Theoretical and Scientific Foundations of Nursing

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Practical Tips for Literature Synthesis Cheryl Westlake, PhD, RN, ACNS-BC

The clinical nurse specialist (CNS), as an advanced practice nurse, has the primary goal of continuous improvement in patient outcomes and nursing care

by creating clinical practice environments that reflect evidence-based practices and interventions.1 A synthesis of the literature may be needed to answer a clinical ques- tion for implementation in practice, serve as an indepen- dent paper for publication as a review, or be part of a larger project such as a research proposal, dissertation, or data-based publication. In order to achieve this goal, the CNS needs to be able to systematically review the lit- erature and synthesize the findings on issues related to patient outcomes and nursing care.

The synthesis of the literature is intended to do more than just document or summarize the relevant literature. Rather, the synthesis of the literature is intended to pro- vide a detailed analysis and yield conclusions about the current state of the science and the knowledge gaps about the topic of interest. An example of such a review created by Dumoulin and Hay-Smith2 on pelvic floor muscle training for urinary incontinence in women was published as a synopsis in the journal Clinical Nurse Specialist by McLoughlin and McAuley.3 The review serves as the example cited throughout this article.

While creating and writing a synthesis of the literature may seem like a daunting task to the CNS who has many demanding responsibilities and literature sources with which to maintain currency, the goal of this article is to provide a simple guide for the process that may be used easily by the CNS. Specifically, the purpose of this article is to provide a step-by-step process of how one might approach the literature synthesis. The specific topics covered in this article are the steps involved in a synthe- sis of the literature including recommendations about

how to analyze each individual paper for potential inclu- sion in the analysis and synthesis, specific processes for analyzing the collective papers, and suggestions for writ- ing the final product. Tools one might use to facilitate the process with examples using the Dumoulin and Hay- Smith’s2 article are provided to smooth the process and soothe the mind of the ambitious CNS.

A literature synthesis is a focused review, in-depth eval- uation, critical analysis, and creative compilation of infor- mation based on patterns, alternatives, or relationships gleaned from the process that allow one to come to a higher level of understanding or knowledge about a spe- cific topic. ‘‘It works very much like a jigsaw puzzle. The individual pieces (arguments) must be put together in or- der to reveal the whole (state of knowledge).’’4

CONSIDER AND REFINE THE QUESTION The first step in the synthesis of the literature is to care- fully consider and refine the question the CNS wishes to ask of the literature. Particular attention to the proposed concepts, research design, sample selection criteria and process, measures, and statistical analyses is warranted and recommended to ease the process. Refinement of the topic and clarity about the question are critical at the onset and is enhanced by the expert knowledge base of the CNS. The eventual quality of the synthesis of the literature is dependent, in part, on this important first step. Issues for consideration are provided in Figure 1.

Using the example of urinary incontinence, the posed question may have been: What is the difference in wom- en’s outcomes for different interventions for urinary in- continence including to pelvic floor muscle training?

LITERATURE SEARCH Next, the CNS needs to consider the focused question and describe the state of the science related to the CNS’s potential future as reflected in the available literature. In addition, the CNS needs to address the knowledge gaps and the areas where the available literature does not inform the CNS’s potential future project. The quality of

Author Affiliation: Professor and Associate Dean, International and Community Programs, School of Nursing, Azusa Pacific University, California. The author reports no conflicts of interest. Correspondence: Cheryl Westlake, PhD, RN, ACNS-BC, School of Nurs- ing, Azusa Pacific University, 720 E Foothill Blvd, Azusa CA 91702 ([email protected]). DOI: 10.1097/NUR.0b013e318263d766

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Column Editor: Janice Buelow, PhD, RN, FAAN

the literature search is dependent on the thoroughness and accuracy of the writer’s search. Thus, consultation with a librarian is recommended as librarians are expert in search methods and terms.

