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How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

  • Search for relevant literature
  • Evaluate sources
  • Identify themes, debates, and gaps
  • Outline the structure
  • Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

  • Quick Run-through
  • Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

  • Demonstrate your familiarity with the topic and its scholarly context
  • Develop a theoretical framework and methodology for your research
  • Position your work in relation to other researchers and theorists
  • Show how your research addresses a gap or contributes to a debate
  • Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

Literature review guide

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

  • Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
  • Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
  • Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
  • Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

  • Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
  • Body image, self-perception, self-esteem, mental health
  • Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

  • Your university’s library catalogue
  • Google Scholar
  • Project Muse (humanities and social sciences)
  • Medline (life sciences and biomedicine)
  • EconLit (economics)
  • Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

  • What question or problem is the author addressing?
  • What are the key concepts and how are they defined?
  • What are the key theories, models, and methods?
  • Does the research use established frameworks or take an innovative approach?
  • What are the results and conclusions of the study?
  • How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
  • What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

  • Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
  • Themes: what questions or concepts recur across the literature?
  • Debates, conflicts and contradictions: where do sources disagree?
  • Pivotal publications: are there any influential theories or studies that changed the direction of the field?
  • Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

  • Most research has focused on young women.
  • There is an increasing interest in the visual aspects of social media.
  • But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

  • Look at what results have emerged in qualitative versus quantitative research
  • Discuss how the topic has been approached by empirical versus theoretical scholarship
  • Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

  • Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically evaluate: mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

  • Sampling methods
  • Simple random sampling
  • Stratified sampling
  • Cluster sampling
  • Likert scales
  • Reproducibility

 Statistics

  • Null hypothesis
  • Statistical power
  • Probability distribution
  • Effect size
  • Poisson distribution

Research bias

  • Optimism bias
  • Cognitive bias
  • Implicit bias
  • Hawthorne effect
  • Anchoring bias
  • Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

  • To familiarize yourself with the current state of knowledge on your topic
  • To ensure that you’re not just repeating what others have already done
  • To identify gaps in knowledge and unresolved problems that your research can address
  • To develop your theoretical framework and methodology
  • To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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Article Contents

Introduction, selection of a topic, scientific literature search and analysis, structure of a scientific review article, tips for success, acknowledgments, conflict of interest statement.

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A Step-by-Step Guide to Writing a Scientific Review Article

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Manisha Bahl, A Step-by-Step Guide to Writing a Scientific Review Article, Journal of Breast Imaging , Volume 5, Issue 4, July/August 2023, Pages 480–485, https://doi.org/10.1093/jbi/wbad028

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Scientific review articles are comprehensive, focused reviews of the scientific literature written by subject matter experts. The task of writing a scientific review article can seem overwhelming; however, it can be managed by using an organized approach and devoting sufficient time to the process. The process involves selecting a topic about which the authors are knowledgeable and enthusiastic, conducting a literature search and critical analysis of the literature, and writing the article, which is composed of an abstract, introduction, body, and conclusion, with accompanying tables and figures. This article, which focuses on the narrative or traditional literature review, is intended to serve as a guide with practical steps for new writers. Tips for success are also discussed, including selecting a focused topic, maintaining objectivity and balance while writing, avoiding tedious data presentation in a laundry list format, moving from descriptions of the literature to critical analysis, avoiding simplistic conclusions, and budgeting time for the overall process.

Scientific review articles provide a focused and comprehensive review of the available evidence about a subject, explain the current state of knowledge, and identify gaps that could be topics for potential future research.

Detailed tables reviewing the relevant scientific literature are important components of high-quality scientific review articles.

Tips for success include selecting a focused topic, maintaining objectivity and balance, avoiding tedious data presentation, providing a critical analysis rather than only a description of the literature, avoiding simplistic conclusions, and budgeting time for the overall process.

The process of researching and writing a scientific review article can be a seemingly daunting task but can be made manageable, and even enjoyable, if an organized approach is used and a reasonable timeline is given. Scientific review articles provide authors with an opportunity to synthesize the available evidence about a specific subject, contribute their insights to the field, and identify opportunities for future research. The authors, in turn, gain recognition as subject matter experts and thought leaders in the field. An additional benefit to the authors is that high-quality review articles can often be cited many years after publication ( 1 , 2 ). The reader of a scientific review article should gain an understanding of the current state of knowledge on the subject, points of controversy, and research questions that have yet to be answered ( 3 ).

There are two types of review articles, narrative or traditional literature reviews and systematic reviews, which may or may not be accompanied by a meta-analysis ( 4 ). This article, which focuses on the narrative or traditional literature review, is intended to serve as a guide with practical steps for new writers. It is geared toward breast imaging radiologists who are preparing to write a scientific review article for the Journal of Breast Imaging but can also be used by any writer, reviewer, or reader. In the narrative or traditional literature review, the available scientific literature is synthesized and no new data are presented. This article first discusses the process of selecting an appropriate topic. Then, practical tips for conducting a literature search and analyzing the literature are provided. The structure of a scientific review article is outlined and tips for success are described.

Scientific review articles are often solicited by journal editors and written by experts in the field. For solicited or invited articles, a senior expert in the field may be contacted and, in turn, may ask junior faculty or trainees to help with the literature search and writing process. Most journals also consider proposals for review article topics. The journal’s editorial office can be contacted via e-mail with a topic proposal, ideally with an accompanying outline or an extended abstract to help explain the proposal.

When selecting a topic for a scientific review article, the following considerations should be taken into account: The authors should be knowledgeable about and interested in the topic; the journal’s audience should be interested in the topic; and the topic should be focused, with a sufficient number of current research studies ( Figure 1 ). For the Journal of Breast Imaging , a scientific review article on breast MRI would be too broad in scope. Examples of more focused topics include abbreviated breast MRI ( 5 ), concerns about gadolinium deposition in the setting of screening MRI ( 6 ), Breast Imaging Reporting and Data System (BI-RADS) 3 assessments on MRI ( 7 , 8 ), the science of background parenchymal enhancement ( 9 ), and screening MRI in women at intermediate risk ( 10 ).

Summary of the factors to consider when selecting a topic for a scientific review article. Adapted with permission from Dhillon et al (2).

Summary of the factors to consider when selecting a topic for a scientific review article. Adapted with permission from Dhillon et al ( 2 ).

Once a well-defined topic is selected, the next step is to conduct a literature search. There are multiple indexing databases that can be used for a literature search, including PubMed, SCOPUS, and Web of Science ( 11–13 ). A list of databases with links can be found on the National Institutes of Health website ( 14 ). It is advised to keep track of the search terms that are used so that the search could be replicated if needed.

While reading articles, taking notes and keeping track of findings in a spreadsheet or database can be helpful. The following points should be considered for each article: What is the purpose of the article, and is it relevant to the review article topic? What was the study design (eg, retrospective analysis, randomized controlled trial)? Are the conclusions that are drawn based on the presented data valid and reasonable? What are the strengths and limitations of the study? In the discussion section, do the authors discuss other literature that both supports and contradicts their findings? It can also be helpful to read accompanying editorials, if available, that are written by experts to explain the importance of the original scientific article in the context of other work in the field.

If previous review articles on the same topic are discovered during the literature search, then the following strategies could be considered: discussing approaches used and limitations of past reviews, identifying a new angle that has not been previously covered, and/or focusing on new research that has been published since the most recent reviews on the topic ( 3 ). It is highly encouraged to create an outline and solicit feedback from co-authors before writing begins.

Writing a high-quality scientific review article is “a balancing act between the scientific rigor needed to select and critically appraise original studies, and the art of telling a story by providing context, exploring the known and the unknown, and pointing the way forward” ( 15 ). The ideal scientific review article is balanced and authoritative and serves as a definitive reference on the topic. Review articles tend to be 4000 to 5000 words in length, with 80% to 90% devoted to the body.

When preparing a scientific review article, writers can consider using the Scale for the Assessment of Narrative Review Articles, which has been proposed as a critical appraisal tool to help editors, reviewers, and readers assess non–systematic review articles ( 16 ). It is composed of the following six items, which are rated from 0 to 2 (with 0 being low quality and 2 being high quality): explanation of why the article is important, statement of aims or questions to be addressed, description of the literature search strategy, inclusion of appropriate references, scientific reasoning, and appropriate data presentation. In a study with three raters each reviewing 30 articles, the scale was felt to be feasible in daily editorial work and had high inter-rater reliability.

The components of a scientific review article include the abstract, introduction, body, conclusion, references, tables, and figures, which are described below.

Abstracts are typically structured as a single paragraph, ranging from 200 to 250 words in length. The abstract briefly explains why the topic is important, provides a summary of the main conclusions that are being drawn based on the research studies that were included and analyzed in the review article, and describes how the article is organized ( 17 ). Because the abstract should provide a summary of the main conclusions being drawn, it is often written last, after the other sections of the article have been completed. It does not include references.

The introduction provides detailed background about the topic and outlines the objectives of the review article. It is important to explain why the literature on that topic should be reviewed (eg, no prior reviews, different angle from prior reviews, new published research). The problem-gap-hook approach can be used, in which the topic is introduced, the gap is explained (eg, lack of published synthesis), and the hook (or why it matters) is provided ( 18 ). If there are prior review articles on the topic, particularly recent ones, then the authors are encouraged to justify how their review contributes to the existing literature. The content in the introduction section should be supported with references, but specific findings from recent research studies are typically not described, instead being discussed in depth in the body.

In a traditional or narrative review article, a methods section is optional. The methods section should include a list of the databases and years that were searched, search terms that were used, and a summary of the inclusion and exclusion criteria for articles ( 17 , 19 ).

The body can take different forms depending on the topic but should be organized into sections with subheadings, with each subsection having an independent introduction and conclusion. In the body, published studies should be reviewed in detail and in an organized fashion. In general, each paragraph should begin with a thesis statement or main point, and the sentences that follow it should consist of supporting evidence drawn from the literature. Research studies need not be discussed in chronological order, and the results from one research study may be discussed in different sections of the body. For example, if writing a scientific review article on screening digital breast tomosynthesis, cancer detection rates reported in one study may be discussed in a separate paragraph from the false-positive rates that were reported in the same study.

Emphasis should be placed on the significance of the study results in the broader context of the subject. The strengths and weaknesses of individual studies should be discussed. An example of this type of discussion is as follows: “Smith et al found no differences in re-excision rates among breast cancer patients who did and did not undergo preoperative MRI. However, there were several important limitations of this study. The radiologists were not required to have breast MRI interpretation experience, nor was it required that MRI-detected findings undergo biopsy prior to surgery.” Other examples of phrases that can be used for constructive criticism are available online ( 20 ).

The conclusion section ties everything together and clearly states the conclusions that are being drawn based on the research studies included and analyzed in the article. The authors are also encouraged to provide their views on future research, important challenges, and unanswered questions.

Scientific review articles tend to have a large number of supporting references (up to 100). When possible, referencing the original article (rather than a review article referring to the original article) is preferred. The use of a reference manager, such as EndNote (Clarivate, London, UK) ( 21 ), Mendeley Desktop (Elsevier, Amsterdam, the Netherlands) ( 22 ), Paperpile (Paperpile LLC, Cambridge, MA) ( 23 ), RefWorks (ProQuest, Ann Arbor, MI) ( 24 ), or Zotero (Corporation for Digital Scholarship, Fairfax, VA) ( 25 ), is highly encouraged, as it ensures appropriate reference ordering even when text is moved or added and can facilitate the switching of formats based on journal requirements ( 26 ).

Tables and Figures

The inclusion of tables and figures can improve the readability of the review. Detailed tables that review the scientific literature are expected ( Table 1 ). A table listing gaps in knowledge as potential areas for future research may also be included ( 17 ). Although scientific review articles are not expected to be as figure-rich as educational review articles, figures can be beneficial to illustrate complex concepts and summarize or synthesize relevant data ( Figure 2 ). Of note, if nonoriginal figures are used, permission from the copyright owner must be obtained.

Example of an Effective Table From a Scientific Review Article About Screening MRI in Women at Intermediate Risk of Breast Cancer.

Abbreviations: ADH, atypical ductal hyperplasia; ALH, atypical lobular hyperplasia; CDR, cancer detection rate; LCIS, lobular carcinoma in situ; NR, not reported; PPV, positive predictive value. NOTE: The Detailed Table Provides a Summary of the Relevant Scientific Literature on Screening MRI in women with lobular neoplasia or ADH. Adapted with permission from Bahl ( 10 ).

a The reported CDR is an incremental CDR in the studies by Friedlander et al and Chikarmane et al. In all studies, some, but not all, included patients had a prior MRI examination, so the reported CDR represents a combination of both the prevalent and incident CDRs.

b This study included 455 patients with LCIS (some of whom had concurrent ALH or ADH). Twenty-nine cancers were MRI-detected, and 115 benign biopsies were prompted by MRI findings.

Example of an effective figure from a scientific review article about breast cancer risk assessment. The figure provides a risk assessment algorithm for breast cancer. Reprinted with permission from Kim et al (28).

Example of an effective figure from a scientific review article about breast cancer risk assessment. The figure provides a risk assessment algorithm for breast cancer. Reprinted with permission from Kim et al ( 28 ).

Select a Focused but Broad Enough Topic

A common pitfall is to be too ambitious in scope, resulting in a very time-consuming literature search and superficial coverage of some aspects of the topic. The ideal topic should be focused enough to be manageable but with a large enough body of available research to justify the need for a review article. One article on the topic of scientific reviews suggests that at least 15 to 20 relevant research papers published within the previous five years should be easily identifiable to warrant writing a review article ( 2 ).

Provide a Summary of Main Conclusions in the Abstract

Another common pitfall is to only introduce the topic and provide a roadmap for the article in the abstract. The abstract should also provide a summary of the main conclusions that are being drawn based on the research studies that were included and analyzed in the review article.

Be Objective

The content and key points of the article should be based on the published scientific literature and not biased toward one’s personal opinion.

Avoid Tedious Data Presentation

Extensive lists of statements about the findings of other authors (eg, author A found Z, author B found Y, while author C found X, etc) make it difficult for the reader to understand and follow the article. It is best for the writing to be thematic based on research findings rather than author-centered ( 27 ). Each paragraph in the body should begin with a thesis statement or main point, and the sentences that follow should consist of supporting evidence drawn from the literature. For example, in a scientific review article about artificial intelligence (AI) for screening mammography, one approach would be to write that article A found a higher cancer detection rate, higher efficiency, and a lower false-positive rate with use of the AI algorithm and article B found a similar cancer detection rate and higher efficiency, while article C found a higher cancer detection rate and higher false-positive rate. Rather, a better approach would be to write one or more paragraphs summarizing the literature on cancer detection rates, one or more paragraphs on false-positive rates, and one or more paragraphs on efficiency. The results from one study (eg, article A) need not all be discussed in the same paragraph.

Move from Description (Summary) to Analysis

A common pitfall is to describe and summarize the published literature without providing a critical analysis. The purpose of the narrative or traditional review article is not only to summarize relevant discoveries but also to synthesize the literature, discuss its limitations and implications, and speculate on the future.

Avoid Simplistic Conclusions

The scientific review article’s conclusions should consider the complexity of the topic and the quality of the evidence. When describing a study’s findings, it is best to use language that reflects the quality of the evidence rather than making definitive statements. For example, rather than stating that “The use of preoperative breast MRI leads to a reduction in re-excision rates,” the following comments could be made: “Two single-institution retrospective studies found that preoperative MRI was associated with lower rates of positive surgical margins, which suggests that preoperative MRI may lead to reduced re-excision rates. Larger studies with randomization of patients are needed to validate these findings.”

Budget Time for Researching, Synthesizing, and Writing

The amount of time necessary to write a high-quality scientific review article can easily be underestimated. The process of searching for and synthesizing the scientific literature on a topic can take weeks to months to complete depending on the number of authors involved in this process.

