nursing article review example

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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Reading and critiquing a research article

Nurses use research to answer questions about their practice, solve problems, improve the quality of patient care, generate new research questions, and shape health policy. Nurses who confront questions about practice and policy need strong, high-quality, evidence-based research. Research articles in peer-reviewed journals typically undergo a rigorous review process to ensure scholarly standards are met. Nonetheless, standards vary among reviewers and journals. This article presents a framework nurses can use to read and critique a research article.

When deciding to read an article, determine if it’s about a question you have an interest in or if it can be of use in your practice. You may want to have a research article available to read and critique as you consider the following questions.

Does the title accurately describe the article?

A good title will pique your interest but typically you will not know until you are done reading the article if the title is an accurate description. An informative title conveys the article’s key concepts, methods, and variables.

Is the abstract representative of the article?

The abstract provides a brief overview of the purpose of the study, research questions, methods, results, and conclusions. This helps you decide if it’s an article you want to read. Some people use the abstract to discuss a study and never read further. This is unwise because the abstract is just a preview of the article and may be misleading.

Does the introduction make the purpose of the article clear?

A good introduction provides the basis for the article. It includes a statement of the problem, a rationale for the study, and the research questions. When a hypothesis is being tested, it should be clearly stated and include the expected results.

Is a theoretical framework described?

When a theoretical framework is used, it should inform the study and provide a rationale. The concepts of the theoretical framework should relate to the topic and serve as a basis for interpreting the results. Some research doesn’t use a theoretical framework, such as health services research, which examines issues such as access to care, healthcare costs, and healthcare delivery. Clinical research such as comparing the effectiveness of two drugs won’t include a theoretical framework.

Is the literature review relevant to the study and comprehensive? Does it include recent research?

The literature review provides a context for the study. It establishes what is, and is not known about the research problem. Publication dates are important but there are caveats. Most literature reviews include articles published within the last 3 to 5 years. It can take more than a year for an article to be reviewed, revised, accepted, and published, causing some references to seem outdated.

Literature reviews may include older studies to demonstrate important changes in knowledge over time. In an area of study where little or no research has been conducted, there may be only a few relevant articles that are a decade or more old. In an emerging area of study there may be no published research, in which case related research should be referenced. If you are familiar with the area of research, review the references to determine if well-known and highly regarded studies are included.

Does the methods section explain how a research question was addressed?

The methods section provides enough information to allow the study to be replicated. Components of this section indicate if the design is appropriate to answer the research question(s).

• Did the researcher select the correct sample to answer the research questions and was the size sufficient to obtain valid results?
• If a data collection instrument was used, how was it created and validated?
• If any materials were used, such as written guides or equipment, were they described?
• How were data collected?
• Was reliability and validity accounted for?
• Were the procedures listed in a step-by-step manner?

Independent and dependent variables should be described and terms defined. For example, if patient falls in the hospital are considered the dependent variable, or outcome, what are the independent variables, or factors, being investigated that may influence the rate at which patient falls occur? In this example, independent variables might include nurse staffing, registered nurse composition (such as education and certification), and hospital Magnet &#174 status.

Is the analytical approach consistent with the study questions and research design?

The analytical approach relates to the study questions and research design. A quantitative study may use descriptive statistics to summarize the data and other tests, such as chi squares, t-tests, or regression analysis, to compare or evaluate the data. A qualitative study may use such approaches as coding, content analysis, or grounded theory analysis. A reader who is unfamiliar with the analytical approach may choose to rely on the expertise of the journal’s peer reviewers who assessed whether the analytical approach was correct.

Are the results presented clearly in the text and in tables and figures?

Results should be clearly summarized in the text, tables, and figures. Tables and figures are only a partial representation of the results and critical information may be only in the text. In a quantitative study, the significance of the statistical tests is important. The presentation of qualitative results should avoid interpretation, which is reserved for the discussion.

Are the limitations presented and their implications discussed?

It is essential that the limitations of the study be presented. These are the factors that explain why the results may need to be carefully interpreted, may only be generalized to certain situations, or may provide less robust results than anticipated. Examples of limitations include a low response rate to a survey, not being able to establish causality when a cross-sectional study design was used, and having key stakeholders refuse to be interviewed.

Does the discussion explain the results in relation to the theoretical framework, research questions, and significance of the study?

The discussion serves as an opportunity to explain the results in respect to the research questions and the theoretical framework. Authors use the discussion to interpret the results and explain the meaning and significance of the study. It’s also important to distinguish the study from others that preceded it and provide recommendations for future research.

Depending on the research, it may be equally important for the investigators to present the clinical and/or practical significance of the results. Relevant policy recommendations are also important. Evaluate if the recommendations are supported by the data or seem to be more of an opinion. A succinct conclusion typically completes the article.

Once you’re done reading the article, how do you decide if the research is something you want to use?

Determine the scientific merit of the study by evaluating the level and quality of the evidence. There are many scales to use, several of which can be found in the Research Toolkit on the American Nurses Association’s website http://www.nursingworld.org/research-toolkit.aspx . Consider what you learned and decide if the study is relevant to your practice or answered your question as well as whether you can implement the findings.

A new skill

A systematic approach to reading and critiquing a research article serves as a foundation for translating evidence into practice and policy. Every nurse can acquire this skill.

Louise Kaplan is director of the nursing program at Saint Martin’s University in Lacey, Washington. At the end of this article is a checklist for evaluating an article.

Selected references

Hudson-Barr D. How to read a research article. J Spec Pediatr Nurs . 2004;9(2):70-2.

King’s College D. Leonard Corgan Library. Reading a research article. http://www.lib.jmu.edu/ilworkshop08/materials/studyguide3.pdf . Accessed September 5, 2012.

Oliver D, Mahon SM. Reading a research article part I: Types of variables. Clin J Oncol Nurs . 2005;9(1):110-12.

Oliver D, Mahon SM. Reading a research article part II: Parametric and nonparametric statistics. Clin J Oncol Nurs . 2005;9(2):238-240.

Oliver D, Mahon SM. Reading a research article part III: The data collection instrument. Clin J Oncol Nurs . 2006;10(3):423-26.

Rumrill P, Fitzgerald S, Ware, M. Guidelines for evaluating research articles. Work . 2000;14(3):257-63.

15 Comments .

very helpful resource to critique any research article

I like it helped me a lot in my critical appraisal. thank you very much.

This article will help me with my understanding of how to read and critique a research article. This article was helpful in breaking down this information very basic to get a clear, concise understanding. Now I can take this information and go to the next level in my discussions

Great information and I will use this article for future reference.

This checklist and explanation for a literature review and/or reading and critiquing a research article was very helpful. As I only have 2 more classes to get my degree, I wish I knew this info 2 semesters ago! I will also pass this along to coworkers that will be going back to school in the near future.

Great article, I enjoyed the information. Thank You for this resource. Carolyn Martinez

Fantastic guide to the interpretation of clinical trials. Found this so helpful!

Great information and article. Thank you for the information.

well explained. its sometimes hard for P.G students to understand the concept but these guidelines are helpful to learn for novice.

This is great,am looking for guilgline on how to do research critique and this is just the solution.Thnks weldone

Unsure how to appropriately critique an article, thank you for your infomation

I am currently taking a Health Service Research course and was not sure how to sturcture my assignment. Thanks for posting this article!

very informative…very helpful to students doing research work.

Great timing; have just been asked to review and article and you provide the guide! Will share with colleagues.

I will be passing this article on to a friend who is taking a nursing research class. This article is a great reference for nursing students.

Comments are closed.

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Literature Review Overview

What is a Literature Review? Why Are They Important?

A literature review is important because it presents the "state of the science" or accumulated knowledge on a specific topic. It summarizes, analyzes, and compares the available research, reporting study strengths and weaknesses, results, gaps in the research, conclusions, and authors’ interpretations.

Tips and techniques for conducting a literature review are described more fully in the subsequent boxes:

• Literature review steps
• Strategies for organizing the information for your review
• Literature reviews sections
• In-depth resources to assist in writing a literature review
• Templates to start your review
• Literature review examples

Literature Review Steps

Graphic used with permission: Torres, E. Librarian, Hawai'i Pacific University

1. Choose a topic and define your research question

• Try to choose a topic of interest. You will be working with this subject for several weeks to months.
• Ideas for topics can be found by scanning medical news sources (e.g MedPage Today), journals / magazines, work experiences, interesting patient cases, or family or personal health issues.
• Do a bit of background reading on topic ideas to familiarize yourself with terminology and issues. Note the words and terms that are used.
• Develop a focused research question using PICO(T) or other framework (FINER, SPICE, etc - there are many options) to help guide you.
• Run a few sample database searches to make sure your research question is not too broad or too narrow.
• If possible, discuss your topic with your professor. 