The refinement of the question and the review of the literature is an iterative process that is recursive in nature with the desired end point a fully refined and focused question with a matching review of the literature. This second step may require some consideration of the ques- tion, review and sorting of the literature, and reconsidera- tion and refinement of the question with another return to the literature (Figure 2).

With each iteration, the CNS is wise to document the changes, additions, or deletions made in the search terms and databases. These changes may be made by hand in a paper notebook at the side one’s computer, online in a notebook such as Notepad (http://www.google.com/ notebook/#b=BDQmGSgoQl92H_PAm) Evernote (http://www .evernote.com/ for personal computer users, or Evernote for Mac users http://www.evernote.com/), or Notes on the iPad, or in a simple word document, or using an applica- tion such as StickyNotes (http://www.sticky-notes.net/ for personal computer users and stickynotesapp.com for Mac users). Whatever the method, the CNS is now well poised to move forward, and the documented changes will serve to streamline the third step.

LITERATURE SEARCH METHODS A complete and comprehensive description of the liter- ature search in very specific, concrete terms is required next. Begin with an introduction that outlines the empir- ical literature reviewed explaining the methods used in your literature search. Remember to include the search strategies, keywords used, databases and periods searched, a description of articles that were excluded and the ra- tionale for the exclusion. For example, considering the question about pelvic floor muscle training posed at the

outset, the following might be offered regarding the search. A search in CINAHL plus full text, Health Source: Nursing/Academic Edition, and MEDLINE with full text of English-language, peer-reviewed, research articles of adult (919 years of age) women using the search terms pelvic floor muscle training yielded 51 results for from 2002 to 2012 that reduced to 38 by adding urinary incon- tinence andwas further reduced to 32 by adding women. All articles were read. Six articles were not included in the final review of the literature. Three were deemed in- appropriate on the basis of the population,5Y7 a fourth because the study was an economic evaluation not a clinical evaluation,8 and 2 additional articles as they were not clinical research studies.9,10 Thus, 26 articles were included for the next stet.

ANALYZE INDIVIDUAL, RETAINED PAPERS Now that the articles for inclusion in the review of the literature have been identified in a cursory fashion, the CNS must critically appraise the quality of the selected empirical studies. Based on the internal (instrument re- liability and statistics, equivalence of participant charac- teristics, and control of experience/environment variables) and external validity characteristics (operations and instru- ment validity, population validity, and ecological validity) by Cook and Campbell,11 evaluate each study that re- mains for consideration in the review of the literature. This review may be done by the CNS and another col- league or two or by an external judge panel. Those arti- cles that are evaluated as being of sufficient quality will be retained for the review of the literature.

REVIEW AND ORGANIZE THE LITERATURE Once the relevant, high quality papers have been iden- tified and located, one needs to read, analyze, and or- ganize them to begin the synthesis. The first step is to analyze each individual article and then organize all the

FIGURE 1. Define your research question.

FIGURE 2. Question refinement and literature review.

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http://www.evernote.com/

http://www.sticky-notes.net/

http://stickynotesapp.com

articles into a usable format for review and synthesis col- lectively. The method frequently used in nursing research courses is to compile the individual articles into a table of evidence or matrix table.12,13

An example of a single entry in a table of evidence using an article from our pelvic floor muscle training muscle re- view of literature is provided in Table 1.13 The table of evidence would include an entry with the associated data included for each of the retained studies.

STRUCTURE AND SUMMARIZE THE LITERATURE Now, the CNS is ready to reflect about the studies in the table for the purpose of structuring and summarizing the information. Review the studies, take notes, sort, and or- ganize your concepts and their relationships. Seek the common points or themes that allow the individual arti- cles to be grouped into specific categories. The created similarity heuristic will facilitate the development of a ta- ble of these common points or themes that will serve as an organizing framework for analyzing, and synthesizing of the individual articles into a whole. These categories may be used later to organize the article.

