• The format is usually a bibliographic essay; sources are briefly cited within the body of the essay, with full bibliographic citations at the end.
• The introduction should define the topic and set the context for the literature review. It will include the author's perspective or point of view on the topic, how they have defined the scope of the topic (including what's not included), and how the review will be organized. It can point out overall trends, conflicts in methodology or conclusions, and gaps in the research.
• In the body of the review, the author should organize the research into major topics and subtopics. These groupings may be by subject, (e.g., globalization of clothing manufacturing), type of research (e.g., case studies), methodology (e.g., qualitative), genre, chronology, or other common characteristics. Within these groups, the author can then discuss the merits of each article and analyze and compare the importance of each article to similar ones.
• The conclusion will summarize the main findings, make clear how this review of the literature supports (or not) the research to follow, and may point the direction for further research.
• The list of references will include full citations for all of the items mentioned in the literature review.

A literature review should try to answer questions such as

• Who are the key researchers on this topic?
• What has been the focus of the research efforts so far and what is the current status?
• How have certain studies built on prior studies? Where are the connections? Are there new interpretations of the research?
• Have there been any controversies or debate about the research? Is there consensus? Are there any contradictions?
• Which areas have been identified as needing further research? Have any pathways been suggested?
• How will your topic uniquely contribute to this body of knowledge?
• Which methodologies have researchers used and which appear to be the most productive?
• What sources of information or data were identified that might be useful to you?
• How does your particular topic fit into the larger context of what has already been done?
• How has the research that has already been done help frame your current investigation ?

Example of a literature review at the beginning of an article: Forbes, C. C., Blanchard, C. M., Mummery, W. K., & Courneya, K. S. (2015, March). Prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors . Oncology Nursing Forum, 42(2), 118+. Retrieved from http://go.galegroup.com.sonoma.idm.oclc.org/ps/i.do?p=HRCA&sw=w&u=sonomacsu&v=2.1&it=r&id=GALE%7CA422059606&asid=27e45873fddc413ac1bebbc129f7649c Example of a comprehensive review of the literature: Wilson, J. L. (2016). An exploration of bullying behaviours in nursing: a review of the literature.   British Journal Of Nursing ,  25 (6), 303-306. For additional examples, see:

Galvan, J., Galvan, M., & ProQuest. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (Seventh ed.). [Electronic book]

Pan, M., & Lopez, M. (2008). Preparing literature reviews: Qualitative and quantitative approaches (3rd ed.). Glendale, CA: Pyrczak Pub. [ Q180.55.E9 P36 2008]

• Write a Literature Review (UCSC)
• Literature Reviews (Purdue)
• Literature Reviews: overview (UNC)
• Review of Literature (UW-Madison)

The  Evidence Matrix  can help you  organize your research  before writing your lit review.  Use it to  identify patterns  and commonalities in the articles you have found--similar methodologies ?  common  theoretical frameworks ? It helps you make sure that all your major concepts covered. It also helps you see how your research fits into the context  of the overall topic.

• Evidence Matrix Special thanks to Dr. Cindy Stearns, SSU Sociology Dept, for permission to use this Matrix as an example.
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What is a Literature Review?

A literature review is an essay that surveys, summarizes, links together, and assesses research in a given field. It surveys the literature by reviewing a large body of work on a subject; it summarizes by noting the main conclusions and findings of the research; it links together works in the literature by showing how the information fits into the overall academic discussion and how the information relates to one another; it assesses the literature by noting areas of weakness, expansion, and contention. This is the essentials of literature review construction by discussing the major sectional elements, their purpose, how they are constructed, and how they all fit together.

All literature reviews have major sections:

• Introduction: that indicates the general state of the literature on a given topic;
• Methodology: an overview of how, where, and what subject terms used to conducted your search so it may be reproducable
• Findings: a summary of the major findings in that field;
• Discussion: a general progression from wider studies to smaller, more specifically-focused studies;
• Conclusion: for each major section that again notes the overall state of the research, albeit with a focus on the major synthesized conclusions, problems in the research, and even possible avenues of further research.

In Literature Reviews, it is Not Appropriate to:

• State your own opinions on the subject (unless you have evidence to support such claims).  
• State what you think nurses should do (unless you have evidence to support such claims).
• Provide long descriptive accounts of your subject with no reference to research studies.
• Provide numerous definitions, signs/symptoms, treatment and complications of a particular illness without focusing on research studies to provide evidence and the primary purpose of the literature review.
• Discuss research studies in isolation from each other.

Remember, a literature review is not a book report. A literature review is focus, succinct, organized, and is free of personal beliefs or unsubstantiated tidbits.

• Types of Literature Reviews A detailed explanation of the different types of reviews and required citation retrieval numbers

Outline of a Literture Review

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Literature Review Overview

What is a Literature Review? Why Are They Important?

A literature review is important because it presents the "state of the science" or accumulated knowledge on a specific topic. It summarizes, analyzes, and compares the available research, reporting study strengths and weaknesses, results, gaps in the research, conclusions, and authors’ interpretations.

Tips and techniques for conducting a literature review are described more fully in the subsequent boxes:

• Literature review steps
• Strategies for organizing the information for your review
• Literature reviews sections
• In-depth resources to assist in writing a literature review
• Templates to start your review
• Literature review examples

Literature Review Steps

Graphic used with permission: Torres, E. Librarian, Hawai'i Pacific University

1. Choose a topic and define your research question

• Try to choose a topic of interest. You will be working with this subject for several weeks to months.
• Ideas for topics can be found by scanning medical news sources (e.g MedPage Today), journals / magazines, work experiences, interesting patient cases, or family or personal health issues.
• Do a bit of background reading on topic ideas to familiarize yourself with terminology and issues. Note the words and terms that are used.
• Develop a focused research question using PICO(T) or other framework (FINER, SPICE, etc - there are many options) to help guide you.
• Run a few sample database searches to make sure your research question is not too broad or too narrow.
• If possible, discuss your topic with your professor. 

2. Determine the scope of your review

The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature Review.

• How many studies will you need to include?
• How many years should it cover? (usually 5-7 depending on the professor)
• For the nurses, are you required to limit to nursing literature?

3. Develop a search plan

• Determine which databases to search. This will depend on your topic. If you are not sure, check your program specific library website (Physician Asst / Nursing / Health Services Admin) for recommendations.
• Create an initial search string using the main concepts from your research (PICO, etc) question. Include synonyms and related words connected by Boolean operators
• Contact your librarian for assistance, if needed.

4. Conduct searches and find relevant literature

• Keep notes as you search - tracking keywords and search strings used in each database in order to avoid wasting time duplicating a search that has already been tried
• Read abstracts and write down new terms to search as you find them
• Check MeSH or other subject headings listed in relevant articles for additional search terms
• Scan author provided keywords if available
• Check the references of relevant articles looking for other useful articles (ancestry searching)
• Check articles that have cited your relevant article for more useful articles (descendancy searching). Both PubMed and CINAHL offer Cited By links
• Revise the search to broaden or narrow your topic focus as you peruse the available literature
• Conducting a literature search is a repetitive process. Searches can be revised and re-run multiple times during the process.
• Track the citations for your relevant articles in a software citation manager such as RefWorks, Zotero, or Mendeley

5. Review the literature

• Read the full articles. Do not rely solely on the abstracts. Authors frequently cannot include all results within the confines of an abstract. Exclude articles that do not address your research question.
• While reading, note research findings relevant to your project and summarize. Are the findings conflicting? There are matrices available than can help with organization. See the Organizing Information box below.
• Critique / evaluate the quality of the articles, and record your findings in your matrix or summary table. Tools are available to prompt you what to look for. (See Resources for Appraising a Research Study box on the HSA, Nursing , and PA guides )
• You may need to revise your search and re-run it based on your findings.

