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Why is it important to do a literature review in research?

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 “A substantive, thorough, sophisticated literature review is a precondition for doing substantive, thorough, sophisticated research”. Boote and Baile 2005

Authors of manuscripts treat writing a literature review as a routine work or a mere formality. But a seasoned one knows the purpose and importance of a well-written literature review.  Since it is one of the basic needs for researches at any level, they have to be done vigilantly. Only then the reader will know that the basics of research have not been neglected.

Importance of Literature Review In Research

The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions.   Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.  It is possible only with profound knowledge of what is wrong in the existing findings in detail to overpower them.  For other researches, the literature review gives the direction to be headed for its success. 

The common perception of literature review and reality:

As per the common belief, literature reviews are only a summary of the sources related to the research. And many authors of scientific manuscripts believe that they are only surveys of what are the researches are done on the chosen topic.  But on the contrary, it uses published information from pertinent and relevant sources like

  • Scholarly books
  • Scientific papers
  • Latest studies in the field
  • Established school of thoughts
  • Relevant articles from renowned scientific journals

and many more for a field of study or theory or a particular problem to do the following:

  • Summarize into a brief account of all information
  • Synthesize the information by restructuring and reorganizing
  • Critical evaluation of a concept or a school of thought or ideas
  • Familiarize the authors to the extent of knowledge in the particular field
  • Encapsulate
  • Compare & contrast

By doing the above on the relevant information, it provides the reader of the scientific manuscript with the following for a better understanding of it:

  • It establishes the authors’  in-depth understanding and knowledge of their field subject
  • It gives the background of the research
  • Portrays the scientific manuscript plan of examining the research result
  • Illuminates on how the knowledge has changed within the field
  • Highlights what has already been done in a particular field
  • Information of the generally accepted facts, emerging and current state of the topic of research
  • Identifies the research gap that is still unexplored or under-researched fields
  • Demonstrates how the research fits within a larger field of study
  • Provides an overview of the sources explored during the research of a particular topic

Importance of literature review in research:

The importance of literature review in scientific manuscripts can be condensed into an analytical feature to enable the multifold reach of its significance.  It adds value to the legitimacy of the research in many ways:

  • Provides the interpretation of existing literature in light of updated developments in the field to help in establishing the consistency in knowledge and relevancy of existing materials
  • It helps in calculating the impact of the latest information in the field by mapping their progress of knowledge.
  • It brings out the dialects of contradictions between various thoughts within the field to establish facts
  • The research gaps scrutinized initially are further explored to establish the latest facts of theories to add value to the field
  • Indicates the current research place in the schema of a particular field
  • Provides information for relevancy and coherency to check the research
  • Apart from elucidating the continuance of knowledge, it also points out areas that require further investigation and thus aid as a starting point of any future research
  • Justifies the research and sets up the research question
  • Sets up a theoretical framework comprising the concepts and theories of the research upon which its success can be judged
  • Helps to adopt a more appropriate methodology for the research by examining the strengths and weaknesses of existing research in the same field
  • Increases the significance of the results by comparing it with the existing literature
  • Provides a point of reference by writing the findings in the scientific manuscript
  • Helps to get the due credit from the audience for having done the fact-finding and fact-checking mission in the scientific manuscripts
  • The more the reference of relevant sources of it could increase more of its trustworthiness with the readers
  • Helps to prevent plagiarism by tailoring and uniquely tweaking the scientific manuscript not to repeat other’s original idea
  • By preventing plagiarism , it saves the scientific manuscript from rejection and thus also saves a lot of time and money
  • Helps to evaluate, condense and synthesize gist in the author’s own words to sharpen the research focus
  • Helps to compare and contrast to  show the originality and uniqueness of the research than that of the existing other researches
  • Rationalizes the need for conducting the particular research in a specified field
  • Helps to collect data accurately for allowing any new methodology of research than the existing ones
  • Enables the readers of the manuscript to answer the following questions of its readers for its better chances for publication
  • What do the researchers know?
  • What do they not know?
  • Is the scientific manuscript reliable and trustworthy?
  • What are the knowledge gaps of the researcher?

22. It helps the readers to identify the following for further reading of the scientific manuscript:

  • What has been already established, discredited and accepted in the particular field of research
  • Areas of controversy and conflicts among different schools of thought
  • Unsolved problems and issues in the connected field of research
  • The emerging trends and approaches
  • How the research extends, builds upon and leaves behind from the previous research

A profound literature review with many relevant sources of reference will enhance the chances of the scientific manuscript publication in renowned and reputed scientific journals .

References:

http://www.math.montana.edu/jobo/phdprep/documents/phd6.pdf

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Conducting a literature review: why do a literature review, why do a literature review.

  • How To Find "The Literature"
  • Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

  • core research in the field
  • experts in the subject area
  • methodology you may want to use (or avoid)
  • gaps in knowledge -- or where your research would fit in

It Also Helps You:

  • Publish and share your findings
  • Justify requests for grants and other funding
  • Identify best practices to inform practice
  • Set wider context for a program evaluation
  • Compile information to support community organizing

Great brief overview, from NCSU

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Literature Review in Research Writing

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Research on research? If you find this idea rather peculiar, know that nowadays, with the huge amount of information produced daily all around the world, it is becoming more and more difficult to keep up to date with all of it. In addition to the sheer amount of research, there is also its origin. We are witnessing the economic and intellectual emergence of countries like China, Brazil, Turkey, and United Arab Emirates, for example, that are producing scholarly literature in their own languages. So, apart from the effort of gathering information, there must also be translators prepared to unify all of it in a single language to be the object of the literature survey. At Elsevier, our team of translators is ready to support researchers by delivering high-quality scientific translations , in several languages, to serve their research – no matter the topic.