The CNS may wish to organize all the individual articles using a single table with all the potential relationships in- dicated and the studies supporting or refuting the relation- ships cited in the table. Using our pelvic floor muscle training example and the article of Borello-France et al,13

the table might be constructed as in Table 2. The final table would include all articles retained in the review of the literature.

Into each of the boxes where a relationship is de- scribed in the table of evidence, a plus or minus sign and the authors/date may be written to indicate studies where the relationship is supported or refuted. Notes and thoughts may be written in the margins for reflection in order for conclusions to be drawn.

Another variation on the similarity heuristic table may be to create the table using only the interventions as the common points across which the literature is reviewed. Now, the CNS might complete the table as indicated in Table 3 and synthesize the literature by intervention. The article by Borello-France et al13 is included in the sample (Table 3). As the original question posed in the pelvic floor muscle training was about a comparison of interventions, such a table may be most useful. Similar to Table 2, all retained articles would be included in the fi- nal version of Table 3.

Another strategy to synthesize the collective literature the CNS may wish to consider is the use of a concept map. Concept maps are tools for organizing and graphically re- presenting knowledge. The concepts are usually indicated by circles or boxes, and the relationships among concepts by colors and between concepts by lines or arrows, if the direction is known. Words or symbols such as +,j, &, and % may be placed on the line to describe the relationships between concepts. Such an organizing tool may provide the CNS with a tool to visualize the relationships between and among the concepts. Concept maps have been described as particularly useful for organizing complex scientific in- formation14 and creating a literature review (Figure 3).15Y18

Table 1. Table of Evidence

Method Sample (Age; UI, SI, UrI, or Mixed)

Treatment (PFMT, None, Sham, PL, or Other)

Outcome (SC, SxI, QOL) Risk Bias

& 2-Arm RCT, parallel design & N = 44 & PFMT supine (n = 22) & Primary end point at 9Y12 wk

& Random sequence generationa& Comparison: supine

PFMT vs supine and upright PFMT

& SI & PFMT alternate exercise between supine, sitting, and standing positions (n = 22)

& Primary outcome: not stated

& Allocation concealmenta

& No a priori power calculation

& 1 US site

& Other outcomemeasures & Blindingb & 38Y70 y old

) QOL (IIQ) & Incomplete outcome datac

& Not pregnant

) Urinary diary & Selective reportingd

& Ambulatory

) Modified 1-h pad test & Symptoms of SI Q1/wk

) Digital PFM assessment (Brink scale)

& Mean age: 51.7 T 8.9 y vs 53.6 T 8.1 y

Abbreviations: IIQ, Incontinence Impact Questionnaire; PFM, pelvic floor muscle; PFMT, pelvic floor muscle training; PL, placebo; QOL, quality of life; RCT, random- ized controlled trial; SC, symptomatic cure; SI, stress incontinence; SxI, symptomatic improvement; UI, urinary incontinence; UrI, urge incontinence. aSelection bias. bPerformance bias and detection bias. cAttrition bias. dReporting bias. Borello-France et al.13

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The literature review as a concept map for the pelvic floor muscle training is represented as an example in Figure 4.

The concept map may be created as a rough hand- drawn diagram, on a computer using a simple document format or concept mapping software (www.SmartDraw.com for personal computer users or Inspiration Maps for the iPadhttp://www.inspiration.com/ipad), or online-developed sticky notes or note cards.

SYNTHESIZE THE LITERATURE At this step, the CNS is challenged with drawing conclu- sions about the concepts and their relationship. Note re- peated words, concepts, and instruments, and conceptual, methodological, and analytical conflicts or contradictions within and between studies. The identification of the pat- terns, trends, strengths, and weaknesses of the reviewed literature may be accomplished by examining the similar- ities and differences between and among the concepts. The state of the science about the topic must be de- scribed, the knowledge gaps illuminated, and the clinical implications delineated. Keep the original question in the forefront as the synthesis is conducted and later written. The synthesis will describe these concepts and their rela- tionships in a way that is novel and creative and may lay the foundation for future work or study.

