research literature in nursing

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?

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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Overview & Steps for Searching the Literature

Literature searching and literature reviews are often used interchangeably but are two different steps in the research process guided by EBM.

• Literature search  is searching the literature for some studies. A search strategy is developed for one or more biomedical databases to search the literature, and gather relevant studies.
• Literature review  is reviewing the studies which have been identified through a literature search. As part of the literature review, the retrieved articles are analyzed and critically appraised. 

The following steps will help guide you through the process of literature searching in PubMed. Though we are focusing on PubMed, these steps can be used across bibliographic databases. 

• Formulate a research question
• Identify primary concepts & gather synonyms
• Locate Medical Subject Headings MeSH (database-specific indexing terms)
• Combine search terms using Boolean operators
• Apply search limits or filters

To learn more about the literature searching process, you can explore Lane Library's Literature Searching guide .

Step 1: Formulate a Research Question

The first step in literature searching involves taking a clinical topic or problem and formulating it into a well-defined, answerable question. The development of a clear and focused question will help to streamline the searching process to locate the literature needed to begin answering the question and addressing the clinical problem. A well-defined, answerable question: 

• defines the focus of your literature search
• identifies the appropriate study design and methods
• makes searching for evidence simpler and more effective
• helps you identify relevant results and separate relevant results from irrelevant ones

What type of question are you asking?

Therapy:  effectiveness/risk of a certain treatment

Diagnosis : accuracy/usefulness of a diagnostic test/tool; application to a specific patient  

Prognosis : probable outcome, progression, or survivability of a disease or condition; likelihood of occurrence

Etiology/Harm : cause or risk factors for a disease or condition; questions about the harmful effect of an intervention or exposure on a patient

Tips for formulating a good question:

• The question is directly relevant to the most important health issue for the patient;
• The question is focused and when answered, will help the patient the most;
• The question is phrased to facilitate a targeted literature search for precise answers

Adopted from CEBM:  what makes a good clinical question   and  Center for Evidence Based Medicine: Asking focused questions  

PICO Framework

In EBM, following the PICO framework is a common way to create a focused and answerable question from a general topic. PICO is a mnemonic used to describe the four elements of a sound clinical foreground question.

PICO  stands for:

• P  - Population/Patient/Problem
• I  - Intervention  
• C  - Comparison or Control
• O  - Outcome

Alternative formats of PICO include PICOT and PICOTT:

• T  - Time
• T  - Type of question
• T  - Type of study

What is the effectiveness of Prozac vs Zoloft in treating adolescents with depression?

P : adolescents with depression

Using PICO to formulate your research question makes it easier to follow the next step in the literature searching process -- identifying primary concepts & gathering synonyms.

Step 2: Identify Primary Concepts & Gather Synonyms

Primary concepts for your research question can be identified using the PICO formula from Step 1. Each of the PICO elements can form a primary concept. If your PICO does not have a  C omparison or  O utcome, or if the Outcome is broad or vague, it is okay to leave out these concepts. Sometimes, one of the elements in the PICO framework will include more than one primary concept. For example, the Population for our example includes the concept of adolescents and the concept of depression.

P :  adolescents  with  depression

I :  Prozac

C :  Zoloft

For each primary concept identified, make a list of other terms with the same or related meaning (synonyms). It is important to gather synonyms, because

Terms have different spellings, plural forms, and acronyms

Concepts are described inconsistently across time, geographies, or even among researchers

Terms have the same/close meaning, disciplinary jargon

Umbrella terms vs specific names for issues, interventions, or concepts

These terms will form the keywords of your search strategy. 

Tips for finding synonyms:

• Do a quick search to find a relevant article or two. Look at the words used in the article titles and abstracts.
• Think of specific examples or types
• Use background information to help brainstorm (e.g. UpToDate, DynaMed, textbooks)
• Explore the entry terms and related subject headings in MeSH (see Step 3)

Remember that building a search strategy is iterative. As you learn more about your topic, you can add more keywords to your search to broaden your results, or remove keywords if you are finding too many results.

Step 3: Locate Medical Subject Headings MeSH (database-specific indexing terms)

What is mesh.

Databases like PubMed use subject headings or controlled vocabularies to index (or label) articles. Subject headings are standardized terms for describing what the articles are about. Subject headings are specific to databases, and in PubMed, they are called Medical Subject Headings or MeSH. MeSH terms are structured hierarchically in a tree structure, and when you search a MeSH term, you search automatically includes all the terms that fall beneath it in the tree. Indexers add MeSH terms to journal article records in PubMed to reflect their subject content. 

MeSH terms are useful in a search to aid in locating synonyms and reduce term ambiguities. It facilitates the retrieval of relevant articles even when authors use different words or spelling to describe the same concept. For instance, using the MeSH term "Blood Pressure" will also find articles that use "pulse pressure," "diastolic pressure," and "systolic pressure."

Since MeSH terms are organized in hierarchies or MeSH trees, it also facilitates the searching for broad and narrow concepts. For instance, the MeSH term "Domestic Violence" will retrieve articles containing narrower topics such as "child abuse," "elder abuse," and "spouse abuse." But you can also expand the search, and move to a broader level, such as "Violence."

To look up a MeSH term, click on " MeSH Database " on PubMed's homepage. Type your concept into the search bar. The MeSH database will return appropriate MeSH (terms) if there are any. Not every concept will have a matching MeSH term. Remember to search for one concept at a time.

adolescents => "Adolescent"[Mesh]

Prozac => "Fluoxetine"[Mesh]

Zoloft => "Sertraline"[Mesh]

depression => "Depression"[Mesh]

When you search for a MeSH term in PubMed, use the [Mesh] tag following your search term to specify where to search for the term in the PubMed record.

You can also locate MeSH terms in PubMed by finding a relevant article and scrolling to the heading "MeSH terms" at the bottom of the article. This only works for articles that have been indexed. 

Other PubMed Search Tags

In addition to searching specifically for MeSH terms, you can also use search tags to search for keywords in particular fields of the PubMed record. When you search in PubMed, you are automatically looking for your keywords in all the record fields. Sometimes this might be too broad and bring back too many search results. You can experiment with field tags like [ti] to look for keywords only in the title or [tiab] to look for keywords only in the title or abstract. Explore all of the available search tags and reach out to your liaison librarian if you have questions using search tags.

Step 4: Combine Search Terms Using Boolean Operators

Now that you've identified keywords for your concepts (step 2) and related MeSH terms (step 3), you can combine your search terms with Boolean Operators to build your search strategy.

Boolean Operators are a set of commands that can be used in almost every search engine, database, or online catalog to provide more focus to a search. The most basic Boolean commands are  AND  and  OR . In PubMed, you can use Boolean Operators to combine search terms, and narrow or broaden a set of results.

