METHODOLOGICAL ISSUES IN NURSING RESEARCH The integrative review: updated methodology

s or dissertations) were excluded (Whittemore 2005b). Data evaluation stage In meta-analysis and systematic reviews, extraction of specific methodological features of primary studies is recommended in order to evaluate overall quality (Cooper 1998, others). Quality scores are subsequently incorporated into the data analysis stage. However, the notion and process of quality is complex and there is no gold standard for calculating quality scores (Jadad et al. 1998, Conn & Rantz 2003). Each type of research design generally has different criteria that exemplify quality (that is, randomization in two-group designs). Therefore, the process is more conducive to reviews in which the sampling frame is narrow and the research designs included are similar, if not identical. Evaluating quality of primary sources in the integrative review method where diverse primary sources are included increases the complexity. Should broader quality criteria that may encompass different research designs and literature be used (losing specificity)? Or should multiple design or literature-specific quality evaluations be undertaken (complicating analysis)? In addition, how is quality defined for primary sources that are not empirical? As no gold standard Table 1 Example of integrative review on the concept of integration (Whittemore 2005b) Stage of review Illustration of decisions and issues Problem identification Theoretical and empirical work in the past decade related to the concept of integration suggested that integration was an important aspect of healing and living with a chronic illness. However, it was unclear what the similarities were across empirical and theoretical reports and whether the process of integration was similar across health-related issues. Greater understanding of the concept of integration was proposed as a possibly effective way to identify stages of healing responsive to nursing interventions. Therefore, the purpose of this integrative review was to analyse the concept of integration as related to health and illness. Literature search Having a specific focus on the experience of integration as related to health, illness, or nursing care facilitated the literature search stage. After using integration as a keyword in the CINAHL database, reports were initially excluded if integration was discussed in terms of health care systems (integrating a new policy in the workplace) or health care education (integrating theory and research into practice). By focusing the review, potentially relevant sources identified were reduced from 3982 to less than 200 reports. Data evaluation The final sample for this integrative review included empirical and theoretical reports. Empirical reports included a wide variety of methods: case study, cross-sectional, grounded theory, phenomenology, and instrument development designs. Due to this diverse representation of primary sources, reports were coded according to two criteria relevant to this review: methodological or theoretical rigour and data relevance on a 2-point scale (high or low). No report was excluded based on this data evaluation rating system; however, the score was included as a variable in the data analysis stage. In general, reports of low rigour and relevance contributed less to the analytic process. Data analysis Data were extracted from primary sources on sample characteristics and method (if empirical) as well as any reference to the concept of integration. Categories that were extracted included the definition of integration, aspects of the process of integration, antecedents, consequences, and facilitators of integration. Related terms were identified in addition to proposed relationships of integration to other variables. Data display matrices were developed to display all of the coded data from each report by category and were iteratively compared. As data were conceptualized at higher levels of abstraction, each primary source was reviewed to verify that the new conceptualization was congruent with primary sources. Presentation A synthesis in the form of a model was developed to comprehensively portray the process of integration. Methodological issues in nursing research Integrative review 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(5), 546–553 549 for evaluating and interpreting quality in research reviews exists, how quality is evaluated in an integrative review will vary depending on the sampling frame. For example, in an integrative review where primary sources are of a similar research design, calculating quality scores and incorporating these scores into the design (that is, inclusion or exclusion criteria) or the analysis may be optimal. In an integrative review with diverse empirical sources, it may only be reasonable to evaluate quality in sources that represent outliers (that is, is methodological quality a viable reason for the discrepant finding?). In an integrative review with a diverse sampling frame inclusive of empirical and theoretical sources, an approach to evaluating quality similar to historical research may be appropriate. In this case, the authenticity, methodological quality, informational value, and representativeness of available primary sources is considered and discussed in the final report (Kirkevold 1997). Theoretical reports may also be evaluated using techniques of theory analysis and critique (Walker & Avant 1995, Chinn & Kramer 2004). It can be seen that evaluating quality of primary sources in an integrative review is complex. Ideally, consideration of the quality of primary sources in an integrative review is addressed in a meaningful way. For example, in a review that encompasses theoretical and empirical sources, two quality criteria instruments could be developed for each type of source and scores could be used as criteria for inclusion/exclusion or as a variable in the data analysis stage as identified in the integrative review of the concept of integration (Table 1). Further practical application and discussion of these proposed strategies are indicated.