review of the literature in nursing research

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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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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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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Doing a Literature Review in Nursing, Health and Social Care

• Michael Coughlan - Trinity College Dublin, Ireland
• Patricia Cronin - Trinity College Dublin, Ireland
• Description

A clear and practical guide to completing a literature review in nursing and healthcare studies.

Providing students with straightforward guidance on how to successfully carry out a literature review as part of a research project or dissertation, this book uses examples and activities to demonstrate how to complete each step correctly, from start to finish, and highlights how to avoid common mistakes.

The third edition includes:

• Expert advice on selecting and researching a topic
• A chapter outlining the different types of literature review
• Increased focus on Critical Appraisal Tools and how to use them effectively
• New real-world examples presenting best practice
• Instructions on writing up and presenting the final piece of work

Perfect for any nursing or healthcare student new to literature reviews and for anyone who needs a refresher in this important topic.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

Praise for the previous edition:

'This book is an excellent resource for practitioners wishing to develop their knowledge and understanding of reviewing literature and the processes involved. It uses uncomplicated language to signpost the reader effortlessly through key aspects of research processes. Practitioners will find this an invaluable companion for navigating through evidence to identify quality literature applicable to health and social care practice.' 

'Students often struggle with writing an effective literature review and this invaluable guide will help to allay their concerns. Key terms are clearly explained, and the inclusion of learning outcomes is a helpful feature for students and lecturers alike.  The examples are also very helpful, particularly for less confident students.  This is an accessible yet authoritative guide which I can thoroughly recommend.' 

'A must have - this book provides useful information and guidance to students and professionals alike. It guides the reader through various research methods in a theoretical and pragmatic manner.' 

' It's a very readable, concise, and accessible introduction to undertaking a literature review in the field of healthcare. The book’s layout has a logical format which really helped me to think methodically about my research question. An excellent reference for undergraduates who are about to undertake their first literature review.' 

'This book is an essential resource for students. Clearly written and excellently structured, with helpful study tools throughout, it takes the reader step by step through the literature review process in an easy, informative and accessible manner. This text gives students the skills they need to successfully complete their own review.' 

'The updating of the chapters will be exceptionally helpful given the rapid changes in online availability of resources and open-access literature.'  

Excellent text for masters and doctoral level students

An excellent primer to help the level 7 students write their systemised review for the assignment.

This book provides a comprehensive overview of the practical process of literature review in healthcare. It contains all details required to conduct a review by students.

This is an excellent clear and concise book on undertaking literature reviews being particularly good at demystifying jargon. It is timely given the move to student dissertations being primarily literature reviews in the current Covid pandemic. However nearly all the examples are drawn from nursing and health making the text less useful for social care and social work. A little disappointing given the title. SW students are likely to gravitate to texts where their subject is more prominent for a primary text.

Accessible, informative, step to step guide

This is a really helpful, accessible text for students and academic staff alike.

A really good addition to the repertoire of skills and techniques for understanding the essential process of literature reviewing.

Preview this book

For instructors, select a purchasing option, related products.

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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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Bashir Y, Conlon KC. Step by step guide to do a systematic review and meta-analysis for medical professionals. Ir J Med Sci. 2018; 187:(2)447-452 https://doi.org/10.1007/s11845-017-1663-3

Bettany-Saltikov J. How to do a systematic literature review in nursing: a step-by-step guide.Maidenhead: Open University Press; 2012

Bowers D, House A, Owens D. Getting started in health research.Oxford: Wiley-Blackwell; 2011

Hierarchies of evidence. 2016. http://cjblunt.com/hierarchies-evidence (accessed 23 July 2019)

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2008; 3:(2)37-41 https://doi.org/10.1191/1478088706qp063oa

Developing a framework for critiquing health research. 2005. https://tinyurl.com/y3nulqms (accessed 22 July 2019)

Cognetti G, Grossi L, Lucon A, Solimini R. Information retrieval for the Cochrane systematic reviews: the case of breast cancer surgery. Ann Ist Super Sanita. 2015; 51:(1)34-39 https://doi.org/10.4415/ANN_15_01_07

Dixon-Woods M, Cavers D, Agarwal S Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006; 6:(1) https://doi.org/10.1186/1471-2288-6-35

Guyatt GH, Sackett DL, Sinclair JC Users' guides to the medical literature IX. A method for grading health care recommendations. JAMA. 1995; 274:(22)1800-1804 https://doi.org/10.1001/jama.1995.03530220066035

Hanley T, Cutts LA. What is a systematic review? Counselling Psychology Review. 2013; 28:(4)3-6

Cochrane handbook for systematic reviews of interventions. Version 5.1.0. 2011. https://handbook-5-1.cochrane.org (accessed 23 July 2019)

Jahan N, Naveed S, Zeshan M, Tahir MA. How to conduct a systematic review: a narrative literature review. Cureus. 2016; 8:(11) https://doi.org/10.7759/cureus.864

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1997; 33:(1)159-174

Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014; 14:(1) https://doi.org/10.1186/s12913-014-0579-0

Moher D, Liberati A, Tetzlaff J, Altman DG Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009; 6:(7) https://doi.org/10.1371/journal.pmed.1000097

Mueller J, Jay C, Harper S, Davies A, Vega J, Todd C. Web use for symptom appraisal of physical health conditions: a systematic review. J Med Internet Res. 2017; 19:(6) https://doi.org/10.2196/jmir.6755

Murad MH, Asi N, Alsawas M, Alahdab F. New evidence pyramid. Evid Based Med. 2016; 21:(4)125-127 https://doi.org/10.1136/ebmed-2016-110401

National Institute for Health and Care Excellence. Methods for the development of NICE public health guidance. 2012. http://nice.org.uk/process/pmg4 (accessed 22 July 2019)

Sambunjak D, Franic M. Steps in the undertaking of a systematic review in orthopaedic surgery. Int Orthop. 2012; 36:(3)477-484 https://doi.org/10.1007/s00264-011-1460-y

Siddaway AP, Wood AM, Hedges LV. How to do a systematic review: a best practice guide for conducting and reporting narrative reviews, meta-analyses, and meta-syntheses. Annu Rev Psychol. 2019; 70:747-770 https://doi.org/0.1146/annurev-psych-010418-102803

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008; 8:(1) https://doi.org/10.1186/1471-2288-8-45

Wallace J, Nwosu B, Clarke M. Barriers to the uptake of evidence from systematic reviews and meta-analyses: a systematic review of decision makers' perceptions. BMJ Open. 2012; 2:(5) https://doi.org/10.1136/bmjopen-2012-001220

Carrying out systematic literature reviews: an introduction

Alan Davies

Lecturer in Health Data Science, School of Health Sciences, University of Manchester, Manchester

View articles · Email Alan

Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making.

Since their inception in the late 1970s, systematic reviews have gained influence in the health professions ( Hanley and Cutts, 2013 ). Systematic reviews and meta-analyses are considered to be the most credible and authoritative sources of evidence available ( Cognetti et al, 2015 ) and are regarded as the pinnacle of evidence in the various ‘hierarchies of evidence’. Reviews published in the Cochrane Library ( https://www.cochranelibrary.com) are widely considered to be the ‘gold’ standard. Since Guyatt et al (1995) presented a users' guide to medical literature for the Evidence-Based Medicine Working Group, various hierarchies of evidence have been proposed. Figure 1 illustrates an example.

Systematic reviews can be qualitative or quantitative. One of the criticisms levelled at hierarchies such as these is that qualitative research is often positioned towards or even is at the bottom of the pyramid, thus implying that it is of little evidential value. This may be because of traditional issues concerning the quality of some qualitative work, although it is now widely recognised that both quantitative and qualitative research methodologies have a valuable part to play in answering research questions, which is reflected by the National Institute for Health and Care Excellence (NICE) information concerning methods for developing public health guidance. The NICE (2012) guidance highlights how both qualitative and quantitative study designs can be used to answer different research questions. In a revised version of the hierarchy-of-evidence pyramid, the systematic review is considered as the lens through which the evidence is viewed, rather than being at the top of the pyramid ( Murad et al, 2016 ).

Both quantitative and qualitative research methodologies are sometimes combined in a single review. According to the Cochrane review handbook ( Higgins and Green, 2011 ), regardless of type, reviews should contain certain features, including:

• Clearly stated objectives
• Predefined eligibility criteria for inclusion or exclusion of studies in the review
• A reproducible and clearly stated methodology
• Validity assessment of included studies (eg quality, risk, bias etc).

The main stages of carrying out a systematic review are summarised in Box 1 .

Formulating the research question

Before undertaking a systemic review, a research question should first be formulated ( Bashir and Conlon, 2018 ). There are a number of tools/frameworks ( Table 1 ) to support this process, including the PICO/PICOS, PEO and SPIDER criteria ( Bowers et al, 2011 ). These frameworks are designed to help break down the question into relevant subcomponents and map them to concepts, in order to derive a formalised search criterion ( Methley et al, 2014 ). This stage is essential for finding literature relevant to the question ( Jahan et al, 2016 ).

It is advisable to first check that the review you plan to carry out has not already been undertaken. You can optionally register your review with an international register of prospective reviews called PROSPERO, although this is not essential for publication. This is done to help you and others to locate work and see what reviews have already been carried out in the same area. It also prevents needless duplication and instead encourages building on existing work ( Bashir and Conlon, 2018 ).

A study ( Methley et al, 2014 ) that compared PICO, PICOS and SPIDER in relation to sensitivity and specificity recommended that the PICO tool be used for a comprehensive search and the PICOS tool when time/resources are limited.

The use of the SPIDER tool was not recommended due to the risk of missing relevant papers. It was, however, found to increase specificity.

These tools/frameworks can help those carrying out reviews to structure research questions and define key concepts in order to efficiently identify relevant literature and summarise the main objective of the review ( Jahan et al, 2016 ). A possible research question could be: Is paracetamol of benefit to people who have just had an operation? The following examples highlight how using a framework may help to refine the question:

• What form of paracetamol? (eg, oral/intravenous/suppository)
• Is the dosage important?
• What is the patient population? (eg, children, adults, Europeans)
• What type of operation? (eg, tonsillectomy, appendectomy)
• What does benefit mean? (eg, reduce post-operative pyrexia, analgesia).

An example of a more refined research question could be: Is oral paracetamol effective in reducing pain following cardiac surgery for adult patients? A number of concepts for each element will need to be specified. There will also be a number of synonyms for these concepts ( Table 2 ).

Table 2 shows an example of concepts used to define a search strategy using the PICO statement. It is easy to see even with this dummy example that there are many concepts that require mapping and much thought required to capture ‘good’ search criteria. Consideration should be given to the various terms to describe the heart, such as cardiac, cardiothoracic, myocardial, myocardium, etc, and the different names used for drugs, such as the equivalent name used for paracetamol in other countries and regions, as well as the various brand names. Defining good search criteria is an important skill that requires a lot of practice. A high-quality review gives details of the search criteria that enables the reader to understand how the authors came up with the criteria. A specific, well-defined search criterion also aids in the reproducibility of a review.

Search criteria

Before the search for papers and other documents can begin it is important to explicitly define the eligibility criteria to determine whether a source is relevant to the review ( Hanley and Cutts, 2013 ). There are a number of database sources that are searched for medical/health literature including those shown in Table 3 .

The various databases can be searched using common Boolean operators to combine or exclude search terms (ie AND, OR, NOT) ( Figure 2 ).

Although most literature databases use similar operators, it is necessary to view the individual database guides, because there are key differences between some of them. Table 4 details some of the common operators and wildcards used in the databases for searching. When developing a search criteria, it is a good idea to check concepts against synonyms, as well as abbreviations, acronyms and plural and singular variations ( Cognetti et al, 2015 ). Reading some key papers in the area and paying attention to the key words they use and other terms used in the abstract, and looking through the reference lists/bibliographies of papers, can also help to ensure that you incorporate relevant terms. Medical Subject Headings (MeSH) that are used by the National Library of Medicine (NLM) ( https://www.nlm.nih.gov/mesh/meshhome.html) to provide hierarchical biomedical index terms for NLM databases (Medline and PubMed) should also be explored and included in relevant search strategies.

Searching the ‘grey literature’ is also an important factor in reducing publication bias. It is often the case that only studies with positive results and statistical significance are published. This creates a certain bias inherent in the published literature. This bias can, to some degree, be mitigated by the inclusion of results from the so-called grey literature, including unpublished work, abstracts, conference proceedings and PhD theses ( Higgins and Green, 2011 ; Bettany-Saltikov, 2012 ; Cognetti et al, 2015 ). Biases in a systematic review can lead to overestimating or underestimating the results ( Jahan et al, 2016 ).

An example search strategy from a published review looking at web use for the appraisal of physical health conditions can be seen in Box 2 . High-quality reviews usually detail which databases were searched and the number of items retrieved from each.

A balance between high recall and high precision is often required in order to produce the best results. An oversensitive search, or one prone to including too much noise, can mean missing important studies or producing too many search results ( Cognetti et al, 2015 ). Following a search, the exported citations can be added to citation management software (such as Mendeley or Endnote) and duplicates removed.

Title and abstract screening

Initial screening begins with the title and abstracts of articles being read and included or excluded from the review based on their relevance. This is usually carried out by at least two researchers to reduce bias ( Bashir and Conlon, 2018 ). After screening any discrepancies in agreement should be resolved by discussion, or by an additional researcher casting the deciding vote ( Bashir and Conlon, 2018 ). Statistics for inter-rater reliability exist and can be reported, such as percentage of agreement or Cohen's kappa ( Box 3 ) for two reviewers and Fleiss' kappa for more than two reviewers. Agreement can depend on the background and knowledge of the researchers and the clarity of the inclusion and exclusion criteria. This highlights the importance of providing clear, well-defined criteria for inclusion that are easy for other researchers to follow.

Full-text review

Following title and abstract screening, the remaining articles/sources are screened in the same way, but this time the full texts are read in their entirety and included or excluded based on their relevance. Reasons for exclusion are usually recorded and reported. Extraction of the specific details of the studies can begin once the final set of papers is determined.

Data extraction

At this stage, the full-text papers are read and compared against the inclusion criteria of the review. Data extraction sheets are forms that are created to extract specific data about a study (12 Jahan et al, 2016 ) and ensure that data are extracted in a uniform and structured manner. Extraction sheets can differ between quantitative and qualitative reviews. For quantitative reviews they normally include details of the study's population, design, sample size, intervention, comparisons and outcomes ( Bettany-Saltikov, 2012 ; Mueller et al, 2017 ).

Quality appraisal

The quality of the studies used in the review should also be appraised. Caldwell et al (2005) discussed the need for a health research evaluation framework that could be used to evaluate both qualitative and quantitative work. The framework produced uses features common to both research methodologies, as well as those that differ ( Caldwell et al, 2005 ; Dixon-Woods et al, 2006 ). Figure 3 details the research critique framework. Other quality appraisal methods do exist, such as those presented in Box 4 . Quality appraisal can also be used to weight the evidence from studies. For example, more emphasis can be placed on the results of large randomised controlled trials (RCT) than one with a small sample size. The quality of a review can also be used as a factor for exclusion and can be specified in inclusion/exclusion criteria. Quality appraisal is an important step that needs to be undertaken before conclusions about the body of evidence can be made ( Sambunjak and Franic, 2012 ). It is also important to note that there is a difference between the quality of the research carried out in the studies and the quality of how those studies were reported ( Sambunjak and Franic, 2012 ).

The quality appraisal is different for qualitative and quantitative studies. With quantitative studies this usually focuses on their internal and external validity, such as how well the study has been designed and analysed, and the generalisability of its findings. Qualitative work, on the other hand, is often evaluated in terms of trustworthiness and authenticity, as well as how transferable the findings may be ( Bettany-Saltikov, 2012 ; Bashir and Conlon, 2018 ; Siddaway et al, 2019 ).

Reporting a review (the PRISMA statement)

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides a reporting structure for systematic reviews/meta-analysis, and consists of a checklist and diagram ( Figure 4 ). The stages of identifying potential papers/sources, screening by title and abstract, determining eligibility and final inclusion are detailed with the number of articles included/excluded at each stage. PRISMA diagrams are often included in systematic reviews to detail the number of papers included at each of the four main stages (identification, screening, eligibility and inclusion) of the review.

Data synthesis

The combined results of the screened studies can be analysed qualitatively by grouping them together under themes and subthemes, often referred to as meta-synthesis or meta-ethnography ( Siddaway et al, 2019 ). Sometimes this is not done and a summary of the literature found is presented instead. When the findings are synthesised, they are usually grouped into themes that were derived by noting commonality among the studies included. Inductive (bottom-up) thematic analysis is frequently used for such purposes and works by identifying themes (essentially repeating patterns) in the data, and can include a set of higher-level and related subthemes (Braun and Clarke, 2012). Thomas and Harden (2008) provide examples of the use of thematic synthesis in systematic reviews, and there is an excellent introduction to thematic analysis by Braun and Clarke (2012).

The results of the review should contain details on the search strategy used (including search terms), the databases searched (and the number of items retrieved), summaries of the studies included and an overall synthesis of the results ( Bettany-Saltikov, 2012 ). Finally, conclusions should be made about the results and the limitations of the studies included ( Jahan et al, 2016 ). Another method for synthesising data in a systematic review is a meta-analysis.

Limitations of systematic reviews

Apart from the many advantages and benefits to carrying out systematic reviews highlighted throughout this article, there remain a number of disadvantages. These include the fact that not all stages of the review process are followed rigorously or even at all in some cases. This can lead to poor quality reviews that are difficult or impossible to replicate. There also exist some barriers to the use of evidence produced by reviews, including ( Wallace et al, 2012 ):

• Lack of awareness and familiarity with reviews
• Lack of access
• Lack of direct usefulness/applicability.

Meta-analysis

When the methods used and the analysis are similar or the same, such as in some RCTs, the results can be synthesised using a statistical approach called meta-analysis and presented using summary visualisations such as forest plots (or blobbograms) ( Figure 5 ). This can be done only if the results can be combined in a meaningful way.

Meta-analysis can be carried out using common statistical and data science software, such as the cross-platform ‘R’ ( https://www.r-project.org), or by using standalone software, such as Review Manager (RevMan) produced by the Cochrane community ( https://tinyurl.com/revman-5), which is currently developing a cross-platform version RevMan Web.

Carrying out a systematic review is a time-consuming process, that on average takes between 6 and 18 months and requires skill from those involved. Ideally, several reviewers will work on a review to reduce bias. Experts such as librarians should be consulted and included where possible in review teams to leverage their expertise.

Systematic reviews should present the state of the art (most recent/up-to-date developments) concerning a specific topic and aim to be systematic and reproducible. Reproducibility is aided by transparent reporting of the various stages of a review using reporting frameworks such as PRISMA for standardisation. A high-quality review should present a summary of a specific topic to a high standard upon which other professionals can base subsequent care decisions that increase the quality of evidence-based clinical practice.

• Systematic reviews remain one of the most trusted sources of high-quality information from which to make clinical decisions
• Understanding the components of a review will help practitioners to better assess their quality
• Many formal frameworks exist to help structure and report reviews, the use of which is recommended for reproducibility
• Experts such as librarians can be included in the review team to help with the review process and improve its quality

CPD reflective questions

• Where should high-quality qualitative research sit regarding the hierarchies of evidence?
• What background and expertise should those conducting a systematic review have, and who should ideally be included in the team?
• Consider to what extent inter-rater agreement is important in the screening process

• Research article
• Open access
• Published: 16 May 2019

An analysis of current practices in undertaking literature reviews in nursing: findings from a focused mapping review and synthesis

• Helen Aveyard   ORCID: orcid.org/0000-0001-5133-3356 1 &
• Caroline Bradbury-Jones 2  

BMC Medical Research Methodology volume  19 , Article number:  105 ( 2019 ) Cite this article

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In this paper we discuss the emergence of many different methods for doing a literature review. Referring back to the early days, when there were essentially two types of review; a Cochrane systematic review and a narrative review, we identify how the term systematic review is now widely used to describe a variety of review types and how the number of available methods for doing a literature review has increased dramatically. This led us to undertake a review of current practice of those doing a literature review and the terms used to describe them.

We undertook a focused mapping review and synthesis. Literature reviews; defined as papers with the terms review or synthesis in the title, published in five nursing journals between January 2017–June 2018 were identified. We recorded the type of review and how these were undertaken.

We identified more than 35 terms used to describe a literature review. Some terms reflected established methods for doing a review whilst others could not be traced to established methods and/or the description of method in the paper was limited. We also found inconsistency in how the terms were used.

We have identified a proliferation of terms used to describe doing a literature review; although it is not clear how many distinct methods are being used. Our review indicates a move from an era when the term narrative review was used to describe all ‘non Cochrane’ reviews; to a time of expansion when alternative systematic approaches were developed to enhance rigour of such narrative reviews; to the current situation in which these approaches have proliferated to the extent so that the academic discipline of doing a literature review has become muddled and confusing. We argue that an ‘era of consolidation’ is needed in which those undertaking reviews are explicit about the method used and ensure that their processes can be traced back to a well described, original primary source.