WRITE THE LITERATURE SYNTHESIS PAPER The final step is for the CNS to write the paper describing the synthesis of the literature. Begin with the question in mind and provide the reader with the rationale about why the synthesis is needed. The background and ratio- nale for the synthesis of the literature may assist the reader in understanding the scope of the concepts, literature, syn- thesis, and implications. Use the steps as the outline for the written work. Tables and figures created by the CNS may serve to communicate the process and elucidate the relation- ships between and among concepts. Describe the similarities and differences, methods and limitations, and strengths and weaknesses of the literature as a whole. Use headings and subheadings to allow the reader to track and facilitate greater understanding of the synthesis of the literature. Focus on the question the synthesis addresses and the totality of the literature rather than on the individual papers. Finish your paper with a concluding paragraph that summarizes the critical findings offered. The use of bullet points may make your key findings abundantly obvious.19 Finally, pro- vide the reader with the important clinical and research implications of the synthesis in a few sentences. Using the example of our pelvic floor muscle training question, Dumoulin and Hay-Smith2 offered:

Table 3. Table Matrix Alternate Form

UI SI UrI

PFMT SC

SxI

QOL Borello-France et al13

& Effect of exercise position (supine or supine and upright positions) - IIQ at baseline and after treatment

& Exercise position j

& PFMT +

Sham SC

SxI

QOL

Placebo SC

SxI

QOL

Other SC

SxI

QOL

Abbreviations: IIQ, Incontinence Impact Questionnaire; QOL, quality of life; PFM, pelvic floor muscle; PFMT, pelvic floor muscle training; SC, symptomatic cure; SI, stress incontinence; SxI, symptomatic improvement; UI, urinary incontinence; UrI, urge incontinence.

Table 2. Literature Matrix

Age PFMT

SHAM, Placebo, Other SC SxI QOL

SI Borello-France et al13j +; no effect of position

UrI

Age X

PFMT X Borello-France et al13 + IIQ; no effect of position

Sham, placebo, other

SC X

SxI X

QOL X

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The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programs for women with stress, urge, or mixed urinary incontinence. Statistical heterogeneity reflecting variation in incontinence type, training, and outcome measurement made interpretation difficult. The treatment effect seems greater in women with stress urinary incontinence alone, who participate in a supervised PFMT program for at least 3 months, but these and other uncertainties require testing in further trials.2(p2)

In summary, a synthesis of the literature is a high-level skill needed often by the CNS in achieving the goals of continuous improvement in patient outcomes and nurs-

ing care through evidence-based practices and interven- tions. The skill may be described in a 7-step process:

1. consider and refine the question to be addressed in the synthesis of the literature;

2. search the literature for relevant studies; 3. analyze the quality of the individual articles; 4. review and organize the literature into a manage-

able form; 5. structure and summarize the collective literature; 6. synthesize the literature addressing the state of the

science and knowledge gaps regarding the original question; and

7. write the synthesis of the literature. Tools the CNS might use to facilitate the process such

as a table of evidence, literature matrix, or concept map

FIGURE 3. Concept mapVsorting relevant information. From Steinerová.19

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were offered, and examples of each provided. Hopefully, the individual CNS reader will feel more empowered to generate and publish these important literature syntheses in order that all CNSs might benefit and use the review in the quest to improve patient outcome\s and nursing care.

Resources Literature Review: Synthesizing Multiple Sources. http://www.iupui

.edu/~uwc/pdf/Literature%20Review%20and%20Synthesis.pdf. Writing A Literature Review and Using a Synthesis Matrix. http://

www.ncsu.edu/tutorial_center/writespeak/PDF%20Handouts/ synthesis%20matrix.pdf.

The Use of Mapping in Literature Review. http://sites.google.com/ site/andycoverdale/texts/the-use-of-mapping-in-literature-review.