2. Determine the scope of your review

The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature Review.

• How many studies will you need to include?
• How many years should it cover? (usually 5-7 depending on the professor)
• For the nurses, are you required to limit to nursing literature?

3. Develop a search plan

• Determine which databases to search. This will depend on your topic. If you are not sure, check your program specific library website (Physician Asst / Nursing / Health Services Admin) for recommendations.
• Create an initial search string using the main concepts from your research (PICO, etc) question. Include synonyms and related words connected by Boolean operators
• Contact your librarian for assistance, if needed.

4. Conduct searches and find relevant literature

• Keep notes as you search - tracking keywords and search strings used in each database in order to avoid wasting time duplicating a search that has already been tried
• Read abstracts and write down new terms to search as you find them
• Check MeSH or other subject headings listed in relevant articles for additional search terms
• Scan author provided keywords if available
• Check the references of relevant articles looking for other useful articles (ancestry searching)
• Check articles that have cited your relevant article for more useful articles (descendancy searching). Both PubMed and CINAHL offer Cited By links
• Revise the search to broaden or narrow your topic focus as you peruse the available literature
• Conducting a literature search is a repetitive process. Searches can be revised and re-run multiple times during the process.
• Track the citations for your relevant articles in a software citation manager such as RefWorks, Zotero, or Mendeley

5. Review the literature

• Read the full articles. Do not rely solely on the abstracts. Authors frequently cannot include all results within the confines of an abstract. Exclude articles that do not address your research question.
• While reading, note research findings relevant to your project and summarize. Are the findings conflicting? There are matrices available than can help with organization. See the Organizing Information box below.
• Critique / evaluate the quality of the articles, and record your findings in your matrix or summary table. Tools are available to prompt you what to look for. (See Resources for Appraising a Research Study box on the HSA, Nursing , and PA guides )
• You may need to revise your search and re-run it based on your findings.

6. Organize and synthesize

• Compile the findings and analysis from each resource into a single narrative.
• Using an outline can be helpful. Start broad, addressing the overall findings and then narrow, discussing each resource and how it relates to your question and to the other resources.
• Cite as you write to keep sources organized.
• Write in structured paragraphs using topic sentences and transition words to draw connections, comparisons, and contrasts.
• Don't present one study after another, but rather relate one study's findings to another. Speak to how the studies are connected and how they relate to your work.

Organizing Information

Options to assist in organizing sources and information :

1. Synthesis Matrix

• helps provide overview of the literature
• information from individual sources is entered into a grid to enable writers to discern patterns and themes
• article summary, analysis, or results
• thoughts, reflections, or issues
• each reference gets its own row
• mind maps, concept maps, flowcharts
• at top of page record PICO or research question
• record major concepts / themes from literature
• list concepts that branch out from major concepts underneath - keep going downward hierarchically, until most specific ideas are recorded
• enclose concepts in circles and connect the concept with lines - add brief explanation as needed

3. Summary Table

• information is recorded in a grid to help with recall and sorting information when writing
• allows comparing and contrasting individual studies easily
• purpose of study
• methodology (study population, data collection tool)

Efron, S. E., & Ravid, R. (2019). Writing the literature review : A practical guide . Guilford Press.

Literature Review Sections

• Lit reviews can be part of a larger paper / research study or they can be the focus of the paper
• Lit reviews focus on research studies to provide evidence
• New topics may not have much that has been published

* The sections included may depend on the purpose of the literature review (standalone paper or section within a research paper)

Standalone Literature Review (aka Narrative Review):

• presents your topic or PICO question
• includes the why of the literature review and your goals for the review.
• provides background for your the topic and previews the key points
• Narrative Reviews: tmay not have an explanation of methods.
• include where the search was conducted (which databases) what subject terms or keywords were used, and any limits or filters that were applied and why - this will help others re-create the search
• describe how studies were analyzed for inclusion or exclusion
• review the purpose and answer the research question
• thematically - using recurring themes in the literature
• chronologically - present the development of the topic over time
• methodological - compare and contrast findings based on various methodologies used to research the topic (e.g. qualitative vs quantitative, etc.)
• theoretical - organized content based on various theories
• provide an overview of the main points of each source then synthesize the findings into a coherent summary of the whole
• present common themes among the studies
• compare and contrast the various study results
• interpret the results and address the implications of the findings
• do the results support the original hypothesis or conflict with it
• provide your own analysis and interpretation (eg. discuss the significance of findings; evaluate the strengths and weaknesses of the studies, noting any problems)
• discuss common and unusual patterns and offer explanations
•  stay away from opinions, personal biases and unsupported recommendations
• summarize the key findings and relate them back to your PICO/research question
• note gaps in the research and suggest areas for further research
• this section should not contain "new" information that had not been previously discussed in one of the sections above
• provide a list of all the studies and other sources used in proper APA 7

Literature Review as Part of a Research Study Manuscript:

• Compares the study with other research and includes how a study fills a gap in the research.
• Focus on the body of the review which includes the synthesized Findings and Discussion

Literature Reviews vs Systematic Reviews

Systematic Reviews are NOT the same as a Literature Review:

Literature Reviews:

• Literature reviews may or may not follow strict systematic methods to find, select, and analyze articles, but rather they selectively and broadly review the literature on a topic
• Research included in a Literature Review can be "cherry-picked" and therefore, can be very subjective

Systematic Reviews:

• Systemic reviews are designed to provide a comprehensive summary of the evidence for a focused research question
• rigorous and strictly structured, using standardized reporting guidelines (e.g. PRISMA, see link below)
• uses exhaustive, systematic searches of all relevant databases
• best practice dictates search strategies are peer reviewed
• uses predetermined study inclusion and exclusion criteria in order to minimize bias
• aims to capture and synthesize all literature (including unpublished research - grey literature) that meet the predefined criteria on a focused topic resulting in high quality evidence

Literature Review Examples

• Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge (2017). Women and Birth : Journal of the Australian College of Midwives
• Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review (2017). Journal of Racial and Ethnic Health Disparities

• Vitamin D deficiency in individuals with a spinal cord injury: A literature review (2017). Spinal Cord

Resources for Writing a Literature Review

These sources have been used in developing this guide.

Resources Used on This Page

Aveyard, H. (2010). Doing a literature review in health and social care : A practical guide . McGraw-Hill Education.

Purdue Online Writing Lab. (n.d.). Writing a literature review . Purdue University. https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html

Torres, E. (2021, October 21). Nursing - graduate studies research guide: Literature review. Hawai'i Pacific University Libraries. Retrieved January 27, 2022, from https://hpu.libguides.com/c.php?g=543891&p=3727230

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What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

• The different types of literature reviews, including systematic reviews and other evidence synthesis methods
• Tools & Tutorials

Literature Review & Systematic Review Steps

• Develop a Focused Question
• Scope the Literature  (Initial Search)
• Refine & Expand the Search
• Limit the Results
• Download Citations
• Abstract & Analyze
• Create Flow Diagram
• Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

• PICO Question Help
• Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

• Background sources (books, point-of-care tools)
• Article databases
• Trial registries
• Grey literature
• Cited references
• Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

• Combine separate concepts with AND  (resulting in a narrower search)
• Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

• Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
• Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

• database thesauri
• reference lists
• relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

• a personal database account (e.g., MyNCBI for PubMed)
• Log in with your NYU credentials
• Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

• Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
• Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

• Filters in PubMed
• CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

• Citation Managers - General Guide

6. Abstract and Analyze

• Migrate citations to data collection/extraction tool
• Screen Title/Abstracts for inclusion/exclusion
• Screen and appraise full text for relevance, methods, 
• Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

• Covidence Support
• Critical Appraisal Tools
• Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

• PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
• PRISMA Diagram Templates  (Word and PDF)
• Make a copy of the file to fill out the template
• Image can be downloaded as PDF, PNG, JPG, or SVG
• Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

• Reporting Guidelines for Systematic Reviews
• Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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• Next: What are Literature Reviews? >>
• Last Updated: May 22, 2024 1:35 PM
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What is a Literature Review?

Key questions for a literature review, examples of literature reviews, useful links, evidence matrix for literature reviews.

• Annotated Bibliographies

The Scholarly Conversation

A literature review provides an overview of previous research on a topic that critically evaluates, classifies, and compares what has already been published on a particular topic. It allows the author to synthesize and place into context the research and scholarly literature relevant to the topic. It helps map the different approaches to a given question and reveals patterns. It forms the foundation for the author’s subsequent research and justifies the significance of the new investigation.

A literature review can be a short introductory section of a research article or a report or policy paper that focuses on recent research. Or, in the case of dissertations, theses, and review articles, it can be an extensive review of all relevant research.