Scientific review articles are common in the medical literature and can serve as definitive references on the topic for other scientists, clinicians, and trainees. The first step in the process of preparing a scientific review article is to select a focused topic. This step is followed by a literature search and critical analysis of the published data. The components of the article include an abstract, introduction, body, and conclusion, with the majority devoted to the body, in which the relevant literature is reviewed in detail. The article should be objective and balanced, with summaries and critical analysis of the available evidence. Budgeting time for researching, synthesizing, and writing; taking advantage of the resources listed in this article and available online; and soliciting feedback from co-authors at various stages of the process (eg, after an outline is created) can help new writers produce high-quality scientific review articles.

The author thanks Susanne L. Loomis (Medical and Scientific Communications, Strategic Communications, Department of Radiology, Massachusetts General Hospital, Boston, MA) for creating Figure 1 in this article.

None declared.

M.B. is a consultant for Lunit (medical AI software company) and an expert panelist for 2nd.MD (a digital health company). She also receives funding from the National Institutes of Health (K08CA241365). M.B. is an associate editor of the Journal of Breast Imaging . As such, she was excluded from the editorial process.

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Zotero . Available at: https://www.zotero.org/ . Accessed October 5, 2022 .

Grimm LJ , Harvey JA. Practical steps to writing a scientific manuscript . J Breast Imag 2022 ; 4 ( 6 ): 640 – 648 .

Gasparyan AY , Ayvazyan L , Blackmore H , Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors . Rheumatol Int 2011 ; 31 ( 11 ): 1409 – 1417 .

Kim G , Bahl M. Assessing risk of breast cancer: a review of risk prediction models . J Breast Imag 2021 ; 3 ( 2 ): 144 – 155 .

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  • 04 December 2020
  • Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

  • An introductory paragraph that explains what your working topic and thesis is
  • A forecast of key topics or texts that will appear in the review
  • Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
  • Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically Evaluate: Mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

  • Summarize the key findings you have taken from the literature and emphasize their significance
  • Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

  • Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
  • Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
  • Qualitative versus quantitative research
  • Empirical versus theoretical scholarship
  • Divide the research by sociological, historical, or cultural sources
  • Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

  • It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
  • Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
  • Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
  • Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

How to write a good scientific review article

Affiliation.

  • 1 The FEBS Journal Editorial Office, Cambridge, UK.
  • PMID: 35792782
  • DOI: 10.1111/febs.16565

Literature reviews are valuable resources for the scientific community. With research accelerating at an unprecedented speed in recent years and more and more original papers being published, review articles have become increasingly important as a means to keep up to date with developments in a particular area of research. A good review article provides readers with an in-depth understanding of a field and highlights key gaps and challenges to address with future research. Writing a review article also helps to expand the writer's knowledge of their specialist area and to develop their analytical and communication skills, amongst other benefits. Thus, the importance of building review-writing into a scientific career cannot be overstated. In this instalment of The FEBS Journal's Words of Advice series, I provide detailed guidance on planning and writing an informative and engaging literature review.

© 2022 Federation of European Biochemical Societies.

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

  • Give a new interpretation of old material or combine new with old interpretations,
  • Trace the intellectual progression of the field, including major debates,
  • Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
  • Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

  • Place each work in the context of its contribution to understanding the research problem being studied.
  • Describe the relationship of each work to the others under consideration.
  • Identify new ways to interpret prior research.
  • Reveal any gaps that exist in the literature.
  • Resolve conflicts amongst seemingly contradictory previous studies.
  • Identify areas of prior scholarship to prevent duplication of effort.
  • Point the way in fulfilling a need for additional research.
  • Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE : Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

  • An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
  • Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
  • An explanation of how each work is similar to and how it varies from the others,
  • Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

  • Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
  • Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
  • Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
  • Persuasiveness -- which of the author's theses are most convincing or least convincing?
  • Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

  • Current Situation : Information necessary to understand the current topic or focus of the literature review.
  • Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
  • History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
  • Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
  • Standards : Description of the way in which you present your information.
  • Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

  • Sources in your literature review do not clearly relate to the research problem;
  • You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
  • Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
  • Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
  • Does not describe the search procedures that were used in identifying the literature to review;
  • Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
  • Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

  • How are they organizing their ideas?
  • What methods have they used to study the problem?
  • What theories have been used to explain, predict, or understand their research problem?
  • What sources have they cited to support their conclusions?
  • How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

  • Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
  • Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
  • Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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Literature Reviews

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Choosing a review type.

  • 1. Define your research question
  • 2. Plan your search
  • 3. Search the literature
  • 4. Organize your results
  • 5. Synthesize your findings
  • 6. Write the review
  • Thompson Writing Studio This link opens in a new window
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literature review of scientific journals

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Overview of types of literature reviews

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  • Literature (narrative)
  • Scoping / Evidence map
  • Meta-analysis

Characteristics:

  • Provides examination of recent or current literature on a wide range of subjects
  • Varying levels of completeness / comprehensiveness, non-standardized methodology
  • May or may not include comprehensive searching, quality assessment or critical appraisal

Mitchell, L. E., & Zajchowski, C. A. (2022). The history of air quality in Utah: A narrative review.  Sustainability ,  14 (15), 9653.  doi.org/10.3390/su14159653

  • Assessment of what is already known about an issue
  • Similar to a systematic review but within a time-constrained setting
  • Typically employs methodological shortcuts, increasing risk of introducing bias, includes basic level of quality assessment
  • Best suited for issues needing quick decisions and solutions (i.e., policy recommendations)

Learn more about the method:

Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: the evolution of a rapid review approach.  Systematic reviews, 1 (1), 1-9.  https://doi.org/10.1186/2046-4053-1-10

Virginia Commonwealth University Libraries. (2021). Rapid Review Protocol .

Quarmby, S., Santos, G., & Mathias, M. (2019). Air quality strategies and technologies: A rapid review of the international evidence.  Sustainability, 11 (10), 2757.  https://doi.org/10.3390/su11102757

  • Compiles evidence from multiple reviews into one document
  • Often defines a broader question than is typical of a traditional systematic review.

Choi, G. J., & Kang, H. (2022). The umbrella review: a useful strategy in the rain of evidence.  The Korean Journal of Pain ,  35 (2), 127–128.  https://doi.org/10.3344/kjp.2022.35.2.127

Aromataris, E., Fernandez, R., Godfrey, C. M., Holly, C., Khalil, H., & Tungpunkom, P. (2015). Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. International Journal of Evidence-Based Healthcare , 13(3), 132–140. https://doi.org/10.1097/XEB.0000000000000055

Rojas-Rueda, D., Morales-Zamora, E., Alsufyani, W. A., Herbst, C. H., Al Balawi, S. M., Alsukait, R., & Alomran, M. (2021). Environmental risk factors and health: An umbrella review of meta-analyses.  International Journal of Environmental Research and Public Dealth ,  18 (2), 704.  https://doi.org/10.3390/ijerph18020704

  • Main purpose is to map out and categorize existing literature, identify gaps in literature
  • Search comprehensiveness determined by time/scope constraints, could take longer than a systematic review
  • No formal quality assessment or critical appraisal

Learn more about the methods :

Arksey, H., & O'Malley, L. (2005) Scoping studies: towards a methodological framework.  International Journal of Social Research Methodology ,  8 (1), 19-32.  https://doi.org/10.1080/1364557032000119616

Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science: IS, 5, 69. https://doi.org/10.1186/1748-5908-5-69

Miake-Lye, I. M., Hempel, S., Shanman, R., & Shekelle, P. G. (2016). What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products.  Systematic reviews, 5 (1), 1-21.  https://doi.org/10.1186/s13643-016-0204-x

Example : 

Rahman, A., Sarkar, A., Yadav, O. P., Achari, G., & Slobodnik, J. (2021). Potential human health risks due to environmental exposure to nano-and microplastics and knowledge gaps: A scoping review.  Science of the Total Environment, 757 , 143872.  https://doi.org/10.1016/j.scitotenv.2020.143872

  • Seeks to systematically search for, appraise, and synthesize research evidence
  • Adheres to strict guidelines, protocols, and frameworks
  • Time-intensive and often take months to a year or more to complete. 
  • The most commonly referred to type of evidence synthesis. Sometimes confused as a blanket term for other types of reviews.

Gascon, M., Triguero-Mas, M., Martínez, D., Dadvand, P., Forns, J., Plasència, A., & Nieuwenhuijsen, M. J. (2015). Mental health benefits of long-term exposure to residential green and blue spaces: a systematic review.  International Journal of Environmental Research and Public Health ,  12 (4), 4354–4379.  https://doi.org/10.3390/ijerph120404354

  • Statistical technique for combining results of quantitative studies to provide more precise effect of results
  • Aims for exhaustive, comprehensive searching
  • Quality assessment may determine inclusion/exclusion criteria
  • May be conducted independently or as part of a systematic review

Berman, N. G., & Parker, R. A. (2002). Meta-analysis: Neither quick nor easy. BMC Medical Research Methodology , 2(1), 10. https://doi.org/10.1186/1471-2288-2-10

Hites R. A. (2004). Polybrominated diphenyl ethers in the environment and in people: a meta-analysis of concentrations.  Environmental Science & Technology ,  38 (4), 945–956.  https://doi.org/10.1021/es035082g

Flowchart of review types

  • Review Decision Tree - Cornell University For more information, check out Cornell's review methodology decision tree.
  • LitR-Ex.com - Eight literature review methodologies Learn more about 8 different review types (incl. Systematic Reviews and Scoping Reviews) with practical tips about strengths and weaknesses of different methods.
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  • Last Updated: Feb 15, 2024 1:45 PM
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Academic Entrepreneurship Ecosystems: Systematic Literature Review and Future Research Directions

  • Open access
  • Published: 16 February 2024

Cite this article

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  • Maria Patrocínia Correia 1 , 2 ,
  • Carla Susana Marques   ORCID: orcid.org/0000-0003-1557-1319 2 ,
  • Rui Silva 2 &
  • Veland Ramadani 3  

Research on the entrepreneurship ecosystem, based on different data and scales, limits the acceptance of a single definition. This conceptual limitation and the still recent research and higher education institutions have come to be seen as ecosystems associated with entrepreneurship. The aim of this study is to contribute to the field of knowledge, identify current and emerging thematic areas and trends and reveal the scientific roots of research on entrepreneurial ecosystems and their relationship with higher education institutions. A bibliometric analysis was developed to analyse a final sample of 110 articles published between 2011 and 2022. In order to develop the analysis, Bibliometrix R-Tool was used and the metadata of two databases (Web of Science and Scopus) was retrieved and merged. The software creates a reference co-citation’s map, which allowed emphasize the state of the art and indicate three thematic clusters: (i) the importance of the higher education context for the entrepreneurial ecosystem, (ii) the evolution and challenges of entrepreneurship education and (iii) academic entrepreneurship ecosystems. The paper concludes by suggesting future research focused on the importance of building an integrated approach to entrepreneurial ecosystems and higher education institutions on a context regional scale.

Avoid common mistakes on your manuscript.

Introduction

The new research on the “entrepreneurship ecosystem” (EE) limits the acceptance of a single definition. According to this conceptual limitation and the still recent research, higher education institutions (HEIs) have come to be seen as ecosystems associated with entrepreneurship. While several bibliometric and systematic literature reviews have advanced for a research agenda for academic entrepreneurial ecosystems (AEEs), a holistic approach that integrates theories, attributes and methods is still necessary.

The concept of EE in HEIs has emerged in the literature (Fetters et al., 2010 ). Consequently, initial studies have addressed the components of these ecosystems (Fetters et al., 2010 ; Graham, 2014 ; Meyer et al., 2020 ), and internal and external actors have been identified (e.g. Hayter, 2016 ; Hayter et al., 2018 ; Meyer et al., 2020 ). Hayter ( 2016 ) and Hayter et al. ( 2018 ) further elaborated on the research by relating the effectiveness of academic EEs to the levels of the interconnectedness of the constituent elements and their collective capacity.

Higher education institutions (HEIs) and their surroundings play a “fundamental role for contemporary societies in the field of education and knowledge generation” (Kobylinska & Lavios, 2020 : 118). For the authors, during the last decade, the university and its surroundings have become a special ecosystem. Specifically, favourable conditions are created for cooperation between various entities, namely, HEI, business incubators, technology transfer centres and funding institutions, which contribute to developing academic entrepreneurship ecosystem (AEE) (Meyer et al., 2020 ; Kobylinska & Lavios, 2020 ). The combination of EE and HEI requires further research.

The systematic literature review (SLR) developed in this article found five studies that allow us to assess what is known about this subject. Malecki ( 2018 ) reviews the literature, concepts and operationalizations of the concept of EE with a bibliometric analysis. Kansheba and Wald ( 2020 ) present a systematic review of the existing literature, develop a research agenda and analysing, only, articles that focused on EEs (conceptual, theoretical or empirical). They concluded that the concept of EEs is poorly theorised and dominated by conceptual studies, revealing existing theoretical and empirical gaps on EEs. In the third SLR found, Kobylinska and Lavios ( 2020 ) aimed to analyse the state of research on University EE and to identify research trends related to the topic. They concluded that the study of University EE is little recognized in the literature, lacking a solid methodological basis and revealed that the topic may constitute a research area of interest. In the fourth review, Guindalini et al. ( 2021 ) present an SLR with bibliometric and network analysis, with the aim of mapping AEE. In this SLR, as in the two previously mentioned, the authors conclude that this topic is at an “embryonic stage of academic research” (Guindalini et al., 2021 : 6). They also find a gap in research regarding evaluation studies that support the targeting of potential scientific discoveries in the market. With bibliometric and SLR, the study develops a holistic framework that integrates sustainability factors into the EE literature. They confirm that EE research has mostly focused on academic entrepreneurship, innovation and regional development, among others.

The originality of this research is directly linked to the chosen emerging theme. In this context, this study aims to complement and stand out from the five reviews found and understand the characteristics of an AEE and their successful development as a potential research area relevant in the future. To this end, a bibliometric analysis is proposed to answer the following research questions: (a) RQ1: Is it possible establish common attributes for AEE?; (b) RQ2: What are the opportunities and challenges that HEIs must recognize to achieve an successful EE?; (c) RQ3: What key areas require further research with regards to AEE?

In order to complement the proposed research questions, this study also responds to the subsequent objectives: to provide a comprehensive overview of the origins of the EE concept, to explore the research conducted so far in this field of study, to reveal the scientific roots of research on EEs and their relationship with the HEIs and to create knowledge for future research on AEEs.

To achieve them, the SLR followed in this article included a rigorous protocol and definition of research steps and a literature review based on scientific articles published in Web of Science (WoS) and Scopus. In addition, the 110 articles related to EEs were submitted to a bibliometric analysis with the Bibliometrix-R tool . In this quantitative bibliometric, we used the analysis of co-citations, which allowed obtaining a citation network composed of clusters.

The article is structured in seven parts. After this introductory section, the theoretical framework on the concept is presented in the second section of the paper and is organized as follows: entrepreneurial ecosystems and academic entrepreneurial ecosystems. In the third section, the methodological characteristics of the research used in the SLR, the sample and the bibliometric analysis method are presented. The results are explained in the fourth section. The thematic analysis exposing the resulting visual maps and discussing the results of the articles classified by clusters is the fifth section. In the sixth and final section, the future lines of research and conclusions are addressed presenting limitations that resulted from the review and future of research.

Theoretical Framework

Defining entrepreneurial ecosystems and academic entrepreneurship ecosystem.

The concept of entrepreneurial ecosystem is an ambiguous term, but, in fact, this concept has been increasingly explored by researchers over the years (Bischoff et al., 2018 ; Clarysse et al., 2014 ; Cohen, 2006 ; Isenberg, 2010 , 2011 ; Kansheba & Wald, 2020 ; Stam & Spigel, 2017 ; Van de Ven, 1993 ). The term entrepreneurial ecosystem (EE) is a composite of two terms.