Galvan J. Writing Literature Reviews: A Guide for Students of the Be-

havioral Sciences. 3rd ed. Glendale, CA: Pyrczak Publishing; 2006.

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2. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;(1):CD005654.

3. McLoughlin G, McAuley C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incon- tinence in women. Clin Nurse Spec. 2010;25(5):226Y227.

4. NC State University Writing and Speaking Tutorial Service Tu- tors. 2006. http://www.ncsu.edu/tutorial_center/writespeak/ PDF%20Handouts/synthesis%20matrix.pdf. Accessed April 19, 2012.

5. Mason L, Roe B, Wong H, Davies J, Bamber J. The role of ante- natal pelvic floor muscle exercises in prevention of postpar- tum stress incontinence: a randomised controlled trial. J Clin Nurs. 2010;19(19/20):2777Y2786.

6. Dias LAR, Driusso P, Aita DLCC, Quintana SM, B+ K, Ferreira CHJ. Effect of pelvic floor muscle training on labour and new- born outcomes: a randomized controlled trial. Braz J Phys Ther. 2011;15(6):487Y493.

7. Batista RL, Franco MM, Naldoni LMV, Duarte G, Oliveira AS, Ferreira CHJ. Biofeedback and the electromyographic activity of pelvic floor muscles in pregnant women. Braz J Phys Ther. 2011;15(5):386Y392.

8. Brunenberg DE, Joore MA, Veraart CP, Berghmans BC, van der Vaart CH, Severens JL. Economic evaluation of duloxetine for the treatment of women with stress urinary incontinence: a Markov model comparing pharmacotherapy with pelvic floor muscle training. Clin Ther. 2006;28(4):604Y618.

9. BL K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Med. 2004;34(7):451Y464.

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11. Cook TD, Campbell DT. Quasi-Experimentation: Design and

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ture review. Alternation. 2007;14(1):262Y276. 13. Borello-France DF, Zyczynski HM, Downey PA, Rause CR,

Wister JA. Effect of pelvic-floor muscle exercise position on con- tinence and quality-of-life outcomes in women with stress uri- nary incontinence. Phys Ther. 2006;86(7):974Y986.

14. Garrard J. Health Sciences Literature Review Made Easy: The

Matrix Method. Gaithersburg, MD: Aspen Publishers; 2004. 15. Novak JD, CaDas AJ. The Theory Underlying Concept Maps and

How to Construct Them; Technical Report IHMC CmapTools 2006-01 Rev 01-2008, Florida Institute for Human and Machine Cognition, 2008. Available at: http://cmap.ihmc.us/Publications/ ResearchPapers/TheoryUnderlyingConceptMaps.pdf. Accessed April 19, 2012.

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tional Conference on Concept Mapping. Tallinn & Helsinki, Finland; 2008.

17. Carnot MJ. Using concept maps to organize information for large scale literature reviews and technical reports: two case studies. In: CaDas AJ, Novak JD, eds. Concept Maps: Theory,

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News. 2004;27(4):31Y39. 19. Steinerová J. Seeking relevance in academic information use.

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FIGURE 4. Concept mapVpelvic floor muscle training. Abbreviations: PFMT, pelvic floor muscle training; SI, stress incontinence; UI, urinary incontinence; UrI, urge incontinence.

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http://www.iupui.edu/~uwc/pdf/Literature%20Review%20and%20Synthesis.pdf

http://www.ncsu.edu/tutorial_center/writespeak/PDF%20Handouts/synthesis%20matrix.pdf

http://sites.google.com/site/andycoverdale/texts/the-use-of-mapping-in-literature-review

http://www.aacn.nche.edu/education-resources/APRNReport.pdf

http://www.ncsu.edu/tutorial_center/writespeak/PDF%20Handouts/synthesis%20matrix.pdf

http://cmap.ihmc.us/Publications/ResearchPapers/TheoryUnderlyingConceptMaps.pdf

http://InformationR.net/ir/13-4/paper380.html