6. Organize and synthesize

• Compile the findings and analysis from each resource into a single narrative.
• Using an outline can be helpful. Start broad, addressing the overall findings and then narrow, discussing each resource and how it relates to your question and to the other resources.
• Cite as you write to keep sources organized.
• Write in structured paragraphs using topic sentences and transition words to draw connections, comparisons, and contrasts.
• Don't present one study after another, but rather relate one study's findings to another. Speak to how the studies are connected and how they relate to your work.

Organizing Information

Options to assist in organizing sources and information :

1. Synthesis Matrix

• helps provide overview of the literature
• information from individual sources is entered into a grid to enable writers to discern patterns and themes
• article summary, analysis, or results
• thoughts, reflections, or issues
• each reference gets its own row
• mind maps, concept maps, flowcharts
• at top of page record PICO or research question
• record major concepts / themes from literature
• list concepts that branch out from major concepts underneath - keep going downward hierarchically, until most specific ideas are recorded
• enclose concepts in circles and connect the concept with lines - add brief explanation as needed

3. Summary Table

• information is recorded in a grid to help with recall and sorting information when writing
• allows comparing and contrasting individual studies easily
• purpose of study
• methodology (study population, data collection tool)

Efron, S. E., & Ravid, R. (2019). Writing the literature review : A practical guide . Guilford Press.

Literature Review Sections

• Lit reviews can be part of a larger paper / research study or they can be the focus of the paper
• Lit reviews focus on research studies to provide evidence
• New topics may not have much that has been published

* The sections included may depend on the purpose of the literature review (standalone paper or section within a research paper)

Standalone Literature Review (aka Narrative Review):

• presents your topic or PICO question
• includes the why of the literature review and your goals for the review.
• provides background for your the topic and previews the key points
• Narrative Reviews: tmay not have an explanation of methods.
• include where the search was conducted (which databases) what subject terms or keywords were used, and any limits or filters that were applied and why - this will help others re-create the search
• describe how studies were analyzed for inclusion or exclusion
• review the purpose and answer the research question
• thematically - using recurring themes in the literature
• chronologically - present the development of the topic over time
• methodological - compare and contrast findings based on various methodologies used to research the topic (e.g. qualitative vs quantitative, etc.)
• theoretical - organized content based on various theories
• provide an overview of the main points of each source then synthesize the findings into a coherent summary of the whole
• present common themes among the studies
• compare and contrast the various study results
• interpret the results and address the implications of the findings
• do the results support the original hypothesis or conflict with it
• provide your own analysis and interpretation (eg. discuss the significance of findings; evaluate the strengths and weaknesses of the studies, noting any problems)
• discuss common and unusual patterns and offer explanations
•  stay away from opinions, personal biases and unsupported recommendations
• summarize the key findings and relate them back to your PICO/research question
• note gaps in the research and suggest areas for further research
• this section should not contain "new" information that had not been previously discussed in one of the sections above
• provide a list of all the studies and other sources used in proper APA 7

Literature Review as Part of a Research Study Manuscript:

• Compares the study with other research and includes how a study fills a gap in the research.
• Focus on the body of the review which includes the synthesized Findings and Discussion

Literature Reviews vs Systematic Reviews

Systematic Reviews are NOT the same as a Literature Review:

Literature Reviews:

• Literature reviews may or may not follow strict systematic methods to find, select, and analyze articles, but rather they selectively and broadly review the literature on a topic
• Research included in a Literature Review can be "cherry-picked" and therefore, can be very subjective

Systematic Reviews:

• Systemic reviews are designed to provide a comprehensive summary of the evidence for a focused research question
• rigorous and strictly structured, using standardized reporting guidelines (e.g. PRISMA, see link below)
• uses exhaustive, systematic searches of all relevant databases
• best practice dictates search strategies are peer reviewed
• uses predetermined study inclusion and exclusion criteria in order to minimize bias
• aims to capture and synthesize all literature (including unpublished research - grey literature) that meet the predefined criteria on a focused topic resulting in high quality evidence

Literature Review Examples

• Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge (2017). Women and Birth : Journal of the Australian College of Midwives
• Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review (2017). Journal of Racial and Ethnic Health Disparities

• Vitamin D deficiency in individuals with a spinal cord injury: A literature review (2017). Spinal Cord

Resources for Writing a Literature Review

These sources have been used in developing this guide.

Resources Used on This Page

Aveyard, H. (2010). Doing a literature review in health and social care : A practical guide . McGraw-Hill Education.

Purdue Online Writing Lab. (n.d.). Writing a literature review . Purdue University. https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html

Torres, E. (2021, October 21). Nursing - graduate studies research guide: Literature review. Hawai'i Pacific University Libraries. Retrieved January 27, 2022, from https://hpu.libguides.com/c.php?g=543891&p=3727230

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What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

• The different types of literature reviews, including systematic reviews and other evidence synthesis methods
• Tools & Tutorials

Literature Review & Systematic Review Steps

• Develop a Focused Question
• Scope the Literature  (Initial Search)
• Refine & Expand the Search
• Limit the Results
• Download Citations
• Abstract & Analyze
• Create Flow Diagram
• Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

• PICO Question Help
• Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

• Background sources (books, point-of-care tools)
• Article databases
• Trial registries
• Grey literature
• Cited references
• Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

• Combine separate concepts with AND  (resulting in a narrower search)
• Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

• Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
• Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

• database thesauri
• reference lists
• relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

• a personal database account (e.g., MyNCBI for PubMed)
• Log in with your NYU credentials
• Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

• Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
• Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

• Filters in PubMed
• CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

• Citation Managers - General Guide

6. Abstract and Analyze

• Migrate citations to data collection/extraction tool
• Screen Title/Abstracts for inclusion/exclusion
• Screen and appraise full text for relevance, methods, 
• Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

• Covidence Support
• Critical Appraisal Tools
• Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

• PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
• PRISMA Diagram Templates  (Word and PDF)
• Make a copy of the file to fill out the template
• Image can be downloaded as PDF, PNG, JPG, or SVG
• Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

• Reporting Guidelines for Systematic Reviews
• Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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What is a Literature Review?

What is a literature review: a tutorial, literature reviews: an overview for graduate students.

• Types of Reviews
• Statistics and Data
• APA Formatting Guide
• Citation Managers
• Library Presentations

A Literature Review Is Not:

• just a summary of sources
• a grouping of broad, unrelated sources
• a compilation of everything that has been written on a particular topic
• literature criticism (think English) or a book review

So, what is it then?

A literature review is an integrated analysis-- not just a summary-- of scholarly writings that are related directly to your research question.  That is, it represents the literature that provides background information on your topic and shows a correspondence between those writings and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

Literature Reviews: An Overview for Graduate Students (by North Caroline State University Libraries)

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What type of review, how to conduct a review, find articles, evaluating articles, full text access tool.

• How to Get Full Articles
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Researchers, academics and librarians all use various terms to describe different types of literature reviews. Indeed there is often inconsistency between the ways the types are discussed. Here are a couple of simple explanations.

The image below describes common review types in terms of speed, detail, risk of bias and comprehensiveness:

"Schematic of the main differences between the types of literature review" by Brennan, M. L., Arlt, S. P., Belshaw, Z., Buckley, L., Corah, L., Doit, H., Fajt, V. R., Grindlay, D., Moberly, H. K., Morrow, L. D., Stavisky, J., & White, C. (2020). Critically Appraised Topics (CATs) in veterinary medicine: Applying evidence in clinical practice. Frontiers in Veterinary Science, 7 , 314. https://doi.org/10.3389/fvets.2020.00314 is licensed under CC BY 3.0

The table below has been adapted from a widely used typology of fourteen types of reviews, (Grant & Booth, 2009).  Here are four of the most common types:

For a more detailed list of review types, see:

Grant, M.J. & Booth, A. (2009).  A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26 (2), 91-108.  DOI: 10.1111/j.1471-1842.2009.00848.x

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) outlines standards of practice completing a systematic review to ensure consistency and high-quality results.