Narrow Results with AND

Use AND in a search to narrow your results. It tells the search engine to return results that contain ALL the search terms in a record.

adolescents AND depression

Note: Both the words  adolescents  and  depression  will be present in every record in the results.

Broaden Results with OR

Use OR in a search to broaden your results by connecting similar concepts (synonyms). It tells the search engine to return results that contain ANY of the search terms in a record.

adolescents OR youth OR teenagers

Note: Search results need to have at least one of the words  adolescents  or  youth  or teenagers .

Use parentheses ( ) to keep concepts that are alike together, and to tell the database to look for search terms in the parentheses first. It is particularly important when you use the Boolean Operator “OR”.

(adolescents OR youth OR teenagers) AND depression

Tip: You can use" Advanced Search " option in PubMed to help build your search strategy. Search concept by concept, adding ORs between all your keywords and MeSH terms for each concept. After you complete a search for each concept, you can use the "Actions" menu in the Advance Search Search History table to add combine your concept searches with AND. This will look for the overlap between your concept searches and help you avoid nesting errors.

Full Search Strategy Example:

("Adolescent"[Mesh] OR adolescent OR teen OR teens OR teenager OR youth OR youths) AND ("Depression"[Mesh] OR depressive OR depression) AND ("Fluoxetine"[Mesh] OR prozac OR fluoxetin* OR sarafem) AND ("Sertraline"[Mesh] OR zoloft OR sertraline OR altruline OR lustral OR sealdin OR gladem)

Step 5: Apply Search Limits or Filters

You can filter your search results using the PubMed filters in the left sidebar. You can filter by study type to look for the highest level of evidence to answer your question. You can also use date filters or filter to English language materials. If the study type you are looking for is not listed, select "Additional Filters" at the bottom of the left sidebar to see all the available options.

Note: Many PubMed filters depend on indexing, and using filters will exclude articles that do not have indexing.

You can also try PubMed's Clinical Queries to narrow your search results to the type of clinical questions you are asking (Therapy, Diagnosis, etc.).

Getting Too Many Results?

If your search retrieves too many results, you can limit the search results by

• replacing general (e.g. vague or broad) terms with more specific ones
• including additional concepts in your search
• using PubMed's sidebar filters on the left panel of the results page to restrict results by publication date, article type, population, and more

Getting Too Few Results?

If your search returns too few results, you can expand your search by

• browsing the  Similar Articles  on the abstract page for a citation to see closely related articles generated by PubMed's algorithm
• Removing specific or extraneous terms from the search string
• Using alternative terms to describe a similar concept used in the search

Handouts and Checklists

• Search syntax for common databases cheat sheet
• Literature searching in PubMed cheat sheet

Databases to Search Journal Articles

• CINAHL (Cumulative Index to Nursing & Allied Health) Provides access to nursing and allied health literature including 50 nursing specialties, speech and language pathology, nutrition, general health, and medicine.

Provides fulltext access to Lane's resources. Contains coverage of over 5000 journals and more than 35.5 million citations for biomedical articles, including, but not limited to, clinical trials, systematic reviews, case reports, and clinical practice guidelines.

• Embase Biomedical and pharmacological abstracting and indexing database of published literature that contains over 32 million records from over 8,500 currently published journals (1947-present) and is noteworthy for its extensive coverage of the international pharmaceutical and alternative/complementary medicine literature.
• Scopus Largest abstract and citation database of peer-reviewed literature featuring scientific journals, books and conference proceedings.
• Web of Science Multidisciplinary coverage of over 10,000 high-impact journals in the sciences, social sciences, and arts and humanities, as well as international proceedings coverage for over 120,000 conferences. Features systematic reviews that summarize the effects of interventions and makes a determination whether the intervention is efficacious or not.
• Joanna Briggs Institute Evidence Based Practice Database Provides evidence-based health information prepared by expert reviewers at Joanna Briggs Institute (JBI). It includes several databases: Best Practice Information Sheets, Consumer Information Sheets, Evidence Summaries, Recommended Practices, Systematic Review Protocols, Systematic Reviews, and Technical Reports.
• Cochrane Library A collection of databases that contain different types of high-quality, independent evidence to inform healthcare decision-making including systematic reviews conducted by the Conchrane Review Groups and randomized controlled trials.
• PsycINFO Provides systematic coverage of the psychological literature from the 1800s to the present through articles, book chapters and dissertations.
• PsycTESTS Provides downloadable access to psychological tests, measures, scales, and other assessments as well as descriptive and administrative information. It includes both published and unpublished tests developed by researchers but not made commercially available.
• ERIC (Education Resources Information Center) Citations and abstracts to journal and report literature in all aspects of educational research. Access Instructions. . . less... Also available through EBSCO and ProQuest

Lane Classes and Tutorials

• NLM PubMed Online Training PubMed training materials by the National Library of Medicine (NLM)

Finding Systematic Reviews & Evidence Summaries

• ACP Journal Club Summarizes the best new evidence for internal medicine from over 120 clinical journals. In this monthly feature of Annals of Internal Medicine, research staff and clinical editors rigorously assess the scientific merit of the medical literature as it is published. A worldwide panel of over 5000 physicians assesses the clinical relevance and newsworthiness of rigorous studies.
• BMJ Best Practice Provides detailed, evidence-based decision trees and a step-by-step approach, covering prevention, diagnosis, treatment and prognosis. Incorporates guidelines, systematic reviews from BMJ Clinical Evidence, and content from Cochrane Clinical Answers and AHFS Drug Information Essentials.
• JAMA Rational Clinical Examination JAMA's groundbreaking series on evidence-based use of the medical history, physical examination, and testing to diagnosis disease.
• NEJM Journal Watch Reviews over 250 scientific and medical journals. The physician-editors survey high-impact medical journals in specialties and topics to identify key findings. The summaries are presented with a clinical perspective and expert commentary.

Find Practice Guidelines

You can find guidelines in many other databases including PubMed, DynaMed, and ClinicalKey. Select a database and search for a specific condition or topic (e.g. preeclampsia), then follow the directions for each database to limit your search to guidelines:

• ClinicalKey for Nursing Specifically designed to provide the information needed to support nursing care, including administering medication, managing nurse policy, monitoring for complications, and providing patient education. Includes drug monographs, clinical topic summaries, videos, images, and journals.
• DynaMed Provides synthesized evidence and objective analysis to answer clinical questions. Features overviews and recommendations, expert reviews, mobile access, and links to Micromedex drug content. Access Instructions. . . less... Instructions for mobile app access
• UpToDate Point-of-care clinical information resource containing succinct and aggressively updated clinical topic reviews. Offers free DME/CE/CPD. Access Instructions. . . less... Mobile app download instructions

• Canadian Medical Association. CPG Infobase: Clinical Practice Guidelines. This database contains approximately 1,200 evidence-based Canadian clinical practice guidelines (CPGs) developed or endorsed by authoritative medical or health organizations in Canada.
• NICE NICE guidelines are evidence-based recommendations for health and care in England.