• The format is usually a bibliographic essay; sources are briefly cited within the body of the essay, with full bibliographic citations at the end.
• The introduction should define the topic and set the context for the literature review. It will include the author's perspective or point of view on the topic, how they have defined the scope of the topic (including what's not included), and how the review will be organized. It can point out overall trends, conflicts in methodology or conclusions, and gaps in the research.
• In the body of the review, the author should organize the research into major topics and subtopics. These groupings may be by subject, (e.g., globalization of clothing manufacturing), type of research (e.g., case studies), methodology (e.g., qualitative), genre, chronology, or other common characteristics. Within these groups, the author can then discuss the merits of each article and analyze and compare the importance of each article to similar ones.
• The conclusion will summarize the main findings, make clear how this review of the literature supports (or not) the research to follow, and may point the direction for further research.
• The list of references will include full citations for all of the items mentioned in the literature review.

A literature review should try to answer questions such as

• Who are the key researchers on this topic?
• What has been the focus of the research efforts so far and what is the current status?
• How have certain studies built on prior studies? Where are the connections? Are there new interpretations of the research?
• Have there been any controversies or debate about the research? Is there consensus? Are there any contradictions?
• Which areas have been identified as needing further research? Have any pathways been suggested?
• How will your topic uniquely contribute to this body of knowledge?
• Which methodologies have researchers used and which appear to be the most productive?
• What sources of information or data were identified that might be useful to you?
• How does your particular topic fit into the larger context of what has already been done?
• How has the research that has already been done help frame your current investigation ?

Example of a literature review at the beginning of an article: Forbes, C. C., Blanchard, C. M., Mummery, W. K., & Courneya, K. S. (2015, March). Prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors . Oncology Nursing Forum, 42(2), 118+. Retrieved from http://go.galegroup.com.sonoma.idm.oclc.org/ps/i.do?p=HRCA&sw=w&u=sonomacsu&v=2.1&it=r&id=GALE%7CA422059606&asid=27e45873fddc413ac1bebbc129f7649c Example of a comprehensive review of the literature: Wilson, J. L. (2016). An exploration of bullying behaviours in nursing: a review of the literature.   British Journal Of Nursing ,  25 (6), 303-306. For additional examples, see:

Galvan, J., Galvan, M., & ProQuest. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (Seventh ed.). [Electronic book]

Pan, M., & Lopez, M. (2008). Preparing literature reviews: Qualitative and quantitative approaches (3rd ed.). Glendale, CA: Pyrczak Pub. [ Q180.55.E9 P36 2008]

• Write a Literature Review (UCSC)
• Literature Reviews (Purdue)
• Literature Reviews: overview (UNC)
• Review of Literature (UW-Madison)

The  Evidence Matrix  can help you  organize your research  before writing your lit review.  Use it to  identify patterns  and commonalities in the articles you have found--similar methodologies ?  common  theoretical frameworks ? It helps you make sure that all your major concepts covered. It also helps you see how your research fits into the context  of the overall topic.

• Evidence Matrix Special thanks to Dr. Cindy Stearns, SSU Sociology Dept, for permission to use this Matrix as an example.
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• Next: Annotated Bibliographies >>
• Last Updated: Jan 8, 2024 2:58 PM
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• Critical Reviews

How to Write an Article Review (With Examples)

Last Updated: April 24, 2024 Fact Checked

Preparing to Write Your Review

Writing the article review, sample article reviews, expert q&a.

This article was co-authored by Jake Adams . Jake Adams is an academic tutor and the owner of Simplifi EDU, a Santa Monica, California based online tutoring business offering learning resources and online tutors for academic subjects K-College, SAT & ACT prep, and college admissions applications. With over 14 years of professional tutoring experience, Jake is dedicated to providing his clients the very best online tutoring experience and access to a network of excellent undergraduate and graduate-level tutors from top colleges all over the nation. Jake holds a BS in International Business and Marketing from Pepperdine University. There are 12 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 3,106,033 times.

An article review is both a summary and an evaluation of another writer's article. Teachers often assign article reviews to introduce students to the work of experts in the field. Experts also are often asked to review the work of other professionals. Understanding the main points and arguments of the article is essential for an accurate summation. Logical evaluation of the article's main theme, supporting arguments, and implications for further research is an important element of a review . Here are a few guidelines for writing an article review.

Education specialist Alexander Peterman recommends: "In the case of a review, your objective should be to reflect on the effectiveness of what has already been written, rather than writing to inform your audience about a subject."

Article Review 101

• Read the article very closely, and then take time to reflect on your evaluation. Consider whether the article effectively achieves what it set out to.
• Write out a full article review by completing your intro, summary, evaluation, and conclusion. Don't forget to add a title, too!
• Proofread your review for mistakes (like grammar and usage), while also cutting down on needless information.

• Article reviews present more than just an opinion. You will engage with the text to create a response to the scholarly writer's ideas. You will respond to and use ideas, theories, and research from your studies. Your critique of the article will be based on proof and your own thoughtful reasoning.
• An article review only responds to the author's research. It typically does not provide any new research. However, if you are correcting misleading or otherwise incorrect points, some new data may be presented.
• An article review both summarizes and evaluates the article.

• Summarize the article. Focus on the important points, claims, and information.
• Discuss the positive aspects of the article. Think about what the author does well, good points she makes, and insightful observations.
• Identify contradictions, gaps, and inconsistencies in the text. Determine if there is enough data or research included to support the author's claims. Find any unanswered questions left in the article.

• Make note of words or issues you don't understand and questions you have.
• Look up terms or concepts you are unfamiliar with, so you can fully understand the article. Read about concepts in-depth to make sure you understand their full context.

• Pay careful attention to the meaning of the article. Make sure you fully understand the article. The only way to write a good article review is to understand the article.

• With either method, make an outline of the main points made in the article and the supporting research or arguments. It is strictly a restatement of the main points of the article and does not include your opinions.
• After putting the article in your own words, decide which parts of the article you want to discuss in your review. You can focus on the theoretical approach, the content, the presentation or interpretation of evidence, or the style. You will always discuss the main issues of the article, but you can sometimes also focus on certain aspects. This comes in handy if you want to focus the review towards the content of a course.
• Review the summary outline to eliminate unnecessary items. Erase or cross out the less important arguments or supplemental information. Your revised summary can serve as the basis for the summary you provide at the beginning of your review.

• What does the article set out to do?
• What is the theoretical framework or assumptions?
• Are the central concepts clearly defined?
• How adequate is the evidence?
• How does the article fit into the literature and field?
• Does it advance the knowledge of the subject?
• How clear is the author's writing? Don't: include superficial opinions or your personal reaction. Do: pay attention to your biases, so you can overcome them.

• For example, in MLA , a citation may look like: Duvall, John N. "The (Super)Marketplace of Images: Television as Unmediated Mediation in DeLillo's White Noise ." Arizona Quarterly 50.3 (1994): 127-53. Print. [9] X Trustworthy Source Purdue Online Writing Lab Trusted resource for writing and citation guidelines Go to source

• For example: The article, "Condom use will increase the spread of AIDS," was written by Anthony Zimmerman, a Catholic priest.

• Your introduction should only be 10-25% of your review.
• End the introduction with your thesis. Your thesis should address the above issues. For example: Although the author has some good points, his article is biased and contains some misinterpretation of data from others’ analysis of the effectiveness of the condom.

• Use direct quotes from the author sparingly.
• Review the summary you have written. Read over your summary many times to ensure that your words are an accurate description of the author's article.

• Support your critique with evidence from the article or other texts.
• The summary portion is very important for your critique. You must make the author's argument clear in the summary section for your evaluation to make sense.
• Remember, this is not where you say if you liked the article or not. You are assessing the significance and relevance of the article.
• Use a topic sentence and supportive arguments for each opinion. For example, you might address a particular strength in the first sentence of the opinion section, followed by several sentences elaborating on the significance of the point.

• This should only be about 10% of your overall essay.
• For example: This critical review has evaluated the article "Condom use will increase the spread of AIDS" by Anthony Zimmerman. The arguments in the article show the presence of bias, prejudice, argumentative writing without supporting details, and misinformation. These points weaken the author’s arguments and reduce his credibility.

• Make sure you have identified and discussed the 3-4 key issues in the article.