• PRISMA 2020 Explanations
• PRISMA 2020 Checklist
• PRISMA 2020 Flow Diagram
• PRISMA Flow Diagram Generator
• PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews

Techniques from the PRISMA process can also be used with other types of reviews to have a systematic process for searching and evaluating results.

• Article Evaluation Handout Key questions to evaluate each section of original research studies (RCTs, cohort studies, etc)

LibKey Nomad is a browser extension that connects you with articles that are library-licensed or open access. LibKey Nomad is available for Google Chrome, Firefox, Safari, Microsoft Edge, Brave, and Vivaldi.

Here is a short demonstration of how it works:

When using LibKey Nomad, you will automatically be directed to the best available version of an article so you don't need to search in multiple places. When the full text of an article is not available, you will be provided with options to request the article through  Interlibrary Loan (ILL).

LibKey Nomad does not require you to create a personal account. It does not track users or hold credentials, and it is only active when you are on the web page of a scholarly publisher or database.  

Getting Started

• Install the LibKey Nomad extension for your browser of choice. (Note: A user account is  not  required to use the extension.)
• Search for and select "James Madison University" from the list of institutions. See images below.
• When you are on publisher websites, Wikipedia, PubMed, and more, you can l ook for the LibKey Nomad button to download PDFs.

Publisher Websites

When you're browsing publisher sites and other web pages, LibKey Nomad provides a link to download the PDF of an article available through the JMU Libraries. It is not necessary to first connect through the JMU Libraries website. If the full text of the article is not available through the JMU Libraries subscriptions, an "Access Options" button will appear, and you will see options for requesting the article through ILL. See example in the image below.

LibKey Nomad also works with Wikipedia. When you're viewing the list of references for an entry, a "Download PDF" button will appear after the citations, if the full text of the article is available from JMU Libraries. An "Article Link" button may appear for citations that are from sources that do not support linking directly to the PDF. For articles not available from JMU Libraries, an "Access Options..." button will appear that provides options for requesting the articles through ILL. See example in the image below.

When you're searching PubMed, LibKey Nomad shows options for downloading a PDF, linking to an article, or additional access options. You can also view the cover images of the journals that articles appear in. LibKey Nomad also provides a link to the complete issue of a journal. Click "View Complete Issue" to browse the table of contents for the issue in which an article appears, helping you find similar articles from the same publication. See example in the image below.

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The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

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Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study

Puvaneswari kanagaraj.

1 Department of Nursing, College of Applied Medical Sciences, University of Bisha, Bisha, Kingdom of Saudi Arabia

Judie Arulappan

2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman

Arpita Pradhan

3 Narayana Multi Specialty Hospital, Kolkata, West Bengal, India

* Current address: Durgapur City Hospital and Clinic Pvt. Limited, Durgapur, West Bengal, India.

Shimmaa Mansour Moustafa Mohammed

4 Faculty of Nursing, Zagazig University, Zagazig, Egypt

Associated Data

Supplemental material, sj-docx-1-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Supplemental material, sj-docx-2-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Introduction

The COVID-19 outbreak disrupted the nursing education across the world. The nursing students faced many challenges in their learning process.

The study explored the experiences and challenges faced by nursing students who had virtual education in India.

The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases. Phase 1: Qualitative data were collected using direct focus group interview with 18 students. Phase 2: Quantitative data were collected from 477 students using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. The analysis was done using the descriptive and inferential statistics and thematic analysis.

Phase 1: The analyzed data produced seven themes and 10 sub-themes; (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. Phase 2: Majority of the students (54.71%) experienced high-level challenges with the nursing education during pandemic. The overall mean and SD of all the domain-wise challenges were 103.39 + 7.11 with the range from 30 to 150. The mean and SD with educational challenges were (20.27 + 3.04), environmental challenges (6.92 + 1.66), communication challenges (17.61 + 4.01), technical challenges (17.39 + 3.75), evaluation challenges (7.09 + 1.94), physical and mental challenges (20.47 + 4.33), career challenges (7.06 + 1.91), and financial challenges (6.61 + 2.1). The demographic variable gender ( P  = 0.045) showed a statistically significant association with the challenges.

Considering the experiences and challenges faced by the nursing students, the nursing administrators shall design educational strategies to mitigate these challenges in nursing education during a pandemic.

Implication

Virtual nursing education offers flexibility in teaching and learning, self-paced learning opportunity, lower the costs, career advancement, comfortable learning environment, more opportunities for participation, easier to track documentation and improves skills in technology. Therefore, the challenges in virtual nursing education should be lessened to have successful teaching learning experiences.

Introduction/Background

The world faced unprecedented challenges during COVID-19 global pandemic ( World Health Organization, 2020 ). The pandemic changed the lives of people at different levels. Additionally, social distancing shaped the social relationship and behavior ( Kaveh et al., 2022 ). COVID-19 significantly strained the healthcare system. In addition, it affected the education in academic institutions and universities to a greater extent ( Dewart et al., 2020 ). As a preventive and control measure, all the schools, colleges, and universities were closed ( Mustafa, 2020 ). In April 2020, 94% of learners worldwide were affected by the pandemic, representing 1.58 billion children and youth in 200 countries ( De Giusti, 2020 ). Likewise, nursing education has undergone many radical changes both in developed and developing countries. The situation affected the learning opportunities of nursing students as their clinical placements were suspended and the face-to-face teaching moved into online teaching. Additionally, the pre-clinical activities such as laboratory and simulation-based teaching were affected due to social and organizational restrictions to limit unnecessary access and contact with others ( Tomietto et al., 2020 ).

To continue the teaching–learning activity, the academic institutions adopted various digital platforms including Zoom, Google meet, WebEx, Udemy, Edmodo, Google classroom, etc. ( Mishra et al., 2020 ). Moreover, web-based conferences were routinely organized by educational institutions during this pandemic ( Kaware, 2022 ). In addition, educational institutions have placed greater emphasis on ERP systems, library modules, fee modules, and examination modules. The virtual learning enhanced the comfort, accessibility, and encouraged remote learning ( Mukhtar et al., 2020 ). Similarly, the learners found it easy to access the online material, were able to record meetings and sessions and retrieve information ( Alsayed & Althaqafi, 2022 ). The faculty and students expressed that online education is useful during the COVID-19 pandemic; it was convenient, flexible, cost low, and encouraged self-learning ( Almahasees et al., 2021 ). Likewise, online education improved the flexibility, ability to teach large classes, increased interaction between the teachers and students and increased learning opportunities for the learners ( Hako, 2021 ). Ultimately, these educational technologies have had significant positive impact on the learning of the students. Additionally, it paves the way toward the blending of technology synchronously or asynchronously into education ( Thaheem et al., 2022 ).