Clinical search engine designed to allow users to quickly and easily find and use high-quality research evidence to support their practice and/or care. Users are able to search across other content types including images, videos, patient information leaflets, educational courses and news.

A searchable database of 26 databases of hyperlinks from evidence-based medicine sites around the world.

Books about Practice Guidelines

• Browse Practice Guidelines for Nurses

Useful Websites

• Center for Evidence-Based Medicine (CEBM)
• Cochrane Evidence Essentials
• Joanna Briggs Institute Evidence-Based Practice Resources
• John's Hopkins Nursing Center for Evidence-Based Practice
• Ohio State's Fuld Institute for EBP
• Oncology Nursing Society - Evidence-Based Practice Learning Library
• Sigma Repository It is a profession-based online platform that freely disseminates nursing research, research-related materials, clinical materials related to evidence-based practice and quality improvements, and educational materials.
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Searching and critiquing the research literature, ann wakefield professor of nursing education, school of nursing and midwifery, university of manchester, manchester.

This article explores how to search and critique the research literature. This involves explaining how to generate a robust literature review question, search databases in the most effective manner and produce a robust analysis of the literature. The article also outlines how a novice literature reviewer might develop the skills required to undertake a critical analysis of the available evidence. In this manner, the reader is able to present a coherent debate on the state of the literature and how this might be used to construct a comprehensive rationale for why further research or analysis of clinical practice may be needed in relation to a particular topic of interest.

Nursing Standard . 28, 39, 49-57. doi: 10.7748/ns.28.39.49.e8867

This article has been subject to double blind peer review

Received: 12 February 2014

Accepted: 20 March 2014

research - research methods - literature review - literature search - clinical reasoning - critical appraisal - critical thinking - critical analysis

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03 June 2014 / Vol 28 issue 39

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Searching and critiquing the research literature

Affiliation.

• 1 School of Nursing and Midwifery, University of Manchester, Manchester.
• PMID: 24866671
• DOI: 10.7748/ns.28.39.49.e8867

This article explores how to search and critique the research literature. This involves explaining how to generate a robust literature review question, search databases in the most effective manner and produce a robust analysis of the literature. The article also outlines how a novice literature reviewer might develop the skills required to undertake a critical analysis of the available evidence. In this manner, the reader is able to present a coherent debate on the state of the literature and how this might be used to construct a comprehensive rationale for why further research or analysis of clinical practice may be needed in relation to a particular topic of interest.

Publication types

• Databases, Bibliographic
• Information Storage and Retrieval*
• Peer Review, Research*
• United Kingdom

• Open access
• Published: 12 May 2022

Registered Nurses' experiences of reading and using research for work and education: a qualitative research study

• Sonia Hines 1 , 2 ,
• Joanne Ramsbotham 2 &
• Fiona Coyer 2 , 3  

BMC Nursing volume  21 , Article number:  114 ( 2022 ) Cite this article

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Considerable resources have been expended, both in universities and health workplaces to improve nurses' abilities to interact with research and research literature to enable their engagement with evidence-based practice. Despite these efforts, a considerable number of nurses experience difficulty with research literature and are reluctant to use it in practice.

This study aimed to explore the experiences and perceptions of Registered Nurses when they have been required to read and understand research literature for work or education.

A qualitative descriptive study using online and in-person focus groups.

Focus groups (online and in-person) were conducted between June and November 2020. Forty participants were included. We used focus group recordings and field notes to collect data. Transcribed records of these focus groups were coded on the basis of similarity of meaning and then subjected to thematic analysis.

Three distinct themes were identified from the data: 'coming into learning about research', fitting research into the reality of nursing life', and 'working towards using research.' Participants described their early experiences in learning about research, experiences both positive and negative in integrating research into practice, and their personal strategies for reading and using research, particularly in the context of significant anxiety about understanding the content of methods and results sections of quantitative research articles.

This study goes beyond the barriers and facilitators dichotomy that has been the majority of the conversation about nurses' evidence-based practice engagement previously, and explores the issues underlying aversion to research literature. Many nurses struggle with the language, numbers, and/or statistics used in research and this requires educational interventions suited to the problem and the population.

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Introduction

Reading and using research is integral to evidence-based practice and therefore to nursing [ 1 ]. It is known, however, that many nurses avoid engagement with research literature and evidence-based practice (EBP) for a variety of reasons [ 2 ]. Positive attitudes to EBP, involvement in research education and activities, regular journal reading, and higher levels of education have been found to be associated with higher levels of EBP engagement [ 3 ]. These positive EBP attitudes may indicate that past experiences and associated feelings about research are a more important factor than perhaps the literature would indicate.

Considerable resources have been expended, both in universities and health workplaces to improve nurses' abilities to interact with research and research literature. Most university nursing degree courses around the world include research education in some form as part of their undergraduate curriculum, however in practice there continue to be nurses who are reluctant to engage with evidence-based practice and research utilization [ 4 ]. Globally, the World Health Organization (WHO) identifies nurse graduate attributes that includes the ability to demonstrate the use of evidence in practice [ 5 ]. This research, which is part of a larger body of work on nurses' research literacy, intends to describe RNs' perspectives on reading and using research in practice and education, to understand their feelings about this activity and to generate new knowledge about their behavior in this area of practice.

A qualitative systematic review of 11 studies has identified a broad range of emotional responses nurses may experience when interacting with research literature including negative feelings such as discomfort, irritation, frustration and vulnerability [ 6 ]. While this small body of qualitative research describes the barriers to nurses' research utilization in practice, a notable gap in understanding the experiences that have led to forming those emotional reactions has been identified.

The requirements for Registered Nurses are clear – they are expected to be able to participate in evidence-based practice and this requires them to be research literate – able to read and understand publications that use research language – but what is equally clear is that nurses find evidence-based practice difficult, challenging or even impossible [ 7 , 8 , 9 ].

In addition to factors such as organizational characteristics and pressures [ 10 ] it has been hypothesized that nurses experience difficulty understanding the language used in research literature [ 9 ]. Difficulties with language, however, may not be the only issue at the root of this problem. Nurses learn a great many specialist terms in their careers, quickly becoming familiar with the particular language used in different clinical, community and other specialist areas, so it seems unlikely that research language alone is the problem. It may be that there are particular feelings and experiences specifically attached to research literature that deter nurses from engaging with it, or other factors affecting their engagement. Much is known about barriers to EBP, but less is known about nurses' experiences and feelings about research in the context of their lives and careers.

The aim of this study was to explore the experiences and perceptions of registered nurses when they have been required to read and understand research literature as part of work or educational activities chiefly, to describe their feelings about this activity, to understand the relationship between these experiences and participants' willingness to engage in activities that require interaction with research literature and their experiences with those activities.