You Might Also Like

• ↑ https://libguides.cmich.edu/writinghelp/articlereview
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548566/
• ↑ Jake Adams. Academic Tutor & Test Prep Specialist. Expert Interview. 24 July 2020.
• ↑ https://guides.library.queensu.ca/introduction-research/writing/critical
• ↑ https://www.iup.edu/writingcenter/writing-resources/organization-and-structure/creating-an-outline.html
• ↑ https://writing.umn.edu/sws/assets/pdf/quicktips/titles.pdf
• ↑ https://owl.purdue.edu/owl/research_and_citation/mla_style/mla_formatting_and_style_guide/mla_works_cited_periodicals.html
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548565/
• ↑ https://writingcenter.uconn.edu/wp-content/uploads/sites/593/2014/06/How_to_Summarize_a_Research_Article1.pdf
• ↑ https://www.uis.edu/learning-hub/writing-resources/handouts/learning-hub/how-to-review-a-journal-article
• ↑ https://writingcenter.unc.edu/tips-and-tools/editing-and-proofreading/

About This Article

If you have to write an article review, read through the original article closely, taking notes and highlighting important sections as you read. Next, rewrite the article in your own words, either in a long paragraph or as an outline. Open your article review by citing the article, then write an introduction which states the article’s thesis. Next, summarize the article, followed by your opinion about whether the article was clear, thorough, and useful. Finish with a paragraph that summarizes the main points of the article and your opinions. To learn more about what to include in your personal critique of the article, keep reading the article! Did this summary help you? Yes No

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This article has a correction. Please see:

• Correction: How to appraise quantitative research - April 01, 2019

• Xabi Cathala 1 ,
• Calvin Moorley 2
• 1 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• 2 Nursing Research and Diversity in Care , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Mr Xabi Cathala, Institute of Vocational Learning, School of Health and Social Care, London South Bank University London UK ; cathalax{at}lsbu.ac.uk and Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/eb-2018-102996

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Introduction

Some nurses feel that they lack the necessary skills to read a research paper and to then decide if they should implement the findings into their practice. This is particularly the case when considering the results of quantitative research, which often contains the results of statistical testing. However, nurses have a professional responsibility to critique research to improve their practice, care and patient safety. 1  This article provides a step by step guide on how to critically appraise a quantitative paper.

Title, keywords and the authors

The authors’ names may not mean much, but knowing the following will be helpful:

Their position, for example, academic, researcher or healthcare practitioner.

Their qualification, both professional, for example, a nurse or physiotherapist and academic (eg, degree, masters, doctorate).

This can indicate how the research has been conducted and the authors’ competence on the subject. Basically, do you want to read a paper on quantum physics written by a plumber?

The abstract is a resume of the article and should contain:

Introduction.

Research question/hypothesis.

Methods including sample design, tests used and the statistical analysis (of course! Remember we love numbers).

Main findings.

Conclusion.

The subheadings in the abstract will vary depending on the journal. An abstract should not usually be more than 300 words but this varies depending on specific journal requirements. If the above information is contained in the abstract, it can give you an idea about whether the study is relevant to your area of practice. However, before deciding if the results of a research paper are relevant to your practice, it is important to review the overall quality of the article. This can only be done by reading and critically appraising the entire article.

The introduction

Example: the effect of paracetamol on levels of pain.

My hypothesis is that A has an effect on B, for example, paracetamol has an effect on levels of pain.

My null hypothesis is that A has no effect on B, for example, paracetamol has no effect on pain.

My study will test the null hypothesis and if the null hypothesis is validated then the hypothesis is false (A has no effect on B). This means paracetamol has no effect on the level of pain. If the null hypothesis is rejected then the hypothesis is true (A has an effect on B). This means that paracetamol has an effect on the level of pain.

Background/literature review

The literature review should include reference to recent and relevant research in the area. It should summarise what is already known about the topic and why the research study is needed and state what the study will contribute to new knowledge. 5 The literature review should be up to date, usually 5–8 years, but it will depend on the topic and sometimes it is acceptable to include older (seminal) studies.

Methodology

In quantitative studies, the data analysis varies between studies depending on the type of design used. For example, descriptive, correlative or experimental studies all vary. A descriptive study will describe the pattern of a topic related to one or more variable. 6 A correlational study examines the link (correlation) between two variables 7  and focuses on how a variable will react to a change of another variable. In experimental studies, the researchers manipulate variables looking at outcomes 8  and the sample is commonly assigned into different groups (known as randomisation) to determine the effect (causal) of a condition (independent variable) on a certain outcome. This is a common method used in clinical trials.

There should be sufficient detail provided in the methods section for you to replicate the study (should you want to). To enable you to do this, the following sections are normally included:

Overview and rationale for the methodology.

Participants or sample.

Data collection tools.

Methods of data analysis.

Ethical issues.

Data collection should be clearly explained and the article should discuss how this process was undertaken. Data collection should be systematic, objective, precise, repeatable, valid and reliable. Any tool (eg, a questionnaire) used for data collection should have been piloted (or pretested and/or adjusted) to ensure the quality, validity and reliability of the tool. 9 The participants (the sample) and any randomisation technique used should be identified. The sample size is central in quantitative research, as the findings should be able to be generalised for the wider population. 10 The data analysis can be done manually or more complex analyses performed using computer software sometimes with advice of a statistician. From this analysis, results like mode, mean, median, p value, CI and so on are always presented in a numerical format.

The author(s) should present the results clearly. These may be presented in graphs, charts or tables alongside some text. You should perform your own critique of the data analysis process; just because a paper has been published, it does not mean it is perfect. Your findings may be different from the author’s. Through critical analysis the reader may find an error in the study process that authors have not seen or highlighted. These errors can change the study result or change a study you thought was strong to weak. To help you critique a quantitative research paper, some guidance on understanding statistical terminology is provided in  table 1 .

• View inline

Some basic guidance for understanding statistics

Quantitative studies examine the relationship between variables, and the p value illustrates this objectively.  11  If the p value is less than 0.05, the null hypothesis is rejected and the hypothesis is accepted and the study will say there is a significant difference. If the p value is more than 0.05, the null hypothesis is accepted then the hypothesis is rejected. The study will say there is no significant difference. As a general rule, a p value of less than 0.05 means, the hypothesis is accepted and if it is more than 0.05 the hypothesis is rejected.

The CI is a number between 0 and 1 or is written as a per cent, demonstrating the level of confidence the reader can have in the result. 12  The CI is calculated by subtracting the p value to 1 (1–p). If there is a p value of 0.05, the CI will be 1–0.05=0.95=95%. A CI over 95% means, we can be confident the result is statistically significant. A CI below 95% means, the result is not statistically significant. The p values and CI highlight the confidence and robustness of a result.

Discussion, recommendations and conclusion

The final section of the paper is where the authors discuss their results and link them to other literature in the area (some of which may have been included in the literature review at the start of the paper). This reminds the reader of what is already known, what the study has found and what new information it adds. The discussion should demonstrate how the authors interpreted their results and how they contribute to new knowledge in the area. Implications for practice and future research should also be highlighted in this section of the paper.

A few other areas you may find helpful are:

Limitations of the study.

Conflicts of interest.

Table 2 provides a useful tool to help you apply the learning in this paper to the critiquing of quantitative research papers.

Quantitative paper appraisal checklist

• 1. ↵ Nursing and Midwifery Council , 2015 . The code: standard of conduct, performance and ethics for nurses and midwives https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21.8.18 ).
• Gerrish K ,
• Moorley C ,
• Tunariu A , et al
• Shorten A ,

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Commissioned; internally peer reviewed.

Correction notice This article has been updated since its original publication to update p values from 0.5 to 0.05 throughout.

Linked Articles

• Miscellaneous Correction: How to appraise quantitative research BMJ Publishing Group Ltd and RCN Publishing Company Ltd Evidence-Based Nursing 2019; 22 62-62 Published Online First: 31 Jan 2019. doi: 10.1136/eb-2018-102996corr1

Read the full text or download the PDF:

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

204 Accesses

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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General election latest: Andrea Leadsom joins Michael Gove as latest Tory MP to announce departure at general election

The number of Tory MPs standing down continues to rise, as Rishi Sunak and Sir Keir Starmer hit the general election campaign trail once more.

Saturday 25 May 2024 06:00, UK

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General election called for 4 July

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By Tim Baker , political reporter

Housing Secretary Michael Gove and former business secretary Andrea Leadsom have said they will not stand at the general election.

Mr Gove announced after nearly 20 years as the Conservative Party MP for Surrey Heath, and serving in multiple cabinets over the course of the last 14 years, "a new generation should lead".

In a letter to his constituency chairman, the veteran cabinet minister said being an MP and minister has been a "profound privilege".

Just hours later on Friday evening, Ms Leadsom, who unsuccessfully stood to lead the Conservative Party against Theresa May in the wake of the Brexit referendum, said she would also be standing down.

In her resignation letter, Ms Leadsom said it has been "the greatest honour to serve the people of South Northamptonshire as their MP for the last 14 years".