Review of Literature

Although online education was beneficial to both the teachers and learners, it posed various challenges to the faculty and students ( Nimavat et al., 2021 ). Poor student attendance, loneliness, issues with internet connectivity and lack of information and technology skills were reported as challenges of online education ( Hako, 2021 ). The faculty and students indicated that efficacy of online teaching and learning is less effective than face–face teaching and learning. Moreover, online learning is ineffective for deaf and hard of hearing students. Likewise, online education is linked to lack of interaction and motivation, data privacy and security and technical issues ( Almahasees & Amin, 2021 ; Alsayed & Althaqafi, 2022 ). Furthermore, online education was inefficient in terms of maintaining academic integrity ( Mukhtar et al., 2020 ). The teachers reported difficulties in motivating the students without visual connection during online teaching ( Moustakas & Robrade, 2022 ). Also, Atout et al., (2022) reported lack of resources for the clinical learning, distracting home environment and challenging evaluation of learners as the barriers for virtual learning.

The challenges faced by the instructors includes transitional difficulties from offline to online teaching, communication barriers, changes in the teaching style and additional time and resources for preparation of teaching. The institutions experienced challenges such as need for additional training for faculty and students, technical and multimedia support, online counselling sessions for teachers and the need to have technical troubleshooting team. Students experienced challenges related to having technical skills to learn online, lack of readiness, network and speed issues, and lack of identity, interaction and participation. There were challenges related to content such as development of new material, regular assignments, multimedia tools, and checking assignments and sharing regular feedback with the students. Technological challenges included device suitability, network stability and speed, tools of conferencing software for online teaching and ease of use. Lastly, the motivational factors included lack of sense of job security, non-availability of salary on time, and lack of family support, mental and emotional support from colleagues and higher authorities ( Siddiquei & Kathpal, 2021 ).

To enhance the online teaching and learning, technical aptitude enhancement, resource management and utilization, time management, control over the learning environment and help seeking are essential ( Barrot et al., 2021 ). Furthermore, formal training for the teachers, and enhancement of psychosocial wellbeing of both the learners and teachers are necessary to curb the feelings of loneliness and isolation. Moreover, the nature of the problems related to the shift from face to face to online learning should be identified to combat these challenges ( Hako, 2021 ). In India, both the undergraduate and postgraduate students were badly affected during the COVID-19 pandemic and experienced many challenges with online education ( Joshi et al., 2020 ; Kamal & Illiyan, 2021 ; Muthuprasad et al., 2021 ; Pandit & Agrawal, 2022 ; Rannaware et al., 2022 ; Sengupta, 2022 ). However, very few studies explored the challenges encountered by the nursing students during the online learning ( Gaur et al., 2020a ; George et al., 2022 ; Kanagaraj et al., 2022 ; Lata & Kudi, 2022 ). Therefore, the authors decided to understand the experiences and challenges encountered by nursing students in their nursing education during the COVID-19 pandemic. We believe that the study finding will be beneficial to the educational authorities, curriculum developers, and policy makers to design appropriate measures and strategies to enhance effective learning both in nursing education and practice.

An exploratory sequential mixed-methods design was utilized in this study. The study integrated qualitative data into quantitative data to understand the experiences and challenges experienced by nursing students’ during the pandemic.

Research Setting

The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. These colleges initiated virtual classes from April 2020. Therefore, these colleges were selected as settings for the study.

The target population of the study included both Diploma and BSN students. The accessible population included both Diploma and BSN students studying in Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India.

Sample, Sample Size, and Sampling Techniques

Three nursing colleges were conveniently selected for the study. In Phase 1, the researchers used purposive sampling technique to collect the qualitative data from six students in each college (Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India). The data collection was done face to face. Thus, in total, 18 students participated in the focused group interview during phase I. For Phase 2, the sample size calculation was done based on the previous cross-sectional study ( Thapa et al., 2021 ). Having the expected proportion of challenges experienced by nursing students as 15%, with 95% confidence interval, and with the precision, the minimum required sample size was 400. In total, all the three nursing colleges had 654 students. Convenient sampling technique was used to collect the data in phase II.

Inclusion and Exclusion Criteria

The study included nursing students who were enrolled for Diploma and BSN program, exposed to online learning, and second, third, and fourth year nursing students. The study excluded those who were not willing to participate, and first year nursing students as they had limited exposure to the virtual theory and clinical classes, which may give a limited and inaccurate data. Considering the inclusion and exclusion criteria, 477 students participated in the study.

Description and Interpretation of Study Instrument

The instruments used in the study were prepared by the researchers of the study. The qualitative data collected during the first phase of the study was utilized in preparing the tool used for the quantitative phase of the study. It included four parts namely demographic variables, background variables, open-ended questions to explore the participant's experiences and challenges and Likert scale to assess the challenges.

Part 1 included the demographic variables of the participants including age, gender, course of study, year of study, residence, and place of attending online classes.

Part 2 comprised of the background variables such as gadgets used for attending online classes, source of internet, mode of theory classes taken during the last 6 months, mode of practical training, methods of teaching theory classes, audio visual aids used, and the virtual platform used.

Part 3 consisted of a questionnaire related to students’ experiences and challenges. It included 15 open-ended questions related to the aspects of theoretical learning, practical learning, study materials, teaching methodology, evaluation process, issues related to physical and mental health, issues related to technology and issues related to finance.

Lastly, Part 4 included a Likert scale on challenges having 30 questions with eight domains; educational challenges (six items), environmental challenges (two items), communication challenges (five items), technical challenges (five items), evaluation challenges (two items), physical challenges (six items), career challenges (two items), and financial challenges (two items). Dimensions were evaluated using 5-point Likert scale varying from strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The total score ranges from 30 to 150. The domain-wise challenges were interpreted as 1–50 = low challenges, 51–100 = moderate challenges, 101–150 = high challenges. The instrument was prepared in English and no translations were done.

Reliability and Validity of the Tool

Content validity was obtained from eight experts in the field of nursing education. The calculated content validity index was 0.80. Pilot study was conducted with 10% of the study participants (42 students) to test the reliability of the tool before administering to the main study participants. Using Cronbach's alpha (inter-item reliability), the internal consistency assessed was 0.89, which is highly reliable. The participants participated in the pilot study were excluded from the main study.

Ethical Considerations

Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022) and Institutional review board. After getting the ethical approvals, formal permission was obtained from the Head of Nursing colleges to collect data. The researchers explained the purpose of the study to the participants involved in both quantitative and qualitative data collection. The participants were informed that their participation in the study was voluntary. Since the participants were not forced to participate in the study, they were given the freedom to withdraw from the study at any time without any penalty. The participants signed the informed consent and responded to all the questions and returned the completed questionnaire. All the audio recordings were coded and password protected. It was explained to the participants that they were not exposed to any kind of risk. To keep the data anonymous, no identifying information was collected from the participants. The researchers maintained confidentiality of information throughout the study period. All the collected data were stored in a password protected file. Only, the investigators of the study had access to the data.

Data Collection (Qualitative Phase)

In Phase I of the study, three focus groups were selected using purposive sampling technique. Each group included six participants with a total of 18 nursing students. After getting the consent, the participants shared their experiences and challenges faced during their educational training in the pandemic. The interviews were conducted from 25/2/2022 to 25/3/2022 and each interview lasted for 1.30 h to 2 h. The first and third authors conducted the interview. The first author is a PhD and the third author is a BSN holder. The first author is an assistant professor and the third author is a staff nurse. Both of them were females. Both of them were trained in qualitative data collection. The researchers established rapport with the study participants. The researcher used 15 open-ended probing questions and the participants were given the freedom to express additional views and comments. All the interviews were conducted in person in the college and audio recorded with their consent. Focus group discussions were continued till the data saturation occurred. The transcripts were returned to the participants for their correction.

Data Collection (Quantitative Phase)

In Phase II, the quantitative data were collected using convenient sampling technique. The total number of students participated in the study were 477. The questionnaires were transferred to Google forms and were circulated to the students after explaining the objectives and getting the informed consent. The quantitative data were collected from 11/04/2022 to 20 /04/2022. The response rate was 72.9% (477) which included Narayana Hrudayalaya College of nursing (88 participants), Koshy's College of nursing (235 participants) and Kirubanidhi College of nursing (154 participants).