Research question

This study was designed to answer the question, "How do registered nurses experience and perceive reading and using research for work and education?".

This study employed a qualitative descriptive design, as described by Sandelowski [ 11 ], Milne [ 12 ], Lambert [ 13 ], and Kim [ 14 ]. The aim of the qualitative descriptive design, according to Lambert, is to comprehensively summarize particular events experienced by individuals [ 13 ]. Used widely in nursing due to its pragmatic, simple approach, qualitative descriptive research seeks to understand experiences and perceptions without transforming them beyond recognition [ 15 ]. The qualitative descriptive design was derived from the interpretivist research paradigm which holds that reality and truth are socially constructed and that complex phenomena can have many interpretations [ 16 ].

Qualitative descriptive studies, considered a form of naturalistic inquiry [ 17 ], use straightforward methods of data collection, such as focus groups, to elicit information about participant experiences and so this methodology is most suitable for research questions such as those being posed in this study. This design is categorized by minimal transformation of the data, and to this end we attempted to utilize the participants' own voices as much as possible to convey their experiences as they described them [ 14 ].

In this study, we conducted a series of online and in-person focus groups utilizing semi-structured interviews to collect participants' responses to open-ended questions and prompts from the researcher about their experiences and perceptions. Focus groups, due to their inherently social nature, are ideal for revealing attitudes, beliefs and experiences.

Sample/participants

The study protocol planned for a sample size of 75 registered nurses, however data saturation was reached at 40 participants and so recruitment was ceased. Sampling was not purposive, and any interested registered nurse was eligible to volunteer to participate.

The study population was planned to be drawn from registered nurses attending educational short courses or sessions at the study location (a center for education and research in a remote Australian town), however this was disrupted by the COVID-19 pandemic and travel and contact restrictions meant that in-person short courses and other education were moved to online delivery, preventing recruitment for in-person data collection, except for five participants for one focus group. Additional participants were then recruited to participate in online focus groups using nursing forum posts, social media, email, and personal contacts. Eligible participants were any adult person holding a current nursing registration with AHPRA (Australian Health Professional Regulation Agency), currently practicing in any health setting and with any educational background.

Data collection

Data were collected between June and October of 2020. Online focus groups were conducted using Zoom video-conferencing software, which enabled video as well as audio capture of participants' interactions. Video-conferencing supported participant to participant interactions, as well as participant to researcher, and moderately replicated the strength of the social elements of an in-person focus group. The single in-person focus group was audio-recorded only, but field notes were recorded. Post-interview field notes were also recorded for the online focus groups. Fourteen focus groups were scheduled, with 45 min allocated to each. Following their completion of the consent form, participants were contacted with a range of focus group times to choose from and once three to six participants had chosen the same time slot, the group time was confirmed and took place. In three cases, scheduled participants did not attend or advise their inability to attend, and so the data collection proceeded with only one participant.

Expectations for the group in terms of turn-taking, disagreements and politeness were discussed at the start of each group's session. Focus groups each generally took 30–45 min to discuss the questions in the interview guide, although occasionally more time was taken due to lively conversation.

The interview guide (Fig.  1 ) was developed by the researchers at the beginning of the study and changed iteratively over the course of the interviews in response to the discussions and two more questions were added. Questions in the interview guide were designed to answer the research question, and influenced by Melnyk's work on EBP in organizations, and EBP education [ 18 , 19 , 20 ] as well as the researchers' previous work in this field. The primary researcher was the only interviewer.

Interview guide. Items with asterisks* were added iteratively

Data analysis

This study used the six stage thematic analysis process recommended by Braun and Clark [ 21 ]:

After verbatim transcription of the audio recordings by a professional transcription service, the first author spent considerable time reading the transcripts and becoming familiar with the data.

Transcripts were entered into NVivo 12 (QSR International) which was used to aid thematic analysis. Initial codes were developed from both meaning and context by the PI at a semantic level of meaning. The codes were checked by the associate investigators to improve dependability.

Codes were then categorized into groups on the basis of patterns of similar meanings.

Categorization into themes and subthemes was achieved through repeated readings of the transcripts and considering the meaning of participants' statements. The associate investigators checked and gave input on the themes and subthemes at this stage.

The themes and subthemes were named in an iterative process that involved repeated readings and returns to the participant data to select the appropriate illustrative quotes which were then used verbatim to convey participants experiences and perceptions.

The sixth and final stage involved writing up the data, deciding on the order the themes and subthemes would be presented and making final decisions about how the story of the research might best be told. At this stage, participant names were replaced with pseudonyms to preserve confidentiality.

Reflexivity

The primary researcher SH is a registered nurse coming from a professional background in nursing research and education, particularly focusing on evidence-based practice and research capability. Reflecting on her experiences teaching and learning about research and EBP, she needed to recognize her biases and prior assumptions regarding the root causes of disengagement with research and EBP literature, acknowledging these in discussions and making space for participants to relate their own experiences.

Trustworthiness

The trustworthiness of this research was enhanced through careful attention to credibility, transferability, dependability, confirmability, auditability, and reflexivity [ 22 , 23 ]. The credibility and auditability of this study was enhanced by the use of extensive record keeping for the field notes, recordings, transcripts, and coding. Decisions about coding and data management were clearly documented. After each focus group field notes were recorded and checked against the recording.

Transferability and authenticity [ 24 ] have been addressed by recording and reporting detailed 'thick' descriptions of the interactions and discussions in each focus group. While qualitative research is not precisely transferable, there are similarities between many kinds of human experiences and readers of the research may recognize the findings as transferable to their own context, particularly as we have included the participants' own words as much as practicable [ 22 ].

Dependability in qualitative research is similar to the concept of reliability in quantitative research [ 25 ]. In this study we have ensured the research has been accurately reported, that decisions were documented and so are able to be clearly auditable. The use of an interview guide to ensure the same questions are asked of each focus group was also designed to increase the dependability of the study. The confirmability of the study will be established when the above methods for achieving credibility, transferability and dependability have been enacted [ 22 ]. All data related to the study has been retained: focus group recordings, transcripts, field notes, coding decisions, the codebook, and NVivo files. Completeness of reporting was ensured by following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline [ 26 ].

Participant descriptions

Initially 53 registered nurses (RN) volunteered and signed a consent to participate, however not all responded to the contact emails to arrange a focus group time or were able to find a suitable time to participate, and so 40 registered nurses completed the study in 14 focus groups of 1–6 participants. All focus groups were planned to be at least three participants in addition to the investigator, however last-minute cancellations meant that was not always possible and three focus groups proceeded with only one participant and the researcher conversing.