What is a literature review?

A literature review is a study – or, more accurately, a survey – involving scholarly material, with the aim to discuss published information about a specific topic or research question. Therefore, to write a literature review, it is compulsory that you are a real expert in the object of study. The results and findings will be published and made available to the public, namely scientists working in the same area of research.

How to Write a Literature Review

First of all, don’t forget that writing a literature review is a great responsibility. It’s a document that is expected to be highly reliable, especially concerning its sources and findings. You have to feel intellectually comfortable in the area of study and highly proficient in the target language; misconceptions and errors do not have a place in a document as important as a literature review. In fact, you might want to consider text editing services, like those offered at Elsevier, to make sure your literature is following the highest standards of text quality. You want to make sure your literature review is memorable by its novelty and quality rather than language errors.

Writing a literature review requires expertise but also organization. We cannot teach you about your topic of research, but we can provide a few steps to guide you through conducting a literature review:

  • Choose your topic or research question: It should not be too comprehensive or too limited. You have to complete your task within a feasible time frame.
  • Set the scope: Define boundaries concerning the number of sources, time frame to be covered, geographical area, etc.
  • Decide which databases you will use for your searches: In order to search the best viable sources for your literature review, use highly regarded, comprehensive databases to get a big picture of the literature related to your topic.
  • Search, search, and search: Now you’ll start to investigate the research on your topic. It’s critical that you keep track of all the sources. Start by looking at research abstracts in detail to see if their respective studies relate to or are useful for your own work. Next, search for bibliographies and references that can help you broaden your list of resources. Choose the most relevant literature and remember to keep notes of their bibliographic references to be used later on.
  • Review all the literature, appraising carefully it’s content: After reading the study’s abstract, pay attention to the rest of the content of the articles you deem the “most relevant.” Identify methodologies, the most important questions they address, if they are well-designed and executed, and if they are cited enough, etc.

If it’s the first time you’ve published a literature review, note that it is important to follow a special structure. Just like in a thesis, for example, it is expected that you have an introduction – giving the general idea of the central topic and organizational pattern – a body – which contains the actual discussion of the sources – and finally the conclusion or recommendations – where you bring forward whatever you have drawn from the reviewed literature. The conclusion may even suggest there are no agreeable findings and that the discussion should be continued.

Why are literature reviews important?

Literature reviews constantly feed new research, that constantly feeds literature reviews…and we could go on and on. The fact is, one acts like a force over the other and this is what makes science, as a global discipline, constantly develop and evolve. As a scientist, writing a literature review can be very beneficial to your career, and set you apart from the expert elite in your field of interest. But it also can be an overwhelming task, so don’t hesitate in contacting Elsevier for text editing services, either for profound edition or just a last revision. We guarantee the very highest standards. You can also save time by letting us suggest and make the necessary amendments to your manuscript, so that it fits the structural pattern of a literature review. Who knows how many worldwide researchers you will impact with your next perfectly written literature review.

Know more: How to Find a Gap in Research .

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

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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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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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

  • Explains the background of research on a topic.
  • Demonstrates why a topic is significant to a subject area.
  • Discovers relationships between research studies/ideas.
  • Identifies major themes, concepts, and researchers on a topic.
  • Identifies critical gaps and points of disagreement.
  • Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

  • Make sure your research question is not too broad or too narrow.  Is it manageable?
  • Begin writing down terms that are related to your question. These will be useful for searches later.
  • If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

  • This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

  • use the tabs on this guide
  • Find other databases in the Nursing Information Resources web page
  • More on the Medical Library web page
  • ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

  • Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
  • Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
  • Review the abstracts of research studies carefully. This will save you time.
  • Use the bibliographies and references of research studies you find to locate others.
  • Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
  • Ask your librarian for help at any time.
  • Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

  • What was the research question of the study you are reviewing? What were the authors trying to discover?
  • Was the research funded by a source that could influence the findings?
  • What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
  • Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
  • If there are conflicting studies, why do you think that is?
  • How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

  • Review the abstracts carefully.  
  • Keep careful notes so that you may track your thought processes during the research process.
  • Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

  • Provide a comprehensive and updated review of the literature;
  • Explain why this review has taken place;
  • Articulate a position or hypothesis;
  • Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

  • Demonstrate how a study fills a gap in research
  • Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

  • Organizes or describes a topic
  • Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

  • It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
  • It may be too focused. Some niche studies may miss the bigger picture.
  • It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
  • It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

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Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

  • October 26, 2022 recording
  • Last Updated: Oct 26, 2022 2:49 PM
  • URL: https://guides.lib.utexas.edu/literaturereviews

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  • UConn Library
  • Literature Review: The What, Why and How-to Guide
  • Introduction

Literature Review: The What, Why and How-to Guide — Introduction

  • Getting Started
  • How to Pick a Topic
  • Strategies to Find Sources
  • Evaluating Sources & Lit. Reviews
  • Tips for Writing Literature Reviews
  • Writing Literature Review: Useful Sites
  • Citation Resources
  • Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

  • To develop a theory or evaluate an existing theory
  • To summarize the historical or existing state of a research topic
  • Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

  • A research paper assigned in a course
  • A thesis or dissertation
  • A grant proposal
  • An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

  • Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

  • Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

  • Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

  • Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

  • UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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  • Next: How to Pick a Topic >>
  • Last Updated: Sep 21, 2022 2:16 PM
  • URL: https://guides.lib.uconn.edu/literaturereview

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Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Cover of Handbook of eHealth Evaluation: An Evidence-based Approach

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

  • formulating the research question(s) and objective(s),
  • searching the extant literature,
  • screening for inclusion,
  • assessing the quality of primary studies,
  • extracting data, and
  • analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health ( m-health ) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

  • Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
  • Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
  • Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
  • Analyzing data using quantitative or qualitative methods.
  • Presenting results in summary of findings tables.
  • Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Table 9.1. Typology of Literature Reviews (adapted from Paré et al., 2015).