Peer Review reports

Over the past twenty years in nursing, literature reviews have become an increasingly popular form of synthesising evidence and information relevant to the profession. Along with this there has been a proliferation of publications regarding the processes and practicalities of reviewing [ 1 , 2 , 3 , 4 ], This increase in activity and enthusiasm for undertaking literature reviews is paralleled by the foundation of the Cochrane Collaboration in 1993. Developed in response to the need for up-to-date reviews of evidence of the effectiveness of health care interventions, the Cochrane Collaboration introduced a rigorous method of searching, appraisal and analysis in the form of a ‘handbook’ for doing a systematic review [ 5 ] .Subsequently, similar procedural guidance has been produced, for example by the Centre for Reviews and Dissemination (CRD) [ 6 ] and The Joanna Briggs Institute [ 7 ]. Further guidance has been published to assist researchers with clarity in the reporting of published reviews [ 8 ].

In the early days of the literature review era, the methodological toolkit for those undertaking a literature was polarised, in a way that mirrored the paradigm wars of the time within mixed-methods research [ 9 ]. We refer to this as the ‘dichotomy era’ (i.e. the 1990s), The prominent methods of literature reviewing fell into one of two camps: The highly rigorous and systematic, mostly quantitative ‘Cochrane style’ review on one hand and a ‘narrative style’ review on the other hand, whereby a body of literature was summarised qualitatively, but the methods were often not articulated. Narrative reviews were particularly popular in dissertations and other student work (and they continue to be so in many cases) but have been criticised for a lack of systematic approach and consequently significant potential for bias in the findings [ 10 , 11 ].

The latter 1990s and early 2000, saw the emergence of other forms of review, developed as a response to the Cochrane/Narrative dichotomy. These alternative approaches to the Cochrane review provided researchers with reference points for performing reviews that drew on different study types, not just randomised controlled trials. They promoted a systematic and robust approach for all reviews, not just those concerned with effectiveness of interventions and treatments. One of the first published description of methods was Noblet and Hare’s (1998) ‘Meta-ethnography’ [ 12 ]. This method, although its name suggests otherwise, could incorporate and synthesise all types of qualitative research, not just ethnographies. The potential confusion regarding the inclusion of studies that were not ethnographies within a meta-ethnography, promoted the description of other similar methods, for example, the meta-synthesis of Walsh and Downe (2005) [ 13 ] and the thematic synthesis of Thomas and Harden (2008) [ 14 ]. Also, to overcome the dichotomy of the quantitative/qualitative reviews, the integrative review was described according to Whitemore and Knafl (2005) [ 15 ]. These reviews can be considered to be literature reviews that have been done in a systematic way but not necessarily adhering to guidelines established by the Cochrane Collaboration. We conceptualise this as the ‘expansion era’. Some of the methods are summarised in Table  1 .

Over the past two decades there has been a proliferation of review types, with corresponding explosion of terms used to describe them. A review of evidence synthesis methodologies by Grant and Booth in 2009 [ 20 ] identified 14 different approaches to reviewing the literature and similarly, Booth and colleagues [ 21 ] detailed 19 different review types, highlighting the range of review types currently available. We might consider this the ‘proliferation era’. This is however, somewhat a double-edged sword, because although researchers now have far more review methods at their disposal, there is risk of confusion in the field. As Sabatino and colleagues (2014) [ 22 ] have argued, review methods are not always consistently applied by researchers.

Aware of such potential inconsistency and also our own confusion at times regarding the range of review methods available, we questioned what was happening within our own discipline of nursing. We undertook a snap-shot, contemporary analysis to explore the range of terms used to describe reviews, the methods currently described in nursing and the underlying trends and patterns in searching, appraisal and analysis adopted by those doing a literature review. The aim was to gain some clarity on what is happening within the field, in order to understand, explain and critique what is happening within the proliferation era.

In order to explore current practices in doing a literature review, we undertook a ‘Focused Mapping Review and Synthesis’ (FMRS) – an approach that has been described only recently. This form of review [ 19 ] is a method of investigating trends in academic publications and has been used in a range of issues relevant to nursing and healthcare, for example, theory in qualitative research [ 23 ] and vicarious trauma in child protection research [ 24 ].

A FMRS seeks to identify what is happening within a particular subject or field of inquiry; hence the search is restricted to a particular time period and to pre-identified journals. The review has four distinct features: It: 1) focuses on identifying trends in an area rather than a body of evidence; 2) creates a descriptive map or topography of key features of research within the field rather than a synthesis of findings; 3) comments on the overall approach to knowledge production rather than the state of the evidence; 4) examines this within a broader epistemological context. These are translated into three specific focused activities: 1) targeted journals; 2) a specific subject; 3) a defined time period. The FMRS therefore, is distinct from other forms of review because it responds to questions concerned with ‘what is happening in this field?’ It was thus an ideal method to investigate current practices in literature reviews in nursing.

Using the international Scopus (2016) SCImago Journal and Country Rank, we identified the five highest ranked journals in nursing at that time of undertaking the review. There was no defined method for determining the number of journals to include in a review; the aim was to identify a sample and we identified five journals in order to search from a range of high ranking journals. We discuss the limitations of this later. Journals had to have ‘nursing’ or ‘nurse’ in the title and we did not include journals with a specialist focus, such as nutrition, cancer etcetera. The included journals are shown in Table  2 and are in order according to their ranking. We recognise that our journal choice meant that only articles published in English made it into the review.

A key decision in a FMRS is the time-period within which to retrieve relevant articles. Like many other forms of review, we undertook an initial scoping to determine the feasibility and parameters of the project [ 19 ]. In our previous reviews, the timeframe has varied from three months [ 23 ] to 6 years [ 24 ]. The main criterion is the likelihood for the timespan to contain sufficient articles to answer the review questions. We set the time parameter from January 2017–June 2018. We each took responsibility for two and three journals each from which to retrieve articles. We reviewed the content page of each issue of each journal. For our purposes, in order to reflect the diverse range of terms for describing a literature review, as described earlier in this paper, any paper that contained the term ‘review’ or ‘synthesis’ in the title was included in the review. This was done by each author individually but to enhance rigour, we worked in pairs to check each other’s retrieval processes to confirm inter-rater consistency. This process allowed any areas of uncertainty to be discussed and agreed and we found this form of calibration crucial to the process. The inclusion and exclusion criteria are shown in Table  3 .

Articles meeting the inclusion criteria, papers were read in full and data was extracted and recorded as per the proforma developed for the study (Table 4 ). The proforma was piloted on two papers to check for usability prior to data extraction. Data extraction was done independently but we discussed a selection of papers to enhance rigour of the process. No computer software was used in the analysis of the data. We did not critically appraise the included studies for quality because our purpose was to profile what is happening in the field rather than to draw conclusions from the included studies’ findings.

Once the details from all the papers had been extracted onto the tables, we undertook an analysis to identify common themes in the included articles. Because our aim was to produce a snap-shot profile, our analysis was thematic and conceptual. Although we undertook some tabulation and numerical analysis, our primary focus was on capturing patterns and trends characterised by the proliferation era. In line with the FMRS method, in the findings section we have used illustrative examples from the included articles that reflect and demonstrate the point or claim being made. These serve as useful sources of information and reference for readers seeking concrete examples.

Between January 2017 and June 2018 in the five journals we surveyed, a total of 222 papers with either ‘review’ or ‘synthesis’ in the title were retrieved and included in our analysis. We identified three primary themes: 1) Proliferation in names for doing a review; 2) Allegiance to an established review method; 3) Clarity about review processes. The results section is organised around these themes.

Proliferation in names for doing a review

We identified more than 35 terms used by authors to describe a literature review. Because we amalgamated terms such as ‘qualitative literature review’ and ‘qualitative review’ the exact number is actually slightly higher. It was clear from reading the reviews that many different terms were used to describe the same processes. For example qualitative systematic review, qualitative review and meta-synthesis, qualitative meta-synthesis, meta-ethnography all refer to a systematic review of qualitative studies. We have therefore grouped together the review types that refer to a particular type of review as described by the authors of the publications used in this study (Table  5 ).

In many reviews, the specific type of review was indicated in the title as seen for example in Table  5 . A striking feature was that all but two of the systematic reviews that contained a meta-analysis were labelled as such in the title; providing clarity and ease of retrieval. Where a literature review did not contain a meta-analysis, the title of the paper was typically referred to a ‘systematic review’; the implication being that a systematic review is not necessarily synonymous with a meta-analysis. However as discussed in the following section, this introduced some muddying of water, with different interpretations of what systematic review means and how broadly this term is applied. Some authors used the methodological type of included papers to describe their review. For example, a Cochrane-style systematic review was undertaken [ 25 ] but the reviewers did not undertake a meta-analysis and thus referred to their review as a ‘quantitative systematic review’.

Allegiance to an established literature review method

Many literature reviews demonstrated allegiance to a defined method and this was clearly and consistently described by the authors. For example, one team of reviewers [ 26 ] articulately described the process of a ‘meta-ethnography’ and gave a detailed description of their study and reference to the origins of the method by Noblet and Hare (1988) [ 12 ]. Another popular method was the ‘integrative review’ where most authors referred to the work of one or two seminal papers where the method was originally described (for example, Whitemore & Knafl 2005 [ 15 ]).

For many authors the term systematic review was used to mean a review of quantitative research, but some authors [ 27 , 28 , 29 ],used the term systematic review to describe reviews containing both qualitative and quantitative data.

However in many reviews, commitment to a method for doing a literature review appeared superficial, undeveloped and at times muddled. For example, three reviews [ 30 , 31 , 32 ] , indicate an integrative review in the title of their review, but this is the only reference to the method; there is no further reference to how the components of an integrative review are addressed within the paper. Other authors do not state allegiance to any particular method except to state a ‘literature review’ [ 33 ] but without an outline of a particular method for doing so. Anther review [ 34 ] reports a ‘narrative review’ but does not give further information about how this was done, possibly indicative of the lack of methods associated with the traditional narrative review. Three other reviewers documented how they searched, appraised and analysed their literature but do not reference an over-riding approach for their review [ 35 , 36 , 37 ]. In these examples, the review can be assumed to be a literature review, but the exact approach is not clear.

In other reviews, the methods for doing a literature review appear to be used interchangeably. For example in one review [ 38 ] the term narrative review was used in the title but in the main text an integrative review was described. In another review [ 39 ] two different and distinct methods were combined in a ‘meta-ethnographic meta-synthesis’.

Some authors [ 40 , 41 ] referred to a method used to undertake their review, for example a systematic review, but did not reference the primary source from where the method originated. Instead a secondary source, such as a textbook is used to reference the approach taken [ 20 , 42 ].

Clarity about review processes

Under this theme we discerned two principal issues: searching and appraisal. The majority of literature reviews contain three components- searching, appraisal and analysis, details of which are usually reported in the methods section of the papers. However, this is not always the case and for example, one review [ 43 ] provides only a search strategy with no information about the overall method or how critical appraisal or analysis were undertaken. Despite the importance of the process of analysis, we found little discussion of this in the papers reviewed.

The overwhelming trend for those doing a literature review was to describe a comprehensive search; although for many in our sample, a comprehensive search appeared to be limited to a database search; authors did not describe additional search strategies that would enable them to find studies that might be missed through electronic searching. Furthermore, authors did not define what a comprehensive search entailed, for example whether this included grey literature. We identified a very small number of studies where authors had undertaken a purposive sample [ 26 , 44 ]; in these reviews authors clearly stated that their search was for ‘seminal papers’ rather than all papers.

We reviewed the approaches to critical appraisal described in the papers and there were varying interpretations of what this means and which aspect of the included articles were to be subject to appraisal. Some authors [ 36 , 45 , 46 ] used the term ‘critical appraisal’ to refer to relevance of the paper to the review, rather than quality criteria. In that sense critical appraisal was used more as an inclusion criterion regarding relevance, rather than quality in the methods used. Mostly though, the term was used to describe the process of critical analysis of the methodological quality of included papers included in a review. When the term was used in this way to refer to quality criteria, appraisal tools were often used; for example, one review [ 47 ] provides a helpful example when they explain how a particular critical appraisal tool was used to asses the quality of papers in their review. Formal critical appraisal was undertaken by the vast majority reviewers, however the role of critical appraisal in the paper was often not explained [ 33 , 48 ]. It was common for a lot of detail to be provided about the approach to appraisal, including how papers were assessed and how disagreements between reviewers about the quality of individual papers were resolved, with no further mention of the subsequent role of the appraisal in the review. The reason for doing the critical appraisal in the review was often unclear and furthermore, in many cases, researchers included all papers within their review regardless of quality. For example, one team of reviewers [ 49 ] explained how the process, in their view, is not to exclude studies but to highlight the quality of evidence available. Another team of reviewers described how they did not exclude studies on the basis of quality because of the limited amount of research available on the topic [ 50 ].

Our review has identified a multiplicity of similar terms and approaches used by authors when doing a literature review, that we suggests marks the ‘proliferation era’. The expansion of terms used to describe a literature review has been observed previously [ 19 , 21 ]. We have identified an even wider range of terms, indicating that this trend may be increasing. This is likely to give the impression of an incoherent and potentially confusing approach to the scholarly undertaking of doing a literature review and is likely to be particularly problematic for novice researchers and students when attempting to grapple with the array of approaches available to them. The range of terms used in the title of papers to describe a literature review may cause both those new to research to wonder what the difference is between a qualitative evidence synthesis and a qualitative systematic review and which method is most suitable for their enquiry.

The clearest articles in our review were those that reported a systematic review with or without a meta-analysis. For example, one team of reviewers [ 25 ] undertook a Cochrane-style systematic review but did not undertake a meta-analysis and thus referred to their review as a ‘quantitative systematic review’. We found this form of labelling clear and helpful and is indeed in line with current recommendations [ 8 ]. While guidelines exist for the publication of systematic reviews [ 8 , 51 ], given the range of terms that are used by authors, some may be unclear when these guidelines should apply and this adds some confusion to the field. Of course, authors are at liberty to call their review processes whatever they deem appropriate, but our analysis has unearthed some inconsistencies that are confusing to the field of literature reviewing.

There is current debate about the status of literature reviews that are not ‘Cochrane’ style reviews [ 52 ]. Classification can be complex and whilst it might be tempting to refer to all non Cochrane-style reviews as ‘narrative reviews’ [ 52 ], literature reviews that conform to a recognised method would generally not be considered as such [ 53 ] and indeed the Cochrane Collaboration handbook refers to the principles of systematic review as applicable to different types of evidence, not just randomised controlled trials [ 5 ] .This raises the question as to whether the term systematic review should be an umbrella term referring to any review with an explicit method; which is implicit in the definition of a systematic review, but which raises the question as to how rigorous a method has to be to meet these standards, a thorny issue which we have identified in this study.

This review has identified a lack of detail in the reporting of the methods used by those doing a review. In 2017, Thorne raised the rhetorical question: ‘What kind of monster have we created?‘ [ 54 ]. Critiquing the growing investment in qualitative metasyntheses, she observed that many reviews were being undertaken that position themselves as qualitative metasyntheses, yet are theoretically and methodologically superficial. Thorne called for greater clarity and sense of purpose as the ‘trend in synthesis research marches forward’ [ 54 ]. Our review covered many review types, not just the qualitative meta-synthesis and its derivatives. However, we concur with Thorne’s conclusion that research methods are not extensively covered or debated in many of the published papers which might explain the confusion of terms and mixing of methods.

Despite the proliferation in terms for doing a literature review, and corresponding associated different methods and a lack of consistency in their application, our review has identified how the methods used (or indeed the reporting of the methods) appear to be remarkably similar in most publications. This may be due to limitations in the word count available to authors. However for example, the vast majority of papers describe a comprehensive search, critical appraisal and analysis. The approach to searching is of particular note; whilst comprehensive searching is the cornerstone of the Cochrane approach, other aproaches advocate that a sample of literature is sufficient [ 15 , 20 ]. Yet in our review we found only two examples where reviewers had used this approach, despite many other reviews claiming to be undertaking a meta-ethnography or meta-synthesis. This indicates that many of those doing a literature review have defaulted to the ‘comprehensive search’ irrespective of the approach to searching suggested in any particular method which is again indicative of confusion in the field.

Differences are reported in the approach to searching and critical appraisal and these appear not to be linked to different methods, but seem to be undertaken on the judgement and discretion of the reviewers without rationale or justification within the published paper. It is not for us to question researchers’ decisions as regards managing the flow of articles through their reviews, but when it comes to the issue of both searching and lack of clarity about the role of critical appraisal there is evidence of inconsistency by those doing a literature review. This reflects current observations in the literature where the lack of clarity about the role of critical appraisal within a literature review is debated . [ 55 , 56 ].

Our review indicates that many researchers follow a very similar process, regardless of their chosen method and the real differences that do exist between published methods are not apparent in many of the published reviews. This concurs with previously mentioned concerns [ 54 ] about the superficial manner in which methods are explored within literature reviews. The overriding tendency is to undertake a comprehensive review, critical appraisal and analysis, following the formula prescribed by Cochrane, even if this is not required by the literature review method stated in the paper. Other researchers [ 52 ] have questioned whether the dominance of the Cochrane review should be questioned. We argue that emergence of different methods for doing a literature review in a systematic way has indeed challenged the perceived dominance of the Cochrane approach that characterised the dichotomy era, where the only alternative was a less rigourous and often poorly described process of dealing with literature. It is positive that there is widespread acknowledgement of the validity of other approaches. But we argue that the expansion era, whereby robust processes were put forward as alternatives that filled the gap left by polarisation, has gone too far. The magnitude in the number of different approaches identified in this review has led to a confused field. Thorne [ 54 ] refers to a ‘meta-madness’; with the proliferation of methods leading to the oversimplification of complex literature and ideas. We would extend this to describe a ‘meta-muddle’ in which, not only are the methods and results oversimplified, but the existence of so many terms used to describe a literature review, many of them used interchangeably, has added a confusion to the field and prevented the in-depth exploration and development of specific methods. Table  6 shows the issues associated with the proliferation era and importantly, it also highlights the recommendations that might lead to a more coherent reviewing community in nursing.

The terms used for doing a literature review are often used both interchangeably and inconsistently, with minimal description of the methods undertaken. It is not surprising therefore that some journal editors do not index these consistently within the journal. For example, in one edition of one journal included in the review, there are two published integrative reviews. One is indexed in the section entitled as a ‘systematic review’, while the other is indexed in a separate section entitled ‘literature review’. In another edition of a journal, two systematic reviews with meta-analysis are published. One is listed as a research article and the other as a review and discussion paper. It seems to us then, that editors and publishers might sometimes also be confused and bewildered themselves.

Whilst guidance does exist for the publication of some types of systematic reviews in academic journals; for example the PRISMA statement [ 8 ] and Entreq guidelines [ 51 ], which are specific to particular qualitative synthesis, guidelines do not exist for each approach. As a result, for those doing an alternative approach to their literature review, for example an integrative review [ 15 ], there is only general publication guidance to assist. In the current reviewing environment, there are so many terms, that more specific guidance would be impractical anyway. However, greater clarity about the methods used and halting the introduction of different terms to mean the same thing will be helpful.

Limitations

This study provides a snapshot of the way in which literature reviews have been described within a short publication timeframe. We were limited for practical reasons to a small section of high impact journals. Including a wider range of journals would have enhanced the transferability of the findings. Our discussion is, of course, limited to the review types that were published in the timeframe, in the identified journals and which had the term ‘review’ or ‘synthesis’ in the title. This would have excluded papers that were entitled ‘meta-analysis’. However as we were interested in the range of reviews that fall outside the scope of a meta-analysis, we did not consider that this limited the scope of the paper. Our review is further limited by the lack of detail of the methods undertaken provided in many of the papers reviewed which, although providing evidence for our arguments, also meant that we had to assume meaning that was unclear from the text provided.

The development of rigorous methods for doing a literature review is to be welcomed; not all review questions can be answered by Cochrane style reviews and robust methods are needed to answer review questions of all types. Therefore whilst we welcome the expansion in methods for doing a literature review, the proliferation in the number of named approaches should be, in our view, a cause for reflection. The increase in methods could be indicative of an emerging variation in possible approaches; alternatively, the increase could be due to a lack of conceptual clarity where, on closer inspection, the methods do not differ greatly and could indeed be merged. Further scrutiny of the methods described within many papers support the latter situation but we would welcome further discussion about this. Meanwhile, we urge researchers to make careful consideration of the method they adopt for doing a literature review, to justify this approach carefully and to adhere closely to its method. Having witnessed an era of dichotomy, expansion and proliferation of methods for doing a literature review, we now seek a new era of consolidation.

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Aveyard, H., Bradbury-Jones, C. An analysis of current practices in undertaking literature reviews in nursing: findings from a focused mapping review and synthesis. BMC Med Res Methodol 19 , 105 (2019). https://doi.org/10.1186/s12874-019-0751-7

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What is a literature review?