The component of the term—entrepreneur—according to Mason and Brown ( 2014 ) is often associated with “high growth start-ups” or “economies of scale” as being a source of innovation and growth in productivity and employment. The other component of the term—ecosystem—is associated with biology and is defined as the physical environment and all possible interactions in the complex of living and non-living components (Stam, 2015 ). As in ecology, the biological perspective focuses on the rise and fall of many organizations and institutions that are mutually related and play different but complementary roles that enable their birth, growth and survival (Astley & Van de Ven, 1983 ; Freeman & Audia, 2006 ).

Cohen ( 2006 ) was the first to use the concept of EE building on the study of Neck et al. ( 2004 ). Neck et al. ( 2004 ) used qualitative analysis to identify the components present in the EE in Boulder, USA. This concept became more prominent through Daniel Isenberg, in 2010. For this author, an EE is a set of individual elements combined in a complex way. In isolation, each can generate entrepreneurship but cannot sustain it (Isenberg, 2010 , 2011 ). Mason and Brown ( 2014 : 5) more broadly defined an EE as a “set of interrelated entrepreneurial actors, entrepreneurial organizations, institutions and entrepreneurial processes that formally or informally cooperate in relating and mediate performance within the local entrepreneurial environment.” Audretsh and Belitski ( 2017 : 1031) define EE as “institutional and organisational systems as well as other systemic factors that interact and influence the identification and commercialisation of entrepreneurial opportunities.” Acs et al. ( 2014 ) defined entrepreneurial ecosystems as a dynamic, institutionally embedded interaction between entrepreneurial attitudes, capabilities and aspirations of individuals that drives the allocation of resources through the creation and operation of new projects. Stam and Spigel ( 2017 ) point out that it is the coordination that occurs between actors and interdependent factors that enables productive entrepreneurship in each territory.

As this term has captured the attention of researchers, experts and policymakers significant knowledge gaps have also emerged in terms of its conceptual meaning, theoretical foundation and application (Audretsh et al., 2019 ; Kansheba & Wald, 2020 ). According to Audretsh et al. ( 2019 ), the question remains as to what exactly an EE is and what it comprises. It also mentions that the definition of EE does not add value to academic discourses that rely on “networks”, “cluster initiatives”, “triple helix initiatives” or “public–private partnerships”. For the authors, thinking in terms of EEs may only reflect the importance of a particular topic, such as “business ecosystems”, “digital ecosystems”, “financial ecosystems” and “university ecosystems”, among others.

Combining EEs and HEIs: An Overview of Academic Entrepreneurship Ecosystems

In recent decades, some universities have oriented themselves towards a more entrepreneurial direction through the realization of the third mission as a key player in promoting national and regional economic and social development (Etzkowitz & Leydesdorff, 2000 ; Yi & Uyarra, 2018 ) resulting from the interaction of three actors belonging to different helixes—university-industry-government: triple helix model (Etzkowitz & Leydesdorff, 2000 ). Etzkowitz and Zhou ( 2017 ) point out that the thesis of the model is that the university starts to abandon a social, yet important, role of providing higher education and research and starts to assume an essential role equivalent to that of industry and government as a generator of new industries and enterprises. As a result, the entrepreneurial university has become an increasingly significant academic configuration and is considered a vital element (Etzkowitz & Zhou, 2017 ; Wang et al., 2021 ). Pita et al. ( 2021 ) agree, pointing out that universities actively contribute to the development of EEs by providing a skilled workforce and stimulating new enterprises, such as start-ups or spin-offs.

In the entrepreneurial university, knowledge-sharing processes are outlined, which requires the university to reconfigure its traditional educational programmes and approaches to create a favourable context for university entrepreneurship by supporting students in a process that moves from idea generation to idea development, business model and commercialisation (Secundo et al., 2021 ). Another challenge facing HEIs is to shift their focus from education about entrepreneurship to educating for entrepreneurship. This encompasses any programme or pedagogical process of education aimed at achieving entrepreneurial skills and attitudes (Bischoff et al., 2018 ).

Against entrepreneurial HEIs and their pedagogical competencies of entrepreneurship education, researchers highlight that the entrepreneurial university itself can form an EE (Miller & Acs, 2017 ; Wang et al., 2021 ). The EE developed with an academic campus as a context is referred to as “University-based Entrepreneurship Ecosystem” (UBEE) or “University Entrepreneurship Ecosystem” (UEE) or “Academic Entrepreneurship Ecosystem” (AEE). All these terms refer to the ecosystem developed on the university campus, which are part of a wider ecosystem. For Wang et al., ( 2021 : 2), the creation of UEEs, currently, is a “hot topic.”

Naturally, many definitions were put forward, leading to the decision to present, chronologically, a selection of definitions (Table  1 ).

An effective AEE is critical for entrepreneurial academic activities as they not only act as a catalyst for the acceleration of knowledge commercialisation but also as a platform and dynamic in maintaining the sustainable development of academic entrepreneurship (Yi & Uyarra, 2018 ). However, little literature exists on the AEE’s structure and function and particularly how the transition from the academic entrepreneurial system to an AEE occurs (Hayter, 2016 ; Yi & Uyarra, 2018 ).

Similarly, to research on EE, academics attach greater importance to the conceptualisation and elements of the UEE. Several authors identify the factors contributing to the evolution of EEUs (Fetters et al., 2010 ; Graham, 2014 ; Meyer et al., 2020 ). Fetters et al. ( 2010 ) cite seven factors contributing to the evolution of UBEEs: senior leadership, strong teaching and programmatic capacity, long-term commitment, the commitment of financial resources, the commitment to continuous innovation in programmes and curricula, adequate organizational infrastructure and the commitment to increasing critical mass and creating enterprises. Graham ( 2014 ) also identifies seven factors that underpin UEEs: institutions, culture, university leadership, university research capacity, regional or governmental support, effective institutional strategies and strong demand for entrepreneurial students.

Brush ( 2014 ) believed that entrepreneurship education is the core of the UEE. The researcher divided the internal entrepreneurial education ecosystem into three broad areas (introductory/curricular courses, extracurricular activities and research) and four dimensions (stakeholders, resources, infrastructure and culture). Sherwood ( 2018 ), in addition to the elements, identified curricular, extra-curricular components, Technology Transfer Offices (TTO), resources and informal and community engagement. For Wang et al. ( 2021 ), diversified extracurricular activities have played an important role in stimulating students’ interest in entrepreneurship by providing them with a large number of resources. For the authors, student entrepreneurs also tend to get the guidance and resources they need through these activities.

For Bischoff et al. ( 2018 ), although the concrete strengths and conceptualization of UBEEs generally vary between universities, a number of common characteristics can be identified. Secundo et al. ( 2021 ) mention that UBEE facilitates innovation and entrepreneurial opportunities thanks to the knowledge-sharing processes between the various actors. Within a UBEE, for the author, each actor needs to be connected to the other members through a constant flow of knowledge from information that enables the overflow of entrepreneurial knowledge. The author points out that universities may assume different roles according to the size and composition of the entrepreneurial ecosystem, interacting through different channels.

In accordance with the review carried out, the other authors initiate the development of methods to evaluate an AEE. Table 2 shows three of the conceptual models highlighted in the literature review and published chronologically in the last 5 years.

Within this context, further research work on evaluations of AEE is needed. The findings draw attention to considerations as “unique entrepreneurial architecture” (Prokop & Thompson, 2022 : 17). The Prokop and Thompson ( 2022 : 181) study include 81 UEE and, according to the author, “it is in no way reflective of all types of sub-ecosystems, or broader ecosystems.” The study of university and broader EEs is a critical feature to recognize and involve in future studies. This study aims to contribute to this challenge.

Methodology

To produce a comprehensive review article, Hulland ( 2020 ) refers that authors should carry out their studies in a systematic way. A systematic review needs the definition of clear questions, criteria and conclusions that provide new information based on the examined content. According to Aria and Cuccurullo ( 2017 ), this means that the phases adopted in the review can be replicated in all procedures and there should be clarity in all of them. The authors state that the working model of an SLR is based on five stages: study design, data collection, data analysis, data visualization and interpretation.

Ferreira et al. ( 2019 ) mention that one of the most suitable methods for analysing past research works is bibliometric analysis. According to Aria and Cuccurullo ( 2017 ) and Thelwall ( 2008 ), there are relevant points when using bibliometric. For Aria and Cuccurullo ( 2017 ), there are three types of research questions that can be answered using bibliometrics: identify the knowledge base of a topic or field of research, examine the conceptual structure of a topic or field of research and produce a network structure based on a particular scientific community. The relevance for Thelwall ( 2008 ) concerns the types of procedures in bibliometric analysis. The author identified two types of procedures, evaluation bibliometric and relational bibliometric. The first evaluates the productivity and impact of researchers, research centres and countries. The second type examines the similarity and relationship between publications, authors and keywords using co-word, co-authorship and co-citation analyses.

The article will use the suggestions of both authors in bibliometric analysis. It will respond to the three types of questions posed by Aria and Cuccurullo ( 2017 ) and uses both types of procedures, evaluation bibliometric and relational bibliometric. In evaluation bibliometric, mappings, qualitative analyses and baseline indicators are carried out. In relational bibliometrics will analyse co-citations and the respective clusters.

Data Collection and Eligibility Criteria

In additional search, the research papers were determined through the comprehensive advanced search in two databases including Scopus and Web of Science. These choices were justified for two reasons: they are two multidisciplinary databases that include all indexed journals with the highest number of citations in their respective areas of scientific specialization (Huang et al., 2020 ; Pranckuté, 2021 ). They also provide a citation index, generating information about each publication in documents that cite them as well as cited.

Table 3 elucidates the stages that followed in this study.

The keywords come from the research question and was defined the following search query: “entrepreneur* ecosystem*” (in title) AND “universit*” OR “polytechnic*” OR “higher education institution*” (in topic). All the articles from the current year were excluded because at the time of this research the year had not finished. The document type was limited to “article” and “review.” After applying these criteria, it was obtained 183 papers from the research process (104 obtained in SCOPUS and 79 results in Web of Science) (stages 1 and 2 from Table  3 and Fig.  1 ).

figure 1

Process of data collection and analysis

In the third stage, wherein some records were excluded, the data was filtered. To this end, other restrictions were applied:

Eliminating the repeats by cross-referencing the databases (62 documents)

The exclusion of 11 documents, after analysing the content of each, because the global subject of the articles was different from the scope of the study

Although language was not a filter, it should be noted that the search was developed utilizing English, which could be understood as “quasi-filter.”

The procedures followed in the data collection and the application of the eligibility criteria complete Fig.  1 which demonstrates the careful way in which the final database was obtained ( n  = 110).

Mapping and Qualitative Analysis

R-Bibliometrix summarized the mapping of the documents included in the final database with the information considered relevant, as shown in Table  4 . Table 4 reveals that the dataset contains 110 documents published between 2011 and 2022, representing the work of 276 authors from 32 different countries. The average years from publication is 3.31 and the average number of citations per documents 13.4. The number of authors and co-authors per document is 2.5 and 2.7.

The first study in the final database addressed the entrepreneurship ecosystems, and the global innovation networks were written by Malecki in 2011. For the author, the existing knowledge is dispersed as it results from entrepreneurial activity originating from small and medium enterprises, research institutes and universities. Malecki ( 2011 ) suggested the simultaneous integration of local and global knowledge as well as internal and external.

A reading of Tables  4 and  5 reveals that various articles have been published recently (during 2011–2022). Moreover, an increase of publications (except 2012 and 2013) shows an increasing trend, suggesting that the subject has been progressively gaining popularity in the academic community. The results reveal and confirm the increase prevalence of research on EEs over the past 11 years.

In 2022, the number reached 24 articles in the last year of the period. After 2014, there was a considerable increase in the number of published articles. The data shows a turning point in 2018 (14) and 2019 (23). This latter year and 2022 standing out with the highest number of published articles. It is important to mention that more than half of the articles (62) were published in the last 3 years. The production growth rate is 33.5%.

According to the average number of citations, per year, the articles written in 2022 were those with a higher number (9.79) followed by articles from the years 2011, 2018 and 2019. This increment in the interest of EE results from the fact that this concept has assumed a global and multidisciplinary dimension recognized and associated with innovation by the various economic and social actors.

Table 6 presents the five authors and journals that have contributed for research’s development. The most cited papers by author were those of Malecki, with 185, followed by Audretsh, with 111, and Carayannis, with 110. The three authors who have published the most with the highest local impact (TC index) are Cunningham (4 publications, TC 156), Audretsh (3 publications, TC 184) and Menter (3 publications, TC 154).

R-Bibliometrix software was used to identify the keywords mentioned in the 110 documents of the final sample. As can be seen in the Fig.  2 , the most frequently terms mentioned are “entrepreneurial ecosystem”, “entrepreneurial university”, “entrepreneurial education”, “university”, innovation” and “higher education”. This also shows that of the studies analysed word association results as “academic entrepreneurship”.

figure 2

Most mentioned keywords

Table 7 summarizes the applied methodologies. As an emerging theoretical stream, EEs have been studied through qualitative methods. Thus, several articles use a case study technique. There is an increase on quantitative methods using factor analysis and structural equation modelling to understand variations in entrepreneurship and develop metrics. Researchers have used mixed methods, both qualitative and quantitative data collection techniques to address the complexity of the phenomenon.

Concerning methodologies, of a total 110 articles, 59 documents (54%) use a qualitative approach, through the technique of data collection via interviews (in-depth and semi-structured), samples, observation and documentary analysis. The case study technique, inserted in this approach, focuses on 25 articles, meaning that its weighting is 42% in relation to the total number of articles that use qualitative methodologies. The 28 articles (around 25%) use a quantitative approach through data collection techniques involving the application of questionnaires and secondary data (statistics) and eight articles (7%) use mixed methods, namely, they use both qualitative and quantitative data collection techniques. Eight conceptual articles (7%) and seven literature review articles (6%) were identified. Of this literature review, five are based on systematic literature reviews. From the numbers, we deduce that there is no balance of methods in EE and HEI studies and literature reviews are the least frequent type of publication.

Thematic Analysis

In this part of the article, the thematic analysis results will be examined. It will start with the strategic and evolutionary analysis and, subsequently, the networks created by the co-citation analysis. The subsequent figures will be presented all results.

Strategic and Evolutionary Thematic Analysis

The strategic diagram for the studied subject is presented in Fig.  3 . The size of the circles represents the number of occurrences of these words. The upper right quadrant represents the main themes, and the upper left quadrant depicts the more specific themes, considered niche themes. The lower right quadrant represents the basic themes, and the lower left means that the theme may be emerging or disappearing.

figure 3

Strategic diagram

The themes in the upper right quadrant are “academic entrepreneurship” and “entrepreneurial”. All these sets of themes are crucial to the research in this paper.

The theme in the upper left quadrant is “start-ups”, “case study” and “networks.

The lower right quadrant represents the basic themes necessary for understanding the present study: “entrepreneurial ecosystem”, “entrepreneurial education”, “entrepreneurial university”. Also “university” and “technology transfer” are essential for the understanding on the topic. The lower left quadrant given the inexistence of declining themes but also gives the emerging themes, “entrepreneurial education” and “entrepreneur”. All this fact enhances the importance of the sets of themes in the article.

Thus, “networks”, “case study” and “academic entrepreneurship” reveal themselves as major themes. The transversal themes are “entrepreneurial ecosystems” and “university incubators”. This last phase, 2022, was the growth stage of an approach integrating Entrepreneurial Ecosystems and the Entrepreneurial University. Therefore, 2023 could be a high growth phase for an integrated approach to AEEs.