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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  • Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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  • Concluding Remarks

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Literature Review: Purpose of a Literature Review

  • Literature Review
  • Purpose of a Literature Review
  • Work in Progress
  • Compiling & Writing
  • Books, Articles, & Web Pages
  • Types of Literature Reviews
  • Departmental Differences
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  • Know the Difference! Systematic Review vs. Literature Review

The purpose of a literature review is to:

  • Provide a foundation of knowledge on a topic
  • Identify areas of prior scholarship to prevent duplication and give credit to other researchers
  • Identify inconstancies: gaps in research, conflicts in previous studies, open questions left from other research
  • Identify the need for additional research (justifying your research)
  • Identify the relationship of works in the context of their contribution to the topic and other works
  • Place your own research within the context of existing literature, making a case for why further study is needed.

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VIDEO: What is the role of a literature review in research? What's it mean to "review" the literature? Get the big picture of what to expect as part of the process. This video is published under a Creative Commons 3.0 BY-NC-SA US license. License, credits, and contact information can be found here: https://www.lib.ncsu.edu/tutorials/litreview/

Elements in a Literature Review

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Conducting a Literature Review

Benefits of conducting a literature review.

  • Steps in Conducting a Literature Review
  • Summary of the Process
  • Additional Resources
  • Literature Review Tutorial by American University Library
  • The Literature Review: A Few Tips On Conducting It by University of Toronto
  • Write a Literature Review by UC Santa Cruz University Library

While there might be many reasons for conducting a literature review, following are four key outcomes of doing the review.

Assessment of the current state of research on a topic . This is probably the most obvious value of the literature review. Once a researcher has determined an area to work with for a research project, a search of relevant information sources will help determine what is already known about the topic and how extensively the topic has already been researched.

Identification of the experts on a particular topic . One of the additional benefits derived from doing the literature review is that it will quickly reveal which researchers have written the most on a particular topic and are, therefore, probably the experts on the topic. Someone who has written twenty articles on a topic or on related topics is more than likely more knowledgeable than someone who has written a single article. This same writer will likely turn up as a reference in most of the other articles written on the same topic. From the number of articles written by the author and the number of times the writer has been cited by other authors, a researcher will be able to assume that the particular author is an expert in the area and, thus, a key resource for consultation in the current research to be undertaken.

Identification of key questions about a topic that need further research . In many cases a researcher may discover new angles that need further exploration by reviewing what has already been written on a topic. For example, research may suggest that listening to music while studying might lead to better retention of ideas, but the research might not have assessed whether a particular style of music is more beneficial than another. A researcher who is interested in pursuing this topic would then do well to follow up existing studies with a new study, based on previous research, that tries to identify which styles of music are most beneficial to retention.

Determination of methodologies used in past studies of the same or similar topics.  It is often useful to review the types of studies that previous researchers have launched as a means of determining what approaches might be of most benefit in further developing a topic. By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research.

Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take. Should any additional questions arise during the course of the research, the researcher will know which experts to consult in order to quickly clear up those questions.

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Library Guide to Capstone Literature Reviews: Role of the Literature Review

The role of the literature review.

Your literature review gives readers an understanding of the scholarly research on your topic.

In your literature review you will:

  • demonstrate that you are a well-informed scholar with expertise and knowledge in the field by giving an overview of the current state of the literature
  • find a gap in the literature, or address a business or professional issue, depending on your doctoral study program; the literature review will illustrate how your research contributes to the scholarly conversation
  • provide a synthesis of the issues, trends, and concepts surrounding your research

the importance of the review of related literature

Be aware that the literature review is an iterative process. As you read and write initial drafts, you will find new threads and complementary themes, at which point you will return to search, find out about these new themes, and incorporate them into your review.

The purpose of this guide is to help you through the literature review process. Take some time to look over the resources in order to become familiar with them. The tabs on the left side of this page have additional information.

Short video: Research for the Literature Review

Short Video: Research for the Literature Review

(4 min 10 sec) Recorded August 2019 Transcript 

Literature review as a dinner party

To think about the role of the literature review, consider this analogy:  pretend that you throw a dinner party for the other researchers working in your topic area. First, you’d need to develop a guest list.

  • The guests of honor would be early researchers or theorists; their work likely inspired subsequent studies, ideas, or controversies that the current researchers pursue.
  • Then, think about the important current researchers to invite. Which guests might agree with each other?  Which others might provide useful counterpoints?
  • You likely won’t be able to include everyone on the guest list, so you may need to choose carefully so that you don’t leave important figures out. 
  • Alternatively, if there aren’t many researchers working in your topic area, then your guest list will need to include people working in other, related areas, who can still contribute to the conversation.

After the party, you describe the evening to a friend. You’ll summarize the evening’s conversation. Perhaps one guest made a comment that sparked a conversation, and then you describe who responded and how the topic evolved. There are other conversations to share, too. This is how you synthesize the themes and developments that you find in your research. Thinking about your literature research this way will help you to present your dinner party (and your literature review) in a lively and engaging way.