A literature review is a piece of academic writing demonstrating knowledge and understanding of the academic literature on a specific topic placed in context.  A literature review also includes a critical evaluation of the material; this is why it is called a literature review rather than a literature report. It is a process of reviewing the literature, as well as a form of writing.

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In a larger piece of written work, such as a dissertation or project, a literature review is usually one of the first tasks carried out after deciding on a topic.  Reading combined with critical analysis can help to refine a topic and frame research questions.  Conducting a literature review establishes your familiarity with and understanding of current research in a particular field before carrying out a new investigation. After doing a literature review, you should know what research has already been done and be able to identify what is unknown within your topic.

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Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens

• Lisa Merry 1 , 2 , 3 ,
• Bilkis Vissandjée 1 , 2 , 4 &
• Kathryn Verville-Provencher 1  

BMC Nursing volume  20 , Article number:  174 ( 2021 ) Cite this article

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International and migrant students face specific challenges which may impact their mental health, well-being and academic outcomes, and these may be gendered experiences. The purpose of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, with a gender lens.

We searched 10 databases to identify literature reporting on the challenges, coping responses and/or supportive interventions for international and migrant nursing students in college or university programs in Canada, the United-States, Australia, New Zealand or a European country. We included peer-reviewed research (any design), discussion papers and literature reviews. English, French and Spanish publications were considered and no time restrictions were applied. Drawing from existing frameworks, we critically assessed each paper and extracted information with a gender lens.

One hundred fourteen publications were included. Overall the literature mostly focused on international students, and among migrants, migration history/status and length of time in country were not considered with regards to challenges, coping or interventions. Females and males, respectively, were included in 69 and 59% of studies with student participants, while those students who identify as other genders/sexual orientations were not named or identified in any of the research. Several papers suggest that foreign-born nursing students face challenges associated with different cultural roles, norms and expectations for men and women. Other challenges included perceived discrimination due to wearing a hijab and being a ‘foreign-born male nurse’, and in general nursing being viewed as a feminine, low-status profession. Only two strategies, accessing support from family and other student mothers, used by women to cope with challenges, were identified. Supportive interventions considering gender were limited; these included matching students with support services' personnel by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex.

Future work in nursing higher education, especially regarding supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students’ contexts.

Peer Review reports

In 2017, there were over 5 million international students worldwide (i.e., individuals pursuing educational activities in a country that is different than their country of residence) and this number is increasing annually [ 1 ]. This is largely due to a growing demand from students for higher education (college/vocational and university degrees) and the limited capacity in certain countries to meet this need. International experience is also highly valued by many employers and thus studying abroad makes new graduates more competitive in the workforce [ 2 , 3 ]. On the pull-side, academic institutions are wanting to draw the most talented candidates and are looking to increase their student enrollment and revenues [ 2 , 3 ]. Most international students are from Asia, in particular China, India, South Korea and Middle Eastern countries, while top destinations for these students are the US, the UK, France, Australia, Canada and Germany [ 3 ]. These same countries are also primary resettlement sites, and have substantial numbers of migrants (e.g., immigrants, refugees), especially from low and middle-income countries, enrolled in their colleges and universities [ 3 , 4 , 5 , 6 , 7 ]. This is driven by migrants who desire, or who are required to supplement their previous education in order to integrate into the local workforce, and by the expectations of many migrants for their children (including the 1.5 generation) to obtain an academic degree. Academic institutions in these major host countries are therefore needing to respond to and serve a more diverse student clientele.

Nursing is one of the many disciplines with an increasing number of foreign-born students. There are several benefits to the globalization of nursing education, including strengthening the healthcare workforce capacity (front-line workers, administrators, policy-makers, academics as well as researchers), increasing the linguistic and cultural diversity of nursing professionals, and the sharing of new ideas across countries toward the improvement of nursing practice [ 8 , 9 ]. Increasing the level of education among nurses also improves health outcomes, enhances gender equality and contributes to economic growth, especially in low-and-middle-income countries [ 10 , 11 ]. The course of study and clinical training in academic nursing programs however, are demanding and can affect the well-being of students and result in mental health problems [ 12 , 13 , 14 , 15 , 16 ]. Stress in turn can result in failure or students deciding to withdraw from their studies.

The stresses experienced by foreign-born nursing students are magnified due to factors related to their international/migrant status [ 17 , 18 , 19 , 20 ]. Challenges associated with living in a new country, including financial concerns, discrimination (perceived or actual), adapting to a new culture and language, loss of social support and unfamiliarity with the education, health and other systems, may affect education experiences and compound psychological distress. The challenges experienced and impacts may be patterned by gender. Gender is defined as the ‘socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for men, women, boys and girls’ [ 21 ]. The migration process itself is influenced by gender as the opportunity and the level of control over the decision to migrate typically differs between men and women. Fear of being persecuted because of one’s ‘gender identity’ (i.e., a person’s individual experience of gender, which may or may not correspond to one’s biological sex) [ 22 ], may also be the reason one decides to migrate. Transit and post-migration experiences also diverge along gender lines, for example risks for gender-based violence, perceptions by the receiving-country society and integration outcomes often vary between male and female migrants and also by sexual orientation or gender identity (e.g., if one identifies as lesbian, gay, bisexual, transgender and/or intersex) [ 23 ]. Moreover, international female students compared to male students, have reported facing greater expectations to balance home/childcare responsibilities [ 24 , 25 ], experiencing more value conflicts regarding gender roles [ 26 , 27 ], and having stronger emotional and physiological reactions to stress [ 28 , 29 ]. In contrast, male students have expressed feeling stress associated with social status loss and due to traditional expectations to financially provide for the family, and they have been shown to be more likely to process their stress in solitude [ 30 ]. Gender norms can also affect both male and female students’ abilities to relate to members of the opposite sex in academic and clinical settings [ 27 , 31 ]. To effectively support and promote the success of foreign-born nursing students, academic institutions should therefore ensure that approaches and resources not only take into account the foreign-born context, but also consider the gender dynamics that are shaping students’ experiences.

There is an extensive body of literature on foreign-born nursing students [ 17 , 32 , 33 , 34 ], however, we did not identify any review that assessed the literature with a gender lens. Within the nursing education literature, reviews that have examined gender have primarily focused on the experiences of male students in general without any mention of a migrant or international background [ 35 , 36 , 37 , 38 , 39 ]; more recent reviews have considered the experiences of nursing students with diverse sexual and gender identities, although the research in this area remains scarce and also does not refer to foreign-born students [ 40 , 41 , 42 ]. In parallel, other literature has reviewed or discussed the intersection of gender or gender identity/sexual orientation and international status in relation to students’ experiences and its implications for academic institutions and educators, but none of these address the context of nursing or other healthcare professional education [ 43 , 44 , 45 ]. We therefore conducted a scoping review to address this gap. The objective of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant nursing students in academic institutions in major host countries with a gender lens.

A scoping review is commonly used to explore and summarize what is known on a particular topic [ 46 ]. This methodology was therefore selected since our goal was to describe what is known about gender and foreign-born nursing students’ experiences and supportive interventions across a broad array of existing literature while applying a gender lens. We used the Joanna Briggs Institute (JBI) methodology for scoping reviews to guide our approach [ 46 ].

Search strategy

We consulted a university librarian to assist us in selecting the databases and in developing the search strategies. We searched 10 electronic databases including CINAHL, Embase, Cochrane, Medline, Web of Science, the Joanna-Briggs institute EBP database, Psych-Info, Eric, Sociological abstracts and ProQuest. Search terms (subject headings/descriptors, keywords) included those related to international and migrant students and to nursing education; the strategy was adapted for each database and the AND/OR Boolean operators were applied accordingly. Keywords were searched in the titles, abstracts, keywords and subject fields. No language or time restrictions were applied. In order to refine the searches and adjust them for the various platforms, we first conducted test searches in two databases (CINAHL and Medline). An example of one of the search strategies (CINAHL) is presented in Table 1 . Additional papers were identified through the examination of the reference lists of literature review papers that met the inclusion criteria.

Literature selection

We included peer-reviewed research (qualitative, quantitative or mixed methods), discussion papers and literature reviews. Study protocols, abstracts, books and dissertations/theses were excluded. English, French, and Spanish publications were considered. Literature was included if it discussed or reported on challenges, coping responses and/or supportive interventions for foreign-born students studying in an academic nursing program in Canada, the US, Australia, New Zealand or a European country (i.e., high-income countries according to the Organisation for Economic Co-operation and Development that receive large numbers of migrants and international students and that have similar sociocultural norms and political systems) [ 47 ]. Challenges were defined as any difficulties experienced by the students; coping responses referred to any strategies that were used by the students to help overcome, minimize or tolerate challenges; while supportive interventions were policies, programs, or strategies meant to address challenges, enhance coping and improve students’ overall experiences. Challenges, coping and/or interventions could have been examined from the perspective of students and/or educators and administrators or could have just been described and discussed generally. Papers that reported on the evaluation or testing of an intervention were also included.

‘International students’ were defined as individuals with student visas but excluding exchange students and those completing only part of their degree abroad. ‘Migrant students’ were defined as individuals born in another country who moved with the intention of resettling in the new country; this includes immigrants, refugees, and asylum-seekers (i.e., individuals in the process of making a refugee claim) who could have migrated as children or as adults (second generation migrants were excluded). We included literature that focused on ‘English-as a second/additional-language’ (ESL/EAL) students without specifying the countries of origin, since foreign-born students often comprise a significant proportion of ESL/EAL students. Papers that focused on ‘minority’ or non-traditional nursing students were also kept if foreign-born or ESL/EAL students were clearly included and there were results and/or implications specific to this population. Similarly, if a paper included or discussed nursing students generally, it was retained if there were study results and/or implications relevant to foreign-born or ESL/EAL students. Literature that included internationally-trained nurses was considered if the nurses were studying in an academic nursing program; we excluded papers that examined internationally-trained nurses who were completing a transition/integration program.

Lastly, ‘Academic nursing program’ was defined as any program leading to a post-secondary degree including college/vocational, bachelor and graduate degrees in nursing. Papers that studied or discussed students from other healthcare disciplines were only kept if there were results and/or implications that referred to nursing students. Papers could have pertained to students in the context of clinical, theoretical and/or research education and training.

The database searches yielded 8269 records (see Additional file  1 for the search results by database). All citations were downloaded and managed using Endnote. We first removed duplicates and then screened titles to remove citations that clearly did not meet the inclusion/exclusion criteria. We then reviewed abstracts to further eliminate papers that did not meet all of the criteria. For the remaining citations we retrieved and reviewed the full-texts ( n  = 266) in order to confirm eligibility. The screening and selection process was led by KPV and supported by LM and BV via ongoing discussions to ensure that the criteria were being correctly and consistently applied. Articles at this step were mainly excluded because they did not have results and/or implications specific to foreign-born/ESL/EAL students or to nursing students (i.e., all healthcare professionals were examined and discussed together), or because they were theses/dissertations or descriptions of nursing programs that were intended to be advertisements to recruit new students. When there was uncertainty regarding the eligibility of an article, LM independently reviewed it and a decision on whether to include it was made through joint discussion with the other authors. Twenty-three additional papers were identified by examining the reference lists of included review papers. LM read all of the papers and confirmed the final selection (see Fig.  1 for the PRISMA flow diagram).

PRISMA Flow diagram. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine. 2009 Jul 21;6 (7):e1000097

Data extraction, analysis and synthesis

For all eligible papers, we extracted and stored data in an excel file including: 1) paper characteristics (publication type, year, and language); and 2) study/review/discussion paper information. For the latter this included the paper objective, the location(s) of the study/discussion/review, the foreign-born student population(s) of interest in the paper (international students and/or migrants and their countries/regions of origin and length of time in the country; for migrants we also sought information on immigration status), the educational context, whether or not the perspectives of educators and/or administrators were considered/discussed, and information on challenges, coping responses and supportive interventions. For studies, we also extracted information on the research design and data collection methods, and for reviews, we recorded the type of review conducted, the number and type of sources (e.g., articles, books), and the process used to identify sources.

To address the review objective, we critically assessed each paper and recorded information related to gender. To do this, we drew on existing frameworks used to conduct gender analyses in health research [ 48 , 49 ] and LM and BV developed key questions to help guide the assessment. These included the following:

Was sex included or addressed by the authors/researchers?

Was gender explicitly considered by the authors/researchers through use of a framework or lens?

Was gender identity/sexual orientation included or addressed by the authors/researchers?

Was sex and/or gender considered as a variable in analyses?

Were findings and/or implications reported separately by sex and/or gender?

Based on the results and/or discussion points of the papers:

Did sex or gender (appear to) play a role in the challenges experienced by students? For example, at the intersection of sex and gender such as roles within the family, cultural/religious conventions that dictate how men and women should behave, differential access to resources, and experiences of discrimination.

Did coping responses (appear to) differ by sex or gender?

Did interventions (appear to) consider gender roles, norms and expectations?

Did interventions (appear to) consider diversity in gender identities/sexual orientations?

KPV was responsible for extracting the paper characteristics and information; LM verified all data extraction. The assessment of papers for gender related information was conducted by two research assistants. To ensure consistency in the process, 20 papers were reviewed by both research assistants. LM independently assessed all papers. All information collected was collated and synthesized into summary tables and text.

One hundred and fourteen articles were included in the scoping review. A summary of the literature is reported in Table  2 . All of the papers were published in English, 12 were discussion papers, 20 were reviews and 82 were research studies. The publication period spanned 39 years (1981–2019) and just over a quarter of papers ( n  = 30, 26%) were published within the last 5 years. Two-thirds of the research were qualitative studies.

Focus of the research, discussion papers and reviews

Twenty-two of the research papers primarily focused on highlighting challenges faced by foreign-born students; nine of these included the perspectives of educators (Table 2 ). Seventeen research papers aimed to identify or examine coping responses and factors that facilitated success among foreign-born students, while 24 papers generally explored students’ and/or educators’ experiences. Twelve research articles described and reported the findings of evaluations of support programs, courses or other strategies meant to support foreign-born/ESL/EAL students and seven other papers were intervention studies (including qualitative and quantitative), which mostly sought to help students’ overcome learning difficulties due to language barriers.

The discussion papers and reviews had similar foci (Table 2 ). Three discussion papers provided tips on how educators and institutions can support foreign-born/ESL/EAL students, five discussed challenges, implications and strategies to address these, and four other papers described programs, frameworks or approaches to promote the success of students. Among the 20 review papers, all but three included a mix of qualitative, quantitative and other types of literature and only three specifically named the type of review being conducted. Most ( n  = 12) aimed to synthesize the literature on foreign-born/ESL/EAL students’ challenges and support strategies for these students, while five were reviews of the literature of foreign-born/ESL/EAL students’ general experiences, and two focused on interventions including mobile applications to support ESL students’ learning, and programs to improve clinical placement outcomes of international students.

Locations, educational contexts and populations

The majority of the research (57%) was conducted in the United States; four studies were conducted in non-English speaking countries (Norway and Finland) (Table  3 ). All but three of the discussion papers, and one review were also specific to the United States context. Several of the research papers pertained to more than one level of education; overall bachelor or college level studies were included in 90%, and graduate level education in 42%, of studies (Table 3 ). Four discussion papers were limited to bachelor level, four were focused on graduate level, and four others were relevant to nursing education in general. The literature reviews tended to be non-specific, however one and two papers respectively focused on bachelor and doctorate level education. The clinical learning environment was mentioned in two-thirds of the research papers, although was the primary focus in 18% of the research (Table 3 ). The clinical context was also the main focus in six of the reviews.

Across the literature students were described using different terms including ‘foreign-born’, ‘ESL’, ‘EAL’, ‘culturally-and-linguistically diverse (CALD)’, ‘international students’, ‘non-English-speaking background’, ‘immigrants’, and ‘minority or non-traditional students’; in other instances, students were described based on their ethnic background or origin. Length of time in the host country was generally not highlighted; just over a third (34%) of studies with student participants mentioned some information on length of time. International students were the main population of focus in almost half of the studies (Table 3 ). Similarly, they were also the main focus in seven discussion papers and eight of the literature reviews. Thirteen studies, three discussion papers and one review focused specifically on migrants. The remaining literature examined a mix of international students and migrants or were non-specific in their description of the student population (i.e., described as foreign-born or ESL students).

For migrant students, migration history or status were not reported in the description of the participants in any of the research papers nor were they mentioned or discussed in the review and discussion papers. There were five studies however, that implied based on other sections of the paper that they may have included student participants with a refugee or difficult migration background (i.e., political unrest in their country) [ 57 , 77 , 84 , 104 ]. Only one research paper explicitly mentioned students with a refugee background in the introduction and discussion sections [ 57 ].

In the research studies with student participants ( n  = 73), students were mainly from East Asia, Sub-Saharan Africa and South East Asia; top source countries in descending order, were China, Vietnam, the Philippines, Korea, India and Taiwan. Asian students (Taiwan = 1, India = 1, China = 1, and one unspecified) were also the population of interest in two discussion papers and two reviews. Instructors/educators were participants in 34% of studies (Table 3 ) and their perspectives were also explicitly mentioned in two of the literature reviews.

General overview of challenges, coping responses and supportive interventions

Language and communication barriers, including oral and written expression and comprehension, were the challenges highlighted most often in the literature [ 9 , 17 , 18 , 19 , 20 , 33 , 34 , 37 , 42 , 50 , 51 , 52 , 53 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 115 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 133 , 134 , 136 , 139 , 141 , 142 , 143 , 145 , 146 , 147 , 148 , 150 , 151 , 152 , 153 , 154 ]. Language and communication issues occur in academic and clinical settings as well as in social contexts. Learning nursing and medical terminology and colloquial expressions and adapting to a ‘low context communication’ style, were noted as particularly difficult. At the graduate level, academic writing was the major issue, including demonstrating critical analysis [ 71 , 79 , 80 , 115 , 130 , 146 , 148 ].

Cultural barriers were also frequently noted [ 9 , 17 , 18 , 19 , 20 , 34 , 42 , 51 , 52 , 53 , 54 , 55 , 56 , 59 , 63 , 64 , 67 , 68 , 71 , 73 , 74 , 75 , 76 , 77 , 79 , 80 , 82 , 83 , 84 , 85 , 86 , 87 , 89 , 96 , 97 , 100 , 101 , 102 , 103 , 105 , 106 , 107 , 111 , 112 , 115 , 117 , 119 , 120 , 122 , 124 , 125 , 127 , 129 , 132 , 136 , 138 , 139 , 142 , 143 , 145 , 147 , 148 , 150 , 152 , 153 , 154 ]. These included, for example, divergent views regarding the role of nurses in patient care, and different styles of relating socially whether it be with friends or in care-provider-patient interactions. Difficulties with the supervisory-graduate student relationship were identified as well, as international students often expect structured guidance and for supervisors to be readily available to them based on the supervisory styles they have observed in their home countries [ 56 , 80 , 146 ]. The most apparent cultural challenges described were in the classroom milieu; a number of papers reported that foreign-born students struggle with ‘Western’ learning, teaching and evaluation methods (e.g., self-directed and interactive learning, critical analysis and debating). Self-guided learning and conducting independent research were particular concerns for doctoral students [ 56 , 146 ]. All these issues are due to the fact that many foreign-born students come from cultures where teaching is primarily didactic, rote learning is encouraged and students are expected to be passive and to not question instructors. Educators and clinical preceptors are equally challenged in this dynamic and feel unable to assess whether students have understood content and instructions, especially when language barriers are significant [ 65 , 74 , 79 , 94 , 112 , 126 , 150 ]. In the clinical context this also raises concerns about patient safety [ 50 , 74 , 99 , 112 , 150 ]. Overall, educators/supervisors and preceptors expressed feeling that they have insufficient time and resources to adequately support foreign-born students [ 65 , 74 , 79 , 94 , 112 , 126 , 150 ].

In addition to cultural issues, foreign-born students also struggle with the unfamiliarity of the healthcare system and clinical setting [ 9 , 19 , 20 , 37 , 42 , 65 , 92 , 96 , 99 , 100 , 102 , 112 , 115 , 129 , 132 , 146 ]. For graduate students, often they are unable to work clinically in the receiving-country and so they grapple in making links between the theory/research and practice. Regardless of the education level, for students who return to their home country post-graduation, the course content and skills learned, and for graduate students, the research conducted, are not always relevant and applicable to their context [ 53 , 54 , 75 , 84 , 85 , 129 , 148 ]. Conducting research internationally is also not always feasible due to a lack of funding and/or supervisory support abroad [ 148 ].