Data Analysis (Qualitative Phase)

The data were analyzed using thematic analysis. The collected data were transcribed and analyzed using Braun and Clarke's thematic analysis. Reflexive thematic analysis was performed in this study ( Clarke & Braun, 2017 ).

Data Analysis (Quantitative Phase)

The quantitative data were analyzed using descriptive and inferential statistics using SPSS version 22.

Credibility, Dependability, and Transferability

To ensure credibility of the data, the researcher strongly engaged with the focused group interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments given by the research guide, who is the second author of the study who has full knowledge of the study design and methodology. The data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. It ensures transferability.

The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each focus group interview was transcribed immediately after the interview. The transcripts were given to the participants for cross-checking and approval. In addition to ensuring rigor through trustworthiness criteria, the authors followed mixed-methods research legitimation criteria by ensuring design quality, design suitability, within design consistency, design fidelity, and analytic adequacy ( Teddlie & Tashakkori, 2009 ).

Trustworthiness

Trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded, and accurately presented inputs. The transcriptions, coding, and themes–subthemes were discussed by the research team for their verification. Then based on the themes and subthemes the quantitative questionnaire was created by the researchers.

Phase 1 Qualitative Phase

Table 1 shows the frequency and percentage distribution of background variables of 18 participants who shared their experiences and challenges faced during their educational training in the pandemic. Table 2 shows the frequency and percentage distribution of participants’ background variables.

Table 1.

Frequency and Percentage Distribution of Demographic Variables of Nursing Students.

Table 2.

Frequency and Percentage Distribution of Baseline Variables of Nursing Students.

Experiences and Challenges Faced by the Nursing Students

In Phase 1, the experiences and challenges experienced by nursing students with their educational training during the pandemic were analyzed using thematic analysis. Table 3 reports seven themes and 10 sub-themes. The themes identified includes: (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. The sub-themes were: (1.1) problems with internet connectivity, (1.2) issues with the digital platform, (2.1) theoretical learning experience-better, (2.2) deficient practical skills, (3.1) physical stress, (3.2) mental stress, (4.1) unfair evaluation and lack of feedback, (5.1) decreased quality of communication, (6.1) very convenient, and (7.1) difficult to concentrate.

Table 3.

Themes and Subthemes of Experiences and Challenges Faced by Nursing Students.

Theme 1: Technical Issues: A Concern

Modern technology is progressive in all sectors. With this technology, it was possible to deliver training in all educational sectors including nursing education during COVID-19. Though it was helpful, technical problems interrupted the teaching–learning process. Most of the participants expressed their concern related to technical issues. It includes issues with internet connectivity, and issues with the digital platform.

Subtheme 1: Problems with Internet Connectivity

Constant network issues were an unavoidable fact for many students. Students could not be connected to the virtual class on time due to the internet connectivity issues and they had to miss attending the classes.

“Sometimes it keeps on showing error code and by the time I get connected the class is completed by the faculty” (5A).

Students stated that they faced technical and network issues while attending the classes.

“During online classes, we have faced a lot of technical and network issues” (2A).

In addition, fluctuations in the network connectivity were another technical issue faced by students and it affected the virtual learning of the students.

“I faced fluctuations in my network during a natural calamity in my place so I missed many classes during that time” (13A).

Subtheme 2: Issues with the Digital Platform

There are various platforms used to deliver online educational training. The participants expressed their difficulties as they had hitches in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning.

Digital platform did not work if the application is not updated on time. This was stated as below;

“If I did not update the app on time, it will not work” (1A).

Students faced problems in joining the virtual platform due to issues with the virtual platform.

“Sometimes I faced problems with joining with the virtual platform” (8A).

Lack of experience in using the virtual platform by both the faculty and student was another challenge stated by the students.

“Had struggle to join the meeting initially for both students and faculties because it was very new to us” (5A).

Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

“I struggled while submitting the answer sheets /assignment through digital platforms” (4A).

Theme 2: Regular Rhythm in Educational Training: But not Complete

Virtual education is a boon during pandemic. It took the education system in a rhythmic manner. Though the online lectures were beneficial, at times, students faced few challenges.

Subtheme 1: Online Theoretical Learning Experience

The students utilized the opportunities to learn from online classes with few challenges in attending online classes.

Commencement of online classes helped the students to have continuity in their studies. As the online classes were started on time immediately, it did not affect their theoretical learning.

“…It was not at all possible for the colleges to continue the offline classes so that the apex body instructed to start with online classes and it's good that we were in touch with our studies” (12A).

Different methods and techniques of teaching adopted during online classes enhanced interest in their learning.

“During online classes teacher used to teach with PPTs, and some good videos to make the session interesting. Sometimes they used to conduct lecture cum discussion. That time I was interested to listen to the class” (15A).

“I was interested to attend the online theory classes when teachers used to take a class by showing some videos related to theory content. It was good” (16A).

Students encountered issues with the storage of study materials as they had minimal storage space in their gadgets.

“Teachers used to send notes in PDF form in the mail or by WhatsApp. When I have storage issues in my gadgets, I deleted the content because of storage issues” (18A).

Subtheme 2: Deficient Practical Skills

Practical training is a major part of nursing profession. Students faced many challenges while attending online practical classes.

Most of the students stated that their theoretical learning through virtual mode was excellent. However, students felt that learning practical skills through direct clinical experience is rewarding than learning through virtual platform.

“…theory classes were very good. But in case of practical, like IV infusion, it was very easy to watch the procedure in a virtual platform, but it was very difficult to perform. I feel offline clinical exposure is better than online” (3A).

Students stated that they learnt basic nursing skills through direct clinical experience before the pandemic. However, the students lack confidence in performing the skills that they learnt through videos. The students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning.

“…During my first-year clinical posting, I learnt basic procedure like vital signs checking, wound care, surgical dressing, etc with the direct clinical experience, suddenly everything goes on online, the faculty used to show us best videos. While watching videos I feel I can do. But when it's time to do directly, my hands were shivering and I was not confident. I feel offline exposure is better, we can get more exposure” (1A).

Huge gap in practical learning due to the pandemic affected the learning of the students. Thus, the students did not recommend online learning for learning the skills.

“I did not get adequate practical posting in my first year because of COVID-19. It continued with the second year too. So I have a huge gap with practical learning. For practical learning, online learning is not appropriate” (7A).

Theme 3: Stress and Strain

Prolonged online training affects the students’ physical as well as mental health. They felt more stressful.

Subtheme 1: Physical Stress

Students experienced physical symptoms such as strain in the eyes, neck pain, back pain and numbness in the legs due to prolonged usage of phone and sitting.

“I have to write my notes by seeing my phone. Every time I need to continuously see my mobile and make notes. It was straining my eyes and stressful for me” (16A).

“While attending online classes I used to keep my video on and listen to the class. Due to prolonged sitting, I have neck pain, eye strain also” (5A).

“I felt back pain and numbness in my leg while attending the online classes with prolonged sitting. I used to walk in between for some time to reduce the numbness” (12A).

Subtheme 2: Mental Stress

Students were anxious, as they could not complete the given tasks in online classes.

“I was anxious because I did not complete my task given in online classes, I was lazy” (4A).

As the students did not get practical experience in the clinical area, their confidence levels were low during the pandemic. Moreover, as the students did not get any opportunity to practice directly in the clinical area during the pandemic, they felt tensed and lacked confidence to directly practice on the patient after the pandemic.

“Due to lack of practice in clinical, my confidence had come down” (8A).