Figure  4 presents the evolution of research topics in entrepreneurial ecosystems and the relationship with the university. The data were analysed using the author’s keywords and cut-off points in the years 2014, 2018 and 2020. The results reveal a thematic evolution of the conceptual frameworks from 2011 to 2022. From the general concept of “Entrepreneurial Ecosystem” (2011–2014), “innovation” emerges in the thematic evolution (2015–2017). Therefore, the cut-off points were two periods when the first publications on the topic of the paper appeared (three publications in 2011–2014 and nine publications in 2015–2017).

figure 4

Thematic evolution, with cut-off points

In 2018, results of the emergence of thematic areas such as “education” and “higher education” are revealed. From 2019, “entrepreneurial ecosystem” gives way to “entrepreneurial education”, “entrepreneurial university” and its “ecosystem”. Likewise, the area of “innovation” gives way to a unique “entrepreneurial ecosystem” based on “entrepreneurial education”, “university”, “higher education” and “academic entrepreneurship”. The thematic evolution of the conceptual framework between 2018 and 2022 revealed that these periods are the most productive and creative with the highest number of base themes and driving themes evolving in these periods.

Cluster Analysis

A bibliometric analysis was carried out to understand how this field of study is divided into research clusters, and the co-citations were analysed. No cut-off point for the number of citations per document has been defined. All linked documents were selected, leaving us with a final analysis with 50 documents distributed by clusters. Each of the clusters, identified with different colours, can be observed in Fig.  5 . The colours indicate the clusters and the articles belonging to them. In addition, each article’s weight is assigned based on the links’ total strength, and the number of citations the publication has received. The top nodes are the publications with the highest link strength.

figure 5

Clusters networks through the co-citation analysis technique

Based on the visualization of Fig.  5 and after analysing the resulting network and the content of the articles, it is concluded that the research is divided into three thematic clusters (Table  8 ).

Cluster 1 (Blue)—Conceptualization and Attributes of Entrepreneurship Ecosystems

The first cluster is focused on the definition and attributes present in EEs. No consensus has been reached in the academic community on the theoretical characterization of the concept and the elements that characterize it.

While there is none accepted definition of an EE, as Spigel ( 2018 ) points out, the most active area of interest has been around the types of domains (Isenberg, 2010 , 2011 ), components (Cohen, 2006 ) or attributes (Spigel, 2017 ).

Diverse literature provides tools that show several factors considered important for a successful EE. Cohen ( 2006 ) refers to formal and informal networks, government, university, skilled human resources, support services, funding and talent. The works of Isenberg ( 2010 , 2011 ) list six domains present in the ecosystem: policy, funding, culture, support, human capital and markets.

Spigel ( 2017 ) efforts to rank the categories of an EE in terms of (i) cultural attributes (entrepreneurship stories, supportive culture), (ii) social attributes (talent, mentors, networks, investment capital) and (iii) material attributes (infrastructure, universities, support services, public policies, open markets). Spigel and Harrison ( 2018 ) give attention to several factors such as governance, knowledge, industry, actors, resources and benefits.

Table 9 summarizes the attributes by applying them to the EEs.

Although the topic on the attributes of EEs is innovative, it has not been without trials. Several articles highlight criticisms of previous work (Alvedalen & Boschma, 2017 ; Brown & Mason, 2017 ; Malecki, 2018 ; Nicotra et al., 2018 ; Stam & Spigel, 2017 ). Alvedalen and Boschma ( 2017 ), Nicotra et al. ( 2018 ) and Stam and Spigel ( 2017 ) highlighted the lack of a clear analytical framework to empirically explain the cause-effect relationship of EEs’ attributes and their effects on productive entrepreneurship. The static approach of EE studies was another criticism highlighted as its evolution over time was not considered. Finally, Malecki ( 2018 ) noted the lack of an issue related to spatial scale.

Cluster 2 (Red)—Spatial Context and Knowledge Ecosystems

Beyond definitional debates, the lead author of this cluster, Stam ( 2015 ), expresses himself critically concerning studies of EEs. He underlines that it is not only generating entrepreneurship that makes it a good EE. He also mentions that the approaches only offer a long list of elements without a cause-effect relationship and concludes that it is unclear what level of geographical analysis the approaches have taken into consideration. The author refers that a new emerging approach to EE occurs, conveying a new view on people, networks and institutions. From this emerging approach, differentiations have emerged at two levels: spatial context and dynamics of knowledge ecosystems.

The first sub-division of this cluster refers to the importance of context in EEs (Acs et al., 2014 ; Cohen, 2006 ; Spigel, 2017 ; Stam, 2015 ). For Stam ( 2015 ), the common denominator in this sub-cluster seems to be that entrepreneurs create value in a specific institutional context. The author approach emphasizes the interdependencies within the context and provides a bottom-up analysis of the performance of regional economies. Stam ( 2015 ) argues that EEs open the door to a shared responsibility among actors that foster, encourage and support entrepreneurs, asking about the systemic services that a region tries to achieve.

The second sub-cluster analyses the dynamics of knowledge ecosystems, namely, the role of HEIs for value creation in a given context. Kuratko ( 2005 ), in his study, notes that younger people have become the most entrepreneurial generation since the Industrial Revolution. The growth and development in programmes and curricula dedicated to entrepreneurship and the creation of new projects have been remarkable. The number of colleges and universities offering entrepreneurship-related courses has increased. However, among this enormous expansion, for Kuratko ( 2005 ) there remains the challenge of the academic legitimacy of entrepreneurship. Although there has been this significant growth, the author points out two specific challenges to academia: (i) development of academic programmes and specialized human resources to improve the quality of courses and (ii) commitment by institutions to create formal academic programmes.

Clarysse et al. ( 2014 ) analysed the tension between knowledge and business ecosystems. In relation to the success factors, they seem similar: diversity of organizations and key actors. However, regarding the factors, anchor organizations in knowledge are universities and public research organizations that do not directly compete with the ecosystem. In contrast, key actors in EEs are based on companies that are competitors in the ecosystem. Another difference lies in value creation. In knowledge ecosystems, to Clarysse et al. ( 2014 ), the value creation flows from upstream to downstream, while in EEs, the value creation process is non-linear . The author’s note that some studies already include universities as part of the knowledge system but that further research could focus on analysing the circumstances under which a university could be considered an ecosystem and how the interaction between knowledge and business ecosystems would occur. Miller and Acs ( 2017 ) explore the EE of higher education by choosing a university campus because the “entrepreneurial opportunities had been identified and/or the process of firm-formation had begun by multiple founders…” (p. 82).

Cluster 3 (Green)—Inter-institutional Relationships in University’s Ecosystem

This third cluster leads us to the wider set of relationships in the university’s ecosystem, strategies and their specificities of regional/local factors. Audretsch et al. ( 2019 ) refers that EE is a vehicle for carrying entrepreneurs, policymakers and managers of linked companies and all their relationships organizing the EE. For the author, an EE is defined by frontiers, and the necessary resources are produced and absorbed within and beyond those boundaries.

Audretsch and Belitski ( 2017 ) set out to develop a model that captured both regional and local systemic factors to better understand and explain variations in entrepreneurial activity. In their study, they found four domains under EEs in European cities: norms and culture, infrastructure and equipment, formal institutions and Internet access and connections. To Audretsch and Link ( 2017 : 431), conceptually a university represents a “reservoir of knowledge, knowledge embodied in faculty…”. Universities are one part of the complexity of the research. They have evolved towards taking an active role in regional development and the dynamics of local networks. This evolution in the model involves inter-institutional relationships between the three actors, leading to an increasing overlap of their roles. The work of Schaeffer and Matt ( 2016 ) showed that universities cannot replicate the mechanisms that lead to the success of an EE but rather adapt their strategies to the specificities of each regional context.

Can academia encompass a third mission, beyond research and teaching? This question was formulated by Etzkowitz and Leydesdorff ( 2000 : 110). Three spaces emerge from the triple helix model: the consensus space, a knowledge space (R&D activities) and innovation space.

Schaeffer and Matt ( 2016 ) state these are coordinated and managed by a regional innovation officer. The authors refer that this responsibility can be assigned to the university to contribute to developing the regional networks. They analysed the university of Strasbourg’s Technology Transfer Offices (TTO) and supported entrepreneurial academic activities over 15 years. The study reveals a strong growth in the structure of the TTO and its role as a boundary, changing objectives and developing collaborations with other regional actors. As pointed by Fini et al. ( 2011 ) and Vohora et al. ( 2004 ), since university faculty have limited entrepreneurial experience, networks with outside contacts are crucial to motivate the creation of entrepreneurial activities as well as their success.

In addition to TTOs, entrepreneurship education, either as part of the academic programme or as an extra-curricular offering, can provide students and faculty with important knowledge to stimulate and support entrepreneurial efforts (relationship to Cluster 2). While most of the study streams have focused on the role of faculty as academic entrepreneurs, Boh et al. ( 2016 ) focused on the role of students. The typology created by the authors provides insight into the various responsibilities of students and faculty in technology commercialisation. It is the different relationships between students, faculty and entrepreneurs and the analysis of the strengths and weaknesses of each that can lead to the creation of a successful spinoff. The authors, Boh et al. ( 2016 ), group into six the university practices, independent of the TTOs: project disciplines for technology commercialisation, mentoring programmes, incubator programmes, entrepreneurial business plans and entrepreneurial education for students and university professionals.

Other authors analyse the relation between social networks and academic entrepreneurship (Clarysse et al., 2011 ; Fini et al., 2011 ; Vohora et al., 2004 ), Spinoffs (Lockett & Wright, 2005 ; Fini et al, 2011 , 2017 ; Vohora et al., 2004 ; Clarysse et al., 2011 ; Hayter, 2016 ) and the entrepreneurial environment and academic programmes supporting entrepreneurship (Fini et al., 2011 ). As pointed by Fini et al. ( 2011 ) and Vohora et al. ( 2004 ), since university faculty have limited entrepreneurial experience, networks with outside contacts are crucial to motivate the creation of entrepreneurial activities as well as their success. Vohora et al. ( 2004 ) argues that networks are pathways through which access to opportunities will be achieved, for example, gaining knowledge of the market that motivates the creation of the spinoff. Hayter ( 2016 ) uses Vohora et al. ( 2004 ) qualitative model of entrepreneurial development and that includes four stages of development: opportunity recognition, commitment, credibility and sustainability, as well as the resources and network elements associated with each stage. Entrepreneurial development and its success are reflected in the progression of the university spinoff , overcoming the obstacles of each stage, with the aim of achieving entrepreneurial sustainability.

Hayter ( 2016 ), using mixed methods, compares the composition and contribution of social networks among entrepreneurial academics and analyses how these networks relate to the development trajectory of university spinoffs . The traditional definition of spinoff , according to Hayter et al. ( 2017 ) focuses on the role of faculty establishing a company based on a technology licensing agreement, with their home university. University spinoffs , for Hayter ( 2016 ), are an important vehicle for generating productivity, job creation and prosperity for regional economies. The author also mentions that spinoffs are a window through which the contributions of universities can be examined. He compares the composition and contribution of social networks among entrepreneurial academics and analyses how these networks relate to the development trajectory of university spinoffs.

Cluster Relations

The three clusters are related. The cluster 2 indicates the importance of higher education for EE and cluster 3 leads us to the triple helix model with the focus on university entrepreneurial experience. Cluster 1 introduces definitions and attributes necessaries to understand the EE and their relationship with or within the HEIs. This cluster creates a theoretical background with relevant publications in entrepreneurship research.

Clusters 2 and 3 have a robust relation. Notably, the position of Stam ( 2015 ) and Spigel ( 2017 ) influences 2 clusters, indicating higher link strength and confirming its centrality in the EE literature. Various articles from cluster 2 criticize the analytical framework that produces long lists of factors that enhance entrepreneurship. Their perspective enables researchers to measure an EE within a country or territory by considering their specificities. This understanding highlights the configuration, structure and evolution of ecosystems influenced by ecosystem process and territorial boundaries.

In cluster 3 it is evident that the challenge of the third mission that academia encompass emphasizes entrepreneurship and the corresponding emergence of the entrepreneurial university. The relationships between students, faculty and entrepreneurs and the analysis of the strengths and weaknesses of each can lead to the creation of a successful spinoff.

To understand the substance of AEE and how the broad research was advanced, the group of these three clusters creates a fundamental and theoretical base to: the terminology of EE, the higher education context and the emergence of an AEE (Fig.  6 ).

figure 6

Academic entrepreneurship ecosystem model

Contributions and Future Research Directions

The scientific literature about entrepreneurial ecosystems has been growing, and within it, one area that has been gaining impulse has been the academic ecosystem. This paper contributes by attempting to consolidate the most important of this growing literature and to try to confirm it.

This study brings important theoretical contributions to the existing literature. Firstly, this study led to a survey and mapping of the main investigations on EE and their relationship with the HEI. Secondly, this study strengthens the credibility of the AEE theoretical frameworks in lending support to the importance of analysing the specific contributions of HEIs to the development of an EE. Thirdly, the developed co-citation analysis allowed obtaining an understanding about the existing field of knowledge on EEs and AEE, identifying their scientific origins and revealing research roots.

Most contributions are conceptual providing an understanding of the different elements that form conducive AEE. Therefore, as a fourth contribution, this study emphasizes the need for more empirical research, especially regarding potential causal relations between elements, context factors, outputs and outcomes of entrepreneurial ecosystems. The few empirical studies on entrepreneurial ecosystems have majorly applied case studies including qualitative methods (Kansheba & Wald, 2020 ; Malecki, 2018 ; Nicotra et al., 2018 ). There is a need of deploying other methodological approaches for more rigor and generalizability purposes.

The above leads us to propose as possible future research directions. As mentioned, most research studies on EEs and AEEs have adopted the qualitative methodological approach (particularly case studies), which is understandable since the research topic is emergent. However, considering the systematic research conducted here, it is believed that this topic would benefit from implementing mixed methodologies (as has already been carried out by some of the authors included here). Thus, with the adoption of qualitative and quantitative methodologies, it will be attempted, in a future line of research, to build an assessment tool for an AEE.

The composition of clusters groups generated research points. Studying an AEE based on a regional scale will imply, firstly, building a theoretical framework, based on multiple dimensions, which allows the development of the EE model. HEIs are a complex process which involves an extensive research approach to accurately represent the levels and components of the entire entrepreneurial ecosystem (cluster 1). It will be necessary to study whether the HEI develops strategies adapted to the specificities of its EE. Likewise, to explore the pillars of the model from the point of view of young university students who show varying degrees of entrepreneurial intention (cluster 2). Several studies have found that entrepreneurship education has a positive impact on students’ entrepreneurial intention (Peterman & Kennedy, 2003 ; Souitaris et al., 2007 ; Pruett et al., 2009 ; Engle et al., 2010 ; Lanero et al., 2011 ; Sanchez, 2013 ; Bae et al., 2014 ; Sansone et al., 2021 ). Vanevenhoven ( 2013 ) and Fiore et al. ( 2019 ) have warned of the need for more research into the impact of entrepreneurship education on students in different contexts. Although there has been a growing number of publications on the role of intentions in the entrepreneurial process (Liñán & Fayolle, 2015 ; Ferreira-Neto et al, 2023 ), there is still a gap in research on how to improve the presence of higher education students in entrepreneurial activities so that they can face the problems of the labour market. A broader study could be undertaken, from a mixed approach, to establish mechanisms to collect appropriate data and to establish the different levels of success of EE outcomes, by the HEI (cluster 3).

Finally, the relevance of knowledge of skilled people has brought to the policy agenda of governments worldwide the need to modernize science and higher education systems and institutions (Santos et al., 2016 ; Scott, 2000 ). Portugal is characterized as a developed country but with a poorly qualified workforce in European average terms, facing structural barriers to economic growth (Carneiro et al., 2014 ). It was also a country that has seen one of the fastest developments in its scientific system at the beginning of the twenty-first century (Heitor et al., 2014 ). The emergence of the COVID-19 pandemic has brought new challenges to the country: the establishment of telework and the intense decline in economic activity were some of the most evident cross-cutting changes, with direct consequences for the emergence of new forms and policies to support the employment (Sousa & Paiva, 2023 ).