Other challenges experienced by foreign-born students included loneliness, social exclusion/isolation, discrimination, resettlement issues (e.g., immigration, housing), financial concerns and maintaining a work-life balance [ 9 , 17 , 18 , 19 , 20 , 33 , 34 , 37 , 42 , 52 , 53 , 55 , 59 , 65 , 68 , 71 , 73 , 74 , 75 , 77 , 79 , 80 , 82 , 83 , 84 , 87 , 89 , 91 , 93 , 94 , 95 , 96 , 97 , 100 , 103 , 105 , 106 , 107 , 109 , 111 , 113 , 115 , 120 , 121 , 122 , 123 , 127 , 128 , 129 , 138 , 139 , 142 , 143 , 145 , 146 , 147 , 148 , 150 , 152 , 153 , 154 ]. Access to research funding, limited interaction with student peers and transitioning from a leadership role (held in their home country) to a student position, were challenges specifically noted by international graduate students [ 79 , 80 , 148 ]. Feeling inadequately prepared or overwhelmed and unable to optimize their skills upon return to the home country, were also highlighted as particular issues at the graduate level [ 56 , 75 , 79 , 148 ]. Mental health problems, including stress, feeling pressure to succeed, depression, a loss of self-esteem, feelings of guilt (for leaving their families) and anxiety, were commonly reported across the literature irrespective of the level of education [ 9 , 17 , 18 , 19 , 20 , 33 , 55 , 65 , 68 , 71 , 75 , 76 , 79 , 80 , 82 , 84 , 86 , 89 , 91 , 93 , 94 , 95 , 97 , 98 , 100 , 102 , 105 , 106 , 111 , 112 , 115 , 117 , 122 , 126 , 127 , 128 , 130 , 134 , 138 , 139 , 142 , 143 , 145 , 146 , 148 , 152 , 153 , 154 ].

The main coping responses used by foreign-born nursing students to overcome challenges, included accessing support (emotional, practical and/or informational) from family and friends, especially student peers with a similar cultural or linguistic background, and staying focused and determined to succeed [ 18 , 20 , 34 , 52 , 53 , 54 , 66 , 73 , 76 , 79 , 80 , 81 , 82 , 89 , 91 , 93 , 94 , 95 , 96 , 103 , 105 , 106 , 107 , 111 , 115 , 117 , 121 , 122 , 123 , 127 , 128 , 129 , 130 , 141 , 142 , 143 , 145 , 146 , 148 , 151 , 152 , 153 , 154 ]. Maintaining their culture and values, but also accepting and being open to differences, were identified as coping mechanisms to deal with cultural barriers, while positive thinking and celebrating successes, were highlighted as ways that students boost their sense of self-worth and reduce stress [ 20 , 34 , 56 , 64 , 71 , 73 , 79 , 80 , 85 , 89 , 91 , 93 , 96 , 107 , 123 , 127 , 145 , 152 , 153 , 154 ]. Numerous papers also reported that students use various strategies (e.g., asking for clarifications, using non-verbal communication, doing additional reading), and actively develop their skills, in order to gain confidence and overcome language and academic barriers [ 18 , 20 , 61 , 71 , 73 , 75 , 76 , 80 , 82 , 84 , 88 , 90 , 92 , 93 , 98 , 99 , 101 , 103 , 104 , 105 , 106 , 107 , 109 , 111 , 113 , 115 , 117 , 120 , 123 , 127 , 128 , 129 , 130 , 133 , 146 , 151 , 152 , 153 ].

There were several interventions that were described or suggested in the literature as being potentially helpful to foreign-born students (reported in Table  4 ); the vast majority of these were based on anecdotal evidence. At the structural level, it was recommended that institutions be actively committed, in the form of mission statements, action plans and dedicated resources, to cultivating an inclusive and equitable education environment [ 17 , 20 , 33 , 37 , 50 , 51 , 53 , 63 , 64 , 68 , 74 , 79 , 80 , 82 , 92 , 94 , 95 , 96 , 103 , 106 , 108 , 110 , 112 , 113 , 115 , 117 , 119 , 120 , 121 , 125 , 126 , 127 , 129 , 132 , 138 , 139 , 141 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 ]. Equally noted was the importance of promoting diversity and fostering a sense of belonging [ 17 , 37 , 108 , 127 , 145 , 146 , 148 , 151 , 152 , 153 , 154 ]. It was also recommended that educators and preceptors receive training to ensure that they are aware of the challenges that many foreign-born students encounter and to provide them strategies and tools for teaching a multi-lingual and culturally diverse student population [ 17 , 18 , 33 , 34 , 37 , 50 , 60 , 63 , 64 , 65 , 68 , 71 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 87 , 88 , 89 , 91 , 92 , 93 , 94 , 95 , 96 , 103 , 106 , 107 , 108 , 111 , 112 , 113 , 115 , 117 , 120 , 121 , 123 , 125 , 126 , 127 , 128 , 131 , 138 , 139 , 141 , 143 , 145 , 146 , 147 , 149 , 150 , 151 , 152 , 153 , 154 ]. It was also suggested that instructors have smaller classes, clinical groups and student-supervisory ratios, and more time allotted to devote to foreign-born students [ 20 , 50 , 51 , 64 , 65 , 74 , 79 , 104 , 108 , 112 , 120 , 121 , 127 , 129 , 139 , 147 , 149 , 150 , 151 , 153 ].

According to the literature it may also be beneficial if students have more time to complete their degree, or if the program is adapted to better suit their needs (e.g., an additional session or qualifying year to take pre-requisites, a transition semester with courses modified to allow students to acclimate to their new environment, and/or extra clinical training) [ 37 , 60 , 71 , 79 , 102 , 103 , 104 , 108 , 126 , 133 , 138 , 139 , 148 , 151 , 153 ]. Screening students at the point of admission may also ensure that those who need supplementary support are identified immediately and referred without delay [ 34 , 37 , 73 , 74 , 79 , 92 , 93 , 94 , 108 , 110 , 113 , 119 , 125 , 126 , 131 , 135 , 138 , 139 , 143 , 148 , 149 , 151 , 152 ]. It was also suggested that offering a range of services and resources throughout the academic trajectory could aid students in overcoming a variety of challenges. These included orientation sessions to the institution and clinical settings, workshops to develop writing, critical analysis and test-taking skills, language courses (specific to nursing), writing/editing support (especially at the graduate level), tutoring services, practical assistance including access to financial aid, scholarships and research funding, social activities, peer support initiatives, a mentorship program and counselling/psychological services [ 9 , 17 , 18 , 19 , 20 , 33 , 34 , 37 , 50 , 51 , 52 , 53 , 55 , 60 , 61 , 63 , 64 , 65 , 68 , 69 , 71 , 73 , 74 , 75 , 76 , 77 , 79 , 80 , 82 , 83 , 84 , 85 , 87 , 88 , 89 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 107 , 108 , 109 , 110 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 123 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 138 , 139 , 141 , 142 , 143 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 ].

There were also a number of approaches at the curricular/instructor level that were proposed to help students overcome language and cultural barriers and to facilitate learning whether it be in a classroom, clinical or research supervisory context. For example, using audio-visual material, providing information and expectations in writing, giving frequent and detailed feedback, debriefing one on one with students, speaking more slowly and avoiding colloquial language, verifying understanding, using storytelling, audio-taping lectures, and providing more structured guidance (e.g., writing examples for assignments, standardized forms for clinical documentation) [ 9 , 17 , 18 , 20 , 33 , 34 , 37 , 50 , 51 , 52 , 60 , 61 , 62 , 63 , 64 , 65 , 68 , 69 , 71 , 73 , 74 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 87 , 88 , 90 , 92 , 93 , 94 , 95 , 98 , 99 , 100 , 101 , 102 , 103 , 105 , 106 , 107 , 108 , 110 , 111 , 112 , 115 , 120 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 ]. Evaluations, including assignments and tests could also be modified to accommodate students, for example allowing more time to complete an exam or the opportunity to submit an initial draft of an assignment for feedback before submitting the final version that is to be graded [ 17 , 34 , 37 , 60 , 63 , 64 , 69 , 73 , 74 , 76 , 81 , 84 , 87 , 93 , 100 , 104 , 110 , 111 , 125 , 127 , 128 , 139 , 140 , 143 , 147 , 151 , 152 ]. Course content, evaluations, research topics and clinical experiences may also be adapted to make them more culturally relevant, particularly if students plan to return to work in their country of origin following their graduation [ 17 , 34 , 37 , 60 , 64 , 65 , 68 , 71 , 77 , 87 , 92 , 93 , 95 , 111 , 125 , 127 , 128 , 131 , 136 , 139 , 141 , 142 , 143 , 145 , 147 , 148 , 152 , 154 ]. Equally emphasized was the importance to provide content and an opportunity to learn more about the host country’s healthcare system and approach to nursing practice [ 37 , 63 , 65 , 74 , 80 , 82 , 87 , 92 , 95 , 115 , 129 , 136 , 138 , 140 , 143 , 152 ]. For doctoral students, offering leadership training and opportunities to network and develop their research identity and skills (e.g., conferences, student seminars, research groups, research activities like publishing, committees, joining professional organizations), were also deemed essential [ 65 , 80 , 146 , 148 , 149 ]. Lastly, to increase foreign-born students’ confidence and feelings of inclusion, it was recommended that instructors foster peer to peer learning and positive interactions between students, show interest in foreign-born students (know their name, relate to them on a personal and emotional level) and be encouraging and respectful [ 9 , 17 , 20 , 33 , 34 , 37 , 51 , 52 , 53 , 55 , 65 , 69 , 70 , 71 , 73 , 74 , 75 , 79 , 80 , 81 , 82 , 83 , 84 , 87 , 88 , 89 , 90 , 91 , 93 , 94 , 95 , 96 , 97 , 100 , 103 , 106 , 107 , 112 , 113 , 115 , 117 , 120 , 121 , 122 , 123 , 124 , 125 , 127 , 128 , 130 , 131 , 132 , 136 , 138 , 139 , 140 , 141 , 142 , 143 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 ].

Applying a gender lens

Gender was not explicitly used as a guiding framework or lens, nor was it defined, in any of the studies, literature reviews or discussion papers. Among the research papers that included student participants, 29% did not specify the sex of participants, and although male students were included in 59% of the research (Table 3 ), overall there were many more female participants compared to male participants across and within studies -over three quarters of the studies with both male and female participants clearly had more females than males. Other gender identities/sexual orientations (e.g., lesbian, gay, non-binary, transgender) were not identified or named in any of the study samples. One study, however, acknowledged that there was a lack of gender diversity among their participants [ 95 ].

Of all the studies that included both men and women, only one reported results for the foreign-born students by sex. This study, which examined predictors of success among a cohort of Saudi Arabian students enrolled in an accelerated bachelor program (a collaborative initiative between Saudi Arabia and a US University), showed that the mean graduating grade point average (GPA) varied among female students depending on whether or not they were married or had family present with them in the United States- i.e., single females and women who had no family in the US had lower GPAs compared to their respective counterparts, but these variations were not observed among the male students [ 66 ]. One other study and two reviews, which focused on ‘non-traditional students’, also reported results for male nurses, and reported that men tended to feel excluded and delegated to certain roles because of their gender, and felt they were stereotyped as being homosexual [ 37 , 42 , 70 ]. These findings however, did not pertain specifically to foreign-born/ESL/EAL students.

Four quantitative studies included sex as a variable in their analyses with foreign-born students. The study by Carty et al. (2007) showed that overall male students had a higher graduating GPA compared to their female counterparts. A study in Finland with international students found that female students were more likely than male students to perceive cultural diversity in the clinical placement as causing negative consequences, however there were no differences between men and women regarding their perceptions of the impacts of language barriers on their clinical training [ 109 ]. Another study, conducted in the US, found sex to not be predictive of attrition among ESL students studying in pre-licensure programs in the state of Texas [ 72 ]. Similarly, the fourth study found no association between sex and academic or clinical placement stress among international students studying nursing at the undergraduate level in programs across Australia [ 100 ].

With respect to challenges, we identified several papers that reported results and/or that discussed issues related to gender roles and expectations. In one study, conducted more than 30 years ago, a female student participant expressed that it was initially disconcerting, and that it required significant adaptation to come to terms with the idea that women should be assertive and outspoken when interacting with physicians [ 54 ]. Similarly, in another study, timidity and not wanting to speak up, was noted to be more challenging for female ESL students compared to male students [ 84 ]. In another older study, male students from Saudi Arabia who were studying in the US, found it challenging to have mixed-gender classes, to socialize with female students, to learn about women’s health and to care for female patients in the clinical setting, particularly hygiene and bathing (these same results were also highlighted in a review paper) [ 17 , 64 ]. Likewise, in another US study (and review), Omani women found it challenging to adapt to openness between sexes, going out alone and independent decision-making [ 107 , 153 ]. Similar findings were also shown in a study in the UK, where Middle-Eastern women who were completing a doctoral degree, reported finding it difficult to manage everything on their own as they were used to being surrounded by extended family and doing daily activities collectively; consequently these women also reported feeling very lonely [ 80 ].

Other difficulties related to gender norms and the mixing of men and women were also reported/discussed, including a hesitation among students to form friendships with the opposite sex because it was deemed inappropriate [ 81 ]; male students feeling uncomfortable receiving input or direction from female instructors [ 84 ]; female students feeling it is inappropriate to be in ‘intimate’ contact with patients [ 86 ]; and women finding it challenging to relate to their native-born female colleagues due to different value systems [ 97 ]. The review by Olson (2012) suggested that some female students may not be supported by family during their studies because male family members felt threatened by the possibility that their wives/daughters may earn more income than them [ 34 ]. One study also found that female international students more than male students, faced additional challenges professionally post-graduation, irrespective of whether or not they returned to their country of origin, and that these challenges were rooted in the divergent and conflictual cultural norms and expectations of women between the host country and country of origin [ 84 ]. Another study supported this notion as it found that international female students from Canada or Europe studying in the US seemed to have less difficulty adjusting to the US compared to other international students due to a greater resemblance in gender norms across the US, Canada and Europe [ 96 ].

Managing family/childcare and household responsibilities while studying, and feeling pressure to ascribe to a ‘traditional’ female role, were described as challenges for women in a number of papers [ 34 , 74 , 82 , 83 , 86 , 102 , 122 , 152 , 153 ]. In one study (but highlighted in four different papers), a woman reported significant stress due to her husband and in-laws who disapproved of her studying and who felt that she was a ‘bad wife and mother’ for pursuing her studies [ 34 , 82 , 83 , 153 ]. Feeling guilty about leaving children behind also appeared to be a concern particularly affecting women [ 89 , 128 ]. In contrast, a male student, in the study by Gardner (2005), reported feeling immense pressure to succeed, because he was recognized as a leader in his community in his home country and he felt he needed to return with a nursing degree so that he could help his community [ 83 ].

Perceived discrimination was noted in four papers; in one (a research study), an instructor participant reported that a student had shared with her that a patient had said that he did not like the student because the student was ‘a man and foreign’ [ 74 ]. In another study, women reported discrimination due to wearing a hijab and being Arab [ 115 ]. This latter issue was further highlighted in two review papers [ 145 , 153 ].

Nursing being perceived as a feminine profession and low status employment was also highlighted as an issue. In one study, a male student participant shared that he felt that his father had concerns about him pursuing nursing as a profession because of his gender [ 76 ]. In another study, women from non-English speaking background cultures reported not being supported by their family to pursue their studies in nursing as the profession was deemed to be the type of work that is only done by “loose women or prostitutes” [ 86 ].

We did not identify many results or discussion points related to gender and coping. One recent US study, suggests that female students who were mothers found mutual understanding and support from other female students who also had children [ 76 ]. Extended family support also seems to be source of help for female students who are trying to balance studying with home/family obligations [ 34 ]; in one study a student sent her child to India to be cared for while she completed her studies; providing a better life for her daughter was also a motivating factor that kept her going [ 83 ]. Family back home, calling male family members, was also identified as a source of support for the Omani nursing students in the US who were not used to being alone and who found making decisions on their own, challenging [ 107 ]. Although not a coping mechanism per se, a number of papers also mentioned that female international students had increased confidence over time and enjoyed the new independence that they had gained while living and studying in the host country [ 75 , 80 , 101 , 115 , 128 , 153 ].

A handful of papers made reference to gender in relation to supportive interventions. One study described a female educator calling on a male colleague to intervene with a male international student on a sensitive topic in order to make the student more comfortable since he was from a cultural background where women usually do not have authoritative roles [ 84 ]. Sending letters or involving family members in the orientation was recommended in one study and two reviews, as an approach to enhance family support and understanding for female students who face challenges balancing their studies with family and household responsibilities [ 34 , 83 , 152 ]. Similarly, including fathers and husbands in the admission process was a strategy described in the paper by Robinson et al. (2006) to ensure support for Indian women who wished to pursue their studies in an American university [ 138 ]. In the same paper, female applicants were interviewed by women during the recruitment process, and gender dynamics (in reference to male dominance) was considered when pairing female students with community supports once arrived in the US [ 138 ]. Matching advisors and international students by sex was also discussed in the paper by Thompson (2012) as an approach to promote comfort for students who are not used to receiving advice from or confiding in someone of the opposite sex [ 141 ]. In the study by King et al. (2017), a standardized simulation patient was used as a method to give EAL students an opportunity to get used to providing care to patients of the opposite sex [ 101 ]. And avoiding gender bias when presenting exemplars, was given as teaching tip when teaching international students, in the paper by Henderson (2016), [ 136 ].

Lastly, gender identity/sexual orientation was not considered or highlighted in any of the results or discussions related to challenges, coping responses or interventions across the literature. The review by Greene et al. (2012) which outlines strategies for promoting the success of international students, however, recommended that students be exposed to and learn how to care for patients with different backgrounds, including different sexual orientations, although no details were provided on how this should be done [ 33 ]. The review by Koch et al. (2015) also reported on the clinical placement experiences of lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) nursing students, but this was for nursing students in general and not specific to foreign-born/ESL/EAL students [ 42 ]. The review highlighted that overall there is very little known about the experiences of LGBTQ nursing students.

Overall, the literature mostly reflects women’s experiences, there was less focus on men, and students who identify as other genders/sexual orientations were not visible in the research and discussions. Our review shows that international and migrant nursing students face a number of challenges associated with different cultural roles, norms and expectations for men and women; other challenges included perceived discrimination, and in general nursing being viewed as a feminine, low-status profession. We only identified a couple of strategies, accessing support from family and other student mothers, used specifically by female students to cope with some of the challenges associated with gender roles and norms, and we found nothing regarding men’s coping responses. Supportive interventions that considered gender were limited; these included matching students with support persons and advisors by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex. Taken together, the results reveal that sex, gender and gender identity/sexual orientation have been under examined and discussed in the literature on international and migrant nursing students in academic institutions in major host countries.

Equity, diversity and inclusion (EDI) are fundamental to the nursing profession and its practice as nurses interface with individuals, families and communities in very intimate ways (physically, psychologically, socially and spiritually/existentially) and during the most vulnerable moments of life, which are greatly influenced by one’s social group memberships/identities such as gender, culture, religion, ethnicity and sexuality. Therefore in order to promote the health and well-being for all, nurses must be prepared to respond to the needs of diverse populations and to provide care that is safe and that addresses inequities. It also requires a workforce that reflects the population demographics. Despite there being a movement towards inclusivity, the profession, however, remains predominantly Caucasian (in high-income countries) and heteronormative, especially at the leadership levels, and gender and gender identity/sexual orientation discrimination are still prevalent [ 39 , 155 , 156 , 157 , 158 ]. Rectifying this problem begins with nursing education programs that are inclusive, fair, and that celebrate diversity within the curriculum, and among the student, faculty and administrative bodies. EDI are currently top priority for many academic institutions in major migrant/international student receiving-countries [ 159 , 160 , 161 ]. Many have developed strategic plans and have a mandate to implement strategies to reduce discrimination and bias and create more respectful learning environments where the presence and expression of differences are valued and supported and everyone feels they belong and can thrive. Gender issues in higher education and the need for gender-sensitive interventions at the structural and curricular levels in order to attract and retain students, have been identified in both the nursing and international education literature, respectively [ 25 , 30 , 31 , 36 , 162 , 163 , 164 ]; more recently, there has also been greater attention given to gender identity/sexual orientation [ 40 , 41 , 43 , 45 , 165 ]. To further develop EDI best practices, and to advance the profession and practice, future research and discussion papers in nursing higher education must also address the intersections of gender, gender identity/sexual orientation and foreign-born status.

The review also highlights that a variety of terms have been used in the literature to describe foreign-born students, and that although migrant students have been included to some extent, the role of migration history/status and length of time in country have not been considered, making it difficult to tease out information about groups in more vulnerable contexts. More recently-arrived migrants are more likely compared to more established migrants to experience cultural barriers, be unfamiliar with a host country’s systems and have difficulty accessing services. Many refugees and asylum-seekers have experienced trauma and difficult migration trajectories that can exacerbate mental health issues and further complicate adjustment to a new academic environment [ 166 , 167 , 168 ]. Refugees and asylum-seekers are also more likely compared to other migrants and international students to have experienced disruptions in their education and to face language barriers and social-economic disadvantages during resettlement [ 166 , 167 , 168 ]. They are also more likely to experience family separation and may feel greater pressure to succeed especially if family members in the home country are financially dependent on them. Asylum-seekers also are commonly excluded from social programs and have the added strain of not knowing what their future holds. Therefore to have a more nuanced understanding of foreign-born nursing students’ challenges and coping responses, and to better identify supportive interventions, future work should take into account not only gender and gender identity/sexual orientation, but also the migration context (status and length of time), which should be clearly defined [ 41 , 169 , 170 , 171 , 172 ].