Short video: Empirical research

Video: How to locate and identify empirical research for your literature review

(6 min 16 sec) Recorded May 2020 Transcript 

Here are some useful resources from the Writing Center, the Office of Research and Doctoral Services, and other departments within the Office of Academic Support. Take some time to look at what is available to help you with your capstone/dissertation.

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You can watch recorded webinars on the literature review in our Library Webinar Archives .

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What is the Purpose of a Literature Review?

What is the Purpose of a Literature Review?

4-minute read

  • 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

Literature Review Editing Services 

Ensure your literature review is polished and ready for submission by having it professionally proofread and edited by our expert team. Our literature review editing services will help your research stand out and make an impact. Not convinced yet? Send in your free sample today and see for yourself! 

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Literature Reviews

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the importance of the review of related literature

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the importance of the review of related literature

Definition: A literature review is a systematic examination and synthesis of existing scholarly research on a specific topic or subject.

Purpose: It serves to provide a comprehensive overview of the current state of knowledge within a particular field.

Analysis: Involves critically evaluating and summarizing key findings, methodologies, and debates found in academic literature.

Identifying Gaps: Aims to pinpoint areas where there is a lack of research or unresolved questions, highlighting opportunities for further investigation.

Contextualization: Enables researchers to understand how their work fits into the broader academic conversation and contributes to the existing body of knowledge.

the importance of the review of related literature

tl;dr  A literature review critically examines and synthesizes existing scholarly research and publications on a specific topic to provide a comprehensive understanding of the current state of knowledge in the field.

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❌ An annotated bibliography

❌ Original research

❌ A summary

❌ Something to be conducted at the end of your research

❌ An opinion piece

❌ A chronological compilation of studies

The reason for conducting a literature review is to:

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Need, Importance and 5 Sources of Review of Related Literature in Educational Research

Back to: Introduction to Educational Research Methodology

Educational research means the organized collection and examination of the data related to education. It is a scientific study that examines the learning and teaching methods for better understanding of the education system. It is an observation and investigation in the field of education. Research is done in search of new knowledge or to use the existing knowledge in a better way. It helps to acquire useful knowledge and solve the challenges faced in education. Research tries to get a better understanding of education. 

Literature review means the overview of the works published previously on a subject matter. It is the summary of the work done by other authors on a topic. Literature review will help a researcher in understanding how to carry on the research and what needs to be covered. 

Need of Reviewing Related Literature 

i. Avoid repetition and duplication of the study.

ii. Find out the gaps in research.

iii. Identify the additional research needed to be done.

iv. Gain extensive knowledge on a particular topic. 

v. Help understand what has already been covered about a topic and the findings need to be done for future research. 

Importance of Review of Related Literature

i. Help researchers to understand their topic of interest in-depth. 

ii. Help to identify the gaps uncovered by previous authors on a topic and collect relevant data.

iii. Get an understanding of how to carry on the research. 

Five Sources to Review Related Literature 

Scholarly journal articles.

Journal articles are an important source of literature review. It helps to understand how to carry out the research and the findings to be done.

Government websites

To collect statistical data, government websites can be very beneficial as it can provide a lot of information. Government websites are another important source of literature review. 

Academic books 

Academic books consist of works written by several authors. It contains original work which will be very helpful in literature review. 

Conference pages

Conference and seminar reports are also an important source of literature review to understand the thoughts of authors and works previously published in a field of study. 

Libraries contain numerous books and works on a topic by different authors. Plenty of information and facts can be obtained from this source of literature review. 

  • Systematic review
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  • Published: 12 February 2024

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

  • Sophia Ackerhans   ORCID: orcid.org/0009-0005-9269-6854 1 ,
  • Thomas Huynh 1 ,
  • Carsten Kaiser 1 &
  • Carsten Schultz 1  

Implementation Science volume  19 , Article number:  11 ( 2024 ) Cite this article

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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.

Peer Review reports

Contributions to the literature

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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Overby CL, Erwin AL, Abul-Husn NS, Ellis SB, Scott SA, Obeng AO, et al. Physician attitudes toward adopting genome-guided prescribing through clinical decision support. J Pers Med. 2014;4:35–49.

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Grout RW, Cheng ER, Carroll AE, Bauer NS, Downs SM. A six-year repeated evaluation of computerized clinical decision support system user acceptability. Int J Med Inform. 2018;112:74–81.

Sicotte C, Taylor L, Tamblyn R. Predicting the use of electronic prescribing among early adopters in primary care Recherche Prédire le taux d ’ utilisation de la prescription électronique chez ceux qui viennent de l ’ adopter dans un contexte de soins primaires 2013;59.

Pevnick JM, Asch SM, Adams JL, Mattke S, Patel MH, Ettner SL, et al. Adoption and use of stand-alone electronic prescribing in a health plan-sponsored initiative. Am J Manag Care. 2010;16:182–9.

Meulendijk M, Spruit M, Drenth-Van Maanen C, Numans M, Brinkkemper S, Jansen P. General practitioners’ attitudes towards decision-supported prescribing: An analysis of the Dutch primary care sector. Health Informatics J. 2013;19:247–63.

B S, A P, M K, A S, F M, B P-KP, et al. Comparative evaluation of different medication safety measures for the emergency department: physicians’ usage and acceptance of training, poster, checklist and computerized decision support. BMC Med Inform Decis Mak. 2013;13:79.

Holden RJ, Karsh BT. The Technology Acceptance Model: Its past and its future in health care. J Biomed Inform. 2010;43:159–72.