All these reasons have been supporting the need to make a RSL focused on how young graduates capture new forms and conditions of the exercise of work. This knowledge is crucial to investigate wow the entrepreneurial skills or the academic entrepreneurship path is in the future.

Conclusions and Limitations

The quest to identify and define EEs has become an issue of great importance as countries, regions and cities handle with an entrepreneurial economy. The range of these topics is wide and ambiguous. Researchers and practitioners have assessed various contributions, most of which identify HEIs as important development institutions. Marques et al., ( 2021 : 133) highlight their importance, stating that HEIs “… are seen as organizations responsible for human resource training, knowledge transfer, and regional development”.

This work used data from the Scopus and WoS databases. Based on 110 academic articles obtained through a rigorous data collection process, the study went beyond describing elementary information, standing out in relation to the review studies found and filling a gap in the field of EEs taking into consideration higher education institutions. It also revealed the embryonic state of research (2011–2022) and reinforced the scientific importance of the topic since about 56% of the articles were published in the last 3 years. The results were published in a variety of indexed journals. However, this study shows the limitations in other literature reviews.

Despite considering that this study constitutes a work that will be the object of the development in the coming years, the study is not without limitations. The first limitation concerns to the search strategy. This study is based on the regular updating of databases with the consequent increase or decrease in the number of indexed journals, so a bibliometric analysis of an emerging topic can be subject to substantial variations in just a very few years. The other limitation of this study is that it used two different databases to analyse a particular topic. Despite being two of the most influential databases, the overview could be improved by including other databases. Another limitation is the subjectivity present in the scientific articles analysis. Although bibliometric methods help to reduce subjectivity, it is not possible to completely exclude some interpretative biases.

Data Availability

Available upon reasonable request from the corresponding author.

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Exploring the role of professional identity in the implementation of clinical decision support systems—a narrative review

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Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity.

We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists).

One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system’s ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user’s professional status and expertise and is improved over the course of implementation.

This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.

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We provide a comprehensive literature review and narrative synthesis of the role of professional identity in CDSS implementation among diverse health care professionals and identify human, technological, and organizational determinants that influence professional identity and implementation.

The review shows that a perceived threat to professional identity plays a significant role in explaining failures of CDSS implementation. As such, our study highlights the need to recognize significant challenges related to professional identity in the implementation of CDSS and similar technologies. A better understanding and awareness of individual barriers to CDSS implementation among health professionals can promote the diffusion of such data-driven tools in health care.

This narrative synthesis maps, interconnects, and reinterprets existing empirical research and provides a foundation for further research to explore the complex interrelationships and influences of perceived professional identity-related mechanisms among health care professionals in the context of CDSS implementations.

Health care organizations increasingly implement clinical decision support systems (CDSSs) due to rising treatment costs and health care professional staff shortages [ 1 , 2 ]. CDSSs provide passive and active referential information, computer-based order sets, reminders, alerts, and patient-specific data to health care professionals at the point of care by matching patient characteristics to a computerized knowledge base [ 1 , 3 , 4 ]. These systems complement existing electronic health record (EHR) systems [ 5 ] and support various functional areas of medical care, such as preventative health, diagnosis, therapy, and medication [ 6 , 7 ]. Research has shown that CDSSs can improve patient safety and quality of care [ 8 , 9 , 10 ] by preventing medication errors and enhancing decision-making quality [ 11 ]. However, despite their potential benefits, their successful implementation into the clinical workflow remains low [ 1 , 12 ]. To facilitate CDSS acceptance and minimize user resistance, it is crucial to understand the factors affecting implementation success and identify the sources of resistance among the users [ 1 , 13 , 14 ].

In the health care innovation management and implementation science literature, a range of theoretical approaches have been used to examine the implementation and diffusion of health care information technologies. Technology acceptance theories focus on key determinants of individual technology adoption, such as ease of use , perceived usefulness or performance expectancy of the technology itself [ 15 , 16 , 17 ]. Organizational theories emphasize the importance of moving beyond an exclusive focus on the acceptance of technology by individuals. Instead, they advocate for examining behaviors and decisions with a focus on organizational structures and processes, cultural and professional norms, and social and political factors such as policies, laws, and regulations [ 18 , 19 ]. Other studies analyze the implementation of new technologies in health care from a behavioral theory perspective [ 20 ] and propose frameworks to explain how and why resistances emerge among users, which may have cognitive, affective, social, or environmental origins [ 13 , 21 , 22 ]. For example, the Theoretical Domains Framework has been applied to the behavior of health care professionals and serve as the basis for studies identifying influences on the implementation of new medical technologies, processes, or guidelines [ 21 , 23 ]. Other, more holistic, implementation frameworks, such as the Nonadoption, Abandonment, Scale-up, Spread and Sustainability framework , identify determinants as part of a complex system to facilitate CDSS implementation efforts across health care settings [ 13 ].

However, these theoretical approaches do not sufficiently take into account the unique organizational and social system in hospitals, which is characterized by strong hierarchies and the socialization of physicians into isolated structures and processes, making CDSS implementation particularly difficult [ 5 , 24 , 25 ]. Health care professionals are considered to have an entrenched professional identity characterized by the acquisition of a high level of expertise and knowledge over a long period of time, as well as by their decision-making authority and autonomy in clinical interventions. Defined roles and structures of different professional groups in medical organizations help to manage the multitude of tasks under high time pressure [ 26 ]. In addition, heath care professionals bear a high degree of responsibility in terms of ensuring medical quality and patient well-being [ 27 ]. Changing their professional identity is particularly difficult as they work in organizational contexts with high levels of inertia and long-lived core values based on established practices and routines [ 27 ]. This resilience of health care professionals’ identity makes it particularly difficult to implement new technologies into everyday medical practice [ 28 ].

By integrating existing evidence into an individual physician’s decision-making processes, CDSSs carry the disruptive potential to undermine existing, highly formalized clinical knowledge and expertise and professional decision-making autonomy [ 5 , 24 , 29 , 30 ]. Research has shown that health professionals may perceive new technologies, such as CDSSs, as a threat to their professional identity and draw potential consequences for themselves and their professional community, such as the change of established organizational hierarchies, loss of control, power, status, and prestige [ 31 , 32 , 33 ]. Nevertheless, other studies have shown that health professionals view CDSSs as tools that increase their autonomy over clinical decisions and improve their relationship with patients [ 34 , 35 ]. In addition, these consequences may vary widely by country, professional status, and medical setting. As a result, the use and efficacy of CDSSs differ around the world [ 24 ]. We therefore suggest that a better understanding of the identity-undermining or identity-enhancing consequences of CDSSs is needed. Despite growing academic interest, there is surprisingly scant research on the role of perceived identity threats and enhancements across different professional hierarchies during CDSS implementation and how they relate to other human, technological, and organizational influencing factors [ 5 , 36 , 37 ].

Therefore, the purpose of this narrative review is to analyze the state of knowledge on the individual, technological, and organizational circumstances that lead various health professionals to perceive CDSSs as a threat or enhancement of their professional identity. In doing so, this study takes an exploratory approach and determines human , organizational , and technological factors for the successful implementation of CDSSs. Our study extends the current knowledge of CDSS implementation by deconstructing professional identity related mechanisms and identifying the antecedents of these perceived threats and enhancements. It addresses calls for research to explore identity theory and social evaluations in the context of new system implementation [ 5 , 38 , 39 ] by aiming to answer the following research questions: What are the human, technological, and organizational factors that lead different health care professionals to perceive a CDSS as a threat or an enhancement of their professional identity? And, how do perceptions of threat and enhancement of professional identity influence CDSS implementation?

This study is designed to guide medical practice, health IT providers, and health policy in their understanding of the mechanisms that lead to conflicts between health professionals’ identity and CDSS implementation. It is intended to identify practices that may support the implementation and long-term use of CDSSs. By narratively merging insights and underlying concepts from existing literature on innovation management, implementation science, and identity theory with the findings of the empirical studies included in this review, we aim to provide a comprehensive framework that can effectively guide further research on the implementation of CDSSs.

Understanding professional identity

Following recent literature, professional identity refers to an individual’s self-perception and experiences as a member of a profession and plays a central role in how professionals interpret and act in their work situations [ 25 , 37 , 40 , 41 , 42 ]. It is closely tied to a sense of belonging to a professional group and the identification with the roles and responsibilities associated with that occupation. Professionals typically adhere to a set of ethical principles and values that are integral to their professional identity and guide their behavior and decision-making. They are expected to have specialized knowledge and expertise in their field. In return, they are granted a high degree of self-efficacy, autonomy, and ability to act in carrying out these tasks [ 25 , 43 ]. In addition, professionals make active use of their identities in order to define and change situations. Self-continuity and self-esteem encourages these professionals to align their standards of identification with the perceptions of others and themselves [ 44 ]. Many professions have formal organizations or associations that promote and regulate their shared professional identity [ 45 ]. Membership in these associations, adherence to their standards and to a shared culture within their field, including common rituals, practices, and traditions, may reinforce their professional identity [ 33 , 36 , 45 ].

Studies in the field of health care innovation management and implementation science reported a number of professional identity conflicts that shape individual behavioral responses to change and innovation [ 5 , 24 , 33 , 36 , 45 , 46 ]. The first set of conflicts relates to individual factors and expectations, such as their personality traits, cognitive style, demographics, and education. For example, user perception of a new technology can be influenced by professional self-efficacy, which can be described as perceived feeling of competence, control and ability to perform [ 47 ]. Studies have shown that innovations with a negative impact on individual’s sense of efficacy tend to be perceived as threatening, resulting in a lower likelihood of successful implementation. Users who do not believe in their ability to use the new system felt uncomfortable and unconfident in the workplace and were more likely to resist the new system [ 48 , 49 ].

The second set of studies relates professional identity to sense-making, which involves the active process of acquiring knowledge and comprehending change based on existing professional identities as frames of references [ 50 ]. For example, Jensen and Aanestad [ 51 ] showed that health care professionals endorsed the implementation of an EHR system only if it was perceived to be congruent with their own role and the physician’s practice, rather than focusing on functional improvements that the system could have provided. Bernardi and Exworthy [ 52 ] found that health care professionals with hybrid roles, bearing both clinical and managerial responsibilities, use their social position to convince health care professionals to adopt medical technologies only when they address the concerns of health care professionals.

The final set of studies address struggles related to a disruption of structures and processes that lead to the reorganization of the health professions [ 53 , 54 ] and the introduction of new professional logics [ 55 ]. These can result in threat perceptions from the perspective of health professionals regarding their competence, autonomy, and control over clinical decisions and outcomes. Accordingly, the perception of new systems not only influences their use or non-use, but implies a dynamic interaction with the professional identity of the users [ 56 ]. CDSSs may be perceived as deskilling or as a skill enhancement by reducing or empowering the responsibilities of users and thereby as compromising or enhancing the professional role, autonomy and status.

Taking the classical theoretical frameworks for the evaluation of health information systems [ 57 ] and this understanding of professional identity as a starting point, our narrative review identifies, reinterprets, and interconnects the key factors to CDSS implementation related to threats or enhancement of health professionals’ identity in different health care settings.

We conducted a comprehensive search of the Web of Science and PubMed databases to identify peer-reviewed studies on CDSS implementations published between January 2010 and September 2023. An initial review of the literature, including previous related literature reviews, yielded the key terms to be used in designing the search strings [ 1 , 49 ]. We searched for English articles whose titles, abstracts, or keywords contained at least one of the search terms, such as “clinical decision support system,” “computer physician order entry,” “electronic prescribing,” or “expert system.” To ensure that the identified studies relate to CDSS implementation, usage, or adoption from the perspective of health care organizations and health care professionals, we included, for example, the words “hospital,” “clinic,” “medical,” and “health.” The final search strings are provided in Table S 1 (Additional file 1). We obtained a total of 6212 articles. From this initial list, we removed 1461 duplicates, 6 non-retrievable studies, and 1 non-English articles. This left us with a total of 4744 articles for the screening of the titles, abstracts, and full texts. Three authors independently reviewed these articles to identify empirical papers which met the following inclusion criteria: (a) evaluated a CDSS as a study object, (b) examined facilitating factors or barriers impacting either CDSS adoption, use or implementation, (c) were examined from the perspective of health care professionals or medical facilities, and (d) represented an empirical study. We identified 220 studies that met our inclusion criteria. The three authors independently assessed the methodological quality of these 220 selected studies using the Mixed Methods Appraisal tool (MMAT), version 2018 [ 58 ]. The MMAT can be used for the qualitative evaluation of five different study designs, i.e., qualitative, quantitative, and mixed methods approaches. It is a qualitative scale that evaluates the aim of a study, its adequacy to the research question, the methodology used, the study design, participant recruitment, data collection, data analysis, presentation of findings, and the discussion and conclusion sections of the article [ 59 ]. One hundred thirty-one studies were included in the review after excluding studies based on the MMAT criteria, primarily due to a lack of a defined research question or a mismatch between the research question and the data collected [ 58 ]. Any disagreement about the inclusion of a publication between was resolved through internal discussion. Figure  1 summarizes our complete screening process.

figure 1

Overview of article screening process

The studies included in the review were then subject to a qualitative content analysis procedure [ 60 , 61 ] using MAXQDA, version 2020. For data analysis, we initially followed the principle of “open coding” [ 62 ]. We divided the studies equally among the three authors, and through an initial, first-order exploratory analysis, we identified numerous codes, which were labeled with key terms from the studies. Based on a preliminary literature review, we then developed a reference guide with the main categories of classic theoretical frameworks for health information systems implementation (human, technology, organization) [ 57 ] and further characteristics of the study. Second-order categories were obtained through axial coding [ 62 ], which reduced the number of initial codes but also revealed concepts that could not be mapped to these three categories (i.e., perceived threat to professional autonomy and control). This allowed us to identify concepts related to professional identity. Subsequently, a subset of 10% of the studies was randomly selected and coded by a second coder independently of the first coder [ 63 ]. Then, an inter-coder reliability analysis was performed between the samples of coder 1 and coder 2. For this purpose, Cohen’s kappa, a measure of agreement between two independent categorical samples, was calculated. Cohen’s kappa showed that there was a high agreement in coding ( k  = 0.8) [ 64 ]. We coded for the following aspects: human, organizational, technological, professional identity factor conceptualizations, dependent variables, study type and type of data, time-frame, clinician type sample, description of the CDSS, implementation phase [ 65 ], target area of medical care [ 7 ], and applied medical specialty. Tables 2 , 3 , 4 , 5 , 6  and 7 and Table S 2 provide detailed data as per the key coding categories.

Descriptive analysis

A total of 131 studies were included in our review. In line with recent reviews of CDSS implementation research [ 6 , 14 , 57 ], the reviewed articles are distributed widely across journals (Table  1 ).

The examined articles were drawn from 69 journals, 55 of which provide only one article. The BMC Medical Informatics and Decision Making and International Journal of Medical Informatics published nearly a third of the included studies, with 67 articles overall in medical informatics journals. There are additional clusters in medical specialty-related (33), health services, public health, or health care management-related (12), and implementation science-related (2) journals. The journals’ 5-year impact factor measured in 2022 ranged between 2.9 and 9.7. Of our included articles, 67 were published between 2010 and 2016, while 64 were published between 2017 and 2023.

The review includes a mixture of qualitative ( n  = 61), quantitative ( n  = 40), and mixed methods ( n  = 30) studies. Unless otherwise noted, studies indicated as qualitative studies in Table S 2 involved interviews and quantitative studies involved surveys. Interviews with individual health care professionals were the most common data collection method used ( n  = 38), followed by surveys ( n  = 58), and focus group interviews ( n  = 25). Most of the interviews were conducted with physicians ( n  = 60) and nursing professionals ( n  = 23). The studies were performed at various sites and specialties, with primary care settings ( n  = 35), emergency ( n  = 11), and pediatric ( n  = 6) departments being represented most frequently. Forty-five articles researched exclusively physicians and 10 covered nurse practitioners as respondents in their sample. Four studies surveyed pharmacists, one study surveyed medical residents as a single target group, and 20 articles included clinical leaders in addition to clinicians to their sample. Twenty-eight studies were longitudinal, although studying system implementation at one point in time will insufficiently explain the expected impact of the novel system on, e.g., the organizational performance outcomes over time [ 67 ]. The studies collected data in 29 different countries, with the most common being the USA ( n  = 41), the UK ( n  = 18), and the Netherlands ( n  = 11).