The results of the review show that generally there is an abundance written on supportive interventions for foreign-born nursing students in academic institutions, however it remains mostly descriptive and anecdotal. The results raise a number of questions regarding the specifics on how institutions and educators can best be supportive. For example, language and communication remain significant issues yet it is unclear what level of language ability should be required upon admission- high level requirements restrict access while a low level requirement puts undue stress on students, particularly since nursing requires knowledge of specific terminology. Likewise, to what extent should educators adapt teaching approaches and evaluations to facilitate adjustment to the new academic milieu and how can educators effectively provide emotional support whilst maintaining their professional stance? Furthermore, what should the role of institutions be in ensuring that foreign-born students are adequately prepared for work post-graduation, whether they stay in the host country or decide to return to their country of origin, especially when increasingly these institutions are integrating notions of EDI in their mandates? For example, should institutions provide additional support to prepare foreign-born students for the licensure exam in the host country? Alternatively, should institutions provide training within the program that is relevant to international students’ country of origin context and/or provide re-entry programs prior to students’ return home? It would be timely to also study and debate these broader questions related to supportive interventions.

Limitations and strengths

We purposely chose to not use ‘gender’, ‘gender identity’ or related terms in our search strategy so that our search would be broad, however, this exclusion may have contributed to missing some literature. We did not include grey literature, which may explain the lack of language diversity (French and Spanish publications), and consequently the small number of papers on students’ experiences in non-English speaking host countries. Due to the scoping nature of the review we did not closely analyze or report on the evidence related to the identified challenges, coping responses and supportive interventions (e.g., prevalence of challenges, evaluations of interventions). We also did not report on the overall benefits or positive experiences of foreign-born nursing students, which would have been informative. Nevertheless, the review was very thorough and provides a comprehensive overview with a gender lens, of the challenges, coping strategies and supportive interventions that have been studied and discussed over a 39 year period. The results also highlight gaps in the literature, especially with regards to gender.

Future research

Future research on challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, should include sex and gender-based analyses; an intersectionality-based approach, including gender, gender identity/sexual orientation, migration/international status and context, as well as other identity markers (e.g., race, religion) is warranted. Additional reviews on existing gender and gender-identity/sexual orientation sensitive interventions in nursing/healthcare education in general, and for foreign-born students across a variety of disciplines, would also be informative. Overall, more studies that test and evaluate supportive interventions for international and migrant nursing students, at both the structural and curricular levels are needed; a systematic review would be useful as well to provide a better evidence base for academic institutions to draw from. Since most of the literature to date has focused on the US context, and much more has been written on undergraduate students, more research in non-English speaking countries, and with graduate students, especially at the doctoral level, would also be worthwhile.

The literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, has significant gaps with regards to how it addresses the contributions and consequences of sex, gender and gender identity/sexual orientation related experiences. To draw and retain a diversity of candidates to the nursing profession, and to create more inclusive and equitable learning environments, future work, especially with respect to supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students’ contexts.

Availability of data and materials

All data generated and analysed during this study are included in this published article and the original sources.

Abbreviations

Culturally and linguistically diverse

Cumulative Index to Nursing & Allied Health Literature

English as an additional language

Evidence-based practice

Equity, diversity and inclusion

Excerpta Medica dataBASE

Education Resources Information Centre

English as a second language

Grade point average

Lesbian, gay, bisexual, transgender and queer/questioning

United Kingdom

United States

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Acknowledgements

We would like to acknowledge and thank Assia Mourid, the librarian for allied health sciences at the University of Montreal for her assistance in developing the database search strategies and support in conducting the database searches. We would also like to thank Ye Na Kim for her help with the data extraction and Aracely Estefania Rodriguez Espinosa and Kassandre Thériault for their support in the assessment of the literature for gender related information.

This work was supported by the SHERPA research centre, the University Institute with regards to cultural communities of the CIUSSS West-Central Montreal and by the Quebec Population Health Research Network (QPHRN). LM was supported by a research scholar junior 1 award from The Fonds de recherche du Québec- Santé (FRQS) .

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LM and BV conceived the idea for the review, obtained funding and supervised the literature search, review and selection process. KPV developed the database search strategies (with assistance from a librarian), conducted the searches, reviewed and selected the literature, and extracted the data and created the summary tables; KPV also aided in the writing of the methods section of the manuscript. LM drafted the manuscript. BV contributed to the results and discussion sections and critically revised the manuscript for intellectual content. All authors read and approved the final version of the manuscript.

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Merry, L., Vissandjée, B. & Verville-Provencher, K. Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens. BMC Nurs 20 , 174 (2021). https://doi.org/10.1186/s12912-021-00678-0

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The role of connection with nature in empirical studies with physiological measurements: a systematic literature review

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It is well described that exposure to nature reduces physiological stress, and connectedness to nature can have a moderating effect. However, few studies have so far examined the construction of the connection with nature in relation to physiological processes. In this systematic review, we collected studies that used a physiological measure and included a scale to measure connectedness to nature. Our aim was to assess the role of nature relatedness at the level of physiological processes and to summarize the results published so far. Our review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A literature search was conducted in 3 different databases (PubMed, ScienceDirect and Google Scholar). As keywords, we used all the different questionnaires that measure connectedness to nature, combined with terms related to physiological measures. After final screening, 28 articles met the inclusion criteria for the review. The studies were very diverse in terms of purpose, intervention and methods, so narrative synthesis was conducted without measures of effect. We found evidence for a mediating effect of nature connectedness on the associations between nature exposure and cognitive function, brain activity, blood pressure, cortisol level and mental health. Studies investigating nature relatedness as state-like characteristics have shown that exposure to nature increases the level of connection to nature. Eye-tracking studies have confirmed that this measurement method can be used to investigate nature relatedness at a physiological level, which could be a useful complement to self-report questionnaires in future studies.

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Introduction

The benefits of exposure to nature.

A large number of studies have shown that exposure to nature has a positive effect on well-being and physical health (Hartig et al. 2014 ; Keniger et al. 2013 ). Individuals living and interacting green spaces report being more energetic, in better general health and with a greater sense of purpose in life (Sifferlin 2016 )). More than 2500 years ago, Cyrus the Great intuitively created lush green gardens in the crowded Persian capital to improve people’s health and promote a sense of “calm” in the busy city. In the sixteenth century, the Swiss-German physician Paracelsus stated: “The art of healing comes from nature, not from the physician”. Today’s scientific evidence confirms what people have long known intuitively: That nature has great benefits for the human brain, reflected in increased happiness, health/well-being and cognition (Williams 2016 ). The stress-reducing effects of nature are recognized and used in many therapies. The Japanese Shinrin-yoku (taking in the atmosphere of the forest) forest bathing therapy has a long tradition. There are numerous studies demonstrating the beneficial effects of Shinrin-yoku from a physiological and psychological perspective, including studies by Tsunetsugu et al. ( 2007 ) and Park e al. ( 2008 , 2010 ).

These benefits can be explained by various contemporary hypotheses of human–nature interaction (Berto 2014 ), which explains the mechanisms by which spending time in nature can affect human health (Jimenez et al. 2021 ). The biophilia hypothesis (Kellert and Wilson 1995 ) claims that humans have an evolutionarily determined innate tendency to seek connection with nature. The Theory of Attention Restoration (ART) suggests that nature facilitates recovery from the mental fatigue associated with a diminished ability to control attention in modern life. According to this theory, spending time in natural environments allows people to recover from mental fatigue and restore the ability to direct attention (Kaplan 1995 ). Finally, according to the Stress Reduction Theory, physiological symptoms of stress, as measured by cortisol levels and autonomic nervous system activity, are reduced by exposure to nature. Although causal relationships are unclear, these theories complement each other, as attentional restoration has been linked to emotions (Hartig et al. 1997 ): Attentional fatigue may be an aftereffect of stress and a condition that increases emotional/stress vulnerability (Berto 2014 ).

As humans have an innate connection to the natural world, exposure to stimuli from natural sources influences feelings or emotions by activating the parasympathetic nervous system to reduce stress and autonomic arousal (Ulrich et al. 1991 ). Green spaces provide children with opportunities for exploration, creativity, risk-taking, mastery and control, which positively influence various aspects of brain development, according to proponents of the biophilia hypothesis (Kahn and Kellert 2002 ). Adam György has also emphasized the importance of evolutionary thinking in understanding psychological phenomena (Ádám, 1998 ). Koivisto and colleagues ( 2022 ) found that top-down cognitive processes influence the psychophysiological effects of the environment and hypothesized that individual’s associations modulate the innate bottom-up effects of exposure to nature. However, the mechanisms linking nature exposure and health outcomes are diverse, not fully understood, and may act in isolation or synergistically (Kruize et al. 2019 ).

Additionally, it is important to note that only certain natural elements (safe and comfortable for humans) are beneficial. Similarly, phobias of certain natural elements, such as fear of getting lost (Berg and Heijne 2005 ), fear of wild animals/dangerous animals or fear of forest (Skår 2010 ) can be traced back to evolutionary causes.

In this article, nature is defined in a narrow way: As an aspect of modern society, separated from nature. But it is important to realize that nature can also cause stress in the absence of civilisation, which is why people built civilisation. The benefits of interacting with nature are particularly strong in modern, nature deprived societies.

The role of nature relatedness

Despite this obvious attraction towards nature, there is considerable variability in the extent to which individuals are drawn to nature (Nisbet et al. 2009 ). Nature relatedness is a trait that indicates how much an individual feels connected to the natural world. The human–nature relationship depends on a number of other factors. These include values, gender, nationality, the quality of the environment and time spent in nature. Some researchers suggest that positive emotions from exposure to nature lead to a deeper connection with nature (Nisbet & Zelenski 2011 ), while others suggest the opposite, that attachment to nature influences mood changes during outdoor activities (Mayer et al. 2008 ).

Nature connectedness is a possible mediator between nature exposure and well-being and quality of life. A study of 863 participants in China examined the associations between nature exposure, nature connectedness and mental well-being (Liu et al. 2022 ). It found that connection to nature moderated the associations between nature exposure, as measured by the frequency of visitation, amount of nearby green space and parks and mental well-being. Similarly, another recent study found that connection with nature mediated the link between nature exposure and quality of life (Baceviciene and Jankauskiene 2022 ).

On the other hand, it also has to be noted that there are researches, which found additional mediators between nature relatedness and well-being. Different concepts of connection to nature fostered in different cultural and social contexts modulate relation to nature and subsequent well-being outcomes (Cleary et al. 2017 ). In addition, other factors, such as spirituality, may moderate the relationship between nature and well-being (Trigwell et al. 2014 ; Kamitsis and Francis 2013 ). Another mediating factor, which influences the link between well-being and connectedness to nature could be life purpose, which is also a key dimension of eudemonic well-being, according to Howell and colleagues ( 2013 ). Kövi et al. found that gratitude, as a self-transcendent emotion, provides a significant indirect link between nature relatedness, mental health and quality of life (Kövi et al. 2023 ). Similarly, Kryazh et al. confirmed that trust mediates the relationship between connection to nature and both the subjective well-being and eudemonistic well-being (Kryazh 2019 ). Research by Zhang et al. has shown that connectedness to nature predicts well-being only when people are emotionally attuned to the beauty of nature (i.e. they have positive emotional responses to the sight of nature’s beauty) (Zhang et al. 2014 ).

Previous studies of exposure to nature (Kjellgren and Buhrkall 2010 ; McSweeney et al. 2021 ; Ottosson & Grahn 2005 ) suggests that past experiences and interactions with nature influence and possibly enhance the benefits of future exposure. It is also known that higher expression of nature relatedness affects the individual’s stress recovery and restoration through the positive effects of the natural environment (McEwan et al. 2021 ; Mcsweeney et al. 2015 ).

While most studies have focused on the association of nature relatedness with well-being and subjective stress, fewer studies have measured the physiological stress response as indicated by changes in blood cortisol levels, cardiovascular indicators (blood pressure BP), heart rate (HR) and heart rate variability (HRV), brain activity or respiratory function. As the natural environment can have a significant impact on the body’s stress-related physiology (Laumann et al. 2003 ), it is important to explore how stress manifests itself physiologically. Stress refers to an individual’s response to mental, social, environmental and/or physical demands (Selye 1956 ). Stress can cause a range of physiological and behavioural changes, most notably affecting the functioning of the autonomic nervous system (ANS), which consists of the sympathetic and parasympathetic nervous systems. Depending on the changes in the ANS, a person may feel relaxed, agitated, stressed or rejuvenated. For example, there is evidence that exposure to nature can immediately stabilize breathing and blood pressure in stressed people (Annerstedt and Währborg 2011 ; Chang and Chen 2005 ).

Concepts and measures of connection with nature

A wide range of scales have been used to measure attitudes towards nature (brief summary in Table 1 ). The convergence and divergence of different questionnaires commitment to nature (COM) (Davis et al. 2009 ), connectedness to nature (CTN) (Mayer and Frantz 2004 ), connectivity with nature (CWN) (Dutcher et al. 2007 ), emotional affinity towards nature (EATN) (Kals et al. 1999 ), environmental identity (EID) (Clayton and Opotow 2003 ), inclusion of nature in self (INS) (Schultz 2001 ) and nature relatedness (NR) (Nisbet et al. 2009 ) were examined in an empirical study (Tam 2013 ). According to the results different measures are closely correlated and converge to a single factor, thus they measure the same construct. They were also similarly correlated with different criterion variables (e.g. big five traits, contact with nature, well-being). The following is a brief description of the characteristics of each questionnaire.

The Nature Relatedness Scale is one of the most commonly used measurement tool. Both single-factor and three-factor structures (self, perspective and experience factors) were shown to be viable by Nisbet and colleagues ( 2009 ). However, the single-factor structure was considered more promising because in the original form many items loaded on multiple factors, which were highly correlated (Nisbet et al. 2009 )). Subsequent studies also consistently favoured a single overall NR factor and found high internal consistency of full-scale items (Howell et al. 2011 ; Nisbet et al. 2011 ). The short form of the questionnaire (NR-6) is particularly useful when an assessment of elements of connectedness rather than environmental attitudes is needed (Nisbet and Zelenski 2013 ).

Connectedness to Nature Scale (Mayer and Frantz 2004 ) has an original and a modified version. While the former treat connectedness to nature as a trait characteristic, the latter is measuring present feelings about nature connection. Both assess cognitive beliefs instead of affective attitudes (Perrin and Benassi 2009 ).

Environmental Identity Scale (EID) includes several dimensions: Interaction with natural elements, importance of nature, importance of belonging to nature and positive feelings towards nature (Clayton et al. 2021 ). Both the original and the short form of the EID showed good internal consistency (Piskóti 2015 ).

Another concept, Inclusion of Nature in Self (INS), focuses on the cognitive aspect of nature relatedness. Schultz's ( 2001 ) graphical measure was based on Aron, Aron, Tudor and Nelson’s concept of self ( 1991 ). Respondents are shown seven pairs of circles (one is labelled “self” and the other “nature”) with varying degrees of overlap, and they select the pair that best describes their relationship with nature.

The Love and Care of Nature Scale (LCN) is a reliable and valid measurement of an individual’s feelings towards nature. It also showed higher internal consistency than NR-21 and INS scales (Salatto et al. 2021 ). The construct of love and deep caring for nature expresses the individual’s personal and specifically emotional relationship with nature (Perkins 2010 ).

The importance of experiencing nature or preferring urban environments appears to differ between individuals (Korpela et al. 2010 ; Tyrväinen et al. 2007 ). This difference is measured by the Urban-Nature Orientedness Scale (Ojala et al. 2019 ).

Two of the studies included in this review used a single-item question to measure nature relatedness. Lau and colleagues ( 2023 ) used a scale from zero to 100, in Chen’s ( 2022 ) study a 5-point scale was used to measure participants’ current connectedness to nature.

Overall, there are many different ways of measuring the connectedness with nature, and it is quite certain that many subjective and health indicators are related to this construct. However, the objective physiological links have been little studied, so little is known about how individuals’ level of connectedness with nature relates to their different responses to the natural environment. Our aim with this review was to investigate the role of nature relatedness at the level of physiological processes and to summarize the results published so far.

The review was conducted by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Liberati et al. 2009 ). As keywords, we used all of the different questionnaires for measuring connectedness with nature combined with terms relating to physiological measures (for details see in Table 2 ). The search engine was set to scan the whole articles (title, abstract and text) for the keywords. Searching was conducted in three databases: PubMed, ScienceDirect and Google Scholar. We performed the screening in January and February of 2023. Only English articles were included (theses, reviews, meta-analyses, conference papers, books and dissertations were excluded), and no time filter was used. Only articles published in peer-reviewed journals were eligible in order to maintain the high quality of the articles. Search strategy characteristics and study inclusion/exclusion criteria are reported in Table 2 . All empirical studies were included which (1) used any kind of questionnaire measuring connectedness with nature and (2) assessed associations between the aforementioned construct and an objective physiological variable. No restriction was used with respect to age, health status, gender or nationality of the studied sample. To decide on inclusion the two authors (VG and ZsD) read the titles and abstracts of the papers as a first step. In the next step, both authors read the full text of the selected articles and made the final decision on inclusion. In case of any ambiguity, disagreements were resolved by consensus. Initial search identified 5109 records from the three databases and through additional resources. After screening the titles, the abstracts of the relevant articles were checked by the two authors. Ninety-two percentage of the articles were not relevant. Either no nature-related questionnaire was included, or no physiological measurement tool was used. After removing duplicates, 36 unique citations remained and were screened for eligibility (Fig.  1 ). According to the final screening, 28 articles met the inclusion criteria of the review.

Selection of studies

Of the 28 studies identified, eight measured changes of cortisol (Bakir-Demir et al. 2021 ; Beil & Hanes 2013 ; Geniole et al. 2016 ; Gidlow et al. 2016 ; Jones et al. 2021 ; Niedermeier et al. 2019 ; Souter-Brown et al. 2021 ; Sumner & Goodenough 2020 ), thirteen performed cardiovascular assessments (HR, BP) (Chan et al. 2021 ; Huber et al. 2023 ; Lau et al. 2023 ; Lim et al. 2020 ; McEwan et al. 2021 ; McSweeney et al. 2021 ; Michels et al. 2021 , 2022 ; Morris et al. 2021 ; Ojala et al. 2019 ; Reeves et al. 2019 ; Salatto et al. 2021 ; Schebella et al. 2020 ) and three applied both type of measurements (Gidlow et al. 2016 ; Michels et al. 2021 ; Sumner & Goodenough 2020 ). Of the remaining seven studies, three investigated neurological functions (Bailey & Kang 2022 ; Koivisto et al. 2022 ; Sudimac & Kühn 2022 ), two examined eye movements(Chen et al. 2022 ; Giray et al. 2022 ) and the last two consisted of other measurements (e.g. body composition, faecal serotonin level) (Sobko et al. 2020 ; Teixeira et al. 2021 ). In the following, we briefly describe the relevant studies and summarize their main findings about the connection between nature relatedness and physiological changes.

Neuroendocrine measurements

Eight publications were found that examined the relationship between nature relatedness and changes in cortisol levels due to exposure to nature. While three studies found positive association between the decrease of physiological stress measured by cortisol and nature relatedness (Beil & Hanes 2013 ; Souter-Brown et al. 2021 ; Sumner & Goodenough 2020 ), four studies found no association between them (Bakir-Demir et al. 2021 ; Geniole et al. 2016 ; Gidlow et al. 2016 ; Niedermeier et al. 2019 ). One study used nature relatedness just as a control variable in a walking in natural and urban environment intervention experiment, hence no specific statistical results were presented (Jones et al. 2021 ). The results of each study are discussed in detail below.

All three studies which found association between connectedness and nature and decreasing cortisol level used some kind of nature exposure as an intervention. In Sumner and Goodenough’s ( 2020 ) investigation, participants walked among free-roaming lemurs in a British safari park while salivary cortisol level and heart rate were measured. The aim was to understand whether a short interaction with non-domestic animals might reduce stress and improve well-being of participants and whether nature relatedness might influence these changes. According to the results no changes in heart rate were found, but there was a statistically significant reduction in participants’ salivary cortisol levels following the animal encounters. The decrease of cortisol level was correlated with nature relatedness level of the individuals. Beil and Hanes ( 2013 ) also found a connection between environmental identity and decreasing cortisol level in their cross-over pilot study, where the effect of urban environments on physiological and psychological stress was investigated. Participants were exposed to one of four urban environments settings (very natural, mostly natural, mostly built and very built) in random order for 20 min on separate days. Negative association was found between environmental identity (EID) and changes in salivary cortisol and amylase levels, indicating a possible link between environmental identity and physiological response. The association between personal environmental identification and saliva outcome measures indicates that individuals with higher EID scores may be physiologically more sensitive to their environment. No correlation was found between EID and subjective stress markers, suggesting that physiological sensitivity may be due to sensory-perceptual processing independent of conscious awareness. In a recent study where salutogenic natural design as a stress-reducing health promotion tool was examined (Souter-Brown et al 2021 ), negative association between cortisol level and nature relatedness also was detected. Two intervention groups (30-min pastime in a sensory garden or in an urban plaza) and control group were applied with between-subject design and salivary cortisol (also perceived well-being and stress, productivity) were measured before and after the intervention. To understand whether people with higher nature connectedness are more or less affected by the dose of nature, the Nature Relatedness Scale (NR-21) was used. The main findings were that NR increased and cortisol level decreased in the sensory garden group compared to both the urban plaza and control groups. Biodiversity has also been found to increase NR levels.