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Singer SJ, Hayes JE, Gray GC, Kiang MV. Making time for learning-oriented leadership in multidisciplinary hospital management groups. Health Care Manage Rev. 2015;40:300–12.

Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Heal Ment Heal Serv Res. 2011;38:65–76.

Liang H, Xue Y, Ke W, Wei KK. Understanding the influence of team climate on it use. J Assoc Inf Syst. 2010;11:414–32.

Holden RJ, Brown RL, Scanlon MC, Karsh BT. Modeling nurses’ acceptance of bar coded medication administration technology at a pediatric hospital. J Am Med Informatics Assoc. 2012;19:1050–8.

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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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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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Leveraging implementation science with using decision support technology to drive meaningful change for nurses and nursing leadership.

View as pdf A later version of this article appeared in  Nurse Leader ,  Volume 21, Issue 6 , December 2023 . 

Abstract Technology, such as clinical decision support, can play a role in supporting nurses’ decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting effective decision-making in practice and leadership. The purpose of this article is to discuss decision-making and information needs among nurses across roles and explain how technology and implementation science approaches can complement effective decision-making interventions.

Across settings and nursing roles, effective decision-making is fundamental to excellent nursing and patient care. For example, nurses in patient care roles often spend more time with patients than any other health discipline and frequently need to make decisions about when to inform the health care team with changes in a patient’s condition. Nurses in leadership roles must make a wide range of managerial decisions concerning nurse staffing, human resources, and which clinical technologies to advocate for the support direct care nurses’ decision-making. Factors such as increasing patient acuity, escalating evidence base, and global pandemics have led to increased complexity in nurse decision-making across roles. Technology can play a role in supporting nurses’ decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting effective decision-making in practice and leadership. The purpose of this article is to discuss decision-making and information needs among nurses across roles and explain how technology and implementation science approaches can complement effective decision-making interventions.

Decision-making Across Nursing

Decision-making, or executing a choice among options, is an essential process in nursing and numerous theories and models have been developed to describe and study nurse decision-making. 1-3 Approaches to decision-making can be broadly categorized as rational, using logical steps or rule-based thinking to determine the best option, or intuitive, which describes using instinct or subconscious pattern recognition to make a choice. 4  Over time, thinking has transformed from viewing nurse decision-making as primarily a rational process, to a process that is influenced by real-world demands, such as needing to make decisions with limited information, changing conditions, interruptions, and/or time pressure. 5,6 In these situations, experienced nurses rapidly apply insight from previous experiences to make decisions. 7,8  Given the variation in how decisions are made and real-world demands that nurses and leaders are faced with, a one-size-fits-all approach may not be useful when developing and implementing nurse decision-making interventions.

Information is a fundamental component of the decision-making process and is generated from diverse sources. Digital technologies (e.g., clinical decision support, telehealth, monitoring systems, artificial intelligence) can provide important new sources of information and address limitations to existing information sources, such as organizing EHR data to efficiently identify a patient’s risk for clinical deterioration. However, technologies that fail to adequately address information needs, or are difficult to use, will have limited adoption. Understanding the types of information nurses need in direct care and leadership roles, what information is available, and limitations to existing information sources is needed to evaluate interventions to support decision-making.

Technologic Considerations for Supporting Direct Care Nurses’ Information Needs

Nurses need timely, patient-specific clinical information to provide care. The electronic health record (EHR) is the primary source of patient data, however substantial documentation demands have significantly impacted nurse workload and workflows for finding relevant information. Studies estimate that nurses spend 35 to 41% of their time in the EHR documenting and reviewing patient information. 9,10 While nurses generate large amounts of data in the EHR, documenting an average of 631-875 flowsheet data points and spending an average of 21 minutes documenting notes per shift, there are significant challenges with organizing and synthesizing patient data. 11,12

An integrative review of EHR’s impact on nurses’ cognitive work identified the following limitations to meeting nurse information needs in the EHR: developing an overview of the patient’s history, current status, and plan; synthesizing information using EHR-generated reports to support information needs during a shift and at handoff; and achieving shared understanding of patient goals and care coordination. 13 Similar needs were found by Keenan et al. over a decade ago including the need for a centralized overview of patients accessible to all members of the healthcare team and effective technology to support nurse to nurse change of shift handoffs. 14   Given these challenges, work in two key areas – reducing documentation burden in the EHR and incorporating nurse information needs into EHR redesign are critical to support direct care nurse work.

Another critical area is related to nurses’ expectation to incorporate research into decision-making. This is commonly referred to as evidence-based practice: applying the best available evidence along with patient preferences in making clinical decisions and is a foundation of high-quality nursing care. 15 However, there is a persistent gap of 15 to 17 years between current best evidence and daily practice. 16,17   Studies of information needs and information use for evidence-based practice offer additional perspectives for understanding barriers to routinely using evidence in practice. Findings over the past 15 years indicate that nurses routinely seek out information from colleagues since they share clinical context and are accessible. 18,19  However, information shared by colleagues may be outdated or inaccurate when technology-based tools, such as clinical decision support, can provide nurses with up to date accurate information during a time that integrates well with nurses decision making workflow.

Technologic Considerations for Supporting Nurse Leaders’ Information Needs          

Nurse leaders across roles and settings must integrate patient and organizational data to optimize patient outcomes. Information needs vary by timing of decision. Nurse managers describe short-term information needs about patients related to throughput and staffing needs and long-term information needs focused on meeting organizational priorities, such as quality improvement initiatives and nurse retention. 20, 21 Whereas short-term information was commonly reported to come from the EHR and situational awareness, or understanding of the local environment, long-term information needs require leaders to search for information across sources. A recent review of nursing management information systems found that nursing leaders use information systems to manage human resources, determine nursing workload (nurse to patient ratio) and control costs. 22  These systems are largely based on two sources of data: patient classification measures and hospital resource measurement. The authors did not find a central database or decision support tool to support the work of nurse leaders, suggesting a critical need for new technology to address this gap.