Included studies were additionally coded according to the implementation phase in which the study was conducted (i.e., exploration, adoption/preparation, implementation, sustainment phase) [ 65 ]. In 43 of the included studies, the analysis was conducted during the exploration phase, i.e., during a clinical trial or an exploration of the functionality and applicability of a CDSS. Nineteen studies were conducted in the active implementation phase, 15 studies in an implementation adoption or preparation phase, and 46 studies in a sustainment phase (i.e., implementation completed and long-term system use). The revealing studies involved an investigation in multiple implementation phases.

Following Berner’s study [ 7 ], we classified the examined CDSSs of the included studies according to specific target areas of care. As such, in 93 articles, CDSSs for planning or implementing treatment were studied. Thirty-seven studies examined CDSSs whose goal was prevention or preventive care screening. In 31 studies, the functional focus of the CDSSs was to provide specific suggestions for potential diagnoses that match a patient’s symptoms. Seventeen CDSSs of the included studies focused on follow-up management , 15 studies studied CDSSs for hospital and provider efficiency care plans and 12 focused on cost reduction and improved patient convenience (i.e., through duplicate testing alerts). Most CDSSs supported medication-related decisions and processes, such as prescribing, administration, and monitoring for effectiveness and adverse effects ( n  = 30). An overview of the characteristics of the included studies can be found in Table S 2 .

In the 131 included studies, we identified 1219 factors, which we categorized into human, technological, organizational, and professional identity threat and enhancement-related factors to implementation (Table  2 ). The total amount of factors is reported in Table  2 for each of our framework’s dimension and for each of our inferred factor sub-categories. The following section delves into the elements of our framework (Fig.  1 ), starting with the most commonly identified factors. Finally, the CDSS implementation outcomes are described.

Technological factors

At the technological level, perceptions of threat to professional identity were associated with factors related to the nature of the clinical purpose of the CDSS and system quality, such as compatibility of the CDSS with current clinical workflows [ 68 , 69 , 70 ], customization flexibility, intuitive navigation [ 71 , 72 , 126 ], and scientific evidence and transparency of the decision-outcome [ 73 , 74 , 191 ] . A total of 532 technological factors in 125 included studies were identified. In 21 studies, technological factors were related to study participants’ perceptions of professional identity threat, while in 9 studies these factors were related to perceived professional identity enhancements (Table  3 ). The exemplary quotes are chosen based on their clarity and representativeness related to the overall themes.

The reviewed studies focused primarily on medication-oriented CDSSs. Relevance, accuracy, and transparency of the recommendations’ quality and scientific evidence were found to be crucial for their acceptance and use. “ Irrelevant, inaccurate, excessive, and misleading alerts ” were associated with alert fatigue and lack of trust [ 72 , 75 , 76 , 127 , 144 ]. Some senior physicians preferred the provision of evidence-based guidelines that would reinforce their knowledge, while others advised junior physicians to override the CDSS recommendations in favor of their own instructions. However, residents tended to follow CDSS recommendations and used them to enhance their confidence about a clinical decision [ 69 , 77 , 128 ]. Physicians had diverse perceptions of the scientific evidence supporting the CDSS recommendations. Some regarded it as abstract or useless information that was not applicable to clinical decision making in practice. These physicians preferred a more conventional approach to learning from the “eminences” of their discipline while pragmatically engaging in the “art and craft” of medicine. CDSSs were perceived as increasingly undermining clinical work and expertise among health professionals [ 24 ]. In some studies examining AI (artificial intelligence)-based CDSS, explainability and transparency of the CDSS recommendations played a major role in maintaining control over the therapeutic process [ 78 , 129 ].

Many studies indicated that the introduction of a CDSS was perceived as a disruptive change to established clinical workflows and practices [ 12 , 79 , 80 , 81 , 167 ]. The fit of CDSS with standardized clinical workflows was seen as critical to the CDSS implementation. Senior clinicians preferred their own workflows and protocols for complex patient cases [ 82 ]. Geriatricians, for example, considered CDSS recommendations inappropriate for their clinical workflows because geriatric patients are typically multi-morbid and require individualized care [ 77 ]. Intuitiveness and interactivity of the CDSS were found to reduce the perceived threat to professional identity [ 5 ], and customization and adjustment of alerts based on specialties’ and individual preferences were perceived to increase competence [ 10 , 127 , 130 ]. Physicians considered that successful implementation of the CDSS depends on the integration of existing clinical processes and routine activities and requires collaboration as well as knowledge sharing among experienced professionals [ 24 ].

Organizational factors

A total of 287 organizational factors in 104 included studies were identified. In 17 studies, organizational factors were related to study participants’ perceptions of professional identity threat, while in 7 studies these factors were related to perceived professional identity enhancements (Table  4 ). In the included studies, organizational factors influencing professionals’ perceived threat to their identity have been studied from multiple perspectives, such as internal collaboration and communication [ 145 , 178 ], (top) managers’ leadership and support [ 79 , 83 ], innovation culture and psychological safety [ 24 ], organizational silos and hierarchical boundaries [ 69 , 70 ], and the relevance of social norms and endorsement of professional peers [ 161 ].

The empirical studies showed that the innovation culture plays a critical role in driving change in health care organizations. In this regard, resistance to the implementation of CDSSs may be due to a lack of organizational support as well as physicians’ desire to maintain the status quo in health care delivery [ 24 , 70 , 75 ]. Several key factors influenced the implementation in this regard. These included appropriate timing of the implementation project, user involvement, and dissemination of understandable information through appropriate communication channels [ 70 ]. Some studies showed that an innovation culture characterized by interdependence and cooperation promotes social interaction (i.e., a psychologically safe environment ), which in turn facilitates problem-solving and learning related to CDSS use [ 193 , 194 ]. For example, nursing practitioners recognized the potential of CDSSs for collaboration in complex cases, which had a positive impact on team and organizational culture development [ 24 ].

S upportive leadership (e.g., by department leaders) was found to be critical to successful CDSS implementation. This includes providing the necessary resources, such as time and space for training, technical support, and user involvement in the implementation process, which were negatively associated with perceived loss of control and autonomy [ 11 , 69 , 79 , 83 , 84 , 145 , 174 ]. Involving not only senior physicians but also nursing and paramedical leaders increased the legitimacy of CDSSs throughout the professional hierarchy and helped to overcome the negative effect of low status on psychological safety by flattening hierarchical distances [ 24 , 70 , 72 ]. In contrast, imposing a CDSS on users, led to resistance. Some physicians and nurses felt that the use of the CDSS was not under their voluntary control (i.e., “we have no choice”, “it’s not an option to not use it”) because these systems have become “as essential as … carrying a pen and a stethoscope,” with physicians feeling that they now “are reliant on the CDSS” [ 10 ]. In other cases, top-down decisions led to the resolution of initial resistance toward the CDSS [ 167 ]. Overall, committed leadership that involved users and transcended professional silos and hierarchies was critical to successful CDSS implementation. In this context, an established hierarchy and culture of physician autonomy impeded communication, collaboration, and learning across professional and disciplinary boundaries [ 54 , 195 , 196 ]. A well-designed CDSS minimized professional boundaries by, for example, empowering nurses and paramedics to make independent treatment decisions [ 8 , 180 ]. CDSSs thus provided structured means for nonmedical professionals to receive support in their clinical decision-making that was otherwise reserved for professionals with higher authority [ 34 ]. Since CDSSs allow widespread access to scientific evidence, they often led to nursing practitioners’ control or oversight of medical decisions, putting junior physicians in an inferior position, and thus providing an occasion to renegotiate professional boundaries and to dispute the distribution of power [ 24 , 77 ].

In addition, the provision of sufficient training and technical support were essential to ensure that physicians and nursing practitioners felt confident in using the CDSS and increased their satisfaction with the system [ 77 , 85 ]. Embedding new CDSSs into routine practice required communication and collaboration among professionals with clinical expertise and those with IT expertise [ 86 , 145 , 178 ]. Involving physicians and nursing practitioners in decision-making processes increased their willingness to change their long-standing practice patterns and embrace the newly introduced CDSS [ 5 , 10 ]. Facilitating the CDSS uptake therefore required legitimization of the system’s designers and exploited data sources [ 24 ]. Similarly, the success or failure of CDSSs implementation depended on the ability of the new system to align with existing clinical processes and routine activities. Often, successful adoption was at risk when the implementation was too far away from the reality of clinical practice because those responsible for designing the CDSS poorly understood the rationale for designing the system in a particular way [ 145 ].

In addition, some studies indicated that resistance was overcome by communicating the benefits of the CDSS through contextual activities and providing opportunities to experience the system firsthand. Sharing positive implementation experiences and fostering discussions among actual and potential users could bridge the gap between perceptions and actual use [ 145 , 146 ]. In this regard, endorsement from “ respected ” and “ passionate ” internal change promoters , such as expert peers, was seen as key to overcoming user resistance [ 82 ]. Confirmation from clinical experts that the new system improves efficiency and quality of care was essential for the general system acceptance [ 154 ]. Thus, social influence played an important role, especially in the initial phase of system use, while this influence decreased as users gained experience with the CDSS [ 182 ].

Human factors

A total of 197 human factors in 99 included studies were identified. In 17 studies, human factors were related to study participants’ perceptions of professional identity threat, while in 6 studies these factors were related to perceived professional identity enhancements. Table 5 summarizes the key findings from the included articles, which relate to three factors: individual attitudes and emotional responses, experience and familiarization with the CDSS , and trust in the CDSS and its underlying source.

It is reported in the empirical studies that physicians often failed to fully utilize the features of CDSSs, such as protocols, reminders, and charting templates, because they often lacked experience and familiarization with the CDSS [ 3 , 79 , 87 , 127 ]. In addition to insufficient training and time constraints, limited IT skills were reported as the main reasons [ 83 , 87 , 147 , 185 ]. As a result, users interacted with the CDSS in unintended ways, leading to data entry errors and potential security concerns [ 88 ]. According to Mozaffar et al. [ 131 ], this includes physicians’ tendency to enter incorrect data or select the wrong medication due to misleading data presentations in the system. Inadequate IT skills and lack of user training also contributed to limited understanding of the full functionality of CDSSs. As such, physicians interviewed in one study expressed the lack of knowledge about basic features of a CDSS, including alerts, feedback, and customization options, as a major implementation barrier [ 127 ]. Some studies reported that the lack of system customization to meet the personal preferences of users and the lack of system training weakened their confidence in the system and compromised their clinical decision-making autonomy [ 10 , 83 , 89 , 90 , 127 , 183 ].

Some studies indicated that there were trust issues among physicians and nursing practitioners regarding the credibility of the decision-making outcome [ 132 , 154 ], the accuracy of the CDSS recommendations’ algorithm [ 146 ], and the timeliness of medical guidelines in the CDSS [ 127 ]. Seniors appreciated medication-related alerts but felt that their own decision-making autonomy regarding drug selection and dosing was compromised by the CDSS [ 74 ]. However, they tended to use the CDSS as a teaching tool for their junior colleagues, advising them to consult it when in doubt [ 77 , 128 ]. In some cases, this led to junior physicians accepting CDSS suggestions, such as computer-generated dosages, without independent verification [ 128 , 144 , 154 ].

Several studies indicated that the CDSS introduction elicited different individual attitudes and emotional responses . More tenured health care professionals were “ frightened ” when confronted with a new CDSS. Others perceived the CDSS as a “ necessary evil ” or “ unwelcome disruption ” [ 81 ], leading to skepticism, despair, and anxiety [ 3 , 145 , 167 ]. Younger physicians, on the other hand, tended to be “ thrilled ” and embraced the technology’s benefits [ 84 , 147 , 167 ]. Motivation, enthusiasm, and a “can do” attitude toward learning orientation and skill development positively influenced engagement in CDSS [ 11 , 83 , 84 , 145 , 184 ].

The role of professional identity threat and enhancement perceptions in CDSS implementation

Overall, we found 90 factors in 65 included studies related to perceptions of professional identity threat among the study participants. Forty-four factors in 34 included studies were associated with perceived professional identity enhancements. We identified three key dimensions of professional identity threat and enhancement perceptions among health care professionals impacting CDSS implementation along different implementation phases [ 197 ]. Table 6 contains exemplary quotes illustrating the findings.

A number of physicians perceived CDSSs as an ultimate threat to professional control and autonomy , leading to a potential deterioration of professional clinical judgment [ 30 , 69 , 77 , 154 , 155 ]. Most nurse practitioners, on the other hand, experienced a shift in decision-making power, providing an occasion to renegotiate professional boundaries in favor of health care professionals with lower levels of expertise [ 24 ]. Thus, nurses associated the implementation of a CDSS with enhanced professional control and autonomy in the performance of tasks [ 34 , 155 , 169 ]. Pharmacists often advocated for medication-related CDSSs, which in turn increased physician dependency and resistance to new tasks [ 12 , 84 , 178 ]. The latter was a consequence of physicians’ increasing reliance on pharmacists for complex drug therapies, as physicians had to relinquish some decision-making authority to pharmacists by restructuring of decision-making processes [ 74 ].

Senior physicians frequently expressed concerns about overreliance on CDSS and potential erosion of expertise , which they believed led to patient safety risks [ 10 , 24 , 75 , 89 , 155 ]. They complained that overreliance on CDSS recommendations interfered with their cognition processes. For example, in medication-related CDSSs, clinical data such as treatment duration, units of measure, or usual doses are often based on pharmacy defaults that may not be appropriate for certain patients. According to these physicians, their junior colleagues might not double-check recommended medication doses and treatment activities, leading to increased patient safety risk [ 131 ]. In another study, general practitioners expressed concerns about the deskilling of future physicians through CDSSs. Some CDSSs required a high level of clinical expertise, skill, and knowledge regarding the correct entry of clinical information (e.g., symptoms) for proper support in clinical decisions. Many physicians feared that the use of CDSSs would erode this knowledge and thus allow the CDSS recommendations to lead to incorrect decisions [ 30 ]. This potential loss of skills and expertise was seen as particularly problematic in situations where decision support for medications and e-prescriptions varied from facility to facility. Physicians working at different institutions who relied on the CDSS for medication treatment support used at one institution reported that they had difficulties making the correct clinical decisions at the other institution [ 154 ]. From the reviewed articles, it appeared that senior physicians perceived CDSSs as an intrusion into their professional role and object to their expertise and time being misused for “ data entry work ” [ 10 ]. They enjoyed the freedom to decide what to prescribe, when to prescribe it, and whether or not to receive more information about it [ 77 ] and were determined not to “ surrender ” and “ be made to use [the CDSS] ” [ 82 ].

In line with the increasing dependence of physicians on pharmacists when using CDSS for medication treatment, pharmacists used the CDSS to demonstrate their professional skills and to further develop their professional role [ 178 ]. Nurse practitioners were empowered by CDSSs guidance to systematically update medications and measurements during their hectic daily clinic routine [ 24 , 91 ], to independently manage more complicated scenarios [ 8 ], and to facilitate their decision-making [ 92 ]. Some physicians stated that CDSS recommendations facilitated their critical thinking to critically reflect on the medication more than usual and facilitated more conscious decisions [ 133 ]. Increased professional identity enhancement in terms of skills and expertise were thus often associated with technological factors such as enhanced patient safety, improved efficiency, and quality of care [ 9 ].