In contrast to these findings, five studies found no association between cortisol reduction and nature relatedness. In a Turkish questionnaire study (Bakir-Demir et al. 2021 ), the cumulative cortisol level from a segment of hair was examined instead of saliva. The authors investigated whether connectedness to nature helps young adults cope with stress through emotion regulation. According to their hypothesis individuals with higher levels of connectedness to nature would have lower levels of subjective and objective cumulative stress. In contrast, the results showed that only perceived stress and connectedness to nature were correlated, but no association was found for the objective cortisol level. Connectedness to nature predicted adaptive emotion regulation strategies. However, non-adaptive regulatory strategies were not related to NR. These results show the importance of examining the different characteristics of stress separately and confirm the hypothesis that connectedness to nature has restorative powers. This effect is particularly apparent for positive outcomes, such as adaptive regulation skills (Bakir-Demir et al. 2021 ). In the last four studies with cortisol measurements, some form of exercise was used as an intervention. Neither of them found any association between nature relatedness and level of cortisol. Psychological and physiological responses to self-paced 30-min walks in three environments (pleasant urban, natural (green) and natural with water (blue)) were compared in a cross-over field-based trial (Gidlow et al. 2016 ). There was no difference between the three environments in terms of cortisol and mood, all of which had a positive effect on these variables, although greater restoration experiences and cognitive function improvements were observed in green and blue environments. In these cases, no potential relationship linking nature relatedness with restorative experience or cognitive function were observed. Heart rate variability data from baseline to 30-min after the walk did not show consistent patterns, or any differences in environmental response.

Niedermeier et al ( 2019 ) investigated the effects of anthropogenic elements on the physiological response to acute stress during exercise in green environments. A secondary aim of their study was to investigate the possible impact of connectedness to nature on outdoor exercise. The between-subject design consisted of two mountain hiking groups: One encountered fewer anthropogenic elements on the route, the other experienced more of them. Results showed that regardless of the environment in which the tour took place, affective states were positively affected by the intervention, but no association was found between cortisol variation and nature relatedness, nor between affective states and nature relatedness, although the mean nature relatedness level of the participants was high which may have hidden the possible effects of nature connectedness.

Geniole and colleagues ( 2016 ) compared the benefits of an outdoor walk in a restored naturalized landfill site and an urban area. During pre–post measurements testosterone and cortisol concentration (both from saliva), attentional control, mood and arousal were measured. It has been hypothesized that the effects of exposure to nature are more pronounced in people who are more connected to nature. According to the results walking in both environments improved energy and attention regulation and reduced cortisol concentrations, mood improved more in the naturalized area. Connectedness with nature had moderating effects in the case of mood: The mood of men with high nature connectedness improved more after both walks, while the mood of men reporting low nature connectedness improved only after the walk in the natural environment and decreased after the urban interaction. This suggests that being more connected to nature helps to neutralize the negative effects of urbanization. However, this was only true for this subjective variable, with no such link for cortisol.

In the last study (Jones et al. 2021 ) presented here, no specific results on the effect of nature relatedness were reported, it was only used as a control variable. This between-subject, longitudinal study investigated what “dose” of nature is required for health benefits, and whether repeated visits to the same natural or pleasant urban environments are consistently beneficial to health (measured with salivary cortisol, restorative experience, etc.). No significant effects of the natural environment on mood or salivary cortisol were found.

Cardiovascular measurements

Twelve studies were found that examined a physiological indicator related to the cardiovascular system and connectedness of nature. Heart rate, heart rate variability, blood pressure and oxygen saturation were used as objective variables, and NR, CNS, EID, INS or LCN questionnaires were applied to measure participants’ relationship with nature. Most of these researches did not investigate the association between physiological measurements and nature relatedness, only examined changes in connectedness with nature as a result of an intervention or used this personality trait to detect demographic differences.

McSweeney and colleagues ( 2021 ) examined stress response (i.e. changes in time and frequency domain indices of heart rate variability) associated with indoor environments with and without multi-sensory and immersive natural elements. Also the effect of nature relatedness (NR-6) on HRV outcomes (average NN intervals, HF, LF/HF) was investigated and two attention demanding tasks (Search and Memory test, Digit Span Test) were carried out. According to the results no significant differences between control and exposure groups in heart rate variability were revealed. However, increases in N–N intervals and a significant reduction in LF/HF ratios immediately after attention demanding tasks indicated that indoor nature exposure suppressed the sympathetic nervous system, and provided recovery from stress. Natural elements could facilitate recovery from mental fatigue and stress as a source of stress recovery. Since there was no significant correlation between NR and any HRV markers at any time points, the results also indicated that there is no relationship between physiological stress measured by HRV and connection to nature. It seems to be that nature is physiologically beneficial regardless of an individual’s NR score.

We found seven studies, where connectedness with nature and cardiovascular variables were measured, but the relationship between them was not investigated. They only explored changes in connectedness with nature as a result of different interventions. All but one (Morris et al. 2021 ) found that exposure to nature (even virtually) and exercise significantly increased participants’ affinity to nature (Chan et al. 2021 ; Huber et al. 2023 ; Lau et al. 2023 ; Lim et al. 2020 ; McEwan et al. 2021 ; Salatto et al. 2021 ). As nature connectedness has only been studied to a limited extent, these studies will only be briefly described.

In the study of McEwan et al. ( 2021 ), two stress reducer and well-being enhancer intervention was compared: Forest Bathing and Compassionate Mind Training (CMT). Heart rate variability was measured during each session to see, which aspects of the intervention offered the greatest benefit to participants. The results showed that affinity to nature (INS) improved in all groups, and INS scores improved to a greater extent for participants who also participated in forest bathing. Although at the follow-up measurement (4-month post intervention) nature connection scores had decreased. In the case of physiological (HRV) and subjective variables no significant differences were observed between conditions, showing that Forest Bathing has a similar effect to CMT, an established well-being intervention.

The effectiveness of virtual nature contact was investigated in two research (Lau, Chan). In Lau and colleagues’ ( 2023 ) investigation, increased happiness and relaxation were observed after the nature intervention, also this group had significantly higher level of nature connectedness after the virtual nature exposure. But no significant effects on physiological variables (e.g. cardiovascular responses in BP, HRV and average peripheral oxygen saturation) were detected. The results demonstrated that the heightened nature connectedness of the virtual nature group over the urban group remained during the 2-week follow-up. Also the effects of virtual natural and urban environments on cardiovascular activity (heart rate, HRV), nature connectedness and affect were examined in a Singapore research (Chan et al. 2021 ). Two studies were implemented, one with young adults and one with senior citizens. They found in both studies that nature connectedness was significantly greater after the nature condition. This resulted in reduced negative affectivity and greater parasympathetic activation in the case of the young sample and in increased positive affectivity in the case of the senior sample.

Salatto et al. ( 2021 ) investigated the effect of B-alanine induced painful sensation during outdoor hiking with a double blind, placebo-controlled crossover trial. After participants consumed either B-alanine or a placebo, participants immersed themselves in the natural environment for 45 min and then completed a short hike uphill as fast as possible without running. According to the results no significant difference in HR was observed between treatments. Connectedness to nature increased with exercise. Pain induced by B-alanine consumption had no effect on connection to nature, so an increase in painful feelings does not necessarily diminish one’s connectedness to the natural world. The relationship between green exercise and elevated nature connectedness has practical implications: If someone spends time exercising in a green environment then a deeper connection and love for nature can develop, which increases the desire for subsequent green exercises. This can lead to chronic health improvements.

Nature relatedness also increased due to the intervention in a recent experimental study. In a randomized, controlled clinical trial Huber et al. ( 2023 ) studied the effects of two types of 6-day long nature-based therapies (forest therapy and mountain hiking) on sedentary couples. Several physiological (HR, static balance, body composition, aerobic fitness, transepithelial water loss, differential blood counts, fractional exhaled nitric oxide) and psychological variables were investigated. According to the results participants benefited physically and mentally from both interventions, but nature connectedness increased only slightly in both intervention groups.

One of the studies found investigated non-healthy population (Morris et al. 2021 ). The aim of this research was to offer psychological and/or physiological benefits for people living with cancer with a ten-week exercise programme including nature intervention. Although many physiological (e.g. blood pressure, aerobic fitness, flexibility) and psychological variables have been measured (e.g. sense of coherence), also the results were analysed both quantitatively and qualitatively, but in the case of nature relatedness, the authors only measured its change as a result of the 10-week programme. They found that nature relatedness did not significantly improve over time, but incremental increases were still observed.

In an experimental field study Lim and colleagues ( 2020 ) compared the effectiveness of guided and unguided nature immersion on mood, nature connectedness and heart rate. They found that there were no significant differences between guided and unguided immersion in the change in nature connectedness, mood or heart rate, and nature connectedness and mood improved post-immersion in both groups.

In five studies nature relatedness was only used to explore demographic differences (Reeves et al. 2019 ) or divide participants into groups for statistical analysis (Ojala et al. 2019 ) or to control its potential confounding effect (Michels et al. 2021 , 2022 ; Schebella et al. 2020 )—but no additional analyses with NR were conducted. We have also included these studies in our summary table (see in the Supplement section), but we will not describe them here in detail.

Brain functions, EEG measurements

The neural mechanisms underlying the stress-reducing effects of exposure to nature are still largely unexplored. This is also reflected in the number of articles concerning nature relatedness and brain function. We found three studies where nature relatedness and brain function were examined. One research was based on fMRI measurements (Sudimac and Kühn 2022 ) and two studies used electroencephalography (Bailey and Kang 2022 ; Koivisto et al. 2022 ) and they have all found that connectedness with nature has a relevant effect on specific brain functions during exposure to nature.

Sudimac and Kühn ( 2022 ) examined in their fMRI-study the effect of natural versus urban environment on amygdala activity, and the potential sex differences in amygdala activity change after a one-hour walk in a natural vs. urban environment. Participants underwent the fMRI scanning procedure including two social stress tasks (Montreal Imaging Stress Task and Fearful Faces Task) before and after the walk. According to the results, after the walk in nature stress reaction measured by amygdala activity decreased and cognitive performance improved, but only in women. Men performed better on the arithmetic task after the walk in the urban environment. Interestingly they also found that the stronger connectedness to nature was in women, the decrease in their amygdala activity was greater during the social stress task after the urban walk. Overall the results suggested beneficial effects of nature exposure on the stress-related brain regions and these salutogenic effects were more pronounced in women.

Koivisto et al. ( 2022 ) aimed to test whether top-down cognitive processes (manipulation of stimulus-source attribution of a soundscape) influence the psychophysiological effects of environments. Participants listened to an ambiguous sound that was attributed to either nature (waterfall) or industry (factory). Subjective reports of relaxation and pleasantness, electroencephalography (brain’s alpha band activity 8–13 Hz) and electrodermal activity (EDA) were measured in the experiment with within-participants design. According to the results, the influence of source attribution was reflected both in subjective and objective measures. Subjective experiences were more pleasant, and the power of the brain’s lower alpha band activity was stronger when the sound was attributed to nature. They also found that nature connectedness moderated the effect of source attribution on theta band power and electrodermal activity. The greater was the nature connectedness, the stronger was the theta activity in the waterfall condition. Overall, it supports the influence of top-down cognitive processes on the psychophysiological effects of environments and assumes that the individual’s meanings and associations modulate the innate bottom-up effects of exposure to nature.

The aim of the last intervention study with EEG measurements was to determine the cognitive and neurological effects of 10-min walking or sitting in an outdoor environment (Bailey and Kang 2022 ). Mental speed and acuity with Stroop test and theta ( θ ), alpha ( α ), beta ( β ) and gamma ( γ ) bandwidths were measured before, after and 10 min post intervention. According to the results both sedentary and walking participants showed improvements in cognitive performance after the outdoor session, regardless the type of the intervention. Higher connection to nature (also state mindfulness during the intervention) were related to lower levels of frontal beta amplitudes during the outdoor intervention in both groups. Since elevated frontal beta is an indicator of rumination, a sense of connection with the natural world can enhance one’s ability to be more present in the moment, to get away from everyday stress and enjoy the benefits and mental restoration of the natural environment.

Eye-tracking measurements

Two studies were found that included eye movement tracking and a scale measuring connection to nature, but only one of them investigated the link between nature relatedness and eye movements (Chen et al. 2022 ). Participants were shown a 360-degree virtual reality scene with urban and natural environmental elements while eye movements were monitored. NR Scale questionnaire was collected one week later, and all participants were divided into three groups depending on their NR scores. They found that individuals’ nature relatedness level correlated with their eye movements in the area of interest. Those who scored low on the NR Scale spent less time looking at green plant elements than buildings, and vice versa. For the medium NR group, no clear difference in eye movement was found between trees and buildings. They also found that NR Self subscale was significantly associated with eye movements characteristic of nature interests, but NR Perspective and NR Experience showed no significant relation with eye-movement tracking scores. The results suggest that this physiological measurement is suitable to investigate nature relatedness. Many existing studies have demonstrated a link between NR and behaviour, but most of them used self-report measures of behaviour, such as interviews and questionnaires (Colléony et al. 2017 ; Flowers et al. 2016 ). The study highlights another important aspect, it demonstrates the “top-down” effects of cognition on perception.

In the second study, Giray et al. ( 2022 ) investigated the shopping preferences and motivations behind consumption patterns of women with children. They used eye-tracking methods to examine how connectedness to nature and other subjective factors influenced the purchase of organic products. They also played birdsongs to some participants in order to investigate the effect of this stimulus on mood and connectedness to nature. The results showed that objective and subjective knowledge about the products and visual attention to organic product labels are positively correlated with the purchase of these commodities. However, mood states and connectedness to nature did not show such a correlation with purchase preference. Those who were exposed to birdsongs gave higher CtN and mood scores than respondents who were not listening to bird sounds.

Other measurement methods in nature relatedness research

We found two studies that did not fit into the categories above in terms of physiological variables, because they examined anthropometric and exercise-related physiological factors. Although both of them used connectedness to nature in their analysis, we thought it important to involve them in this review.

In a Portugal study, the relationship among connectedness with nature, physical activity and body composition was investigated (Teixeira et al. 2021 ). Several variables were measured, most of which were anthropometric (e.g. body composition (fat mass, visceral fat, skeletal muscle mass, etc.) and exercise-related (accelerometry). The results did not reveal any differences between men and women regarding connectedness to nature scores, but interestingly women with more children and men with dogs had higher CN scores. The results also showed that women who were more connected to nature had a higher number of steps per day. In the case of bioimpedance data no relevant connection with NR was found.

The only study that examined children investigated the effect of a 10-week outdoor nature-related programme (Play&Grow) on gut microbiota, faecal serotonin and perceived stress (Sobko et al. 2020 ). The results showed that after the environmental programme children in the intervention group were more connected to nature, their perceived general stress levels decreased (particularly anger frequency), the abundance of certain gut microbiota was altered and gut serotonin levels did not decrease (in contrast to the matched control condition). Overall alteration of the gut microbiome may be associated with greater exposure to the natural environment and connectedness to nature, but further mechanistic studies are needed to strengthen the role of gut microbiota in the relationship between connectedness to nature and improved psychosocial behaviour.

Many previous studies have shown that being in connection with nature is associated with a better quality of life, better physical and mental health and also promotes proenvironmental behaviours (Geng et al. 2015 ), which could play an important role in addressing the current environmental crisis. But little research has been done to date on its relationship with objective physiological changes. The purpose of this review was to summarize recent literature on nature relatedness and physiology.

We identified 28 studies, most of them measured cardiovascular variables (13), changes in cortisol level (8), brain functions (3), eye movements (2) and exercise-related or anthropometric variables (2). The most frequently used questionnaire related to nature connection was the Nature Relatedness Scale (NR-21 and NR-6 were also used in 7–7 cases). The trait-type CTN-14 was used in 4 studies and the state-type CNS-13 in 3 studies. Also, several researches applied the INS (3) or its short form (1). The remaining studies used either the EID (2), LCN (1), EINS (1) or other form of measures (e.g. urban-nature orientedness scale, adapted for children, one item question).

Summarizing the results, evidence for mediating effect of nature connectedness on the associations between nature exposure and lower level of cortisol, better cognitive function, altered brain activity was found. These results confirm the restorative power of connecting with nature and support the hypothesis of the Theory of Attention Restoration. However, the results also suggest that there are individual differences between people and that nature is not equally beneficial to everyone. These differences may also lead to differences in NR. Nature relatedness may develop in people who experience stress relief in nature and not in people who do not feel the benefits of nature as much. Several studies have found a link between stress reduction (in the term of decreasing cortisol) and high levels of nature relatedness. Also there is some evidence that people who are more connected to nature may be physiologically more sensitive to their environment. However, in a significant proportion of measurements, no association between connectedness to nature and cortisol levels was found. These contradictory results are probably due to the huge methodological heterogeneity: There is considerable variation in the applied questionnaires, interventions, samples and experimental designs, which makes it almost impossible to compare the results. Another factor is that the majority of studies examined nature relatedness in combination with some type of activity whose benefits are well known (i.e. outdoor exercise). Most of the studies that have examined cardiovascular variables have not addressed the role of nature relatedness. However, where this link has been investigated, no association between changes in HRV and connectedness with nature has been found. One explanation could be the idea, often mentioned in György Ádám’s studies, that humans are unable to accurately perceive their internal physiological state (Ádám, 2009 ). It is also possible that, among the physiological markers of stress, cortisol levels could be a more appropriate measure of connection to nature and the effects of NR. This suggests that of the physiological markers associated with stress, cortisol levels may be a more appropriate measure to investigate the effects of exposure to nature and nature relatedness. Besides measuring cortisol, measurements of brain function are also promising of the three studies identified, all three found detectable results for NR-related changes in brain function. Higher connectedness to nature was associated with lower frontal beta amplitude and stronger theta activity during natural interventions and reduced amygdala activity during social stress task. These findings all suggest that nature relatedness might play an important role in the Stress Reduction Theory of nature exposure. Furthermore, because frontal beta activity is associated with rumination and attentional processes, and NR seems to reduce these, it also fits with the idea of Attentional Restoration Theory.

Eye-tracking studies have confirmed that this measurement method can be used to investigate nature relatedness at physiological level, which could be a useful complement to self-report questionnaires in future studies.

In terms of exercise-related measurements, two studies have confirmed that a stronger connection to nature goes hand in hand with more physical activity in nature. This relationship has been described in survey studies with children and young men (Molina-Cando et al. 2021 ; Puhakka et al. 2018 ) but has so far been poorly investigated by objective measurement. The promotion of nature relatedness can lead to chronic health improvements, since if someone spends time exercising in the natural environment then a deeper connection with nature can develop, which increases the desire for subsequent green exercises. Studies investigating nature relatedness as state-like characteristics have shown that being exposed to nature increased the level of connection to nature. This supports Nisbet and Zelenski’s hypothesis ( 2011 ) that positive emotions from exposure to nature lead to a deeper connection to nature.

Implications for future biology

In line with Biologia Futura’s aim to “provide new avenues for future research in biology”, we have summarized below the biological aspects of the paper that are worthy of further study and/or may have practical implications.

In addition, our finding that among physiological markers of stress, changes in cortisol levels appear to be more appropriate than cardiovascular markers in order to examine the relationship between stress and nature raises important questions. Further studies would be needed to explore causal relationships.

It seems promising to include eye tracking in NR studies. This is a less explored area, but from what we have seen so far, it could be an important addition to self-report questionnaires.

Another interesting issue is the question of individual differences. It would be interesting to examine whether different levels of NR also mean that exposure to nature does not have the same beneficial effects on individuals.

The article presents many studies that combine exposure to nature with exercise in nature. As the latter has been shown to have a positive effect on mood and stress reduction, it would be interesting to look at the positive effects of NR in isolation.

Although one of the studies we reviewed (Gidlow 2016 ) compared two different natural environments (blue, green) in terms of stress reduction, no significant difference was found. Nevertheless, it would be interesting to further investigate what kind of natural environment is most beneficial for humans.

Overall, there have been few studies on nature relatedness using physiological measures, and there is considerable heterogeneity in their methodologies. However, the results are promising and there is a strong need for further replication studies using rigorous methodologies to confirm the results so far and to explore causal relationships.