Ms Leadsom, who is currently a junior health minister, was business secretary under Mrs May.

Read more here:

On the final day the House of Commons sat before the election, the view from the back of the chamber said it all.

As Theresa May - in her familiar flame red suit - left the chamber after a speech by Ben Wallace, the Tory benches were packed, Labour's almost deserted.

MPs were taking part in a "Valedictory Debate", an unprecedented and hastily convened piece of parliamentary business for departing MPs to say their farewells.

And while the debate was going on, an historic milestone was reached: the number of Conservatives standing down exceeded the number in 1997 after 18 years of Tory rule.

With an announcement by the 74-year-old Bexleyheath and Crayford MP Sir David Evennett, the total number of MPs retiring or quitting had reached 76 - one more than the 75 in 1997.

And by the time parliament prorogued at 8.25pm, the number had reached 78, after two shock announcements, first from Michael Gove and then former cabinet minister Andrea Leadsom.

In a moment of pure parliamentary theatre, the news of Mr Gove's departure was broken to stunned MPs in the Commons by Matt Hancock, who'd earlier made an emotional farewell speech.

Then while the prorogation ceremony was taking place came the bombshell announcement from Dame Andrea, now a junior health minister, that she's quitting too. And with a barb at Rishi Sunak too!

Read Jon's full analysis here:

Rishi Sunak has called a general election for this summer.

The prime minister has been saying for months he would call a vote for the "second half of the year", and he has now confirmed it will be on 4 July.

Parliament will be prorogued later  today  - which means that will mark the formal end of this session of parliament.

On  Thursday, 30 May , parliament will formally be dissolved.

This means that members of parliament cease to be members of parliament, and become candidates in the election - or not, if they are standing down.

The campaign will then take place ahead of polling day on  Thursday, 4 July , when polls will close at 10pm.

Following the vote, the new elected MPs will travel to London to meet in parliament for the first time on  Tuesday, 9 July .

The Speaker of the House of Commons will be elected and MPs will be sworn in.

The formal state opening of parliament and a King's Speech will take place on  Wednesday, 17 July .

Our political reporter Alix Culbertson explains more below...

In January 2023, Rishi Sunak made five promises.

Since then, he and his ministers have rarely missed an opportunity to list them. In case you haven't heard, he promised to:

• Halve inflation
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• Cut NHS waiting lists and times
• Stop the boats

See below how he is doing on these goals:

By  Alexandra Rogers , political reporter

Labour's shadow education secretary has been criticised for refusing to rule out an increase in university tuition fees if the party wins the general election.

The National Union of Students (NUS), which represents university and college students across the UK, said a potential rise in tuition fees would "hamper their future" and that loan debt was already "unsustainable".

Bridget Phillipson said during a BBC Question Time debate on Thursday evening that UK universities were facing "enormous challenges" and the question of how they would be funded did not have any "straightforward" answers.

She said the decade-long freeze on tuition fees, which has set them at about £9,000 per year, meant universities across the country were "increasingly struggling to cover the cost of tuition".

But pressed by fellow panellists whether she would rule it out, the shadow education secretary did not answer.

By Professor Michael Thrasher, Sky News election analyst

The electoral geography of the UK is changing.

Following the recommendations of independent Boundary Commissions for England, Scotland, Wales and Northern Ireland, the next UK general election - which Sky News understands will be on 4 July - will be fought on new constituency boundaries, replacing those in operation since 2010.

This is the sixth periodic review to be implemented since the war. The next review is not scheduled until October 2031.

Exploring how this movement of voters affects the political makeup of the House of Commons is a task that Colin Rallings and myself have been doing over the past thirty years following previous boundary adjustments.

There are winners and losers in different parts of the UK - read the full analysis here:

With the general election campaign officially under way, what better time to keep a close eye on the latest polling?

The Sky News live poll tracker - collated and updated by our Data and Forensics team - aggregates various surveys to indicate how voters feel about the different political parties.

See the latest update below - and you can read more about the methodology behind the tracker  here .

We've got three key dates for your diary from the Electoral Commission should you need to register to vote in the general election.

18 June: This is the deadline to register, which you can do online at gov.uk/register-to-vote .

19 June: This is the deadline to apply for a postal vote, should you not be around when polling stations open on 4 July.

26 June: This is the deadline to apply for a proxy vote, which allows someone to vote on your behalf, and also to apply for a Voter ID certificate should you not have another valid form of identification.

This is the first general election where ID is needed to vote - find out more about registration here:

The latest edition of Electoral Dysfunction  is in your podcast feeds now, and one of the main topics was the optics of Rishi Sunak's announcement of the general election date.

In case you missed it, he went out on to Downing Street in the pouring rain, and throughout his speech, the song Things Can Only Get Better by D:Ream was blaring out - which was the official anthem of Sir Tony Blair's landslide victory for Labour in 1997 ( more here ).

Our political editor Beth Rigby  explained that Mr Sunak did the announcement on the street because he "wanted to be traditional".

But former Scottish Tory leader Ruth Davidson  branded the launch "disastrous", saying: "The idea of tradition and all the rest of it, well, that's great and all.

"But you're the prime minister - you make the traditions here.

"How f****** incompetent do you have to be to launch a campaign that badly?

"And how much do you not protect your boss by allowing him to do it or encouraging him to do it?"

She added: "Wait for a break in the clouds, okay? Look, how hard is that?"

Jess Phillips , Labour MP for Birmingham Yardley said he wanted to avoid advertising that he is a centi-millionaire by having "a lackey holding an umbrella".

She added that he "wouldn't have lost a single vote" if someone had been holding an umbrella, or he'd delivered the speech inside.

"He will lose votes because of the way he launched it," she said.

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Sir Keir Starmer's tour of key battlegrounds kicked off in Scotland on Friday. His message was singular: change. And his target was singular, too: take out the SNP.

In four elections on the bounce, Labour has been nearly wiped out in Scotland by the SNP. In 2019, the party returned one MP to Westminster from Scotland. It now has two. The task in this election campaign is to turn that into dozens.

"This is an election about change, and Scotland's voice is vital. It needs to be a leading voice," he said in a slick campaign event with hundreds of people holding up "change" placards and cheering Sir Keir and Scottish Labour leader Anas Sarwar on.

"Send a message, send a message: that is the height of the SNP's ambition, to send a message of protest to Westminster. I don't want Scotland to send a message. I want Scotland to send a government. A Labour government."

Ask Labour strategists, and they say Scotland is vital to get Labour over the line to a majority because of how far behind Labour were in England back in 2019. They are operating a twin attack on two failing governments - the SNP one in Holyrood and the Conservative government in Westminster - to implore voters to switch back from the SNP to kick the Tories out.

Starmer told me in Glasgow that winning in Scotland was important numerically but also to him personally, because he wants to be a prime minister, should Labour win, that governs for the whole of the UK.

Read Beth's full analysis here...

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A quantitative systematic review of the association between nurse skill mix and nursing‐sensitive patient outcomes in the acute care setting

急症护理情况下护士技巧组合与护理敏感类患者结果之间联系的定量系统综述, diane e. twigg.

1 School of Nursing and Midwifery, Edith Cowan University, Joondalup Western Australia, Australia

2 Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands Western Australia, Australia

Yvonne Kutzer

Elisabeth jacob, karla seaman, associated data.

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

A quantitative systematic review included studies published in English between January 2000 – September 2018.

Data sources

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix‐methods designs were included if the quantitative component met the criteria.

Review methods

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy‐five percent or more of studies with significant results found this association.