Furthermore, physicians strongly associated their professional identity with their central role in the quality of patient care based on a high level of empathy and trust between physician and patient [ 45 , 195 ]. Their perceived threat to professional identity lead to a sense of loss in clinical professionalism and control over patient relationships [ 162 , 170 ] . CDSS usage was perceived as unprofessional or disrupting to the power dynamic between them and their patients [ 89 , 93 , 171 ]. As a result, they indicated that established personal patient relationships were affected by imposed CDSS use [ 81 ]. Other physicians saw CDSSs as having potential to enhance patient relationships providing them with more control over the system and treatment time, facilitating information and knowledge sharing with patients and building trust between patients and physicians [ 35 , 94 ].

Mapping the perceptions of threat and enhancement of professional identity among physicians and other health care professionals identified in each study to implementation phases allowed for an examination of the evolution of identity perceptions in CDSS implementations. Table 7 assigns the identity perceptions among physicians and other health care professionals to the different implementation phases. The findings illustrate that threat perceptions were predominantly perceived before and at the beginning of implementation. With steady training, use and familiarization with the CDSS, the perceived threat to professional identity slightly decreased in the sustainment phase, compared to the pre-implementation phase, while perceptions of enhancement of professional identity increased. During the exploration phase, physicians in particular perceived the CDSS as undermining their professional identity, and this perception remained relatively constant through the sustainment phase. Other health care professionals, such as nurse practitioners and pharmacists often changed their perspective over the course of the implementation phases and perceived the CDSS as supporting their control, autonomy, and skill enhancement at work.

CDSS implementation outcomes

In total, we identified 93 benefits related to CDSS implementation in the reviewed studies (Table  2 ). The most commonly evaluated benefits were improvements in work efficiency and effectiveness through the use of CDSSs, improvements in patient safety, and improvements in the quality of care . Prevention of prescription and treatment errors was also frequently mentioned. The included studies measured CDSS implementation in various ways, which we classified into seven groups (Table  8 ). Most studies measured or evaluated self-reported interest in using the system or intention, willingness to use, or adoption , followed by self-reported attitude toward CDSSs , and both self-reported and objective measure of implementation success . Objective actual use measurement was evaluated in only 10 studies, while self-reported use was measured in seven studies, and self-reported satisfaction and performance of the system was measured in five studies. Both self-reported and objective measure of usefulness and usability was measured in one study.

Although we included 40 quantitative studies in our review, only a few of these empirically measured the direct effect of professional identity threat or related organizational consequences on implementation, adoption, or use of CDSSs. Two studies empirically demonstrated a direct significant negative relationship between perceived professional autonomy and intention to CDSS use [ 5 , 48 ]. Another four studies found empirical evidence of an indirect negative association between threats to professional identity and actual CDSS use. Physicians disagreed with the CDSS recommendation because they perceived insufficient control and autonomy over clinical decision making [ 79 , 88 ] and lacked confidence in the quality of the CDSS and its scientific evidence [ 154 ].

Main findings

The purpose of this narrative review was to identify, reinterpret, and interconnect existing empirical evidence to highlight individual, technological, and organizational factors that contribute to professional identity threat and enhancement perceptions among clinicians and its implications for CDSS implementation in health care organizations. Using evidence from 131 reviewed empirical studies, we develop a framework for the engagement of health care professionals by deconstructing the antecedents of professional identity threats and enhancements (Fig. 2 ). Our proposed framework highlights the role of cognitive perceptions and response mechanisms due to professional identity struggles or reinforcements of different individual health care professionals in the implementation of CDSSs. Our work therefore contributes to the growing literature on perceived identity deteriorations with insights into how knowledge-intensive organizations may cope with these threats [ 37 , 45 , 46 ]. We categorized clinicians’ professional identity perceptions into three dimensions: (1) perceived threat and enhancement of professional control and autonomy , (2) perceived threat and enhancement of professional skills and expertise , and (3) perceived loss and gain of control over patient relationships . These dimensions influenced CDSS implementation depending on the end user’s change of status and expertise over the course of different implementation phases. While senior physicians tended to perceive CDSSs as undermining their professional identity across all implementation stages, nurse practitioners, pharmacists, and junior physicians increasingly perceived CDSS as enhancing their control, autonomy, and clinical expertise. Physicians, on the other hand, were positive about the support provided by the CDSS in terms of better control of the physician–patient relationship. In most studies, professional identity incongruence was associated with technological factors, particularly the lack of adaption of the system to existing clinical workflows and organizational structures (i.e., process routines), and the fact that CDSS functionalities have to meet the needs of users. The lack or presence of system usability and intuitive workflow design were also frequently associated as antecedents of professional identity loss. The other dimensions (i.e., human and organizational factors) were encountered less often in relation to professional identity mechanisms among health care professionals. Only six studies found empirical evidence of an indirect or direct negative relationship between health professionals’ perceived threats to professional identity and outcomes of CDSS implementation, whereas no study explicitly analyzed the relationship between dimensions of professional identity enhancement and outcomes of CDSS adoption and implementation.

figure 2

A framework for the role of professional identity in CDSS implementation

Interpretations, implications and applicability to implementation strategies

The results indicate that healthcare professionals may perceive CDSSs as valuable tools for their daily clinical decision-making, which can improve their competence, autonomy, and control over the relationship with the patient and their course of treatment. These benefits are realized when the system is optimally integrated into the clinical workflow, meets users’ needs, and delivers high quality results. Involving users in design processes, usability testing, and pre-implementation training and monitoring can increase user confidence and trust in the system early in implementation and lead to greater adoption of the CDSS [ 146 ]. To address trust issues in the underlying algorithm of the CDSS, direct and open communication, transparency in decision-making values, and clinical evidence validation of the CDSS are crucial [ 154 ]. CDSS reminders and alerts should be designed to be unobtrusive to minimize the perceived loss of autonomy over clinical decisions [ 77 ].

Contrary, the implementation of a CDSS often lead to substantial changes of professional identity and thereby often associated with fear and anxiety. A sense of a loss of autonomy and control was linked to lower adoption rates and thus implementation failure. Cognitive styles, which may be expressed in emotional reactions of users toward the CDSS, reinforced reluctance to implement and use the system [ 145 , 167 ]. This underscores the importance of finding expert peers and professionals who are motivated and positive toward CDSS adoption and use, and who can communicate and promote the professional appropriateness and benefits of the CDSS to their colleagues [ 82 , 83 , 184 ]. This promotes a focus on the improvement and benefits of the CDSS while maintaining the integrity, perceived autonomy, control, and expertise of physicians and nurses.

Accordingly, the included studies show that health professionals respond to the professional identity threat triggered by the CDSS implementation by actively maintaining, claiming, or completely changing their identity [ 39 ], which is consistent with previous studies elaborating on the self-verification of professionals [ 44 ]. For example, physicians delegated routine tasks to other actors to maintain control over the delivery of services and thereby enhance their professional status [ 201 ]. Pharmacists used the introduction of CDSS for drug treatment to demonstrate their skills to physicians and to further develop their professional role [ 178 ]. Maintaining authority over the clinical workflow without the need for additional relational work with lower-status professionals was seen as one of the main factors for health care professionals’ CDSS acceptance in our findings [ 10 , 12 , 84 , 178 ]. Physicians influence change processes, such as the implementation of CDSS, in a way that preserves the status quo of physicians’ responsibilities and practices. They often stated their objective to avoid increasing dependence on lower-status professionals such as nurses or pharmacists who were gaining control by using the new CDSS. In addition, CDSS users frequently criticized the system’s lack of fit with clinical work processes and that the systems were not able to replace the clinical expertise and knowledge [ 12 , 34 , 77 , 82 ]. The loss of control over the patient-physician relationship also represented a key component of identity undermining through the introduction of CDSSs. Many physicians expressed that their trust-building interaction with patients was eroded by the functionalities of the CDSS [ 81 , 170 ]. The fact that the use of CDSSs saves time in patient therapy and treatment, freeing up time for their patients, was rarely expressed [ 12 , 147 ]. This underscores the need to cope with the physician’s strong identification with their professional role, their tendency to preserve the status quo, and self-defense against technological change during the implementation of CDSSs.

Furthermore, the reviewed studies emphasized the importance of both inter- and intra-professional involvement, collaboration, and communication in health care organizations, during the CDSS implementation, suggesting that these mechanisms influence the extent and quality of cooperative behavior, psychologically safe environments, and role adaptation of different professional groups [ 26 , 54 , 55 , 202 ]. Among the studies we reviewed, managerial support and collaboration influenced coordination during CDSS implementation [ 82 , 83 , 174 ], such as by providing usability testing and time for efforts to change the understanding of why and how health care professionals should modify their routine practices [ 74 , 95 ].

Overall, the review shows that the consideration of perceived professional identity mechanisms among health care professionals plays an important role when implementing new CDSSs in health care organizations. Additionally, perceived threats and enhancements of professional identity should be considered and regularly assessed in long-term oriented implementation strategies. These strategies often include methods or techniques to improve the adoption, implementation, and sustainability of a clinical program or practices [ 203 ] and may span from planning (i.e., conducting a local needs assessment, developing a formal implementation plan) to educating (i.e., conduct educational meetings, distribute educational materials) to restructuring professional roles to managing quality (i.e., provide clinical supervision, audit, and feedback) [ 204 , 205 ]. To ensure implementation, health care professionals of all hierarchies should be involved in the planning and decision-making processes related to CDSS implementation. Continuous feedback loops between health care professionals, IT staff, and implementation managers can help identify unforeseen threats to professional identity and necessary adjustments to the implementation plan. The review found that perceived identity threats particularly need to be addressed among highly specialized physicians to account for their knowledge-intensive skills, expertise, and clinical workflows [ 24 , 96 ]. In addition, the purpose of CDSS implementation and information about how it aligns with organizational strategic goals and individual professional development should be clearly and continuously communicated at all stages of implementation.

Our review also confirms that health care professionals’ perceptions of the effectiveness of CDSSs reinforce the impact of organizational readiness for the ongoing and required transformation of healthcare [ 17 ]. Comprehensive assessments of the suitability of the system for established or changing clinical workflows and the technical quality of the CDSS should be prioritized at the beginning of the implementation. Training programs should be developed to help professionals adapt to the new medical systems and allay fears of a loss of competence or relevance. To mitigate threats to professional identity in the long term, it is necessary to foster an organizational culture of adaptability, learning, and psychological safety, in which it is acceptable to make mistakes and learn from them. In addition, ongoing leadership support and professional development opportunities are critical to ensure that health care professionals continue to adapt their roles and keep pace with technological developments [ 79 , 84 ].

Limitations

A literature review of a large sample of empirical studies has many advantages [ 206 ]. However, some limitations arise from the study design. First, our included studies were mainly conducted in the USA or UK (see Table S 2 ). The dominance of these two countries may pose a potential bias, as different cultures may have different implications for CDSS implementation and threat perceptions among health care professionals. Therefore, there is a need for caution in generalizing the findings on the impact of human, technological, and organizational factors on professional identity perceptions among professionals across different cultures. More studies are needed to provide a nuanced understanding of professional identity mechanisms among health care professionals across a broader range of cultures and countries.

Second, broad search terms were used to identify a larger number of articles in the literature review and to identify professional identity based on implementation and adoption factors mentioned in the included studies from the perspective of health professionals who were not specifically identified as threats to or enhancements of professional identity. This could also be considered a methodological strength, as this review combines findings from qualitative, quantitative, and mixed methods studies on this construct from a large and diverse field of research on CDSS implementation. However, non-English language articles or articles that did not pass the MMAT assessment may have been overlooked, which would have provided valuable information on further barriers and facilitators (i.e., threats to professional identity in different cultures), affecting the rigor of this study.

Third, most of the studies reviewed captured CDSSs for use in primary care settings. CDSSs in highly specialized specialties or those that frequently treat multi-morbid patients, such as cardiology and geriatrics, require features that allow for detailed workflow customization. In such specialties, even more attention needs to be paid to balancing provider autonomy and workflow standardization [ 97 ]. As such, future research should provide the missing evidence in such complex settings.

Fourth, we were only able to identify a limited number of studies that empirically analyzed the causal relationships included in our framework. There is a lack of studies that use longitudinal research designs, quantitative data, or experimental study designs. Therefore, the identified effects of technological, organizational, and human factors on professional identity and consequently on implementation success need to be interpreted with caution. Future research should test whether the determinants and effects of professional identity mechanisms among healthcare professionals can be observed in real-world settings.

Professional identity threat is a key cognitive state that impedes CDSS implementation among various health care professionals and along all implementation phases [ 31 , 45 ]. Health care managers need to engage in supportive leadership behaviors, communicate the benefits of CDSSs, and leverage supportive organizational practices to mitigate the perception and effect of professional identity threat. An innovation culture needs to support the use of CDSSs and top management commitment should reduce uncertainty about why a new CDSS is needed [ 24 ]. Therefore, leaders should raise awareness of the relevant CDSS functionalities and communicate the terms and conditions of use. It is crucial to involve clinicians in updating CDSS features and developing new ones to ensure that CDSSs can be quickly updated to reflect rapid developments in guideline development [ 195 ]. One way to achieve this is to engage proactive, respected, and passionate individuals who can train colleagues to use the CDSS and promote the potential benefits of the system [ 70 , 82 ].

Our framework presented in this study provides a relevant foundation for further research on the complex relationship between human, technological, and organizational implementation factors and professional identity among different health care professionals. The findings also guide health care management experts and IT system developers in designing new CDSSs and implementation strategies by considering the ingrained norms and cognitions of health care professionals. As suggested above, more research is needed to determine whether some barriers or facilitators are universal across all types of CDSSs or whether there are domain-dependent patterns. In this context, research that explicitly focuses on AI-based CDSSs becomes increasingly important as they become more relevant in medical practice. In fact, five of the studies included in our research, conducted over the last 3 years, examined factors related to the adoption and implementation of AI-based CDSS [ 73 , 74 , 96 , 205 , 206 ]. AI-based CDSSs extend to full automation and can discover new relationships and make predictions based on learned patterns [ 97 ]. However, with their opaque and automated decision-making processes, AI-based systems may increasingly challenge professional identity as they increasingly disrupt traditional practices and hierarchies within healthcare organizations, posing a threat to professional expertise and autonomy [ 156 ]. This may further hinder the implementation and sustainable use of these systems compared to non-AI-based systems. Future research could examine overlaps in barriers and facilitators between CDSSs and AI-based systems, which are of relevance for professional identity threat perceptions among health care professionals, and assess the reasons behind these differences. In addition, translating the findings for different medical contexts may provide valuable insights. This can eventually lead to guidelines for the development of CDSS for different specialties.

Some factors were found less frequently during our analysis; in particular, communication of the benefits of a CDSS to users, the importance of trust across different hierarchies and among staff involved in implementation, and government-level factors related to the environment. While the former factors represent important psychological safety and acceptance of the CDSS, the level of the environment represents a minor role in the perception of professional identity. Future research is needed, however, to determine whether all of these factors play an important role in CDSS implementation. Furthermore, future research could explore the role of middle managers and team managers in health care organizations rather than the role of senior management in managing professional identity threats when leading change. Our narrative review found that clinical middle managers may have a special role in legitimizing CDSSs [ 156 ]. In addition, a future research opportunity arises from the perceived role and identity enhancement through new technologies and their consequences for social evaluation in hierarchical healthcare organizations [ 35 , 132 , 155 ].

Overall, the findings of this review are particularly relevant for managers of CDSS implementation projects. Thoughtful management of professional identity threat factors identified in this review can help overcome barriers and facilitate the implementation of CDSSs. By addressing practical implications and research gaps, future studies can contribute to a deeper understanding of the threat to professional identity and provide evidence for effective implementation strategies of CDSSs and thus for a higher quality and efficiency in the increasingly overburdened health care system.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Artificial intelligence

  • Clinical decision support system

Electronic health record

Mixed Methods Appraisal tool

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SA conceived the study, developed the literature search, screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and conceptualized and wrote the sections of the manuscript. TH conceived the study, developed the literature search, screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and edited the sections of the manuscript. CK screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and revised the manuscript. CS planned and coordinated the study and edited the manuscript. All authors read and approved the final manuscript.