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Gál, V., Dömötör, Z. The role of connection with nature in empirical studies with physiological measurements: a systematic literature review. BIOLOGIA FUTURA 74 , 281–294 (2023). https://doi.org/10.1007/s42977-023-00185-0

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Augmenting the spirit of research among nursing personnel: A narrative review

Affiliations.

• 1 Department of Nursing, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.
• 2 Nursing College, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.
• PMID: 38482331
• PMCID: PMC10931854
• DOI: 10.4103/jfmpc.jfmpc_77_23

Background: In health-related technology, the professionalism paradigm has shifted from a traditional-based approach to evidence-based nursing practice (EBP). For nurses, EBP as a systematic approach to problem solving is well supported and is based on translating the best current research findings into a decision made on patient care or nursing intervention.

Objective: To review the strategies to develop the research capacity among nurses.

Design: A keyword search was used to locate relevant articles. Bibliographic data were retrieved from PubMed, Google Scholar, Scopus, CINAHL, and Medline. A total of 100 articles were retrieved, and 27 were included in the article.

Results: Major challenges affecting the development of research skills have been identified including lack of time for research, high teaching loads, and need to balance this work with administrative and clinical responsibilities, Lack of funding, shortage of skilled personnel, and absence of research infrastructure. Some of the skills identified in the literature for augmenting research capacity, i.e., infrastructure development, promotion of research cultures and environments, and facilitation of training.

Conclusion: However, more empirical studies are needed to understand the process of implementing and evaluating capacity building in nursing, clinical as well as academic. Capacity building is globally important because it can improve the quality of nursing education, the caliber of nurses, and the standard of care that patients receive.

Keywords: Augmenting spirit; barriers; nurses; nursing faculties; nursing research; nursing students; strategies.

Copyright: © 2024 Journal of Family Medicine and Primary Care.

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What is the impact of long-term COVID-19 on workers in healthcare settings? A rapid systematic review of current evidence

Roles Formal analysis, Project administration, Writing – original draft

* E-mail: [email protected]

Affiliation Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

Roles Data curation, Software, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

Affiliation School of Nursing, Midwifery & Paramedic Practice, Robert Gordon University, Aberdeen, United Kingdom

Roles Conceptualization, Data curation, Funding acquisition, Supervision, Writing – review & editing

• Moira Cruickshank, 
• Miriam Brazzelli, 
• Paul Manson, 
• Nicola Torrance, 
• Aileen Grant

• Published: March 5, 2024
• https://doi.org/10.1371/journal.pone.0299743
• Peer Review
• Reader Comments

Long COVID is a devastating, long-term, debilitating illness which disproportionately affects healthcare workers, due to the nature of their work. There is currently limited evidence specific to healthcare workers about the experience of living with Long COVID, or its prevalence, pattern of recovery or impact on healthcare.

Our objective was to assess the effects of Long COVID among healthcare workers and its impact on health status, working lives, personal circumstances, and use of health service resources.

We conducted a systematic rapid review according to current methodological standards and reported it in adherence to the PRISMA 2020 and ENTREQ statements.

We searched relevant electronic databases and identified 3770 articles of which two studies providing qualitative evidence and 28 survey studies providing quantitative evidence were eligible. Thematic analysis of the two qualitative studies identified five themes: uncertainty about symptoms, difficulty accessing services, importance of being listened to and supported, patient versus professional identity and suggestions to improve communication and services for people with Long COVID. Common long-term symptoms in the survey studies included fatigue, headache, loss of taste and/or smell, breathlessness, dyspnoea, difficulty concentrating, depression and anxiety.

Healthcare workers struggled with their dual identity (patient/doctor) and felt dismissed or not taken seriously by their doctors. Our findings are in line with those in the literature showing that there are barriers to healthcare professionals accessing healthcare and highlighting the challenges of receiving care due to their professional role. A more representative approach in Long COVID research is needed to reflect the diverse nature of healthcare staff and their occupations. This rapid review was conducted using robust methods with the codicil that the pace of research into Long COVID may mean relevant evidence was not identified.

Citation: Cruickshank M, Brazzelli M, Manson P, Torrance N, Grant A (2024) What is the impact of long-term COVID-19 on workers in healthcare settings? A rapid systematic review of current evidence. PLoS ONE 19(3): e0299743. https://doi.org/10.1371/journal.pone.0299743

Editor: Akaninyene Eseme Bernard Ubom, OAUTHC: Obafemi Awolowo University Teaching Hospital Complex, NIGERIA

Received: May 18, 2023; Accepted: February 11, 2024; Published: March 5, 2024

Copyright: © 2024 Cruickshank et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the study are available from the published studies included in the systematic review. In addition, the relevant data are submitted as supporting material.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Long COVID (LC) has rapidly emerged as a long-term debilitating illness [ 1 ] described by the World Health Organisation (WHO) as “devastating” [ 2 ]. Health and social care workers have a higher prevalence of self-reported LC compared to other occupational groups [ 3 ]. For health care workers (HCW), this is likely to be due to an increased risk of exposure and their central role in caring for patients with COVID-19, especially early in the pandemic when little was known about the virus, and many months before a vaccine was introduced [ 4 ].

The current joint NICE, SIGN and RCGP guideline on the management of long-term effects of COVID-19 (NG188) provides the following definitions:

• Acute COVID-19: Up to 4 weeks
• Ongoing symptomatic COVID-19: From 4 weeks up to 12 weeks
• Post- COVID-19 syndrome: Continuing for more than 12 weeks and not explained by an alternative diagnosis [ 5 ]

The term ‘Long COVID’ encompasses ongoing symptomatic COVID-19 and post-COVID-19 syndrome definitions above (i.e., signs and symptoms from 4 weeks after acute COVID-19).

Long COVID is an emerging condition for which a clear treatment care pathway or management options have yet to be established. However, given NHS workers have been disproportionately affected by LC, NHS England has put support measures in place, including occupational health, mental health hubs and guidance for health professionals returning to work, and for managers of these staff [ 6 ]. The Scottish Government has pledged £10 million over three years for LC support, although not specifically directed to NHS workers.

At present, there is limited evidence about narratives and experiences of those living with LC and their abilities to self-manage its consequences. In addition, there is little information specific to healthcare workers on the prevalence of LC, its pattern of recovery and its impact on healthcare resources.

This rapid systematic review focuses on the experiences of those working in healthcare settings and with LC symptoms, the impact on self-reported health, professional working lives, personal circumstances, and use of health services.

A systematic rapid review was conducted and reported in adherence to the PRISMA 2020 statement and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Statement [ 7 , 8 ]. The methods for this appraisal were pre-specified in a research protocol (PROSPERO database registration number: CRD42021288181; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=288181 )

Eligibility criteria

Eligible studies were written in English, published from December 2019 in a peer-reviewed journal and assessed participants with LC. Initial searches were conducted in November 2021 and were updated in December 2022. Evidence was considered from studies of any design reporting the experiences and/or impact of LC symptoms in HCW and including working performance, personal circumstances, or use of healthcare resources in healthcare workers. Eligible studies reported a definition of LC, or the criteria used to identify participants with LC symptoms. Clinical and non-clinical staff were eligible for inclusion. Social care staff and staff working in care homes and other long-term care facilities were not eligible for inclusion. Opinions and commentaries were excluded.

Studies reporting quantitative data only were grouped for narrative synthesis. Studies reporting qualitative data were grouped under emerging narratives and themes.

Information sources and search strategy

A highly sensitive search strategy was developed by an information specialist (PM). The search strategy included database index and free-text terms to encompass the two facets of the longer-term effects of COVID-19 and all categories of workers in healthcare settings. A range of clinical and social science databases was searched, including Medline, Embase, CINAHL, Web of Science, PsycInfo, and ASSIA. There was no restriction on language or study type at the search stage. Results were limited to those published from December 2019. Searches were all carried out in November 2021 and updated in December 2022. The reference lists of all studies selected for full-text appraisal were screened for additional studies. A sample Medline search strategy is presented in S1 Appendix .

Study selection

One reviewer (MC) screened all titles and abstracts identified by the initial and updated literature searches and a second reviewer (MB) screened those selected for full-text screening. One reviewer (MC) screened all potentially eligible full-text reports and those considered eligible were checked by a second reviewer (MB). Studies selected for inclusion were cross-checked by two experts (AG, NT).

Data collection, quality appraisal and data synthesis

One reviewer (MC) conducted data extraction and a second reviewer (MB) checked the data extracted by the first reviewer. A third reviewer (AG) independently extracted data and cross-checked with the data agreed by the first two reviewers. For the updated searches, four reviewers (MC, AG, NT, MB) conducted data extraction and all extracted data were cross-checked by one reviewer (MC). At all stages, disagreements were resolved by consensus.

The following information was recorded from each included study: research question and setting, objectives and methods, demographic characteristics of participants, definition of LC, symptoms of LC, self-reported information on health status, effects of LC on working life or personal circumstances, use of healthcare services resources, and interpretation of findings from studies’ authors.

The methodological quality of the included studies was assessed by a single researcher (MC) using the Quality of Reporting Tool (QuaRT) [ 9 ] and double checked by a second researcher (MB).

A pragmatic approach was adopted for the analysis of the results of the identified studies. Three researchers (MC, MB, AG) examined the qualitative studies to identify the main prominent and recurrent themes, organised the findings under ’descriptive’ thematic headings and produced a holistic interpretation.

The initial literature searches identified 2089 records which were screened for relevance. Of these, 56 were considered potentially relevant and selected for full-text assessment. A total of 14 papers reporting 12 primary studies met the inclusion criteria. The updated searches identified 1681 records. A further 18 studies met the inclusion criteria and were included in the review, giving a total of 30 studies published in 32 papers.

A PRISMA flow diagram detailing the study selection process is presented in Fig 1 .

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https://doi.org/10.1371/journal.pone.0299743.g001

Studies’ characteristics

Of the 30 included studies, two provided qualitative evidence [ 10 , 11 ] and the remaining 28 survey studies used quantitative methods for collecting data on persistent COVID-19 symptoms [ 12 – 39 ]. The two qualitative studies were both conducted in the UK and recruited 43 participants [ 10 ] and 13 participants [ 11 ], respectively, with more than half of participants being medical doctors or GPs. Median age was 40 years in one study [ 10 ] and the age of most of participants in the other study was between 30 and 39 years [ 11 ].

The research question was described in most studies, but the study design was justified in only a few studies. Participant selection and recruitment were reported adequately in most studies, as were data collection and analysis methods. Only one study failed to report all domains adequately [ 13 ] while four studies reported all domains adequately [ 10 , 11 , 14 , 15 ]. In general, the quality of the identified studies was judged to be satisfactory.

Results of qualitative studies

From the two included qualitative studies [ 10 , 11 ], we identified five themes related to the experience of health workers with LC:

• Uncertainty about symptoms
• Difficulty accessing services
• Importance of being listened to and supported
• Patient versus professional identity
• Suggestions to improve communication and services for people with LC.

Each of these themes is summarised below.

Uncertainty about symptoms.

Participants experienced and described unfamiliar, unpredictable, and fluctuating symptoms which did not fit their clinical knowledge.

As healthcare workers, participants were able to recognise their physical and mental symptoms but struggled to make sense of the nature and duration of these symptoms and they expressed concern about returning to work too soon or before the complete resolution of symptoms.

Most participants described a deterioration in their ability to carry out everyday tasks, including clinicians concerned about the safety of their practice, and raised concerns over whether they would ever recover or return to work.

It’s difficult because I keep getting new things, which is one of the frustrations of this. The brain stuff seems to be getting better, to the level that I can function. When the brain wasn’t working that made me very scared because I need my brain! Not to be blasé, but with the chest pain and stuff I can still work because I can work remotely. If I don’t have my brain I can’t work, I can’t plan, I can’t string a sentence together… I did get a bit scared when I was ill for so long…(Doctor; Taylor 2021)[ 11 ]

Those who had returned to work worried that they were not able to cope at the required level or contribute enough to the workplace.

Participants turned to online social media groups for support and information. They also expressed newfound empathy for patients suffering from post-viral states and/or for those whose test results had not find anything conclusive.

It wasn’t an active prejudice, but in the back of my mind I hadn’t thought about it… a number of us in the group have said how ashamed we are of some of the attitudes we’ve had towards people, and lack of empathy… This concept of being irritated by patients when they’re not really pleased when something comes back normal… Hopefully, it will make me a better and more empathetic doctor at the end. (Doctor; Taylor 2021) [ 11 ]

Difficulty accessing services.

Participants described problems accessing and navigating care. They experienced delayed, absent, or inappropriate responses and perceived a lack of interest and support from their GPs in acknowledging and investigating their symptoms. In the study by Taylor et al., the doctors reported that their professional expertise had not been recognised or taken seriously, and some participants had called on personal contacts to secure appointments or referrals to specialists.

“I’d messaged a friend from medical school who’s a cardiologist as I was wondering about pericarditis… I’ve always tried to be a good patient and go through my GP and things, but it wasn’t working. So that’s when I started messaging people and calling in favours.” (Doctor; Taylor 2021) [ 11 ]

Participants reported also accessing private consultations for investigations, where positive test results helped them access specialist NHS referral.

“My friend said “if you’ve got a mate in cardiology then ask for an echo” . So I did . And I don’t normally like to ask for favours… I reached out and he said “if you pay the fees for the echo then we’ll do it”… I felt disappointed I was unable to access this on the NHS . [ … ] ” (Doctor; Taylor 2021) [ 11 ]

Participants reflected on the lack of clinical pathways for LC and advocated a coordinated and multi-disciplinary approach.

The importance of being listened to and supported.

Participants emphasised the value of being listened to by a clinician.

“Then I spoke to my normal GP when she got back and that was probably the single most helpful conversation that I had during all of this because she , I was really struggling with how bad the fatigue was… I couldn’t really have a shower without an hour’s sleep afterwards and was feeling absolutely awful . Just feeling really grotty all the time . And she completely validated that I wasn’t one of her nightmare patients .” (Doctor; Taylor 2021) [ 11 ]

Continuity of carer was important for participants as their story was often lengthy, unfamiliar, and multifaceted.

The focus when you do get a new GP speaking to you seems to be that they go back to the beginning and I’ve had a few consultations where I know I don’t need to go to the hospital but your assessment is really all-around ‘do I stay at home and wait this out or do I go to the hospital?’ and there’s nothing in between that. And I think if there was the same GP who we are able to consult regularly they would build a picture of your baseline and I think that’s what’s lost with digital ways of working. (Doctor; Ladds 2020) [ 10 ]

Similarly, online LC support groups were considered important for reassurance, validation, and the opportunity to engage with others.

Patient versus professional identity.

Combining their professional identity as healthcare workers with their role as patients was found particularly challenging by the participants.

I have found it very difficult to dissociate my doctor’s brain from my patient’s brain. I found it very difficult to… I’m a trainer as well, and I found it very difficult to dissociate my educator’s brain from my patient’s brain so I’ve had that dynamic going on for several weeks. I said to him “I hope I’ve handed over that locus of control, I’m putting trust in you, you’re looking after me, I will go by your advice” (Doctor; Taylor 2021) [ 11 ]

Because of their own professional experience, participants were fully aware of the doctor-patient relationship and recognised that the uncertainty of their symptoms was somewhat difficult to address from a doctor’s perspective. They feared they could have been perceived as a burden.

They were also frustrated by the fact that their doctors did not perceive and treat them as ‘patients’ and struggled to understand the expectation that, as healthcare workers, they were left to decide their own treatment.

[My GP] does rely heavily on me being a doctor and making my own management plan… There’s a place for ICE [Ideas, Concerns and Expectations] but I need someone to be my doctor. If I don’t come up with something, it’s “wait and see”, or a blood test (Doctor; Taylor 2021) [ 11 ]

Based on their experience of patients experiencing uncertain and persistent COVID symptoms, participants also reflected on their role as healthcare workers and their attitude in dealing with patients’ concerns and requests in the past. Their own experience was an opportunity to re-evaluate the needs of patients and adopt a more sympathetic approach in the future.

Suggestions to improve communication and services for people with Long COVID.

Based on their own experience of LC, participants felt an obligation to share their insight and raise awareness.

I mean not to sort of self-grandiose our group but there’s a certain responsibility to put down our experiences so they can be opened up to other people who don’t have the language and the access that we potentially have to communicate it to primary healthcare to access the services that need to be put in place for them (Doctor; Ladds 2021) [ 10 ]

Participants reflected on how to overcome the limitations of the current health services for patients with COVID. They advocated a multi-disciplinary approach to identify and address LC symptoms and the need for more personalised services.

My expectation of such a clinic would be to rule out treatable causes or complications, based on our symptoms. And then active involvement with physiotherapies and occupational therapies maybe a psychologist […] we now know that COVID is a multi-system disease so the fact that you don’t display signs of respiratory infection doesn’t mean that you don’t have a problem. (Allied healthcare professional; Ladds 2021) [ 10 ]

Some participants also suggested establishing user-friendly online or telephone services to provide reliable information to people with LC.

Results of quantitative studies

Twenty-eight of the included studies assessed the symptoms of healthcare workers experiencing LC. A summary of the characteristics of these studies is presented in Table 1 , along with a summary of the studies’ findings.

https://doi.org/10.1371/journal.pone.0299743.t001

Overall, the proportions of healthcare workers experiencing long-term symptoms ranged from 23.1% at 6 months after infection [ 12 ] to 73% (in people with a positive nasopharyngeal swab; NPS; median 117 days since infection) [ 36 ]. The most common symptom was fatigue, [ 13 – 16 , 18 – 27 , 29 , 30 , 33 , 35 , 38 , 39 ] with proportions ranging from 4% at 8 months after COVID-19 infection [ 14 ] to 75% at 1 month after COVID-19 infection [ 21 ]. Headache reports [ 14 – 17 , 19 – 21 , 24 , 26 , 29 – 31 , 35 , 39 ] ranged from 0.5% at > 60 days since infection [ 20 ] to 42% at 1 month after infection [ 21 ]. Proportions of loss of taste and/or smell [ 15 , 17 – 20 , 24 – 26 , 28 – 31 , 33 , 35 , 36 , 39 ] ranged from 0.5% at up to 60 days and >60 days [ 20 ] to 51.1% at >3 months after infection [ 15 ]. Other commonly reported symptoms were dyspnoea [ 14 – 17 , 21 , 26 , 28 – 32 , 38 ], concentration/attention difficulties [ 14 – 16 , 18 , 20 , 26 , 29 – 32 , 35 ], respiratory problems (i.e. breathlessness, breathing difficulties, shortness of breath) [ 13 , 15 , 18 – 20 , 24 , 35 , 39 ] depression [ 16 , 19 , 21 , 35 , 37 ] and anxiety. [ 16 , 19 , 20 , 27 , 31 , 35 , 37 ]

Table 2 presents outcomes relating to working life, personal life, and healthcare use, all of which were scarcely reported by the included studies.

https://doi.org/10.1371/journal.pone.0299743.t002

Six studies assessed the impact of LC symptoms on the working life of HCW. One study reported a median 10 missed working days in those with symptoms lasting <90 days and median 21 missed working days in people with symptoms lasting <365 days.[ 15 ] Four studies reported that workers’ long-term symptoms disrupted their working life [ 14 , 26 , 28 , 29 ]. Some participants reported that their social life and home life were disrupted by the persistence of their symptoms [ 14 ] and others reported being unable to participate in leisure activities because of their ongoing symptoms [ 18 ]. Conversely, one study reported that around three-quarters of HCW were leading a healthier lifestyle in the form of physical activity or taking multivitamins during the post COVID-19 recovery period [ 19 ].

Risk of bias assessment

The findings of the Quality of Reporting Tool assessments for the 30 included studies are reported in Table 3 .

https://doi.org/10.1371/journal.pone.0299743.t003

Our systematic review identified 28 survey studies assessing the presence and impact of LC symptoms among HCW and two qualitative studies assessing their experiences and narratives. In general, quality assessment of the studies found them to be adequately reported.

HCW reported a wide range of diverse symptoms they have attributed to LC. The number and diversity of these LC symptoms have led to considerable challenges in achieving any formal diagnoses, investigations, management plans and prognosis, for those affected. This is reflected in the findings of this review.

Healthcare workers felt bewildered by symptoms and expressed dissatisfaction with access to the healthcare system, and the disengaged and dismissive attitude of some healthcare professionals. They felt their voice as a patient was not heard and their symptoms were not taken seriously, a finding from most lived experience LC studies.

The participants clearly described the difficulty of combining their dual role as healthcare workers and patients and some recognised the challenge their doctors faced in managing a novel condition but felt that the onus was on themselves to provide answers to their questions.