Sixty‐three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure‐to‐rescue; pneumonia; sepsis; urinary tract infection; mortality/30‐day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

目的

在于探讨护士技巧组合(注册护士提供的总时数比例)与急性护理医院患者结果之间的联系。

设计

一项定量系统综述包括2000年1月至2018年9月期间以英语发表的各项研究。

资料来源

搜索了Cochrane Library、CINAHL Plus with Full Text、MEDLINE、Scopus、Web of Science和Joanna Briggs Institute。纳入了观察性和实验性研究设计。如果定量成分符合标准,则纳入混合方法设计。

综述方法

使用了Joanna Briggs Institute的系统综述指南及其关键评估工具。当75%或者更多具备显著结果的研究发现这种联系时,就确定了反向关联。

结果

共纳入了63篇文章。12名患者的结果与护理技巧组合呈负相关(即,较高的护理技能组合与患者结果的改善显著相关)。这些是住院天数;溃疡、胃炎和上消化道出血;急性心肌梗死;约束使用;救援失败;肺炎;败血症;尿路感染;死亡率/30天死亡率;压力性损伤;感染和休克/心脏骤停/心力衰竭。

结论

护理技巧组合影响了12例患者的结果。然而,需要使用实验性或纵向研究设计来进一步调查,从而建立因果关系。需要就技巧组合的定义达成共识,以便能够更有力地评估技巧组合变化对患者结果的影响。

影响

在降低死亡率和救援失败等不良患者结果方面,技巧组合可能比护士人数更为重要,尽管最佳的人员配置在人力资源规划中仍然让人难懂。

1. INTRODUCTION

In their report in the year 2000, the World Health Organization highlighted both the importance and the challenges associated with finding the right mixture of healthcare personnel to achieve the best possible outcomes with the staffing resources available (World Health Organization, 2000 ). In this regard, consideration of the nursing workforce is critical. Skill mix, defined as ‘the proportion of total nurse hours provided by Registered Nurses’ (Twigg, Duffield, Bremner, Rapley, & Finn, 2012 ) (page 2,711), is an important element and involves assessing the mix of nursing staff, both registered and unregistered on a ward and varies in configuration dependent on the country where it is discussed. The nurse mix may include Registered Nurses (RNs), Enrolled Nurses, licensed practical nurses (LPNs), certified nursing assistants (CNAs), assistants in nursing (AINs), healthcare assistants, or other classifications (Jacob, McKenna, & D'Amore, 2015 ).

Various studies have since focussed on the importance of nurse staffing levels in an attempt to define an optimal configuration (Aiken, Clarke, & Sloane, 2002 ; Kim & Bae, 2018 ; Leary et al., 2016 ). Whilst research has explored staffing levels and their impact on patient outcomes, it does not always address nursing skill mix. A systematic review and meta‐analysis published in 2007 for example (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007 ), which analysed nurse staffing levels, focussed on the ratio of Registered Nurses (RNs) to patients and patient outcomes, but not on nurse skill mix.

Despite these efforts, clear evidence‐based guidelines on staffing levels are lacking, particularly in regard to skill mix (Brennan, Daly, & Jones, 2013 ; Sharma, Hastings, Suter, & Bloom, 2016 ). A recent systematic review (Myers, Pugh, & Twigg, 2018 ) that examined the importance of nurse skill mix on patient outcomes focussed specifically on stand‐alone high acuity areas, meaning that findings from this review may not be easily transferrable to other care settings. The only other systematic review on skill mix and patient outcomes (Lankshear, Sheldon, & Maynard, 2005 ) examined articles published up to 2004 and highlighted the relationship between nurse staffing factors (Registered Nurse staffing levels and proportion of RNs in the skill mix) and patient outcomes. Their outcomes included mortality rates, complication rates (pneumonia, urinary tract infections, nosocomial infections, wound infections), failure‐to‐rescue, incidence of adverse events (falls, medication errors), length of stay, or patient satisfaction.

Of additional concern, continuing economic constraints and impending nursing shortages worldwide have led to the increased deployment of less qualified and unregulated health professionals, leading to changes in skill mix in the configuration of the nursing teams (Jacob et al., 2015 ; Roche, Duffield, Friedman, Dimitrelis, & Rowbotham, 2016 ). This is despite at least one study finding increases in unregulated workers has been associated with poorer patient outcomes (Twigg et al., 2016 ). With limited synthesis of the evidence to inform such staffing decisions, there is little guidance for policy makers and managers making those decisions.

The present review aims to expand on previous research by examining more recent studies up to 2018 exploring the impact of nurse skill mix on patient outcomes. The outcome of the review may help inform staffing policy in regard to skill mix changes.

1.1. Background

The conceptual framework developed by McCloskey and Diers ( 2005 ) was used to guide this review and the selection of variables. McCloskey and Diers ( 2005 ) examined the effects of health policy on nursing and patient outcomes sing the work of Aiken et al. ( 2002 ). McCloskey and Diers ( 2005 ) modified Aiken's framework to embed the seminal work of Donabedian's structure‐process‐outcomes framework (Donabedian, 1966 ). Structure was identified as nursing workforce characteristics such as nurse‐to‐patient ratios and skill mix. Process was identified as the processes of care. Outcome was identified as nurse and patient outcomes. This framework has been used to guide further studies including an examination of skill mix (Twigg, Duffield, Bremner, Rapley, & Finn, 2011 ; Twigg et al., 2012 ; Twigg, Gelder, & Myers, 2015 ). In this review, the proportion of total nurse hours provided by Registered Nurses was the structural variable and patient outcomes the outcome variable under review. It was hypothesized that changes in skill mix, for example, fewer Registered Nurse hours, affect the processes of care (such as recognition and response to patient changes) which in turn may impact on patient outcomes.

2. THE REVIEW

The aim of the review was to synthesize the available quantitative evidence on the association of nursing skill mix and patient outcomes sensitive to nursing care in adult patients in acute care hospitals. As such, the review question was: What effect does skill mix have on nurse sensitive patient outcomes?

2.2. Design

The review used a quantitative systematic literature review. Methods of the analysis and inclusion and exclusion criteria were identified in advance and documented in a research protocol. The PICOS framework (Population; Intervention; Comparator; Outcome; Study design) (Schardt, Adams, Owens, Keitz, & Fontelo, 2007 ) was used to refine the inclusion and exclusion criteria and processes and outcomes were guided by the Joanna Brigg Institute for Systematic Reviews. Table ​ Table1 1 outlines the PICOS framework.

PICOS framework

Relevant patient outcomes were identified by reviewing existing literature on the topic (Aiken et al., 2014 ; Duffield et al., 2011 ; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002 ; Twigg et al., 2011 ). The review focussed on acute care hospitals and included studies set in general medical, surgical, combined medical/surgical and step‐down wards, telemetry units and emergency departments. Acute care settings were chosen as the purpose of this review was to expand on previous studies by specifically examining the importance of skill mix in optimal staffing and previous studies were primarily undertaken in acute care settings. Nurse‐reported patient outcomes were not included in the study as the outcome was not directly measured. Exclusion criteria were applied as listed in Table ​ Table1 1 .

2.3. Search methods

Prior to commencing the review, searches were run in Medline and CINAHL to identify whether similar systematic reviews had already been completed in the last 10 years. The PROSPERO register was also checked to determine whether similar reviews were already underway. One study was found to be similar and at the initial protocol development stage, the corresponding author was contacted to determine the progress of the review; however; there was no response provided nor was any output from the systematic review published. A copy of the protocol for this study is provided in the Data S1 (Skill Mix OnlineSUPP_A_SystReviewProtocol).

Studies were identified through searching electronic databases, hand searching the reference lists of relevant articles, author searches, and via examining grey literature databases. In addition, an EBSCOhost Alert Notification and a Web of Science Search Alert was set up to capture any new publications between September 2016 and June 2017. An updated search strategy was conducted in September 2018. A health information librarian was consulted during the development of the MeSH terms (nursing assistants; mortality; sepsis; urinary tract infection; pneumonia; clinical deterioration; quality of health care; patient safety; accidental falls; surgical wound infection; venous thrombosis; shock; heart arrest; medication errors; infection; central nervous system infections). The search strategy was applied to Medline and CINAHL Plus with Full Text and was adapted for Embase, the Cochrane Library, Scopus, Web of Science and the Joanna Briggs Institute Database. The search strategy for each database is outlined in the Data S2 (Skill Mix OnlineSUPP_B_ElectDatabaseSearchStrat.pdf). Grey literature catalogues used included Research Online, Open Grey/EThOS, OAIster, Google Advanced Search and PsycEXTRA.

Limiters included articles published between January 2000 – September 2018 and written in English.

2.4. Search outcome

The search strategy identified a total of 2,702 citations from electronic databases. A comprehensive search for grey literature and hand searches produced an additional 12 articles. After removing duplicates, 2,576 articles were retained and their titles and abstracts subsequently screened for inclusion. This process led to 2,481 citations being excluded and the full‐text of the 95 remaining publications was assessed for eligibility.

2.5. Quality appraisal

The critical appraisal of the selected 95 records was undertaken using the Joanna Briggs Institute (JBI) critical appraisal tools (Godfrey & Harrison, 2015 ). All studies were examined independently by two reviewers, and the results of the critical appraisal reviewed after both reviewers had completed their assessment and discrepancies resolved by consensus.