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Additional file 1: table s1..

Final search strings used to identify articles for the review. Table S2. Characteristics of included studies.

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Ackerhans, S., Huynh, T., Kaiser, C. et al. Exploring the role of professional identity in the implementation of clinical decision support systems—a narrative review. Implementation Sci 19 , 11 (2024). https://doi.org/10.1186/s13012-024-01339-x

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Writing, reading, and critiquing reviews

Écrire, lire et revue critique, douglas archibald.

1 University of Ottawa, Ontario, Canada;

Maria Athina Martimianakis

2 University of Toronto, Ontario, Canada

Why reviews matter

What do all authors of the CMEJ have in common? For that matter what do all health professions education scholars have in common? We all engage with literature. When you have an idea or question the first thing you do is find out what has been published on the topic of interest. Literature reviews are foundational to any study. They describe what is known about given topic and lead us to identify a knowledge gap to study. All reviews require authors to be able accurately summarize, synthesize, interpret and even critique the research literature. 1 , 2 In fact, for this editorial we have had to review the literature on reviews . Knowledge and evidence are expanding in our field of health professions education at an ever increasing rate and so to help keep pace, well written reviews are essential. Though reviews may be difficult to write, they will always be read. In this editorial we survey the various forms review articles can take. As well we want to provide authors and reviewers at CMEJ with some guidance and resources to be able write and/or review a review article.

What are the types of reviews conducted in Health Professions Education?

Health professions education attracts scholars from across disciplines and professions. For this reason, there are numerous ways to conduct reviews and it is important to familiarize oneself with these different forms to be able to effectively situate your work and write a compelling rationale for choosing your review methodology. 1 , 2 To do this, authors must contend with an ever-increasing lexicon of review type articles. In 2009 Grant and colleagues conducted a typology of reviews to aid readers makes sense of the different review types, listing fourteen different ways of conducting reviews, not all of which are mutually exclusive. 3 Interestingly, in their typology they did not include narrative reviews which are often used by authors in health professions education. In Table 1 , we offer a short description of three common types of review articles submitted to CMEJ.

Three common types of review articles submitted to CMEJ

More recently, authors such as Greenhalgh 4 have drawn attention to the perceived hierarchy of systematic reviews over scoping and narrative reviews. Like Greenhalgh, 4 we argue that systematic reviews are not to be seen as the gold standard of all reviews. Instead, it is important to align the method of review to what the authors hope to achieve, and pursue the review rigorously, according to the tenets of the chosen review type. Sometimes it is helpful to read part of the literature on your topic before deciding on a methodology for organizing and assessing its usefulness. Importantly, whether you are conducting a review or reading reviews, appreciating the differences between different types of reviews can also help you weigh the author’s interpretation of their findings.

In the next section we summarize some general tips for conducting successful reviews.

How to write and review a review article

In 2016 David Cook wrote an editorial for Medical Education on tips for a great review article. 13 These tips are excellent suggestions for all types of articles you are considering to submit to the CMEJ. First, start with a clear question: focused or more general depending on the type of review you are conducting. Systematic reviews tend to address very focused questions often summarizing the evidence of your topic. Other types of reviews tend to have broader questions and are more exploratory in nature.

Following your question, choose an approach and plan your methods to match your question…just like you would for a research study. Fortunately, there are guidelines for many types of reviews. As Cook points out the most important consideration is to be sure that the methods you follow lead to a defensible answer to your review question. To help you prepare for a defensible answer there are many guides available. For systematic reviews consult PRISMA guidelines ; 13 for scoping reviews PRISMA-ScR ; 14 and SANRA 15 for narrative reviews. It is also important to explain to readers why you have chosen to conduct a review. You may be introducing a new way for addressing an old problem, drawing links across literatures, filling in gaps in our knowledge about a phenomenon or educational practice. Cook refers to this as setting the stage. Linking back to the literature is important. In systematic reviews for example, you must be clear in explaining how your review builds on existing literature and previous reviews. This is your opportunity to be critical. What are the gaps and limitations of previous reviews? So, how will your systematic review resolve the shortcomings of previous work? In other types of reviews, such as narrative reviews, its less about filling a specific knowledge gap, and more about generating new research topic areas, exposing blind spots in our thinking, or making creative new links across issues. Whatever, type of review paper you are working on, the next steps are ones that can be applied to any scholarly writing. Be clear and offer insight. What is your main message? A review is more than just listing studies or referencing literature on your topic. Lead your readers to a convincing message. Provide commentary and interpretation for the studies in your review that will help you to inform your conclusions. For systematic reviews, Cook’s final tip is most likely the most important– report completely. You need to explain all your methods and report enough detail that readers can verify the main findings of each study you review. The most common reasons CMEJ reviewers recommend to decline a review article is because authors do not follow these last tips. In these instances authors do not provide the readers with enough detail to substantiate their interpretations or the message is not clear. Our recommendation for writing a great review is to ensure you have followed the previous tips and to have colleagues read over your paper to ensure you have provided a clear, detailed description and interpretation.

Finally, we leave you with some resources to guide your review writing. 3 , 7 , 8 , 10 , 11 , 16 , 17 We look forward to seeing your future work. One thing is certain, a better appreciation of what different reviews provide to the field will contribute to more purposeful exploration of the literature and better manuscript writing in general.

In this issue we present many interesting and worthwhile papers, two of which are, in fact, reviews.

Major Contributions

A chance for reform: the environmental impact of travel for general surgery residency interviews by Fung et al. 18 estimated the CO 2 emissions associated with traveling for residency position interviews. Due to the high emissions levels (mean 1.82 tonnes per applicant), they called for the consideration of alternative options such as videoconference interviews.

Understanding community family medicine preceptors’ involvement in educational scholarship: perceptions, influencing factors and promising areas for action by Ward and team 19 identified barriers, enablers, and opportunities to grow educational scholarship at community-based teaching sites. They discovered a growing interest in educational scholarship among community-based family medicine preceptors and hope the identification of successful processes will be beneficial for other community-based Family Medicine preceptors.

Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners by Allison Brown and team 20 studied the impact of COVID-19 on medical learners around the world. There were different concerns depending on the levels of training, such as residents’ concerns with career timeline compared to trainees’ concerns with the quality of learning. Overall, the learners negatively perceived the disruption at all levels and geographic regions.

The impact of local health professions education grants: is it worth the investment? by Susan Humphrey-Murto and co-authors 21 considered factors that lead to the publication of studies supported by local medical education grants. They identified several factors associated with publication success, including previous oral or poster presentations. They hope their results will be valuable for Canadian centres with local grant programs.

Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions by Stephana Cherak and team 22 studied learner-wellness in various training environments disrupted by the pandemic. They reported a negative impact on learner wellness at all stages of training. Their results can benefit the development of future wellness interventions.

Program directors’ reflections on national policy change in medical education: insights on decision-making, accreditation, and the CanMEDS framework by Dore, Bogie, et al. 23 invited program directors to reflect on the introduction of the CanMEDS framework into Canadian postgraduate medical education programs. Their survey revealed that while program directors (PDs) recognized the necessity of the accreditation process, they did not feel they had a voice when the change occurred. The authors concluded that collaborations with PDs would lead to more successful outcomes.

Experiential learning, collaboration and reflection: key ingredients in longitudinal faculty development by Laura Farrell and team 24 stressed several elements for effective longitudinal faculty development (LFD) initiatives. They found that participants benefited from a supportive and collaborative environment while trying to learn a new skill or concept.

Brief Reports

The effect of COVID-19 on medical students’ education and wellbeing: a cross-sectional survey by Stephanie Thibaudeau and team 25 assessed the impact of COVID-19 on medical students. They reported an overall perceived negative impact, including increased depressive symptoms, increased anxiety, and reduced quality of education.

In Do PGY-1 residents in Emergency Medicine have enough experiences in resuscitations and other clinical procedures to meet the requirements of a Competence by Design curriculum? Meshkat and co-authors 26 recorded the number of adult medical resuscitations and clinical procedures completed by PGY1 Fellow of the Royal College of Physicians in Emergency Medicine residents to compare them to the Competence by Design requirements. Their study underscored the importance of monitoring collection against pre-set targets. They concluded that residency program curricula should be regularly reviewed to allow for adequate clinical experiences.

Rehearsal simulation for antenatal consults by Anita Cheng and team 27 studied whether rehearsal simulation for antenatal consults helped residents prepare for difficult conversations with parents expecting complications with their baby before birth. They found that while rehearsal simulation improved residents’ confidence and communication techniques, it did not prepare them for unexpected parent responses.

Review Papers and Meta-Analyses

Peer support programs in the fields of medicine and nursing: a systematic search and narrative review by Haykal and co-authors 28 described and evaluated peer support programs in the medical field published in the literature. They found numerous diverse programs and concluded that including a variety of delivery methods to meet the needs of all participants is a key aspect for future peer-support initiatives.

Towards competency-based medical education in addictions psychiatry: a systematic review by Bahji et al. 6 identified addiction interventions to build competency for psychiatry residents and fellows. They found that current psychiatry entrustable professional activities need to be better identified and evaluated to ensure sustained competence in addictions.

Six ways to get a grip on leveraging the expertise of Instructional Design and Technology professionals by Chen and Kleinheksel 29 provided ways to improve technology implementation by clarifying the role that Instructional Design and Technology professionals can play in technology initiatives and technology-enhanced learning. They concluded that a strong collaboration is to the benefit of both the learners and their future patients.

In his article, Seven ways to get a grip on running a successful promotions process, 30 Simon Field provided guidelines for maximizing opportunities for successful promotion experiences. His seven tips included creating a rubric for both self-assessment of likeliness of success and adjudication by the committee.

Six ways to get a grip on your first health education leadership role by Stasiuk and Scott 31 provided tips for considering a health education leadership position. They advised readers to be intentional and methodical in accepting or rejecting positions.

Re-examining the value proposition for Competency-Based Medical Education by Dagnone and team 32 described the excitement and controversy surrounding the implementation of competency-based medical education (CBME) by Canadian postgraduate training programs. They proposed observing which elements of CBME had a positive impact on various outcomes.

You Should Try This

In their work, Interprofessional culinary education workshops at the University of Saskatchewan, Lieffers et al. 33 described the implementation of interprofessional culinary education workshops that were designed to provide health professions students with an experiential and cooperative learning experience while learning about important topics in nutrition. They reported an enthusiastic response and cooperation among students from different health professional programs.

In their article, Physiotherapist-led musculoskeletal education: an innovative approach to teach medical students musculoskeletal assessment techniques, Boulila and team 34 described the implementation of physiotherapist-led workshops, whether the workshops increased medical students’ musculoskeletal knowledge, and if they increased confidence in assessment techniques.

Instagram as a virtual art display for medical students by Karly Pippitt and team 35 used social media as a platform for showcasing artwork done by first-year medical students. They described this shift to online learning due to COVID-19. Using Instagram was cost-saving and widely accessible. They intend to continue with both online and in-person displays in the future.

Adapting clinical skills volunteer patient recruitment and retention during COVID-19 by Nazerali-Maitland et al. 36 proposed a SLIM-COVID framework as a solution to the problem of dwindling volunteer patients due to COVID-19. Their framework is intended to provide actionable solutions to recruit and engage volunteers in a challenging environment.

In Quick Response codes for virtual learner evaluation of teaching and attendance monitoring, Roxana Mo and co-authors 37 used Quick Response (QR) codes to monitor attendance and obtain evaluations for virtual teaching sessions. They found QR codes valuable for quick and simple feedback that could be used for many educational applications.

In Creation and implementation of the Ottawa Handbook of Emergency Medicine Kaitlin Endres and team 38 described the creation of a handbook they made as an academic resource for medical students as they shift to clerkship. It includes relevant content encountered in Emergency Medicine. While they intended it for medical students, they also see its value for nurses, paramedics, and other medical professionals.

Commentary and Opinions

The alarming situation of medical student mental health by D’Eon and team 39 appealed to medical education leaders to respond to the high numbers of mental health concerns among medical students. They urged leaders to address the underlying problems, such as the excessive demands of the curriculum.

In the shadows: medical student clinical observerships and career exploration in the face of COVID-19 by Law and co-authors 40 offered potential solutions to replace in-person shadowing that has been disrupted due to the COVID-19 pandemic. They hope the alternatives such as virtual shadowing will close the gap in learning caused by the pandemic.

Letters to the Editor

Canadian Federation of Medical Students' response to “ The alarming situation of medical student mental health” King et al. 41 on behalf of the Canadian Federation of Medical Students (CFMS) responded to the commentary by D’Eon and team 39 on medical students' mental health. King called upon the medical education community to join the CFMS in its commitment to improving medical student wellbeing.

Re: “Development of a medical education podcast in obstetrics and gynecology” 42 was written by Kirubarajan in response to the article by Development of a medical education podcast in obstetrics and gynecology by Black and team. 43 Kirubarajan applauded the development of the podcast to meet a need in medical education, and suggested potential future topics such as interventions to prevent learner burnout.

Response to “First year medical student experiences with a clinical skills seminar emphasizing sexual and gender minority population complexity” by Kumar and Hassan 44 acknowledged the previously published article by Biro et al. 45 that explored limitations in medical training for the LGBTQ2S community. However, Kumar and Hassen advocated for further progress and reform for medical training to address the health requirements for sexual and gender minorities.

In her letter, Journey to the unknown: road closed!, 46 Rosemary Pawliuk responded to the article, Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic, by Gutman et al. 47 Pawliuk agreed that international medical students (IMGs) do not have adequate formal representation when it comes to residency training decisions. Therefore, Pawliuk challenged health organizations to make changes to give a voice in decision-making to the organizations representing IMGs.

In Connections, 48 Sara Guzman created a digital painting to portray her approach to learning. Her image of a hand touching a neuron showed her desire to physically see and touch an active neuron in order to further understand the brain and its connections.

SYSTEMATIC REVIEW article

This article is part of the research topic.

The Application of Bioactive Materials in Bone Repair

Effectiveness of Strontium/Silver-Based Titanium Surface Coatings in Improving Antibacterial and Osteogenic Implant Characteristics: A Systematic Review of In-vitro Studies

  • 1 Hannover Medical School, Germany
  • 2 Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Germany

The final, formatted version of the article will be published soon.

Due to the high incidence of implant failures, dual functionalization of titanium surfaces with antibacterial and osteogenic agents, like silver (Ag) and strontium (Sr), has gained significant attention in recent years. However, so far, the combined antibacterial and osteoinductive effectiveness of Ag/Srbased titanium surface coatings has only been analyzed in individual studies. Therefore, this systematic review aims to evaluate the existing scientific literature regarding the PICOS question "Does dual incorporation of strontium/silver enhances the osteogenic and anti-bacterial characteristics of Ti surfaces in vitro?". As a result of a web-based search adhering to the PRISMA Guidelines using three electronic databases (PubMed, Scopus, and Web of Science) until March 31, 2023, a total of 69 publications were identified as potentially relevant and 17 of which were considered appropriate for inclusion into this review. In all included publications, the use of Sr/Ag combination showed enhanced osteogenic and antibacterial effects, either alone or in combination with other agents. Moreover, the combination of Sr and Ag shows potential to synergistically enhance these effects. Nevertheless, further studies need to validate these findings under clinically more relevant conditions and evaluate the mechanism of antimicrobial and osteogenic activity of Sr/Ag combination.

Keywords: Antibacterial, Osteogenic, Silver, Strontium, Titanium

Received: 30 Nov 2023; Accepted: 16 Feb 2024.

Copyright: © 2024 Kheirmand-Parizi, Doll-Nikutta, Denis, Gaikwad and Stiesch. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Marjan Kheirmand-Parizi, Hannover Medical School, Hanover, Germany

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