Evidence already exists in the literature on how healthcare workers are susceptible to physical and mental illness [ 40 , 41 ]. It is, therefore, no surprise that the studies included in this systematic review reported that long-term symptoms following COVID-19 infection were common among healthcare workers. In the survey studies, physical symptoms were reported more frequently than psychological symptoms but having professional medical knowledge did not protect the healthcare workers from the uncertainty and consequent fear about the nature and course of their symptoms. Furthermore, working in the healthcare sector was not an advantage in finding appropriate care. The impact of the problems experienced by people who experienced LC and the need to be listened to and supported by their doctors has been documented in the literature [ 42 ]. A systematic review assessing the barriers health professionals experience in accessing healthcare has highlighted important similarities between them and the general population [ 43 ].

Healthcare workers and especially doctors tend to consider their professional identity their core identity, which is often associated with a strong sense of power and the belief to be ‘invincible’ [ 44 ]. It is, therefore, challenging for their medical self to recognise their own illness and vulnerability. The pre-COVID literature already shows that doctors who have been away from work because of illness tend to internalise the perceived negative response of colleagues and their families to their problems, consider themselves as failures, and express self-stigmatisation views, which represent major barriers to returning to work [ 45 ]. Continuing to improve the training that medical students receive and remodelling of the general perception that ‘doctors are invincible’ may allow doctors to maintain their strong medical identity but be more accepting of their own limits [ 44 ].

Strengths and limitations of the review

Extensive searches were conducted to identify relevant literature and two reviewers were involved in the selection of relevant studies and data extraction. Despite comprehensive searches, it is possible that relevant literature was not identified and it is likely that further relevant literature has since been published, given the fast-paced nature of research into the COVID-19 epidemic and its long-term sequelae. However, in the context of a rapid review, the methods used were robust and by current methodological standards. A potential limitation of our review is that we were not able to investigate associations between the effects of vaccination and LC symptoms, or the difference in LC symptoms between males and females, as they were not reported consistently by included studies. We recommend that future studies consider these potentially informative aspects. There was limited research on UK NHS workers, and the participants of these studies were largely doctors, white and from Western populations. A more representative approach is needed to reflect the diverse occupations and ethnically varied nature of HCW.

Having a medical background did not help healthcare professionals make sense of the wide range of debilitating and unpredictable LC symptoms. The dual role of being a patient and a doctor was particularly problematic and they felt dismissed and unheard by their doctors/clinicians. They reported a variety of persisting symptoms but low levels of sick leave and the need for multidisciplinary care was highlighted. There was little research on NHS workers and participants were mainly doctors, white and from Western populations.

Supporting information

S1 appendix..

https://doi.org/10.1371/journal.pone.0299743.s001

S1 Table. Minimal dataset 1.

https://doi.org/10.1371/journal.pone.0299743.s002

S2 Table. Minimal dataset 2.

https://doi.org/10.1371/journal.pone.0299743.s003

S3 Table. Minimal dataset 3.

https://doi.org/10.1371/journal.pone.0299743.s004

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• 5. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19 [NG188]. 2020. Available from: https://www.nice.org.uk/guidance/ng188 (Accessed 30 September 2021).
• 6. NHS England. Long COVID: the NHS plan for 2021/22. 2021. Available from: https://www.england.nhs.uk/coronavirus/documents/long-covid-the-nhs-plan-for-2021-22/#staff (Accessed 5 October 2022).

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Integrity of Databases for Literature Searches in Nursing

The quality of literature used as the foundation to any research or scholarly project is critical. The purpose of this study was to analyze the extent to which predatory nursing journals were included in credible databases, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus, commonly used by nurse scholars when searching for information. Findings indicated that no predatory nursing journals were currently indexed in MEDLINE or CINAHL, and only one journal was in Scopus. Citations to articles published in predatory nursing journals are not likely found in a search using these curated databases but rather through Google or Google Scholar search engines.

Research, evidence-based practice, quality improvement studies, and other scholarly projects typically begin with a literature review. In research, the review of the literature describes existing knowledge about the topic, reveals gaps and further research questions to be answered, and provides a rationale for engaging in a new study. In evidence-based practice, the literature review provides evidence to answer clinical questions and make informed decisions. Quality improvement studies also begin with a search of the literature to gather available knowledge about a problem and explore interventions used in other settings. The appearance of journals that are published by predatory publishers has introduced the danger that reviews of the literature include inadequate, poorly designed, and low-quality information being used as “evidence”—raising the possibility of risky and harmful practice. Researchers and authors should be confident in the literature they cite; readers should have assurance that the literature review is based on sound, authoritative sources. When predatory journals are cited, that trust is eroded. No matter what type of study or project is being done, the quality of literature is critical for the development of nursing knowledge and for providing up-to-date information, concepts, theories, and approaches to care. 1

An effective literature review requires searching various reliable and credible databases such as MEDLINE (through PubMed or Ovid) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), among others that are relevant to the topic. The ease of searching using a web browser (now commonly referred to as “googling”) has increased the risk of finding sources published in predatory and low-quality journals that have not met the standards of research and scholarship that can be trusted as credible and reliable evidence.

The purpose of this article is to present an analysis of the extent to which predatory nursing journals are included in MEDLINE, CINAHL, and Scopus databases, used by nurse researchers and other nurses when searching for information, and in the Directory of Open Access Journals. This directory indexes “high-quality, open access, peer-reviewed journals” and should not include any predatory journals. 2

Statement of Significance

What is known or assumed to be true about this topic?

The quality of nursing literature used is vital for the development of research studies, application of evidence in clinical settings, and other scholarly projects. Nurse scholars need to be confident as they search the literature that they are accessing sound information sources and not articles from predatory nursing journals, which do not adhere to quality and ethical publishing standards. Citations of articles in predatory nursing journals may be found when searching Google and Google Scholar, making these citations easy to access but potentially resulting in the integration of poor quality research into the nursing literature. On the other hand, searches through credible databases—MEDLINE, CINAHL, and Scopus—are less likely to yield citations from predatory publications.

What this article adds:

This study helps validate the trustworthiness of these databases for conducting searches in nursing.

PREDATORY JOURNALS

Many studies have documented the problem of predatory journals. These journals do not adhere to quality and ethical publishing standards, often use deceptive language in emails to encourage authors to submit their manuscripts to them, are open access but may not be transparent with the article processing charge, may have quick but questionable peer review, and may publish inaccurate information on their Web sites such as impact factor and indexing. 3 – 6 Predatory publishing is an issue in many fields including nursing. In a recent study, 127 predatory journals were identified in nursing. 7

Citations acknowledge the ideas of others and give credit to the authors of the original work. When articles are cited in a subsequent publication, those citations disseminate the information beyond the original source, and the article in which it is cited might in turn be referenced again, transferring knowledge from one source to yet another. When articles in predatory journals are cited, the same process occurs. Those citations transfer knowledge from the predatory publication beyond that source. Studies have found that authors are citing articles published in predatory journals in nursing as well as other fields. 7 – 10 Nurse scholars need to be confident as they search the literature that they are accessing sound information sources and not articles from predatory journals.

NATIONAL LIBRARY OF MEDICINE INFORMATION RESOURCES

The National Library of Medicine (NLM) supports researchers and clinicians through its multiple health information resources including PubMed, MEDLINE, and PubMed Central (PMC). PubMed serves as the search engine to access the MEDLINE database, PMC, and books, chapters, and other documents that are indexed by the NLM. PubMed is free and publicly available: by using PubMed, researchers can search more than 30 million citations to the biomedical literature. 11 The majority of records in PubMed are from MEDLINE, which has citations from more than 5200 scholarly journals. For inclusion in MEDLINE, journals are assessed for their quality by the Literature Selection Technical Review Committee. 12 Five areas are included in this assessment: scope of the journal (ie, in a biomedical subject); quality of the content (validity, importance of the content, originality, and contribution of the journal to the coverage of the field); editorial standards and practices; production quality (eg, layout and graphics); and audience (content addresses health care professionals).

PMC includes journal citations and full-text articles that are selected by the NLM for digital archiving. To be included in PMC, journals are evaluated for their scope and scientific, editorial, and technical quality. 13 Journals considered for inclusion are evaluated by independent individuals both inside and outside PMC. 14 PMC serves as the repository for articles to meet the compliance requirements of the National Institutes of Health (NIH) and other funding agencies for public access to funded research. About 12% of the articles in PMC are deposited by individual authors to be in compliance with funders and 64% by publishers, scholarly societies, and other groups. 15 Beginning in June 2020, as a pilot program, preprints reporting research funded by the NIH also can be deposited in PMC. 16

CINAHL AND SCOPUS

The journal assessment and indexing processes for CINAHL and Scopus are similar to those used by the NLM. However, as private corporations, EBSCO (CINAHL) and Elsevier (Scopus) are not required to make journal selection processes publicly available or explicit. CINAHL has an advisory board for journal selection. A CINAHL representative provided the following criteria for indexing of journals in CINAHL: high impact factor; usage in reputable subject indexes (eg, the NLM catalog); peer-reviewed journals covered by other databases (eg, Web of Science and Scopus); top-ranked journals by industry studies; and article quality (avoiding low-quality journals) (personal communication, October 19, 2020).

Elsevier's Scopus provides a webpage referring to the journal selection and assessment processes. Journals being considered for indexing in Scopus are evaluated by the Content Selection and Advisory Board and must meet the following criteria: peer-reviewed with a publicly available description of the peer review process; published on a regular basis; has a registered International Standard Serial Number (ISSN); includes references in Roman (Latin) script; has English language titles and abstracts; and has publicly available publication ethics and publication malpractice statements. 17

LITERATURE REVIEW

Studies have shown that in health care fields, researchers, clinicians, faculty, and students regularly search MEDLINE for their research and other scholarly and clinical information. 18 – 21 De Groote et al 18 found that 81% of health science faculty used MEDLINE to locate articles for their research. MEDLINE was used by the majority of faculty in each individual health care field including nursing (75%) and medicine (87.5%) for searching the literature and finding articles. In another study of 15 different resources, medical faculty and residents reported that PubMed was used most frequently for searching the databases of the NLM, primarily MEDLINE. 20 Few studies have focused on the search practices of nurses. In a review of the literature, Alving et al 22 found that hospital nurses primarily searched Google for information on evidence-based nursing. They used Google more than bibliographic databases.

The quality of content that is retrieved when using PubMed as a search engine is important considering its widespread use for accessing scholarly and clinical information in nursing and other fields. Manca et al 23 reported that articles published in predatory journals were being retrieved when conducting searches using PubMed and were a concern for researchers. Based on their studies of predatory journals in neurology 24 and rehabilitation, 25 they concluded that predatory journals “leaked into PubMed” through PMC because of less stringent criteria for inclusion of journals. 23 Citations to articles from predatory journals then could be found using the PubMed search engine. However, in a letter to the editor, Topper et al 26 from the NLM clarified that individual articles published in predatory journals might be deposited in PMC to meet the requirements of research funding and be searchable in PubMed. Topper and colleagues make a clear distinction between journals indexed in MEDLINE or PMC and citations of individual articles that were deposited in PMC to meet funder requirements.

The aim of this study was to determine whether predatory nursing journals were included in databases used by nurse researchers and other nurses when searching for information. These databases included MEDLINE (searched via PubMed), CINAHL (EBSCO), and Scopus (Elsevier) and in the Directory of Open Access Journals.

In an earlier study, 127 predatory nursing journals were identified and assessed for characteristics of predatory publications. That dataset was used for the current study. For each predatory nursing journal, information was retrieved from the NLM Catalog, Ulrichsweb, and journal and publisher Web sites. Ulrichsweb 27 provides bibliographic and publisher information on academic and scholarly journals, open access journals, peer-reviewed titles, magazines, newspapers, and other publications. Journal titles of the predatory journals were often similar to nonpredatory journals and could be easily mistaken. To ensure accuracy, the information for each journal was checked for consistency between these sources using the ISSN, exact journal title, and publisher name. The purpose of an ISSN is to identify a publication and distinguish it from other publications with similar names. An ISSN is mandatory for all publications in many countries and having one assigned is considered a journal best practice. 28 For each predatory journal, the following data were collected if available: complete journal title; abbreviated journal title; acronym; ISSN (electronic and/or print); DOI prefix; publisher name and Web site URL; NLM index status; number of predatory journal articles cited in MEDLINE and PMC (when searching using PubMed), in CINAHL, and in Scopus; if the journal was indexed in the Directory of Open Access Journals; status in Ulrichsweb; and Google Scholar profile URL.

Counts of articles cited were checked individually by journal title, publisher, and/or ISSN. Once ISSNs (both electronic and print where available) were assembled, a search algorithm was created, which included all retrieved journal ISSNs. MEDLINE was searched via PubMed using a combination of NLM journal title abbreviations and ISSNs. CINAHL, Scopus, and the Directory of Open Access Journals were searched using a combination of ISSN, journal title abbreviation, full title, and publisher. Results were visually inspected for accuracy and alignment with dataset fields.

Data analysis

Data were collected between January and April 2020. Data were entered into an Excel spreadsheet and organized by predatory journal name; abbreviated journal title; acronym; ISSN (electronic, print); DOI prefix; Web site URL; entry in NLM Catalog (yes/no); index status; number of articles cited in PubMed, CINAHL, and Scopus; Directory of Open Access Journals (included/not included); Ulrichsweb status (active/ceased); publisher; and Google Scholar profile URL. Frequencies and medians are reported.

Of the 127 predatory nursing journals in the dataset, only 102 had ISSNs to use for the search. Eighteen of the journals had records in the NLM Catalog, but only 2 of those had ever been indexed in MEDLINE, and neither are currently indexed. These 2 journals had been published earlier by a reputable publisher but then were sold to one of the large predatory publishers. The NLM Catalog record for these journals indicates that citations of articles from them appeared in MEDLINE through 2014 for one of the journals and 2018 for other, but following their transition to the new publisher are no longer included. Consistent with the MEDLINE results, these same 2 journals had been indexed in Scopus as well. Citations of articles from one of these journals were added to Scopus up to 2014, with no articles cited thereafter. Articles from the second journal continue to be added through 2020. One additional journal from the predatory journal dataset is currently in Scopus, however, only through 2014. None of the predatory nursing journals were indexed in CINAHL based on full journal title, title abbreviation, ISSN, or publisher. Two journals in the dataset were found in the Directory of Open Access Journals.

When searching PubMed, we found citations of articles from 16 predatory nursing journals. The number of citations ranged from 1 to 372 citations (from one of the journals indexed earlier in MEDLINE but sold to a predatory publisher). The second highest number of citations (n = 168) was of articles from a predatory nursing journal that had been depositing articles in PMC (and thus were retrievable when searching PubMed) but is no longer adding new material to PMC. The other citations were of articles deposited in PMC to meet requirements of NIH and other research funding. The predatory journals in which these articles were published, however, are not indexed in MEDLINE or PMC.

There were no articles from predatory nursing journals cited in CINAHL. Scopus has citations from the 2 predatory nursing journals that are no longer indexed there: 616 that were published in one of the journals and 120 from the other. Articles from a third predatory nursing journal in the study dataset, which is currently indexed in Scopus, totaled 173 (see Table).

Abbreviation: CINAHL, Cumulative Index to Nursing and Allied Health Literature.

a Predatory nursing journals with 3 or more citations to articles.

b Search using PubMed.

This analysis documented that none of the predatory nursing journals in the study dataset were currently indexed in MEDLINE or CINAHL, and only one journal is still in Scopus. Most of the citations of articles from predatory journals found in a search of these databases are from earlier years before the journals were sold to one of the large predatory publishers. Other citations are to articles deposited in PMC in compliance with research funder requirements.

By using PubMed as a search engine and entry point to the databases of the NLM, researchers can search millions of records included in MEDLINE, or in process for inclusion, and articles from PMC deposited by publishers or authors for compliance with funders. Six million records, and about 5500 journals, can be searched in CINAHL Complete, 29 and Scopus, the largest of the proprietary databases, provides access to 24000 journals and 60 million records. 30 Results from this study show that very few articles published in predatory nursing journals find their way into a search done using PubMed and Scopus and none into CINAHL.

In a prior study, 814 citations of articles in predatory nursing journals were found in articles published in nonpredatory nursing journals. 7 Based on this current study, the conclusion can be made that these citations are not coming from searches in MEDLINE/PubMed, CINAHL, or Scopus and are likely from searches done using Google or Google Scholar as the search engine. The databases examined in this study are curated by organizations with a vested interest in maintaining and improving the quality of the research literature in those databases.

Searching multiple databases using different search engines can be frustrating and time consuming. There is overlap among MEDLINE, CINAHL, and Scopus. However, these are curated databases and, as this study found, are unlikely to return many, if any, predatory citations as part of the search results. Still, it falls on the searcher to eliminate duplicates and redundant citations. Further, certain types of literature, such as theses, dissertations, and fugitive (or “gray” literature), 31 are unlikely to be found in any of these databases, even though those citations may be important or relevant sources. Given this, it is easy to understand the intuitive appeal of Google Scholar, which provides “one stop shopping”: “From one place, you can search across many disciplines and sources: articles, theses, books, abstracts and court opinions, from academic publishers, professional societies, online repositories, universities and other web sites. Google Scholar helps you find relevant work across the world of scholarly research.” 32 Google and Google Scholar were founded with a mission to become the most comprehensive search engines in the world. While this allows someone to scour the World Wide Web and Internet for some of the most obscure facts available, at the same time, little is done to verify or validate the results that are returned. Thus, it falls on the searcher to be diligent and evaluate the results of a Google or Google Scholar search, which will include citations of articles in predatory journals. This is easily confirmed by the fact that many predatory journal Web sites promote the Google Scholar logo as a sign of indexing or a badge of legitimacy.

Another vexing issue that was revealed in this study is that of reputable journals that have been bought by predatory publishers. This study found 2 journals in this category. Brown 33 reported on 16 medical specialty journals that were purchased from 2 Canadian commercial publishers by a predatory publisher. In all these cases, it is the same predatory publisher, although some of the purchases were made under a different business imprint, adding further confusion to an already muddied situation. Jeffrey Beall, who coined the term “predatory publisher” and maintained the blog “Scholarly Open Access” for almost a decade, was quoted by Brown 33 : “[The company] is not only buying journals, it is buying metrics and indexing, such as the journals' impact factors and listing in Scopus and PubMed, in order to look legitimate.” One positive finding from this study was that the 2 purchased journals that were identified were quickly de-accessioned by the NLM and are no longer indexed in MEDLINE, although citations from their pre-predatory era remain intact.

Recommendations

All of this presents a confusing picture, but it is possible to make some specific recommendations to aid researchers, clinicians, faculty, and students in their literature searches. First, become familiar with the journals and publications in your field. This is a basic foundation of scholarship. As you read articles, remember where they were published, learn journal titles, and focus on sources as well as the content. As you come across predatory journals in nursing and health care, make note of them and learn their titles too. Remember that many predatory journals adopt names that are intended to be confusing and may differ from a legitimate journal by only one letter, such as “Africa” and “African.”

Second, consider carefully how to approach your search from the outset. If you choose to start with MEDLINE (searched via PubMed), CINAHL, or Scopus, then you can have some assurance that the results will not return citations from predatory journals—although you should still verify every citation that you receive. On the other hand, Google and Google Scholar can be a “quick and easy” way to get started but will require that you carefully review and evaluate the results. If you need to venture to other more specialized databases, such as PsycInfo or ERIC (Education Resources Information Center), it is important to carefully inspect the results that you receive. To reduce the risk of including a predatory journal article in research, nursing scholars should use reputable bibliographic databases, which have clear criteria for journal indexing, for their searches.

Third, when you come across a journal title that is not familiar, take time to research it, visit the journal Web site and evaluate the information at the Web site, and determine whether it is a credible source to include in your results. If something seems irregular, then it is worth your time to do more investigating—either on your own or by enlisting the help of a knowledgeable colleague or librarian. Journals change publishers all the time, and while most of these business transfers are benign and probably will not impact you as an end consumer of the literature, that is not always the case. Likewise, the major publishers in the world today are large, multinational conglomerates that regularly spin off or purchase other companies. While this probably will not impact you on a day-to-day basis, it is important to investigate any irregularities when conducting a search of the literature.

Last, because these issues are complex and multifaceted, it is always wise to consult with a librarian who can assist you in every step of the search process. Their knowledge and expertise in information literacy, data sources, and searching techniques can help to ensure that you find the information you need from sources that are reliable and credible.

Researchers, clinicians, faculty, and students need to be careful not to include citations from predatory sources in their literature searches and articles. Predatory journals publish low-quality studies and citing this work erodes the scholarly literature in nursing. The findings of this study offer some reassurance to those who search the professional nursing literature: if you begin a search in a database such as MEDLINE, CINAHL, or Scopus, then the results will probably not include citations to predatory publications. Google and Google Scholar searches, however, may very well include predatory citations, and in that case, it is the searcher's responsibility to carefully evaluate the output and discard findings from nonlegitimate sources. Enlisting the help of a librarian is always beneficial and highly recommended.

Peggy L. Chinn, PhD, RN, FAAN, Editor, Advances in Nursing Science , is a member of our research team and contributed to the study and preparation of the manuscript.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Deepfake Detection: A Systematic Literature Review

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