Thirty‐two articles were excluded following the full‐text assessment and are detailed further in Data S3 (Skill Mix OnlineSUPP_C1‐4_CritAppraisals.pdf). Of these, three studies were excluded as they were deemed to be of insufficient quality (no reported data, unequal comparison group, small sample size); six did not review any skill mix variables and a further five did not measure any nursing‐sensitive patient outcomes; two studies were conducted in a nursing home setting and therefore did not meet inclusion criteria; five studies were literature reviews, three articles could not be sourced and an additional eight articles were excluded for other reasons (not primary research articles, measured nurse perception, cost analysis). This left 63 articles, which were included in the narrative summary. A record of study assignment was kept, which contained the reviewing authors recommendations about inclusion or exclusion as well as some comments on why an article was retained or rejected. Figure ​ Figure1 1 outlines the study flow chart and the articles selected and excluded at each step of the review. The critical appraisal scores for each of the 95 appraised studies are outlined in Data S3 (Skill Mix OnlineSUPP_C1‐4_CritAppraisals.pdf).

Skill mix systematic review prisma flow diagram [Colour figure can be viewed at http://www.wileyonlinelibrary.com ]

2.6. Data abstraction

One author conducted the initial extraction of the data from the selected studies and a second author checked for accuracy. It was planned that disagreements would be resolved via discussion between the two authors; if no agreement was reached, a third author would be consulted. Information was extracted from the included studies about country, population, setting and sample size, aim, study design, number of participants, type of skill mix variable measured, patient outcomes and general findings. The included articles were treated as equal in this study and are summarized in Data S4 (Skill Mix OnlineSUPP_D_IncStudyCharact.pdf) and include estimates of precision for each outcome. An abbreviated summary is reported in Table ​ Table2 2 .

Included study characteristics (a summary)

Abbreviations: ACS, acute coronary syndrome; ADE, adverse drug event; AIN, Assistants in Nursing; b/w, between; CHF, congestive heart failure; CNS, Clinical Nurse Specialist; COPD, chronic obstructive pulmonary disease; ED, Emergency department; EN, Enrolled Nurse; FTE, full time equivalent; FTR, Failure to rescue; HAPU, Hospital acquired pressure ulcers; HCSW, Healthcare Support Workers; HPPD, hours per patient day; Hr, hours; ICU, Intensive care unit; LOS, Length of stay; LPN, Licensed practical nurse; LVN, licensed vocational nurse; LWBS, left without being seen; Mgt, management; MI, myocardial infraction; N , number; NA, Nursing assistant; NDNQI, National Database of Nursing Quality Indicators; Nsg, nursing; NSO, nurse sensitive outcomes; OR, odds ratio; PUFRQCI, PU and Fall Rate Quality Composite Index; Pt, patient; Pnem, pneumonia; Post op, Post‐operative; PU, pressure ulcer; RPN, registered practical nurse; RN, Registered Nurse; SM, skill mix; TEN, Trainee Enrolled Nurses; UAP, unlicensed assistive personnel; UAPU, Unit acquired pressure ulcer; UTI, urinary tract infection; VA, Veteran Affairs; %, Percent; ↑, Increase/higher; ↓, Decrease/lower; −ve, negative; +ve, positive.

2.7. Synthesis

The included studies showed great variation as to how nurse skill mix was measured and conceptualized. They also used a variety of different study designs, making it not feasible to perform a meta‐analysis. The data were thus summarized narratively, comparing results where appropriate.

3.1. Settings

Most studies were completed in general acute care settings, including general medical, general surgical, combined medical/surgical, step‐down, telemetry units, and emergency departments in public hospitals. One study was conducted in a non‐federal hospital and four in veteran affairs or military hospital settings. Two studies were conducted in a respiratory care centre and trauma centre, respectively. Thirty‐six studies were assessed at unit level, 23 at hospital‐level, and four at shift level. Most studies were conducted in North America—40 in the USA and five in Canada. Another five studies were conducted in Australia, three in Taiwan and South Korea, one in New Zealand, Italy, UK, Germany and Finland, and two studies were conducted in Europe involving multiple countries.

3.2. Study designs

The studies included in this review were mainly observational studies without a comparison group. Thirty‐eight studies fell into this category. Another 14 studies were cross‐sectional, seven used a cohort study design with a comparison group, one was a quasi‐experimental design, one was a randomized controlled trial, one was descriptive correlations, and one was a two‐phase measure development study. The study designs of the included papers were generally low. There was one randomized control trial and two pre‐test–posttest quasi‐experimental studies. The remaining studies were either an observational study, analytic design or an observational descriptive study.

3.3. Nursing skill mix variables

The included studies used a variety of methods to define and assess skill mix. The most frequently used variable to measure nurse skill mix was ‘ percentage of nursing hours provided by RNs ’. Nineteen studies used this measure, defining skill mix either as ‘RN hours provided per day’, ‘RN hours provided per patient day’, ‘RN hours provided per shift, ‘number of productive hours worked by RNs’, or ‘RN hours provided per inpatient earned hours’. The ‘ percentage of RNs on staff ’ was also a commonly used way to define skill mix (16 studies). Percentage of RNs on staff was defined as ‘RN full‐time equivalent (FTE)’, ‘percentage of total RN nursing full‐time positions’, ‘RNs on the unit’, ‘percentage of professional nurses’, ‘proportion of licensed nurses (RN & Licensed practicing nurses (LPN))’, ‘percentage of RN on staff with direct caring responsibilities’ and ‘ratio of FTE RNs to average daily census’. Additional skill mix variables used for analysis included ‘nursing skill mix excluding assistants in nursing (AINs) (compared with skill mix including AINs)’, ‘the number of licensed nurses (RNs & LPNs) per 1,000 patient days’, ‘proportion of all licensed nurses (RN or LPN)’, ‘percentage of nurses with a minimum of three years training’, ‘proportion of regulated workers’, ‘mandated nurse ratios’, ‘triage systems using nurses only (vs. Unlicensed assistive personnel (UAPs) only)’ and ‘skill mix on the day shift (compared with night shift)’.

3.4. Nursing‐sensitive patient outcomes

Twenty‐six outcomes sensitive to nursing care were identified in the reviewed studies. These indicators were: length of stay, gastric ulcer/gastritis/upper gastrointestinal bleeding, acute myocardial infarction, restraint use, failure‐to‐rescue, pneumonia, sepsis, urinary tract infections, mortality, pressure injury, infections (excluding urinary tract infections), shock/cardiac arrest/heart failure, falls and falls injury, deep vein thrombosis, central nervous system complications, pulmonary failure or pulmonary embolism, medication error, physiological/metabolic derangement, pain control, ventilator weaning, patient wait time/leaving without being seen, quality of care, 30‐day readmission, postoperative respiratory failure, unplanned endotracheal tube extubation, and hypoglycaemia.

Infections (including wound infections, central line‐associated bloodstream infections, respiratory tract infections and mediastinitis) were grouped together for the purpose of data synthesis, with the exception of urinary tract infections, which were examined separately as they can account for over 30% of healthcare‐associated infections (Gardner, Mitchell, Beckingham, & Fasugba, 2014 ). Mortality and 30‐day mortality were also grouped together as they were often assessed simultaneously. In addition, ‘care processes relating to acute myocardial infarction’ were grouped with ‘acute myocardial infarction’ and ‘heart failure’ and ‘heart failure measures associated with care’ with ‘shock & cardiac arrest’.

3.5. Identified associations

Due to the heterogeneity with regard to significance and directionality of findings, patient outcomes were considered sensitive to nurse skill mix if they fulfilled the following criteria: of those studies with significant findings, three quarters or more of the studies for each patient outcome found an inverse significant relationship, that is, higher skill mix was associated with fewer adverse patient outcomes (Table ​ (Table3). 3 ). Non‐significant findings were also reported.

Relationship between nursing skill mix and patient outcomes

Based on these guidelines, 12 outcomes met the criteria for a higher skill mix associated with a decrease in adverse outcomes. These outcomes were: length of stay, ulcer, gastritis and upper gastrointestinal bleeds, acute myocardial infarction, restraint use, failure‐to‐rescue, pneumonia, sepsis, urinary tract infection, mortality/30‐day mortality, pressure injury, infections (excluding urinary tract infections) and shock/cardiac arrest/heart failure.

Thirteen studies examined skill mix and length of stay, six of which did not report a statistically significant relationship. Of the seven reporting significant results, all found a higher proportion of skill mix was associated with lower length of stay. Six studies examined skill mix and gastritis & upper gastrointestinal bleeds of which one did not report significant results. Of the five significant results, all found an increase in skill mix resulted is a decrease in gastritis & upper gastrointestinal bleeds. Four studies examined skill mix and acute myocardial infarction, two with significant results both of which found an increase in skill mix was associated with a decrease in acute myocardial infarction. Two studies did not have any significant findings. Two studies examined restraint use and both were significant finding a decrease in restraint use with an increase in skill mix (see Table ​ Table3 3 ).