All participants were registered nurses licensed to practice in Australia, located in every state and territory of Australia in a variety of urban ( n  = 23), rural and remote areas ( n  = 17). Most participants were female, and their ages ranged from 24 – 65 years. Participants were working in a wide range of clinical settings including emergency department ( n  = 7), medical-surgical ( n  = 7), intensive and critical care ( n  = 5), mental health ( n  = 5), perioperative services ( n  = 3), oncology ( n  = 3), remote area nursing ( n  = 3), family nursing ( n  = 2), pediatrics ( n  = 1), occupational health ( n  = 1), community nursing ( n  = 1), rehabilitation ( n  = 1), and Aboriginal health ( n  = 1). All spoke fluent English, as required for nursing registration in Australia [ 27 ], however several spoke English as an additional language. Most were very experienced in their nursing career, with an average length of nursing experience of over 20 years and the majority of participants had a postgraduate level of education (Table 1 ).

The 14 focus groups with 40 participants yielded three themes: 'Coming into learning about research', 'Fitting research into the reality of nursing life', and 'Working towards using research' and ten subthemes (Table 2 ). All participant names used here have been pseudonymized. Pseudonyms, ages and length of RN career are provided in parentheses with each participant quote to give further context to participants' responses.

Theme 1: Coming into learning about research

Given our interest in nurses' early learning experiences regarding research, a significant part of each group discussion focused on participants' first encounters with research. Participants had come to nursing from a variety of paths; as school-leavers, mature-age students changing careers or entering the workforce at a later age, so they had a range of educational and life-skills preparation as they entered nursing. Some participants had begun nursing prior to tertiary nursing education implementation, having been trained in hospitals, and this also impacted on their experiences of learning about research even if they had completed tertiary studies at a later time.

Early experiences

Most of our participants had begun their careers when nurse education was very different from today, some in the early days of university education and some through the hospital training system. This time gap had an impact on the recall of these early events for some participants but for others the memories of their experiences were very clear. Participants described, some with laughter, their initial feelings when first faced with learning about research, either in their undergraduate nursing degree or subsequent graduate level studies, conveying a range of reactions:

When I was first exposed to research as an undergrad, I was horrified (Jack, 55, RN 26 years), I mean it was really good. I loved it, but it was a very steep learning curve (Anna, 59, RN 13 years), and, I didn't really take any interest in articles until I started my first Masters (Joy, 52, RN 33 years).

Difficulty understanding the concepts and feeling lost were common experiences for these nurses as they began to learn about research. Using self-deprecating humor, participants spoke of trying to find simple articles they could understand:

What I would try to do is I would try to find this… Try, try to find the sort of research that spoke in the most simplest of terms.., once I got halfway through it and I recognized that it was well beyond, above me…(Walter, 49, RN 29 years)

The volume of research available was confusing to them as students and they found it hard to identify which was relevant:

It's so broad trying to get so much, I think I actually did, you know, like I went to areas that wasn't meant to be trying to gather information because of time limit I found it was overwhelming (Fatima, 47, RN 9 years) and evidence for practice was not necessarily connected to research being used for an assignment: I think as an undergraduate, you can't… The research underpins your theory so that you have some kind of extended understandings to what you're doing and why, but once you actually get into a prac experience and you're actually on the floor with your mentors or etcetera, then you kind of don't link the two together (Kathy, 46, RN 11 years).

Early learning also brought with it problems of how to interact with the research literature. How and if to critique the literature was recalled as a significant problem:

I vividly remember thinking, who am I to put up an argument against this? These people have published this, for goodness sake. You know who am I to say that they're wrong? So that was my first thing was it was really difficult (Sophie, 51 RN 30 years)

Developing a critical mindset was not something they found easy to develop:

I just took them all as gospel. You know, what was in these articles was gospel, and I used what I could (Joy, 52, RN 33 years)

Others, however, felt they had personal characteristics that helped them in their early learning years:

I was always a bit of a bookworm, so yeah, I didn't struggle too much with that (Jenny, 52, RN 27 years)

Help with learning

A great deal of the focus groups' conversations about their formative years dealt with the help participants had received with their research learning, including help from mentors and role-models. One participant remembered:

When I was doing my nursing degree, one of the best and most memorable tutorials I ever had was in a research topic, which are traditionally the ones everyone hates, find really difficult to do. I had a very inspiring tutor in that topic, and the most memorable tutorial I think I ever had was when we discussed ethics in research (Tess, 42, RN 13 years)

Other participants recalled helpful programs such as peer mentoring, learning success programs, and academic writing courses, as well as library services and librarians that were another source of valuable help. Mentors, lecturers, educators and peers were described as helpful, inspirational, or supportive, and they were described as key to surviving these early learning experiences, according to participants' recollections:

Having good role models, and as I said… Or as I said, mentors, but having mentors, good role models, good people around you that value it helps you to value research 'cause you see what they can make of it (Jack, 55, RN 26 years) and: Study-wise, like I said, I had a fantastic mentor that just encouraged me and pushed me and pushed me, and it was wonderful (Sarah, 59, RN 40 years)

Similarly, the absence of role models was felt to be an additional source of difficulty:

…they tell you to find a mentor or… There just wasn't anyone. You know, it's yeah, a small country town. You don't find anyone, there's, there's nobody that understands it, there's nobody that… that can do that interpretation for you…that…can help you with how to do that (Jenny, 52, RN 27 years)

Theme 2. Fitting research into the reality of nursing life

This theme and its three subthemes (organizational issues, interpersonal issues, and confidence) emerged from discussions of how reading and using research connected with the rest of their nursing lives. Participants were asked about how any difficulties they had with learning to understand research impacted on how they perceived their chances for success as a nurse, how pressures from their working life impacted on interacting with research literature, and how their degree of comfort with reading and using research influenced their involvement in work activities. The need or desire to read and use research sometimes did not fit well with a nursing career, especially in the early years when it was perceived that consolidating the tasks of nursing was paramount. Supportive structures, senior staff and peers were spoken of admiringly, with a sense that they were 'lucky' to be in a research-friendly environment. Achieving confidence with reading and using research was seen as a function of personal characteristics rather than the actions of educators and workplaces.

Organizational issues

A prevalent view across multiple focus group discussions was that organizations were perceived to view nurses' involvement in evidence-based practice (other than simply complying with policy) as an optional extra in the context of getting the job done:

There's really no time for anything else, and from a higher level, research is considered something of a luxury. If there's resource cuts, then education and research are always hit first (Samantha, 55, RN 22 years).