In addition to their own information needs, nurse managers play a critical role in advocating for the information needs of the direct care nurses. For example, in the United States there are an increasing number of mandates and digital technologies related to care quality issues such as central line infection and hospital acquired pressure ulcer prevention. Nurse leaders must appraise digital technologies to determine whether the technology supports the direct care nurses’ information needs, ensure that it is easy to use and does not add to nursing workload as well as providing a return on investment.

A Role for Clinical Decision Support 

One technology-based intervention to assist nurses in complex in decision-making processes is clinical decision support (CDS) systems. CDS systems are computer-based tools to organize person-specific data and knowledge for clinicians and patients to improve the quality and safety of health care. 23 CDS is delivered in a variety of formats, such as through order sets, documentation templates, computerized alerts, dashboards, and visualizations, which may be integrated in electronic health record (EHR) systems or exist as applications or technologies outside the EHR. In general, CDS is composed of three key parts. 24

  • Data management: clinical data and decision rules or logic. Decision rules or logic may be developed using literature and current practice (knowledge-based) or artificial intelligence (non-knowledge-based).  
  • Processing: applies the knowledge or algorithms with patient data
  • User interface: the part of the system that communicates a recommendation and is the point the user interacts with (e.g., computer display, mouse).

Guiding principles for developing effective CDS are known as the CDS Five Rights, and state that CDS should communicate the right information, to the right person, in the right format, through the correct channel at the right time in the workflow. 25 These principles provide a valuable framework for nurse leaders to consider in evaluating potential CDS tools.

CDS tools support information management, which is an increasing need in healthcare given the large volumes of clinical, administrative and research data that is generated. Therefore, tools which filter relevant patient data and apply logic to determine a recommendation are needed. However, fewer CDS tools have been developed for nurses than have been for physicians and other members of the health care team. 26

Current Challenges and Opportunities in Nursing Clinical Support

Recognizing the opportunities for CDS to supporting decision-making must be balanced with the reality that gaps in developing and using CDS exist in nursing. A recent review of CDS tools across multiple disciplines found that only two-thirds of clinicians’ report using available CDS. 27 While understanding of CDS usage specifically among nurses is limited, several nurse, patient, organization, and technology factors have been identified to influence nurses’ use of CDS. 28 Given these challenges, the role of implementation science is emerging as an important approach to inform future CDS design and use. 29

Implementation Science

Implementation science centers on how evidence-based practices are adopted and sustained across specific settings. 30 Whereas evidence-based practice describes what recommendation should be used, implementation science focuses on how to best help people consistently do a particular recommendation in their work environment. 31 Implementation science frameworks provide guidance for understanding key components of implementation, such as describing the implementation process, identifying barriers and facilitators to implementation, or conducting an implementation evaluation. 32 Implementation strategies and context important concepts across most implementation science frameworks. Implementation strategies describe the specific interventions chosen to facilitate change. For example, the Iowa Implementation Model for Sustainability Framework provides an organized approach for selecting an implementation strategy based upon phases of implementation. 33 For example, after nurses have obtained knowledge about a practice change, audit and feedback may be one implementation strategy to promote adoption. Related, is the concept of context, or the unique local factors (e.g., unit culture, work environment, resources) that influence how or why implementation is achieved. 34 In partnership with implementation scientists, nurse leaders can identify unique barriers and facilitators to implementation in the local environment and then match the needs to implementation strategies.

Leveraging User-Centered Design

View Figure 1 as pdf

please see pdf

Considering the unique needs of users, or user-centered design, is a concept central to implementation science and CDS design (Figure 1). The goal of user-centered design is to make interventions “useable and useful” by focusing on user needs throughout the design and development process. 35 Implementation science and user-centered design use a variety approaches to obtain end-user input, which may include, workflow mapping, participatory design, rapid prototyping, and usability testing. 36, 37 However, methods to engage nurses early in CDS design and implementation are inconsistently applied.

Nurse leaders are in a key position to advocate for greater involvement of nurses, early and throughout the process of developing and implementing CDS. This may include developing processes for nurses to provide feedback about information needs in their settings, workflow considerations, and opportunities to test and refine CDS prototypes. Greater involvement of nursing informatics within organizations and including opportunities for nurses to receive training in implementation science and user-centered design are additional strategies to support integration of these concepts in CDS design and use. 38-40  An organizational culture that supports nurse information needs by considering both the types of CDS that nurses need and how CDS will be used in daily practice is critical, especially as new technologies are developed and CDS becomes more complex.

Nurses and nurse leaders need to make numerous decisions in highly complex work environments. CDS has an expanding potential to augment decision-making across roles by providing nurses with meaningful, person-specific information in a usable format to positively impact care and outcomes. Nurses that will be the eventual user of the CDS need to be involved early and throughout CDS development to ensure that CDS tools are usable, useful, align with workflow as a part of routine work. Implementation scientists, who understand the local context, are needed to design and test strategies for using CDS, both in specific settings and diffusing CDS use across settings. Approaches which consider both how CDS is designed for nurse users and how CDS is used and implemented across health systems is needed to support effective decision-making for driving change in nursing practice and leadership settings.