“I felt stressed out when I am thinking about my practical learning. I did not get adequate opportunity to practice” (10A).

“After lockdown when I came in the clinical setting, I was tensed about how I will handle the patient” (15A).

Theme 4: Evaluation: A Concern

Evaluation is the process of providing feedback to the students to improve themselves. The test, examination, assignment, and evaluation were new for the students and faculty during the pandemic and there were malpractice incidences by the students.

Sub-Theme 1 - Unfair Evaluation and Lack of Feedback

Students felt conducting exam using Google form as useful.

“Some faculties conducted few exams in Google Form, it was good because at that time I studied and attend the exam” (16A).

Malpractice in the online exam could be observed in the students during virtual learning.

“For the online exam, I never used to study because I can copy from PPT, my screenshots, or from Google and score good marks” (2A, 8A, 17A, 18A).

Students stated that they did not get proper feedback on their assignments.

“In my point of view, some faculties did not give us proper feedback on my assignment writing” (6A).

One student stated the unfair evaluation as the students copied scored well.

“I feel very bad when I write without copying and score very less marks; while the students who did malpractice scored well. So the evaluation was going very wrong” (4A).

Theme 5: Communication

It is necessary to build proper communication between the teachers and students to continue a smooth training session online. However, students felt that this distance learning created a communication gap between teachers and students.

Sub Theme 1- Decreased Quality of Communication

Limited and disrupted communication with the friends and teachers created distress in the students.

“It was not possible for me to communicate face to face with my friends and teachers during the online classes. It was quite distressing” (1A).

“Online class communication was the major problem. We could not communicate with faculties and peers like offline” (18A).

Students felt that they could not clarify their doubts with the faculty. However, faculty responded to their queries through WhatsApp and social media.

“If it comes to communication, it was very limited… During offline we can directly ask doubts to the faculty, but not now” (2A).

“During the online classes communication was not easy like face to face communication. But teachers were responding by WhatsApp and other social media after class time also” (6A).

Theme 6: Comfort Zone

Online classes were attended by the students either from hostel or home.

Subtheme 1: Very Convenient

Students felt comfortable staying home and attending online classes.

“It was convenient for me. Because I can stay at home, take care of my family and attend class also” (8A).

“For me, it was convenient, I got more time and can get up late to attend classes” (2A, 3A, 7A).

Students expressed that their transport expenses could be minimized, as they were not required to travel during the pandemic.

“I could save time. Even transport expenses could be minimized” (10A).

Theme 7: Distraction

Distraction was very high in online classes.

Sub-Theme 1: Difficult to Concentrate

Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings.

“As my internet is on I will get many notifications from other apps during class, it was a distraction for me” (4A, 9A, 11A).

“I attended online classes from my home only. I had disturbance from siblings, during my online classes” (7A, 16A).

Students themselves got distracted as they were using social media in between the online classes.

“I used to browse on Facebook, Instagram, YouTube, etc. during the online classes” (13A).

Phase 2: Quantitative Phase

Table 1 shows the frequency and percentage distribution of participant's demographic variables. Majority (90.6%) of the participants were in the age group between 18 and 23 years. Most of them were females (76.7%). 69.4% of the students were undergraduate (BSN) nursing students, while the rest were in Diploma nursing program. 47.4% of the participants were in their second and 47.4% were in their third year of study. Nearly half (45.3%) were from urban areas and 23.7 were from semi-urban areas, while the remaining (31%) were from rural areas. A large number (83.4%) of students attended the online classes from their hostels.

Table 2 outlines the frequency and percentage distribution of participants’ background variables. The results showed that the majority (98.3%) of the students used mobile phones to attend online classes. Most of them (94.5%) used the mobile data to have the internet connection. Almost half of the participants (52.6%) attended both online and offline classes. More than half (52.6%) of the participants had both online and offline practical exposure, and around 33% had offline clinical exposure. Most of the students (94.5%) attended lecture and discussion sessions. A huge number (93.3%) used power point presentation, and 45.7% of them used videos for teaching. Majority (60%) used Google Meet, while 52.4% used Zoom. The remaining used multiple platforms like Cisco, and Webex.

Figure 1 describes the frequency and percentage of distribution of level of challenges. It was classified as low, moderate, and high level of challenges. Majority of them (54.71%) experienced high-level challenges, 44.6% encountered moderate-level challenges, and the remaining experienced low-level challenges related to their nursing education during the pandemic.

Frequency and Percentage Distribution of Challenges Faced by Nursing Students During Their Educational Training.

The domain-wise challenges with nursing education during pandemic were shown in Table 4 . The eight domains included educational challenges, environmental challenges, communication challenges, technical challenges, evaluation challenges, physical and mental challenges, career challenges, and financial challenges. The mean and standard deviations for educational challenges is (20.27 ± 3.04), environmental challenges (6.92 ± 1.66), communication challenges (17.61 ± 4.01), technical challenges (17.39 ± 3.75), evaluation challenges (7.09 ± 1.94), physical and mental challenges (20.47 ± 4.33), career challenges (7.06 ± 1.91), and financial challenges (6.61 ± 2.1). The overall mean and S.D. of all the domain was 103.39 ±  1 7.11 with the range from 30 to 150.

Table 4.

Assessment of Mean and Standard Deviation of Domain-Wise Challenges Faced by the Nursing Students n  = 477.

Table 5 displays the item-wise challenges. The results of Educational Challenges indicated that almost 38.57% responded that they lack interest in learning. 15.93% either strongly agreed or agreed that face-to-face learning is very effective than E-learning. A larger portion (78.62%) of participants mentioned that the notes and lectures were inadequate. More than half of the participants (54.3%) agreed that virtual demonstration is not very effective for the practical patient care, and 61.21% mentioned that they lack confidence while taking care of patients. The participants provided similar responses during the qualitative phase of the study. The students lack confidence in performing the skills that they learnt through videos. Similarly, the students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning. However, one third of the respondents (33.75%) expressed that they could learn the modern ways of handling patients through videos.

Table 5.

Item-Wise/Domain-Wise Analysis of Challenges Faced by Nursing Students.

With regard to Environmental challenges , 41.51% expressed that they were comfortable with their home or hostel environment to attend online classes. However, more than half (58.91%) said that they were easily distracted while attending classes. Similar findings were seen in the qualitative phase of the study. Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings. Further, the students were distracted as they were using social media during the online class.

In terms of Communication challenges , almost half of them (46.96%) expressed that they had difficulty in sharing their view with the teachers, and 45.91% said that teacher–student interaction was passive. More than half (57.86%) of them expressed that peer group socialization has decreased, missed interaction (48.64%) with other college mates/seniors and experienced loneliness (56.6%) without interacting much with peer groups. Similar to these findings in the quantitative phase, in qualitative phase, the students mentioned that limited and disrupted communication with the friends and teachers created distress in the students. Moreover, the students could not clarify their doubts with the faculty.

Regarding Technical challenges , 44.03% had uncertain internet connection that interrupted the learning process. Around 37.32% expressed that the teachers had difficulty in using technical aspects of the online platforms initially. Around 39.63% had internet issues in their place. Almost 55.56% students faced technical issues with learning platform/device and around 59.54% had difficulty while submitting the answer sheets/assignment through digital platforms. Likewise, the qualitative findings revealed that the students faced technical and network issues while attending the classes. In addition, fluctuation in the network connectivity was another technical issue faced by students and it affected virtual learning. The participants expressed their concerns as they had difficulties in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning. Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

Related to Evaluation challenges , almost half of them (51.15%) mentioned that the online evaluation might create irrational discrimination between students with network issues, and 51.99% of them said that the evaluation/test conducted online was unfair. Consistent findings could be noted during the qualitative phase of study. Students mentioned that malpractice in the online exam occurred and it affected their grades. In addition, students stated that they did not get proper feedback on their assignments.