Some participants perceived that preserving the status quo was a higher priority than promoting practice change:

...if people understood how to use the databases, how to research evidence to back up practice or to, or even just to augment their practice great, but it's so hierarchical in nursing and people guard their policies and procedures with their life. I don't think they want change sometimes (Kerry, 53, RN 18 years)

The hierarchical nature of many nursing structures also worked against participants' desires to become involved in EBP activities:

I have never been involved in projects, before because of the hierarchy, I'm at the bottom level (Fatima, 47 RN 9 years)

Many participants worked in organizations with expectations that staff participate in EBP activities, but that did not necessarily mean that resources or support was available to facilitate these activities:

The fact that I was in a, a large metropolitan health service still didn't mean that I could reach out and grab somebody to help me, So but in more recent times, they've put some structures in place to improve that, and it has improved. However, would I call it supportive? I don't know that I'd call it that (Walter, 49, RN 29 years)

There was a consciousness of different organizations being at different levels of engagement with EBP:

…other organizations I've worked for in the past, they're at the forefront, they're engaged with universities and tertiary providers which work alongside the clinical service, and I think that people have a greater understanding about the importance of research and generating research outputs and also using that to inform practice. Whereas, I think that not all organizations are at that stage, which is just how it is really (Ron, 40, RN 16 years)

Interpersonal issues

Many participants recognized that EBP was not something they could really achieve alone, and that without the cooperation of their team it was unlikely they could influence practice change. There was also considerable discussion of the overt hostility some had faced when trying to change practice or undertake further studies. The nature of interpersonal interactions was of considerable importance to these nurses, reflecting the strong focus on teamwork in nursing. Being 'different' or acting outside the team's norm put individuals at risk of feeling out of place in their workplace or in their job. Other participants related stories of assistance and support and spoke of their pride in their workplace and team for providing high quality care.

The perception that research and EBP are not really core to nursing was clear from several participants, as one said:

I don't think I actually put the two together as either being the researcher or the clinician nurse, in that I often probably was looking for something because I couldn't find the answer to it. So, I would… Nobody else was looking up anything and so I guess I felt odd, actually (Ella, 34, RN 14 years)

The demarcation between EBP and practice as it happens 'in real life' was made quite clear:

And when you have eight hours to finish everything that you have to get done, the urgent priorities take over the important or even, really don't know if you call it important, I'd call it a side gig(Mei, 35, RN 14 years)

Caring was seen to be at odds with intellectual activity:

…whereas nurses, well, you're supposed to care, like where's where does research fit into that? (Jenny, 52, RN 27 years)

People inside and outside of nursing did not seem to perceive research as something that nurses should be concerned with:

a fairly new RN, who's got a position as a researcher and yeah, she's had a lot of flak from people, including in our family, about, "Why are you doing this? Is that what you did nursing for?" So yeah, it just speaks to the stereotypes about how research is not an essential part of our profession, which of course it is (Jack, 55, RN 26 years)

Supportive teams and colleagues were seen to enable practice improvement through research use:

I don't have much experience outside emergency departments, but I do think emergency and critical care, there is generally a good culture around that sort of thing. When I was quite a junior nurse, for my graduate certificate, I had to do a literature review on pressure area injuries in emergency care. And through that I was able to alter our nursing assessment charts to include a Braden score because of the evidence that I showed the organization about the risks of pressure injuries and things like that. And they were very receptive to that I found (Tess, 42, RN 13 years)

Participants appreciated a supportive culture in the workplace:

So, I've just become interested in research recently, and just talking to people who are in that field in the hospital has been really easy and very helpful and supportive. And yeah, and helping me try to do that in helping you try to learn that as well. So, it's yes. Really, really good. Really supportive (Maya, 30, RN 3 years).

Participants identified their own personal characteristics as being key to their confidence with research:

I was always very ambitious and thirsty for knowledge. So I read every you know, there are professional magazines that come out like my first place as a registered nurse was the operating theatre. So I read all the operating theatre magazines that came out (Mona, 52, RN 32 years)

Participants related early experiences with reading research that increased their confidence:

I went to search in the library at the [hospital] and got out some articles and read them, and then told my educator that this is what I'm gonna do, and she was of course very impressed. But that was sort of like an automatic. But not all students did that though. You know what I mean? It's probably because I'm just a type A personality and it worked for me… (Diya, 48, RN 20 years)

Confidence with one aspect of using research was perceived as leading to other things:

Yes, I've been taking on, like, you know, the mentoring and the facilitation of the students. And I wasn't really looking into that side of stuff until I started to get a little bit more into the research stuff (Eve, 30, RN 10 years)

Confidence with research literature was something they perceived in other nurses as well:

The nurses who do read articles do stand out, and they're usually of that caliber, and so they're usually in the middle of their Masters or in the middle of pursuing some form of formal education, and even if they weren't, the thing is they're few and far between, that's what I mean by "they stand out," as nurses, the team is receptive to their passion, but they wouldn't be going looking for articles the way this person would (Mei, 35, RN 14 years)

Theme 3. Working towards using research

This final key theme emerged from the discussions about the participants' experiences with research literature, the feelings they had about using it, and strategies they used for dealing with texts they might find difficult. Four subthemes were identified through repeated readings of the transcripts: approaches to reading and understanding research; using research; mathematics difficulties; and research language. In addition, as a final question to all the focus groups, participants were asked how they would feel if they were asked to read a research paper "right now" and their reactions to that prompt, including their non-verbal observed reactions are discussed.

Approaches to reading and understanding research

This was a somewhat unexpected subtheme developed over the course of the focus groups and so was discussed in more detail with the later groups. Participants spoke of how difficult and time-consuming reading research literature was and related their strategies for extracting the meaning, as they understood it, from the papers they read. Very few participants who spoke about their reading strategies stated that they always read the whole article, instead using a range of different approaches.

The methods section of a research paper was a particular source of discomfort, as this participant described in her approach prior to commencing her research degree:

I'd read the abstract and the introduction, skip through all the middle bits, and read the conclusion. None of the actual research methodologies or any of that made any sense whatsoever (Ella, 34, RN 14 years)

Participants developed strategies to allow them to extract some meaning from research articles, even if they had to take the paper's reliability on trust:

...discussion sections were fine as a uni student but trying to interpret what they was talking about in their methods…. And like their results section I kind of skipped past that to the discussion because it was just easier. They even if they were doing something really simple the terminology they used made no sense (Lyn, 24, RN 3 years)

Details of the methods and results were not considered by some participants to be "relevant" to their needs:

I just want to go straight to the facts, I don't care about all that stuff that's probably relevant to a researcher but it's not to me. I tend to go straight to the end to see what the outcomes were and skip everything in the middle, where it's leading to because that stuff just isn't relevant to me on a day to day basis, I just want the information that is relevant (Maryanne, 46, RN 10 years)

Participants also spoke of making pragmatic decisions about reading papers in the context of their limited time:

If I've got the time, I'll read the whole thing. If not, I won't. Definitely being wary of the methodology and the size of the study, and I guess the particular context and any notes on that (Andy, 25, RN 2 years)

They were aware their strategies were not always 'correct' but they were perceived as effective:

Read the abstract content and results. Read the conclusion. That was enough to get through my 3rd year evidence-based practice subject (Eve, 30, RN 10 years)

Using research

Many of the participants were undertaking or had completed postgraduate studies and spoke about using research in writing assignments, but they were also using research to underpin practice and to justify their practice choices. They seemed acutely aware of the expectations on them to use research in education and practice, and sometimes these expectations were felt to be burdensome. Despite the difficulties many experienced with understanding research literature, they were still generally willing to try to use it whenever it was needed.