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  • Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: A guide to best practice . Lippincott Williams & Wilkins; 2022.
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Sense of belonging is a critical component of workforce retention

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  • Peer review
  • Julie K Silver , associate professor 1 ,
  • Elizabeth H Ellinas , founding director 2 ,
  • Allison C Augustus-Wallace , associate professor-research 3
  • 1 Department of Physical Medicine and Rehabilitation, Harvad Medical School, Boston, MA, USA
  • 2 Center for the Advancement of Women in Science and Medicine, Medical College of Wisconsin Milwaukee, WI, USA
  • 3 Office of Diversity and Community Engagement, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
  • Correspondence to: J K Silver Julie_Silver{at}hms.harvard.edu

Healthcare organisations should foster belonging in all policies and practices

Attrition of doctors from healthcare systems has reached crises levels in the US, UK, and throughout the European Union. The situation is expected to worsen—causing more harm to patients and to doctors, 1 2 3 for whom burnout, moral injury, and stress related health conditions are drivers for dissatisfaction and ultimately attrition. Attrition pathways include doctors reducing hours or effort (“quiet quitting”), moving to another institution, or leaving medicine altogether. Much of the literature on workforce retention focuses on improving pay, hours, workload, and wellbeing. Though these are important issues, one of the most basic human needs—a sense of belonging—has been largely ignored.

A sense of belonging is often described as feeling valued, needed, and in alignment with the values or goals of a group or organisation. 4 5 Belonging is distinct from but related to concepts of diversity and inclusion, and requires workplaces to intentionally welcome individuals from traditionally excluded groups (such as people from an ethnic or religious minority, people with disabilities, and those with a non-dominant sexual orientation).

Attempts to enhance belonging should not focus on acculturation; organisations should instead align their goals with those of individual workers—being “part of the group” must not be synonymous with losing self, culture, or traditions. These cultural needs and experiences enrich the work environment, are individual and multidimensional, and have been identified as critical components of occupational safety and wellbeing. 6 7 8 9

Creating belonging

Belonging is a uniquely personal experience, and factors that promote belonging in one group may not be applicable to others. Anyone, anywhere, can feel they do not belong—such feelings of isolation can have many sources. For example, “under-representation” may be specialty specific: women report feeling unwelcome in some surgical specialties, 10 and male trainees report patient refusal in obstetrics and gynaecology rotations, leading them to move to another specialty. 11

For women, disproportionate responsibility for care giving, lower wellbeing, 12 higher risk of workplace harassment, 13 and well documented obstacles to professional success 14 15 are all factors potentially pushing them out of healthcare. Structural sexism means women often face barriers to returning to work after giving birth, including inadequate leave, lack of private spaces for breast feeding or expressing breast milk, and productivity based pay reductions. Conversely, women’s belief that they can thrive professionally 6 is a key component of belonging that can promote retention in the healthcare workforce.

Organisational cultures, policies, and practices should support individuals to improve their sense of belonging. Effective communication of all workplace policies, practices, and accountability measures relating to belonging is vital to ensure all employees are receptive. 6 7 8 9 To reduce attrition from the workforce, these policies and practices must be designed by clinicians from historically under-represented groups (including women, and especially Black women) then operationalised by healthcare organisations in partnership with all employees. 8 16 Most people are not seeking approval but respect, peace, and safety at work. 17 Organisations must strive for diversity and show clearly that they welcome a blend of cultures and ideas—lack of interest and fear of rejection are strong predictors of intergroup connection and attitudes. 17

Healthcare leaders must acknowledge belonging as a critical component of both doctors’ wellbeing and preventable workforce attrition, and organisations should dedicate resources to measuring it. 18 Effective interventions to enhance belonging should be developed and implemented at individual and population levels, focusing on factors that undermine a sense of belonging. For example, providing breastfeeding resources, adequate parental leave arrangements, and pay structures that don’t punish motherhood may improve new mothers’ sense of belonging.

Workplace environments that respect all under-represented voices, ideas, work, and cultures and support positive interpersonal relationships without loss of individual or group identity are important. 19 Additional measures that can improve wellbeing and help retain staff, include mentoring (especially early in employment), promoting a positive social environment, and strategies that promote team based culture. 20 21 22 Studies conducted in the US, UK, and Canada indicate that when employers and employees work together to mitigate harassment, discrimination, and stress, they support an environment that reflects all employees, improves work-life balance, and reduces attrition rates. 23 24 25 26

Government legislation and high level action are needed to address these issues, retain talented and highly trained clinicians in the healthcare workforce, and improve outcomes for patients. Government action could include new laws, policies, and financial support for research and interventions focused on improving workforce retention through enhancing healthcare professionals’ sense of belonging.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: JKS is an adviser to Simplifed and a venture partner at Third Culture Capital. EHE participates in research funded by the Kern Family Foundation and the National Science Foundation.

Provenance and peer review: Commissioned; not externally peer reviewed.

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the importance of the review of related literature

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  1. The Importance of Literature Review in Scientific Research Writing

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  1. Review of literature

  2. Review of Related Literature and Studies Part 1

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  6. Review of Related Literature vs. Review of Literature Studies: Practical Research 2

COMMENTS

  1. What is the importance of a review of related literature in the study

    A review of related - and preferably recent - literature is meant to set your research in the context of what is currently known about the topic and to establish that what you have to offer is novel, something different from what has been already attempted.

  2. What is the purpose of a literature review?

    What is the purpose of a literature review? What is the purpose of a literature review? 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

  3. Why is it important to do a literature review in research?

    Importance of Literature Review in Research The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions. Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.