With respect to Physical and mental challenges , more than half 62.06% experienced physical strain like headache, backache, neck pain, and eye strain, 47.17% experienced insomnia, around 70.86% had mental stress, 46.75% got addicted to phone due to prolonged usage other than for learning purpose, 56.82% mentioned that the regular life style has changed, and lastly 48.21% were worried about the online teaching applications which lack proper security system. Likewise, same results are discovered in the qualitative phase of the study. Students experienced physical symptoms such as strain in the eyes, neck pain, back pain, and numbness in the legs due to prolonged sitting and continuous usage of phone. Additionally, students were anxious, as they could not complete the given tasks in online classes. Further, as the students did not get practical experience in the clinical area, their confidence levels were low and they felt tensed and lacked self-confidence to directly practice on the patients after the pandemic.

In terms of Career challenges , 56.4% agreed that virtual practical training may affect their career as a registered nurse, and 49.06% agreed that they may not be able to work as a skillful nurse with the virtual learning. Regarding Financial challenges , almost 58.07% agreed that extra money was spent for good internet package and 38.37% bought a new laptop/mobile/electric gadget to attend virtual classes.

With regard to association of demographic variables, only gender (χ 2  = 6.218, p  = 0.045) has shown statistically significant association with problems or challenges faced by the nursing students during educational training in the pandemic at p  < 0.05 level of significance.

During COVID-19 pandemic, face-to-face teaching and learning were converted to virtual learning and the clinical experiences were suspended to protect the students from the pandemic ( Agu et al., 2021 ). The experiences with the online classes were very new for the nursing students. Moreover, the online education became unavoidable and was a good choice for the faculty and students during this pandemic across the world. Even though, the students and teachers had a positive view of the technology, which helped in the teaching–learning process during pandemic, it posted many challenges ( Mousavizadeh, 2022 ).

We conducted a mixed-methods study to explore the experiences and challenges faced by nursing students in their education during COVID-19 in India. The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases; the qualitative data were collected during Phase I using focus group interview with the students. The qualitative data collected during the first phase of the study was utilized in preparing the tool for the quantitative phase of the study. The quantitative data were collected using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. During Phase 1, the analyzed data produced seven themes and 10 sub-themes on the challenges. These themes produced during the qualitative phase further explained the challenges experienced by the nursing students in their education during COVID-19 pandemic in the quantitative phase.

Educational Challenges

Learning motivation encourages learners’ activities and directs and maintains their progress, allowing students to immerse themselves in learning ( Kim, 2020 ). However, virtual learning decreased students’ attention and interest in classes, which then decreased their motivation to learn ( Morfaki & Skotis, 2022 ). Likewise, in the current study most of the students expressed that they lost interest in their learning. Student's interest is very important for academic achievement, so different methods of teaching and learning need to be adopted in future to improve the learning among students during online education ( Mousavizadeh, 2022 ).

During COVID-19 pandemic, the medical and nursing institutions used learning management systems (LMS) and uploaded various reading materials, videos, quizzes, and presentations to encourage the engagement of students in asynchronous learning activities. In addition, online discussion forums were created to facilitate the virtual learning process ( Atwa et al., 2022 ). Some students preferred online learning as it provides structured learning materials and enables studying from home at their own pace and convenience ( Paechter et al., 2010 ; Zheng et al., 2021 ). However, most of the students in different studies conducted across the world preferred face-to-face learning for acquiring motor skills, for establishing interpersonal relationships, and for achieving student learning outcomes ( Arias et al., 2018 ; Faidley, 2021 ; Ramani & Deo, 2021 ; Lim et al., 2021 ). Similarly, Muthuprasad et al. (2021) advocated that the online mode of learning may not be a viable option for practical/skill-oriented courses and therefore hybrid/blended curriculum involving both face to face and online modes of learning shall be adopted by the institutions.

The faculty used different methods of teaching and audio visual aids to enhance the teaching–learning process during the pandemic ( Reimers et al., 2020 ). However, students in the present study mentioned that the notes/lecture content were inadequate. Similar findings were reported in other studies that the quality and effectiveness of lecture were low; and inconsistencies were observed in some professor's lecture during COVID-19 ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ). This warrants the educational institutions to monitor the quality of teaching delivered by the faculty to their students during this pandemic. In addition, the faculty should take self-initiatives for the professional empowerment ( Osmanovic Zajic et al., 2022 ).

The professional preparation of nurses involves many hours of practical and theoretical classes which is conducted face to face, which gives a real learning experience ( Dziurka et al., 2022 ). However, COVID-19 pandemic caused alterations, restrictions, limited clinical placements and simulation training in the campus ( Rohde et al., 2022 ). Thus, many nursing institutions adopted virtual theoretical and practical learning modes. Various studies across the world including the present study reported that virtual practical learning was inappropriate and ineffective in doing practical skills. Additionally, the nursing students lack confidence in taking care of the patients as they did not have hands on training ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Gheshlagh et al., 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ; Wajid & Gedik, 2022 ). Therefore, in addition to direct face-to-face practical training in the clinical areas, more nursing simulations, virtual reality, artificial intelligence and telenursing should be utilized to enhance the practical learning of nursing students ( Dziurka et al., 2022 ).

Environmental Challenges

Student engagement during the virtual classes are very essential. The students are expected to actively participate, show positive conduct, self-regulated, display deep learning and understanding, and should demonstrate positive reactions to the learning environment, peers, and teachers ( Bond et al., 2020 ). However, students in the current study and many other studies were distracted very easily while attending online classes, which limited their learning during pandemic ( Bergdahl, 2022 ; Farrell & Brunton, 2020 ; Fazza & Mahgoub, 2021 ; Hollister et al., 2022 ). Therefore, more peer-to-peer conversations and faculty–student exchanges are recommended to enhance the engagement and learning during the pandemic.

Communication Challenges

Effective communication between the educator and the students enhances the learning experience and creates a positive learning environment. In addition, it improves the exchange of ideas, knowledge, and thought to fulfill the purpose of teaching and learning. However, ineffective communication creates frustration, impaired interpersonal relationships, and lack of motivation ( Alawamleh e al., 2020 ). In consistent to this study, the present participants had difficulty in sharing their view with the teachers, could not socialize with peer groups, and experienced loneliness. Furthermore, studies reported that impaired communication during online learning creates uncertainties and insufficiencies in learning ( Cengiz et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ). Thus, effective communication with the students should be streamlined for successful virtual learning ( Mukasa et al., 2021 ).

Technical Challenges

Online education can be effectively integrated in the nursing curriculum as it guarantees effective problem-based learning. However, the nursing colleges were not adequately prepared to effectively utilize the online teaching and learning in developing and under developed countries ( Molefe & Mabunda, 2022 ). Technical aptitude was lacking among the faculty and students, which posed various challenges ( Barrot et al., 2021 ). Moreover, technical challenges limited the satisfaction of students and faculty toward online teaching and learning ( Mahyoob, 2020 ). Furthermore, failure of internet services, website failures, problems in logging into the site disrupted the teaching–learning process during the pandemic ( Fuchs, 2022 ; Gaur et al., 2020b ). Similar to these studies, the present study participants mentioned that they experienced uncertain internet connection, faced technical issues with learning platform/device, and had difficulty while submitting the answer sheets /assignment through digital platforms. In addition, the teachers had difficulty in using technical aspects of the online platforms. This calls for improving the instructional design and pedagogical methods by training the faculty and students to utilize the digital platforms effectively, which might improve the motivation and engagement of faculty and students during the online education ( Aivaz & Teodorescu, 2022 ).