Using evidence to drive practice change in the interests of patient safety was discussed by several participants:

I don't do research. I use research. So, my emphasis is on finding solid stuff to back up things or, you know, what is evidence based on? That's where I'm still quite active in this field of health and safety (Danni, 54, RN 36 years)

There was a sense that proposed change based on strong evidence was less likely to be argued with:

If I put in an improvement form, I'll often staple a couple of research articles to back it up when I hand it in, and highlight what's relevant, and they don't argue anymore (Noni, 54, RN 38 years).

Participants' own personal safety was also seen to be preserved by the use of the right evidence in practice: Like I work for agency as well. If I don't believe it—if their practices are not based on evidence based practice—I just stick to those places that I know that are evidence based practice because I work in medical oncology/ hematology and I'm very cautious about the fact of how much it will affect me, because I'm still of child-bearing age. So… So, if I work in an area that is not using best practice, I'm not gonna go back there (Bella, 36, RN 14 years).

For some participants working in education, using and normalizing using research was challenging but necessary:

And so, my challenge has been to try and make it relevant to day to day practice. And it's slow, but it's achievable if you can find projects or links where you can sort of embed a little bit of research in there. And then they say that it's not a mystical kind of weird thing that only a bunch of weirdos do somewhere else (Samantha, 55, RN 22 years)

Mathematics difficulties

Difficulties with understanding use of numbers, mathematics, and statistics emerged as a strong theme from these discussions. Participants expressed dismay at the problems they experienced in understanding quantitative results and statistical terminology. Qualitative research, on the other hand, was not considered to be difficult to understand, and the focus of participants' discomfort was centered strongly on numbers and statistics.

Participants found the way that numerical results were written to be confusing:

For me it's the way it's written with all the 0.5 s and all that sort of thing, it doesn't make sense. If it was simple percentages, then that makes sense (Joan, 60, RN 30 years)

There was a sense that statistical terms were a language they did not speak:

...just enough on stats. I think there's something a bit harsher about them being a bit more numbers, but thing I hate about them is almost that foreign language involved, you know, squared chi Wilcoxon and whatever the hell of the names of the and so they frighten me a bit (Sally, 50, RN 8 years)

One participant queried whether discomfort with numbers was related to gender:

It's feeling comfortable with using numbers and whether that's a male or female thing, talk about it as gender, but just feeling really more comfortable, with say, phenomenological studies and things like that just seem to make more sense, and whether that's why I'm a nurse or it's..[trailed off] (Gen, 65, RN 48 years)

However, male participants expressed discomfort also:

The second I saw like, you know, the analysis and all that kind of stuff, I'm like I'm not gonna read over this, you know, You see that I'm not a very numbers person (Bob, 48, RN 1 year)

There was a sense that numbers and feelings were diametrically opposed:

I much prefer to read a qualitative paper… Yeah, rather than… I'd rather read about people's feelings, than the numbers (Joan, 60, RN 30 years)

Numbers were seen as excluding the human element that nurses value:

I also think it's about whether you like the human element and people mattered more to me than numbers. I think it's maybe that and probably I think, you know, when I went to midwifery and child health, that's all about more about humans (Lisa, 54, RN 33 years)

Research language

The specific language used in research was a problem for many participants. They seemed alienated by the language; despite the often-complex terms used by their various clinical specialties the terms used in research seemed untethered from logical meaning. That lack of connection to an action or object that could be clearly conceptualized meant that participants often felt that research was not written with them as readers in mind. When they could see a clear connection to their work or studies, research language became more relatable and easier to understand.

Research language was viewed as alien or foreign:

I think there's an aspect of unfamiliarity with the language too, because it's like reading anything in a foreign language, it's really hard work. And to a lot of nurses, research is a foreign language. They're not being exposed to it (Jack, 55, RN 26 years)

There was a strong sense that research was genuinely regarded as language not everyone could speak:

I haven't done research, so I can talk about research I've read with people at work, but it's like talking another language (Noni, 54, RN 38 years)

Trying to understand the language was full of pitfalls:

So, I started in that levels of hierarchy and evidence. I started then really starting to get picky about what I was really and looking at the language then got confused with intervals and confidence of a lot of talk about 0.95 (Eve, 30, RN 10 years)

Particularly in their early years, it was difficult to engage with research literature due to the language:

I lost interest straight away… I'm better now than I was then, obviously, but in those days, yeah, I was absolutely intimidated by the, the way it was written (Walter, 49, RN 29 years)

The language used in the paper was tied to how much effort participants would put into trying to understand it:

…it was so full of so much jargonized rubbish, that you almost needed to research that research paper, whereas then you find another person who's writing it in a tone or a language that you can understand and you immediately resonate (Kathy, 46, RN 11 years)

Difficulties understanding the language also influenced their reading strategies:

It's a discussion section that I go to. First, the abstract, but then after that the discussion, and only if it's got anything useful, then I will go further if I have to, but that's because the plain English is in the discussion section, that's where they don't dribble on about X equals Y, and we found that, blah, blah, and the average of this was that and… Yeah, 'cause I understand they have to spell out their tables and Excel tables and findings and everything. But the discussion is where the English is, that's where normal human speak is (Mei, 35, RN 14 years)

Despite these issues, most participants, when asked how they would feel if asked to read a research article "right now", responded at least somewhat positively. Some conveyed considerable wariness or concern in the tone of their responses:

I would want to know what the topic was and I would want to know. I would want to know why you wanted me to read it (Nina, 57, RN 9 years)

Some responded with defensiveness:

Again, why? I've got plenty to read. I don't need what you want to give to me to read. Is there any benefits in this particular paper? What is it trying to achieve? So is it a valid study or is it just some ivory tower, need to know something for the sake of it? (Anna, 59, RN 19 years)

Even with a hypothetical request, participants were cautious about committing their time:

I'd be more likely to actually be able to get through it if it was a shorter one rather than a 20 page (Karen, 35, RN 13 years)

Most, however, responded with confidence they would give it a try:

I'm gonna say yes. Tell me what it's about, and I'll say yes, let's read it and see what we can do (Diya, 48, RN 20 years)

Participants in this study responded with a rich variety of stories about their experiences and how they felt about reading and using research literature. Some participants were, as described in the literature, 'research reluctant' [ 28 ] but many held positive views. Having positive attitudes towards research and EBP did not mean participants experienced no challenges with reading and using research, however. Positive attitudes to EBP, combined with involvement in research education and activities, regular journal reading, and higher levels of education have been found to be associated with higher levels of EBP engagement [ 2 , 3 ], but engaging nurses in those educational activities and promoting higher education can be a difficult task.

