Nursing Literature Reviews

A Reflection

Martin Lipscomb

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780415792707
• eBook ISBN: 9781351812696
• Topic: Medicine
• Subtopic: Health Care Delivery

Literature reviews are undertaken by students, researchers, clinicians and educationalists – that is, almost all nurses.

Despite much excellent work, exploring the assumptions and practices that constitute searching for and reviewing literature has merit, and prompting those who undertake these activities to think critically about what it is that they are doing should be encouraged. Widely adopted approaches to structuring reviews (the "standard model") can detrimentally limit the scope or range of literature that is accessed and appraised. It is further proposed that a lack of professional ambition or confidence invests aspects of the way some nurses engage with the sources that are available to them. Across the book, parochialism is challenged. The crucial roles that values and judgement play in reviews are highlighted. It is argued that humanities and arts texts deserve, potentially, a bigger or more assured place in reviews undertaken by nurses. Difficulties in appraising quantitative and qualitative research reports are identified, and benefits linked with taking a contemplative line through the review process are considered.

This book contributes to debates around evidence-based practice and literature reviews more generally. It will appeal to anyone with an interest in professional issues, research, and the philosophy and sociology of nursing.

1

INTRODUCTORY HARRUMPHING

• Nurse reviewers often undervalue wide reading.
• The ‘standard model’ or approach to searching is introduced.
• It is suggested that the standard model restrains creativity.
• A plan of the book is outlined.
• Questions regarding nursing’s professional identity are posed.

Rationales supporting or justifying clinical practice frequently rely on information generated by literature searches and reviews.¹ These activities also describe bedrock or fundamental components of research and scholarship (Christmals and Gross, 2017). Done well, location and appraisal identify what is known or believed, as well as what remains to be discovered. In healthcare they enable alternative treatments and interventions to be judged and compared and, further, reviews inform discussion on the nature and scope of nursing and midwifery² more generally (see e.g. Perry, Henderson and Grealish, 2018; Rasmussen et al., 2018). Being able to effectively search for and review literature are, it is asserted, “core” (Lipp and Fothergill, 2015) or “essential” (Moule, 2018, p. 48) nursing skills. By facilitating informed reflection and critical thinking, these activities contribute to ongoing professional development (Rowson, 2016; Welp et al., 2018), and reviews therefore sustain practice in a manner that is just as vital and integral to patient and user care³ as the hands-on or physical skills that are traditionally more readily identifiable with nursing.

Reviews matter

Recognising their importance, this book offers a considered but nonetheless critical commentary on popular approaches to location and appraisal. That is, models and processes that are taught to and used by most nursing students, researchers, scholars, and clinicians (i.e. almost all nurses.) Much of what is done is sensible. However, several issues impinge upon and hamper reviews and these need to be addressed.

Thus, some nurses do not see the benefit of accessing and learning from the full range of knowledge and ideas that exist. Or, if this statement is too strong, they do not act as if this benefit is realised. Moreover, commonly employed search and review strategies constrict the range of sources retrieved and, hence, nurses undertaking searches are directed to look at only a subset of the material that is available to them. If nurse reviewers are sometimes reluctant to read widely, and/or when reading occurs but potentially useful sources are overlooked, it is reasonable to suppose that location and appraisal proceed sub-optimally. In such instances understanding is degraded and those we care for – the ‘objects’ of research and clinical practice – may be adversely impacted.

Reading

Despite their importance, literature searches and reviews are not always respected. They do not always receive the esteem they deserve. To illustrate what is meant by this, over the past few years I have taken to jotting down the peculiar things that nursing students, educators, and researchers say about these activities and, also, the uses to which literature is put. These statements can be interpreted in several ways. However, for me, they suggest that some nurses attach little significance to location, appraisal, and, worryingly, reading.

‘What’s the smallest number of papers I need to review?’

‘How much of this paper do I need to understand?’

‘I don’t do statistics. I don’t understand them. I don’t read them.’

‘We were told, only reference research.’

‘We were told, never cite anything that’s more than ten years old.’

These comments come from pre- and post-registration (licensure) students working towards first and higher degrees and, in my opinion, they disclose a peculiar and disturbing paucity of ambition. For example, the first inquiry refers to the minimally acceptable number of research papers that need to be found and assessed for an undergraduate dissertation that, at my institution, normally takes the form of a literature review (where such work is termed an Independent Study). The question points towards an intriguing problem, and it is one I return to in future chapters. Nonetheless, within the context in which the query was posed – that is, from the perspective of an instrumentally inclined student – searching for and reviewing more papers than are needed to achieve a good or even outstanding grade represents unnecessary work. Or, put another way, given advertised marking criteria, if students can receive high marks by doing a minimum, why do more? The question therefore ‘makes sense’. And if an expansive review was undertaken, and if this increased the probability that inexperience might be revealed (i.e. errors made), canny students could decide to play safe by doing less.