  4. Conducting a Literature Review: Why Do A Literature Review?

    Why Do A Literature Review? How To Find "The Literature" Found it -- Now What? Example FAQ/Help Why Do A Literature Review? Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

  5. Literature Review in Research Writing

    A literature review is a study - or, more accurately, a survey - involving scholarly material, with the aim to discuss published information about a specific topic or research question. Therefore, to write a literature review, it is compulsory that you are a real expert in the object of study.

  6. How does the review of related literature (RRL) help the ...

    A review of related literature (RRL) is important for obtaining an overview of the current knowledge on the topic. It provides the investigator with a framework on which to build an appropriate hypothesis. Further, an RRL guides the researcher in the direction of adding something new to the field without duplicating previous efforts.

  7. How to Write 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:

  8. The Literature Review: A Foundation for High-Quality Medical Education

    A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met. Literature reviews take time, are iterative, and should continue throughout the research process.

  9. Steps in Conducting a Literature Review

    A literature review is an integrated analysis-- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

  10. Approaching literature review for academic purposes: The Literature

    INTRODUCTION. Writing the literature review (LR) is often viewed as a difficult task that can be a point of writer's block and procrastination in postgraduate life.Disagreements on the definitions or classifications of LRs may confuse students about their purpose and scope, as well as how to perform an LR.Interestingly, at many universities, the LR is still an important element in any ...

  11. What is a literature review?

    A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important ...

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    Example: Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework: 10.1177/08948453211037398 ; Systematic review: "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139).

  13. Chapter 9 Methods for Literature Reviews

    Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour (vom Brocke et al., 2009). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and ...

  14. PDF What is a Literature Review?

    The importance of the literature review is directly related to its aims and purpose. Nursing and allied health disciplines contain a vast amount of ever increasing lit-erature and research that is important to the ongoing development of practice. The literature review is an aid to gathering and synthesising that information. The pur-

  15. Writing a literature review

    A formal literature review is an evidence-based, in-depth analysis of a subject. There are many reasons for writing one and these will influence the length and style of your review, but in essence a literature review is a critical appraisal of the current collective knowledge on a subject. Rather than just being an exhaustive list of all that ...

  16. Literature review as a research methodology: An ...

    A literature review can broadly be described as a more or less systematic way of ... Closely related to the semi-structured review approach is the integrative or critical review approach. ... deciding on inclusion and exclusion criteria is one of the most important steps when conducting your review. However, important to note is the need to ...

  17. The Importance of Literature Review in Research Writing

    A literature review helps you create a sense of rapport with your audience or readers so they can trust that you have done your homework. As a result, they can give you credit for your due diligence: you have done your fact-finding and fact-checking mission, one of the initial steps of any research writing.

  18. LibGuides: Literature Review: Purpose of a Literature Review

    The purpose of a literature review is to: Provide a foundation of knowledge on a topic; Identify areas of prior scholarship to prevent duplication and give credit to other researchers; Identify inconstancies: gaps in research, conflicts in previous studies, open questions left from other research;

  19. Conducting a Literature Review

    By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research. Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take.

  20. PDF Literature Review: An Overview

    The major purpose of reviewing the literature is to determine what has already been done that relates to your topic, This knowledge not only prevents you from unintentionally duplicating another person's research, it also gives you the understanding and insight you need to place your topic within a logical frame.

  21. Role of the Literature Review

    Your literature review gives readers an understanding of the scholarly research on your topic. In your literature review you will: demonstrate that you are a well-informed scholar with expertise and knowledge in the field by giving an overview of the current state of the literature

  22. What is the Purpose of a Literature Review?

    Literature reviews can: 1. Provide a foundation for current research. 2. Define key concepts and theories. 3. Demonstrate critical evaluation. 4. Show how research and methodologies have evolved. 5. Identify gaps in existing research. 6. Support your argument. Keep reading to enter the exciting world of literature reviews!

  23. Getting started

    What is a literature review? Definition: A literature review is a systematic examination and synthesis of existing scholarly research on a specific topic or subject. Purpose: It serves to provide a comprehensive overview of the current state of knowledge within a particular field. Analysis: Involves critically evaluating and summarizing key findings, methodologies, and debates found in ...

  24. Need, Importance And 5 Sources Of Review Of Related Literature In

    Need, Importance and 5 Sources of Review of Related Literature in Educational Research Educational research means the organized collection and examination of the data related to education. It is a scientific study that examines the learning and teaching methods for better understanding of the education system.

  25. Exploring the role of professional identity in the implementation of

    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 ...

  26. Leveraging implementation science with using decision support

    View as pdf A later version of this article appeared in Nurse Leader, Volume 21, Issue 6, December 2023.. Abstract. Technology, such as clinical decision support, can play a role in supporting nurses' decision making, but understanding the complexity and current challenges in nurse decision-making is needed to guide the implementation of technology interventions focused on supporting ...

  27. Sense of belonging is a critical component of workforce retention

    Healthcare organisations should foster belonging in all policies and practices Attrition of doctors from healthcare systems has reached crises levels in the US, UK, and throughout the European Union. The situation is expected to worsen—causing more harm to patients and to doctors,123 for whom burnout, moral injury, and stress related health conditions are drivers for dissatisfaction and ...

  28. Full article: Ensemble 3D CNN and U-Net-based brain tumour

    1. Introduction. Among the most essential and crucial organs in the human body is the brain, as it contains nerve cells and tissues that govern the most important processes of the entire body, such as breathing, muscular movement and our senses [Citation 1].Every cell has its unique capacities; some cells gain functionality as they mature, while others lose capability, resist and become aberrant.