A further eight patient outcomes were found to have decreased adverse outcomes with a higher skill mix in three quarters or more of the studies with significant findings reviewed for each outcome. Twelve studies examined failure to rescue of which three did not report a statistically significant relationship. Of the nine significant findings, eight of these identified an inverse relationship between higher skill mix and fewer failure to rescue events. Thirteen studies examined pneumonia, six of which did not report a statistically significant relationship. Seven studies had significant findings about pneumonia, with six inversely related to skill mix. Twelve studies examined sepsis and six studies did not report a significant relationship between skill mix and sepsis. Six studies did report significant findings about sepsis and five were inversely related to skill mix. Eighteen studies examined urinary tract infections of which seven did not report significant results. Eleven did report significant findings about urinary tract infections and nine of these were inversely related to skill mix. Seventeen studies examined mortality and six did not report significant findings. Eleven studies had significant findings about mortality and nine of these were inversely related to skill mix. Twenty‐four studies examined pressure injuries, of which fourteen did not report significant findings. Of the 10 studies reporting significant findings, most ( N  = 8) reported that a higher skill mix was associated with fewer pressure injuries. Fifteen studies examined infections (excluding urinary tract infections) of which seven did not report significant findings. Of the eight studies with significant findings, six were inversely related to skill mix. Finally, eights studies examined shock/cardiac arrest/heart failure of which four did not report significant findings. Of the four significant findings, three of these were inversely related to skill mix (see Table ​ Table3). 3 ). However, one study examining heart failure (Newhouse et al., 2013 ) was undertaken using a RTC and found a non‐significant outcome for the effect of skill mix.

The remainder of the patient outcomes examined were inconclusive. Eighteen studies examined the relationship between skill mix and falls and falls injury, seven did not report a significant relationship. Of the eleven studies with significant results, six studies found an inverse relationship and five did not, providing mixed results. Deep vein thrombosis, central nervous system complications, pulmonary failure/pulmonary embolism, medication error, physiologic/metabolic derangement and pain control had fewer studies (2–7) per outcome and in each occasion only two studies were significant. Of these, again in each case, one of the two had an inverse relationship with skill mix, again providing mixed results (see Table ​ Table3). 3 ). In addition, five patient outcomes were excluded as although they technically satisfied the stated inclusion criteria, they were not considered suitable outcomes as only one study respectively investigated these outcomes. These were ventilator weaning, hypoglycaemia, patient wait time, quality of care, and 30‐day readmission (Table ​ (Table3). 3 ). One patient outcome, blood incompatibilities, was not included in the final synthesis, as the study in question did not find any occurrences of the outcome during their data collection (Frith et al., 2010 ).

Table ​ Table3 3 outlines the studies that found a significant relationship between nursing skill mix and those that did not, as well as the proportion of significant studies according to directionality, that is, whether a higher skill mix containing more RNs was associated with an increase or decrease in adverse patient outcomes.

4. DISCUSSION

4.1. summary of evidence.

Out of 26 patient outcomes reported in the 63 studies included in this review, 12 showed an inverse association with skill mix, when assessed using pre‐defined criteria. These outcomes were: length of stay, ulcer, gastritis and upper gastrointestinal bleeds, acute myocardial infarction, restraint use, failure‐to‐rescue, pneumonia, sepsis, urinary tract infection, mortality/30‐day mortality, pressure injury, infections (excluding urinary tract infections) and shock/cardiac arrest/heart failure. There was a reduction in these 12 patient outcomes when a higher nursing skill mix containing more Registered Nurses was present. These results are similar to relationships found in regard to a systematic review of nurse staffing hours (Kane et al., 2007 ) where mortality, hospital acquired pneumonia, unplanned extubation, cardiac arrest in ICUs, risk of failure to rescue in surgical patients and length of stay was shorter in ICUs and in surgical patients. Additionally, a systematic review of acute specialist units found higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, and pneumonia (Driscoll et al., 2017 ).

Any relationship between the remainder of the patient outcomes and skill mix was inconclusive. These outcomes were falls and falls injury, deep vein thrombosis, central nervous system complications, pulmonary failure/pulmonary embolism, medication error (in contrast to Driscoll et al. ( 2017 )), physiologic/metabolic derangement, and pain control. Five patient outcomes were excluded as not being suitable as only one study investigated each outcome. These were ventilator weaning, hypoglycaemia, patient wait time, quality of care and 30‐day readmission.

Since the seminal study conducted in the 1980’s found that interaction and coordination amongst clinicians (medical and nursing staff) reduced patient deaths in ICU settings, nurse staffing has been under the research microscope (Knaus, Draper, Wagner, & Zimmerman, 1986 ). Fundamental to this research is the recognition that Registered Nurses provide a continuous (24 hr per day, 7 days per week) surveillance system for patients. This surveillance system enables early detection and prompt intervention when a patient's condition deteriorates, or health issues emerge (Twigg, Duffield, Thompson, & Rapley, 2010 ). The ability of nurses to undertake this critical role is dependent on the hours of care and the skill mix of those providing that care. It is not surprising, therefore, that this review found 12 outcomes inversely related to skill mix. What remains less well understood is how nurses manage less than desired hours of care or skill mix. Emerging research suggests nurses ration their care when there is insufficient nurses or lower skill mix and prioritize the most urgent or critical aspects of care and some care may be altogether missed (Bail & Grealish, 2016 ). How this might have an impact on patient outcomes over their length of stay is less well understood but this care rationing may provide some explanation as to why skill mix is associated with only some but not all patient outcomes (Griffiths et al., 2018 ).

Many decades that have now passed since the first seminal works in this area, however, the research examining the association between skill mix and patient outcomes remains in an exploratory stage evidenced by the number of outcomes studied and the number of non‐significant results. The research is plagued by methodological issues including; many research studies rely on secondary administrative data to recode patient discharge diagnoses into adverse events, different measures and definitions are still being used for staffing and skill mix variables as well as patient outcomes reducing the comparability of results and data and coding processes often vary or are not transparent (Unruh & Zhang, 2012 ).

4.2. Limitations

The results of this quantitative systematic review should be interpreted with caution. The methodological quality of the included studies is far from ideal, with only very few studies using experimental designs. In this review, only three out of the sixty‐three studies included in the narrative summary employed experimental or quasi‐experimental designs. Many of the studies collected self‐reported data using single measurement methods, for example, self‐reported pain scales (Huston, 2001 ) and self‐reported use of falls risk assessment and policy use (Aydin, Donaldson, Aronow, Fridman, & Brown, 2015 ), raising the potential for common method bias (Podsakoff, MacKenzie, & Podsakoff, 2011 ; Wingate, Sng, & Loprinzi, 2018 ). Self‐reported studies may inflate, deflate or have no effect on the relationships being studied due to common method bias (Podsakoff et al., 2011 ). Hence, these results may have over‐ or underestimated the effect of skill mix on patient outcomes. Whilst common method bias has been identified as an issue for self‐reported studies, the studies did not discuss how common method bias was addressed. Common method bias can be decreased by the use of different data collection methods, times and locations and checking the wording, number of items and placement of items in data collection tools to maximize motivation and minimize task difficulty to encourage participants to provide accurate results (Podsakoff et al., 2011 ; Wingate et al., 2018 ).

There was also a large degree of variety of heterogeneity in the definitions and of research methods used for determining the effect of skill mix on patient outcomes makes comparison of data difficult. This review was only able to provide a narrative analysis of results as meta‐analysis could not be performed. Consequently, inferences about causal relationships between nurse skill mix and nursing‐sensitive patient outcomes cannot be drawn.

5. CONCLUSION

Of those studies identifying significant results, there were 12 outcomes where three quarters or more of those studies found an inverse association with increases in nurse skill mix: length of stay, ulcer, gastritis and upper gastrointestinal bleeds, acute myocardial infarction, restraint use, failure‐to‐rescue, pneumonia, sepsis, urinary tract infection, mortality/30‐day mortality, pressure injury, infections (excluding urinary tract infections), and shock/cardiac arrest/heart failure. Nevertheless, there was insufficient evidence to draw inferences about causal relationships since research into nursing‐sensitive outcomes continues to suffer from methodological flaws and heterogeneity of results. This has an impact on the synthesis of research findings and recommendations for future research and policy. More experimental or longitudinal study designs are required, which have the potential to establish causal relationships. Currently, a plethora of studies investigating interactions between nurse skill mix and patient outcomes employ observational designs that lack control of basic confounding variables.

Furthermore, future research must not only produce a widely agreed definition of nurse skill mix and its most appropriate form of measurement but must also investigate the existence of an optimal level of RNs in skill mix and explore potential non‐linear relationships between nursing skill mix and patient outcomes. Nonetheless, this systematic review suggests that critical patient outcomes such as mortality, failure‐to‐rescue, and length of stay can be improved with a higher skill mix. Those making staffing decisions cannot ignore this association.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

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