Alternatively, it might be objected that limiting the number and range of sources accessed during the educative process is perfectly reasonable, and perhaps this comment merely signals some such constraint. The presumption here could be that learning about location and appraisal proceeds incrementally and that, at least in the foundational or initial phase, just as a child’s bike has stabilisers to prevent catastrophe and tears, so students require similar protections when learning. This objection is fine, except, it is not at all clear that the implied development occurs. It would be nice if, as beginners shrug off their novice status, the need for restrictions drop away or are removed. But when is this supposed to happen? When are the upper or higher steps of a staged approach to learning to be tackled?

Note, the reproduced comment came from a third-year undergraduate completing the largest piece of academic work in her degree. If the statement captures something important about the outlook of this student towards engagement with the literature – and I believe it does – we might ask, at what point is, or should, the anticipated transformation to take place? When will this student realise that focusing on ‘the smallest number’ of sources can be antithetical to real or meaningful learning? In a limited number of circumstances, and depending upon the nature of particular questions, there might indeed be a ‘smallest number’ of papers that can be accessed. However, while I cannot quantify or corroborate the following comment, I believe the restricted approach to reading articulated by this student exists widely if not uniformly across the student body. And once qualified (licenced), should this person, or others, turn to the literature to find out about some element or aspect of patient care, their attitude towards location could presumably be the reduced one demonstrated here.

In conversation, academic colleagues suggest it is appropriate to expect wide reading from higher but not necessarily first-degree students. I disagree. It is not unreasonable to expect that all students can and should read widely when undertaking reviews – albeit that the meaning of ‘widely’ presumably varies with the level and purpose of study. Further, only a comparatively small fraction of nurses subject themselves to Masters and doctoral level education, and if wide reading is a good, then my colleagues’ suggestion appears to authorise or sanction poor practice among the majority of nurses (i.e. all those who do not attempt higher degrees). The proposal is also intuitively suspect.

It is not obvious that Masters and doctoral candidates have more time to read than first-degree students (see Brekelmans et al., 2016, regards continuing professional development). Many nurses pursue part-time routes through continuing and higher education, and if these students are parent/carers, and/or if they are holding down demanding clinical or administrative roles (which is often the case), they may have less available time than non-parents/carers and comparatively footloose students entering university straight from school. Lecturers might hope that post-graduate students will be favourably disposed towards reading and well informed about literature searches and reviews. However, ‘hope’ is a fragile basis on which to plan curricula. And if students are not required to read widely in undergraduate programs, if they are not prompted to perform reviews that do more than a minimum, it is not self-evident that this disposition and skill will spring forth sui generis at a later date.

To further muddy the waters, because methodological enchiridia maintain a strict focus on the formulation of answerable questions (discussed shortly), and because research evidence is prized as a search object irrespective of the type of question being addressed, students and researchers might imagine that if location criteria are appropriately and tightly specified, then a manageable (i.e. small) number of papers can and perhaps should be found.⁴ This way of thinking positions reading as a burdensome chore that needs to be controlled, and the idea that contemplative engagement with the literature might have value in and of itself is undermined. Inevitably, this combination of established practice and instruction runs the risk of actively discouraging the development of good practice where good practice equates with wide reading.

The student’s question also has a logic for educators since, given that large numbers of lecturers supervise even larger numbers of dissertations, common expectations need to be agreed among faculty members. Yet in stating an answer (and at the time of writing, the minimum acceptable number of sources that can be reviewed in a third-year Independent Study is four), the rationale for executing a search is subverted. Explicitly, insofar as location and appraisal occur in order that a body of knowledge, or key understandings, or new insights/learning can be recognized, then in all but exceptional circumstances it is ludicrous to imagine these objectives are realistically or substantively achieved using pre-defined quantities of papers. This is not to say that four is too small a number (although it is). Rather, it is proposed that stating a number is wrong in and of itself. Instead – and to prevent the tail wagging the dog – the range, type and number of materials sought and assessed in reviews should follow the question or topic being explored.

Students do not, of course, always ask these sorts of question. Some evidence mature and developed thinking. Yet minimal acceptable expectations easily morph into de facto norms, and experience suggests that even talented students may find themselves nudged into conforming with parochially limiting ways of working because the alternative, wide reading, is not consistently respected by educators. Indeed, academic tutors, the very people who might be expected to challenge pinched attitudes to search and review practices, can instantiate a cramped outlook towards reading:

‘I tell them, go to CINAHL,⁵ one or two official sites – Oh – and the Code. That’s it.’

‘Students don’t read. They don’t have time to read. You can’t expect them to.’

‘If students read anything, they only read to pass assignments.’

‘I say, for this assignment find fifteen references. That’s enough. That’s what I’d do.’

‘To be honest, I don’t read much myself. I only look at what’s required.’

These statements were voiced by nurse lecturers in university settings, and given this, and at the risk of hyperbole, the abrogation of intellectual virtue and aspiration expressed within this advice, assertion and admission is dispiriting if not shocking. Sadly, nurse researchers sometimes fare little better:

‘I tend to only reference nursing research. Is that a problem?’