Evaluation Challenges

Significant changes in the teaching and learning during the pandemic created profound opportunities and threats. Stakeholders and students reported that the evaluation during online learning was biased and ineffective ( Krishnamurthy, 2020 ) and experienced uncertainty toward the examination ( Idris et al., 2021 ). Besides, online learning affects the test scores and grades, student outcomes, attitude, and overall satisfaction with learning ( Szopiński & Bachnik, 2022 ). In the same way, the students in the current study mentioned that the online evaluation created irrational discrimination between students and the evaluation conducted online was unfair. Therefore, standard setting in the evaluation is an essential step considering the learners and educator's perspective, which would improve the teaching–learning process ( Wasfy et al., 2021 ).

Physical and Mental Challenges

COVID-19 pandemic disproportionately affected the physical and mental health of students ( Ro et al., 2021 ). Students missed eating, did not participate in extracurricular activities, and experienced computer-related physical stress ( Idris et al., 2021 ). Likewise, students experienced increased stress due to homework, social isolation and lack of social interactions ( Rao & Rao, 2021 ). In congruent with these study findings, the participants in the present study experienced headache, backache, neck pain, eye strain, insomnia, and mental stress. The authors recommend addressing the physical and mental health issues of the students by promoting the utilization of physical, emotional, and mental health support programs ( Idris et al., 2021 ).

Career Challenges

COVID-19 pandemic impacted the career preference, career perspective, and ideal workplace ( Wang et al., 2022 ). In the same way, the students struggled with the career decision-making process during the pandemic ( Jemini-Gashi & Kadriu, 2022 ). Likewise, working students lost their jobs, which affected their lives, studies, and health ( Tsurugano et al., 2021 ). In line with these studies, students of the present study expressed that virtual practical training will affect their career as a registered nurse and they may not be able to work as a skillful nurse. This calls for the initiation of a structured and well-designed practical training program for the nursing students in the hospitals before their placement as a registered nurse in the clinical practice.

Financial Challenges

The pandemic put a number of students under financial strain, which severely affected their mental well-being ( Negash et al., 2021 ). Similarly, the university students were disproportionately affected by the economic consequences of the pandemic, which escalated the economic uncertainty ( Gewalt et al., 2022 ). The students who lost their economic resources during pandemic experienced higher prevalence of depressive symptoms ( Tancredi et al., 2022 ). Participants in the current study mentioned that they had to spend extra money for good internet package and bought a new laptop/mobile /electric gadget to attend virtual classes, which increased their economic burden. To counterbalance these economic challenges, financial aid schemes for students need to be made available to relieve distress and allow students to focus on their studies ( Gewalt et al., 2022 ).

Strengths and Limitations

The study findings are limited to only few nursing colleges in India. Therefore, the study findings may not be generalizable to other states of India. As the study population was not selected through probability sampling strategy, the representativeness of samples might be lacking in the current study. Moreover, the study instruments were prepared by the investigators of the study that did not undergo rigorous standardization process, which might limit the strength of the study. Based on the study findings, the institutions where the study was conducted should design strategies to mitigate the challenges to have effective teaching and learning.

Implications for Practice

Virtual nursing education can be improved by refining the content and delivery methods, training of nursing faculty to use online educational strategies, and by reducing the technical and environmental barriers. Hybrid and blended teaching–learning strategies may further improve the learning among nursing students.

Virtual education can be very successful if we address the challenges and experiences of the students by performing appropriate groundwork by upgrading the required hardware and software, teaching how to use the facilities, and developing innovative teaching techniques and standard protocols for virtual education.

Supplemental Material

Acknowledgments.

The authors thank the students and faculty members who participated in this study. The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program. The authors would like to acknowledge the nursing students who have participated in the study. Special thanks to the administrators and faculty members of the institutions for their motivation and support during data collection.

Author Contributions: PK designed and conducted the study and wrote the initial draft of the manuscript. JA edited and added additional content and refined the manuscript. AP collected the data. SM edited the manuscript.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval: Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program.

ORCID iDs: Judie Arulappan https://orcid.org/0000-0003-2788-2755

Shimmaa Mansour Moustafa Mohammed https://orcid.org/0000-0002-2956-610X

Supplemental Material: Supplemental material for this article is available online.

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• Volume 21, Issue 2
• Reviewing the literature: choosing a review design
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• Helen Noble 1 ,
• Joanna Smith 2
• 1 School of Nursing and Midwifery , Queen’s University Belfast , Belfast , UK
• 2 School of Healthcare , University of Leeds , Leeds , UK
• Correspondence to Dr Helen Noble, School of Nursing and Midwifery, Queen’s University Belfast, Belfast BT9 7BL, UK; helen.noble{at}qub.ac.uk

https://doi.org/10.1136/eb-2018-102895

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Many health professionals, students and academics including health researchers will have grappled with the challenges of undertaking a review of the literature and choosing a suitable design or framework to structure the review. For many undergraduate and master’s healthcare students their final year dissertation involves undertaking a review of the literature as a way of assessing their understanding and ability to critique and apply research findings to practice. For PhD and Master’s by Research students, a rigorous summary of research is usually expected to identify the state of knowledge and gaps in the evidence related to their topic focus and to provide justification for the empirical work they subsequently undertake. From discussions with students and colleagues, there appears to be much confusion about review designs and in particular the use and perhaps misuse of the term ‘systematic review’. For example, some quantitatively focused researchers subscribe to a ‘Cochrane’ approach as the only method to undertake a ‘systematic review’, with other researchers having a more pragmatic view, recognising the different purposes of a review and ways of applying systematic methods to undertake a review of the literature. Traditionally, systematic reviews have included only quantitative, experimental studies, usually randomised controlled trials. 1 More recently, systematic reviews of qualitative studies have emerged, 2 and integrative reviews which include both quantitative and qualitative studies. 3

In this article, we will build on a previous Research Made Simple article that outlined the key principles of undertaking a review of the literature in a structured and systemic way 4 by further exploring review designs and their key features to assist you in choosing an appropriate design. A reference to an example of each review outlined will be provided.

What is the purpose of undertaking a review of the evidence?

The purpose of a review of healthcare literature is primarily to summarise the knowledge around a specific question or topic, or to make recommendations that can support health professionals and organisations make decisions about a specific intervention or care issue. 5 In addition, reviews can highlight gaps in knowledge to guide future research. The most common approach to summarising, interpreting and making recommendations from synthesising the evidence in healthcare is a traditional systematic review of the literature to answer a specific clinical question. These reviews follow explicit, prespecified and reproducible methods in order to identify, evaluate and summarise the findings of all relevant individual studies. 6 Systematic reviews are typically associated with evaluating interventions, and therefore where appropriate, combine the results of several empirical studies to give a more reliable estimate of an intervention’s effectiveness than a single study. 6 However, over the past decade the range of approaches to reviewing the literature has expanded to reflect broader types of evidence/research designs and questions reflecting the increased complexity of healthcare. While this should be welcomed, this adds to the challenges in choosing the best review approach/design that meets the purpose of the review.

What approaches can be adopted to review the evidence?

• View inline

Key features of the common types of healthcare review

In summary, we have identified and described a variety of review designs and offered reasons for choosing a specific approach. Reviews are vital research methodology and help make sense of a body of research. They offer a succinct analysis which avoids the need for accessing individual research reports included in the review, increasingly vital for health professionals in light of the increasing vast amount of literature available. The field of reviews of the literature continues to change and while new approaches are emerging, ensuring methods are robust and remain paramount. This paper offers guidance to help direct choices when deciding on a review and provides an example of each approach.

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Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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