We deliberately avoided framing the focus group discussions in terms of barriers and facilitators, largely because for more than 30 years a segment of the nursing literature has framed the question of nurses' engagement with EBP and research in terms of this binary [ 29 , 30 , 31 ] with little progression in resolving this issue. Barriers and facilitators, while conceptually helpful in considering issues of implementation, are less so in the presence of an unclear and complex situation such as this. It was also important to gain a deeper understanding of the issues rather than simply statements of barriers or facilitators.

Research methods education at the tertiary level is often designed to train students to conduct research, whereas in most clinical fields such as nursing, the majority of students will be research users [ 32 ]. A systematic review of non-discipline-specific research methods education studies presents some findings similar to the perceptions and experience related by participants in this study [ 32 ]. Earley’s review synthesizes a number of student characteristics observed in the 51 included studies, such as “They are typically anxious or nervous about the course,” “They fail to see the relevance,” and “They come to the course with poor attitudes about research,” [ 32 ](p. 245).

This study adds several nuances to the current conversation about nurses' EBP and research engagement. In exploring the research reading strategies used by the participants this data connects with other work conducted on research reading strategies [ 33 ]. Similar to the findings by Hubbard and Dunbar [ 33 ], their sample of undergraduates and early career researchers in biological sciences placed less value on understanding the methods and results sections of a paper, as did many of the nurses in our study. Some participants in this study believed the methods and results sections held little useful information for them. It has been suggested that addressing research language difficulties can help increase engagement and improve reading strategies [ 33 ].

Research language has been identified as an issue for learners across the professions, including nursing. Nurses in a Swedish quantitative study were asked several questions about their experiences reading research literature, with the vast majority indicating they only "sometimes" understood the research articles they read, and that if research articles used "simple/normal language" they would read them more often and apply the findings in practice [ 4 ]. Participants in our study also commented on their difficulties with the language in research papers and expressed a wish for simpler language to be used. As research writing conventions are unlikely to change, it may be that a different pedagogical approach would be beneficial for bringing learners into an understanding of research literature. Learning the language of research has been compared to second language acquisition and the use of similar teaching and learning approaches has been suggested [ 34 ]. A language-based approach, genre analysis, has been piloted with registered nurses for research methods education with some success, however more work is needed [ 35 ].

Related to participants' difficulties with the methods and results sections of research papers, may be connected to a well-known phenomenon known as mathematics anxiety – a fear of or aversion to mathematics, which often leads to avoidance of mathematics-related activities [ 36 ]. Participants in our study made many mentions of "the numbers"; they felt numbers were hard to understand, incompatible with caring, and confusing. Given the importance of mathematics to nursing, any changes to research methods pedagogy will need to include strategies to improve attitudes to and abilities with understanding and interpreting numerical reporting in research literature [ 37 ].

In our exploration, we focused on nurses' experiences and the feelings they attached to those experiences, rather than research attitudes or knowledge, although both these are important, they are not the whole story. Whatever the sources of the challenges in addressing nurses' engagement with research and EBP, it seems clear that a multifaceted approach is needed. Effective pedagogies along with strategies to address work culture and organizational challenges are all needed to provide the environment for evidence-based healthcare to flourish.

Implications for practice

Some of the factors influencing nurses' perceptions of research, such as mathematics anxiety, may not be modifiable by nursing educators at a tertiary or workplace level, however confidence and self-efficacy in terms of reading and understanding research can be increased by creating success experiences using effective pedagogies [ 38 ]. Creating scaffolded research methods education that gradually introduces nurses into an understanding of research literature focusing on both understanding the language and understanding the statistics and numerical reporting may be the most appropriate approach to creating familiarity, and increasing self-efficacy, therefore leading to better experiences and greater engagement. Increasing the research friendliness of workplaces and availability of mentoring options would encourage all nurses to engage with research.

Implications for research

There is likely to be considerable value in investigating new pedagogical strategies for teaching research, both to undergraduates and registered nurses. Future research could further investigate in detail the theorized link between research aversion and mathematics anxiety.

Limitations

Registered nurses who self-selected to participate in this study may have been systematically different in important ways from nurses who declined to volunteer, particularly in their level of education and interest in research. Many of the participants were in senior roles in their organizations, and some were studying for research degrees. Participants in this study were slightly older than the average Australian RN (44.3 years vs 47.5 for this study) and slightly more likely to be male – 89.1% of Australian RNs are female, while 87.5% of these participants were [ 39 ]. These small differences may affect the transferability of these findings to the wider population, however the findings do align with other work, such as that by Hendricks and Cope [ 4 ], the findings of which are discussed above.

Nurses have a wide range of experiences interacting with research literature, but many report struggling with the language, the numbers, or the statistics. Many nurses value research and EBP and capably use it in practice, however the current reading strategies used by nurses in this study do pose a risk to EBP if research is used without being properly appraised. Nursing workplace cultures are a significant influence on how nurses perceive research reading and use, and workplaces with hostile or apathetic culture toward research risk poor practice and alienating staff interested in improving practice.

Availability of data and materials

The data used in this study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge the valuable contribution of Flinders Rural and Remote Health, NT to enabling the completion of this project.

This study was funded in part by a scholarship awarded to the primary author by the Australian College of Nursing. The funding body had no role in designing, conducting or analyzing the data for this study.

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Contributions

SH conceived and wrote the study protocol with contributions from JR and FC. SH completed and submitted the ethics application in collaboration with JR and FC. JR and FC provided feedback on the interview guide. SH recruited participants and conducted the focus groups. JR and FC provided advice and guidance during data collection. SH arranged for transcription, checked the transcripts against the recordings and conducted the initial coding. Coding decisions were approved by all three authors. Themes and subthemes were initially conceived by SH and then agreed by all three authors. SH wrote the initial draft of the manuscript and revised it in response to feedback from JR and FC. All authors have approved the final manuscript.

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Correspondence to Sonia Hines .

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Ethics approval and consent to participate.

The study was approved by the Central Australian Human Research Ethics Committee in 2020, as well the Queensland University of Technology Office of Research Ethics (approval numbers: CA-20–3639, and 2000000237 respectively). All methods were carried out in accordance with the conditions of the approval and any relevant guidelines and regulations.

Individuals volunteering for the study all provided written informed consent after reading the study's participant information sheet online and signing electronically. Participants were only contacted to arrange an interview time once this had been completed, meaning that individuals had sufficient time to consider whether to participate. All participants consented to being recorded, although some participants chose not to enable video during all or part of the interview due to internet service difficulties or for personal reasons. As a token of gratitude for their time and effort, a $20AUD grocery store gift card was sent to all participants after their interview.

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Hines, S., Ramsbotham, J. & Coyer, F. Registered Nurses' experiences of reading and using research for work and education: a qualitative research study. BMC Nurs 21 , 114 (2022). https://doi.org/10.1186/s12912-022-00877-3

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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.