‘Ignore complex theory and method stuff. That has nothing to do with nursing.’

‘Sociology? Okay. But no one’s interested in abstract ideas.’

‘I have to bumph up the literature search bit. It needs more thrown in.’

‘I only read what directly bears on my subject.’

Interpretation of these comments must take into account the fact that nursing is an applied discipline. It is not a traditional academic or purely intellectual subject and, thus, perhaps inevitably, practical contingency and the immediacy and urgency of demands place students, educators and researchers within contexts and under constraints that encourage an inward facing and restrained stance to engagement with the literature to be adopted. This is understandable. Nurses are busy people. Moreover, we do not know whether the above statements exemplify common or generally held thoughts and beliefs. However, when reading is done to enrich the quality of work/thinking, cursory and superficial engagement with the literature may confuse rather than help. It must therefore be wrong – it is at least problematic – when nurses deliberately seek to limit the range of sources accessed, and it is surely misguided to search only for nursing outputs when non-nursing texts offer informative and instructive viewpoints. At root, while many of our activities focus on or coalesce around ‘hands on’ care, theory and scholarly discourse should not be disparaged or seen as irrelevant when, if taken seriously, this type of material might complement and advance understanding about nursing’s staple concerns.

Student, educator and researcher comments can also be placed within broader conversations concerning the changing nature of higher education (see e.g. Daylight, 2017). Debates of this sort tend to be doom-laden (see Preface). They accentuate deterioration and underplay the positive. Nonetheless, while we want nurses to be interested and enthused by the subjects they study and the projects they undertake, it is suggested that proliferating ‘sectoral managerialism’ (itself a telling phrase), increasing financial burdens (i.e. rising student debt), and reductions in the resources available to students and researchers all combine to cut away at scholarship and education’s more expansive or liberatory potential (Rand, 1984b [1972]; Rolfe, 2012; Traynor, 2013; Glaser, 2015; Graeber, 2015; Paley, 2016; Darbyshire, Thompson and Watson, 2019). That is, when students and researchers operate within clipped and disabling structures, we should not be startled when real learning is marginalised. In these circumstances modules become simply hoops that must be jumped through on the race to accreditation, and research becomes formulaic, tired and uninspired. Understandably, the adoption of narrowly restricted reading strategies is explicable if regrettable in such situations.

Yet, excuses aside, given nursing’s telos or purpose, where underperformance materially and negatively impacts on research, education, and by implication practice, concern with this subject is presumably mandated from the members of a profession which claims it is “other-regarding” (Sellman, 2016, p. 24). Location and appraisal are done well. Often, they are performed superbly. However, searches and reviews of questionable quality are readily sourced and – as the comments reproduced above possibly suggest – regardless of the existence of excellence, something is seriously amiss within parts of the profession. I vehemently and wholeheartedly reject the insular and blinkered attitude to location and appraisal, reading, and cross- and interdisciplinary learning that these quotations assume. It is instead contended that, regardless of the sort of question posed, nurse reviewers need to read more deeply and widely than is at present often the case. And although the connection is difficult to substantiate, I assert that links exist between comprehensive reading, our ability to contemplate and think through what it is that we do and, potentially, improved patient care. My conception of ‘good’ searches and reviews require that we look more critically at our own literature and, when apposite, we need to be prepared to engage with non-nursing sources, including sources located in the humanities and arts. I further propose that checks on what is achievable must be refused, and should the approach that I advocate be adopted, some reassessment of both EBP and nursing’s identity or self-image will be required.

Depending on your outlook the reassessment being promoted is either sensible and mundane, or dangerously radical. The full extent and meaning of what is proposed is made clear in subsequent chapters. However, statements by Gray, Hassanien and Thompson (2017) point towards what I have in mind. Thus, they claim that many nursing researchers turn to high ranking non-nursing journals to publish their work, and they go on to ask “Can this be good for the profession? Surely the best nursing science should be published in the best nursing journals?” (ibid., p. 2034). By reply, I would say ‘not always’.

If nurses want to access the most informative material, and when that material exists in the literature of other disciplines, we should want and be prepared to read outside of nursing. Likewise, in deciding where researcher outputs are to be placed, the benefits, such as they are, of publishing in ‘the best nursing journals’ are just one of the factors that require consideration. Indeed, if the topic or question investigated by nurse researchers is more fully addressed in non-nursing journals, or if a non-nursing journal with a high impact factor is keen to take ‘our’ writing (and let us assume this suggests more people will read and/or cite that work), why not publish in that journal? Nurse researchers produce ideas and findings that are of interest to others, but if we only spe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• In first person – a preface
• Acknowledgements
• 1. Introductory harrumphing
• 2. Two types of question
• 3. Conceptual muddle: an ordinary search (part I)
• 4. Beliefs and values: an ordinary search (part II)
• 5. Nursing and non-nursing sources: an ordinary search (part III)
• 6. Reviewing quantitative research
• 7. Reviewing qualitative research
• 8. The final curtain
• References
• Index