einstein. 2010; 8(1 Pt 1):102-6
Integrative review: what is it? How to do it?
Revisão integrativa: o que é e como fazer
Marcela Tavares de Souza1, Michelly Dias da Silva2, Rachel de Carvalho3
introduction: The integrative review is the methodology that
provides synthesis of knowledge and applicability of results of
significant studies to practice. Objective: To present the phases of an
integrative review and the relevant aspects to be taken into account
when using this methodological resource. Methods: This study was
based on bibliographic search and on the experience of the authors
when performing an integrative review. Results: Presentation of the
six stages of the integrative review process: preparing the guiding
question, searching or sampling the literature, data collection, critical
analysis of the studies included, discussion of results and presentation
of the integrative review. Conclusions: Considering the need to
assure care based on scientific evidence, the integrative review
has been identified as a unique tool in healthcare for it synthesizes
investigations available on the given topic and guides practice based
on scientific knowledge.
Keywords: Literature review as topic; Methodology; Nursing
methodology research ; Evidence-based nursing
introdução: A revisão integrativa é metodologia que proporciona
a síntese de conhecimento e a incorporação da aplicabilidade de
resultados de estudos significativos na prática. Objetivo: Apresentar
as fases constituintes de uma revisão integrativa e os aspectos
relevantes a serem considerados para a utilização desse recurso
metodológico. Métodos: Trata-se de um estudo realizado por meio
de levantamento bibliográfico e baseado na experiência vivenciada
pelas autoras por ocasião da realização de uma revisão integrativa.
Resultados: Apresentação das seis fases do processo de elaboração
da revisão integrativa: elaboração da pergunta norteadora, busca ou
amostragem na literatura, coleta de dados, análise crítica dos estudos
incluídos, discussão dos resultados e apresentação da revisão
integrativa. Conclusões: Diante da necessidade de assegurar uma
prática assistencial embasada em evidências científicas, a revisão
integrativa tem sido apontada como uma ferramenta ímpar no campo
da saúde, pois sintetiza as pesquisas disponíveis sobre determinada
temática e direciona a prática fundamentando-se em conhecimento
Descritores: Literatura de revisão como assunto; Metodologia;
Pesquisa metodológica em Enfermagem; Enfermagem baseada em
Due to the increasingly growing amount and complexity
of information in the field of health, developing artifacts
in scientific research that could lead to more concise
methodological stages and offer professionals better
use of evidence from several studies became crucial.
In this scenario, integrative review is the methodology
that provides synthesis of knowledge and applicability
of results of significant studies into practice(1).
The method analyzed is basically the tool of Evidence-
based Practice (EBP). Originated from the works by the
epidemiologist Archie Cochrane, EBP is characterized
by an approach of clinical care and teaching based on
knowledge about evidence and its quality. Therefore,
it involves defining the clinical problem, identifying the
necessary information, searching studies in the literature
and evaluating them critically, identifying applicability
of data from publications, and determining their use to
The EBP initiatives have increased the need for
producing all types of literature review. Although
important, the review methods most often used
– systematic review and meta-analysis – do not
contemplate relevant nursing issues related to care
and/or impact of disease or of treatment. Due to its
methodological approach, the integrative review allows
including diverse methods, which can potentially play
the significant role in EBP in Nursing(3). Hence, it is
1 Nurse; Specialist in clinical and Surgical Nursing of the Faculdade de Enfermagem of Hospital Israelita Albert Einstein – FEHIAE, São Paulo (SP), Brazil.
2 Nurse; Specialist in clinical and Surgical Nursing of the Faculdade de Enfermagem of Hospital Israelita Albert Einstein – FEHIAE, São Paulo (SP), Brazil.
3 PhD in Nursing; Lecturer and coordinator of Graduate courses of the Faculdade de Enfermagem of Hospital Israelita Albert Einstein – FEHIAE, São Paulo (SP), Brazil.
corresponding author: Marcela Tavares de Souza – Rua Ayrton Perón, 465 – Jardim dos Ipês – cEP 79600-000 – Três Lagoas (MS), Brasil – e-mail: email@example.com
Received on Dec 12, 2008 – Accepted on June 8, 2009
The authors declare no conflict of interest.
einstein. 2010; 8(1 Pt 1):102-6
Integrative review: what is it? How to do it? 103
fundamental to differentiate it from other existing lines
Meta-analysis is the review method that combines
evidence of multiple primary studies by using statistical
tools to enhance objectivity and validity of the findings.
The design and hypotheses of the studies should be
very similar, if not identical. In the meta-analysis
approach, each study is synthesized, codified and input
in quantitative database. Subsequently, the results are
transformed into a common measure to calculate the
general dimension of the effect or of the intervention
Systematic review, in turn, is an exacting synthesis
of all investigations related to one specific question,
focusing primarily on experimental studies, such as
randomized clinical trials. It is different from other
methods of review since it aims at overcoming possible
biases in each stage, following a strict method to search
and select investigations; assessing relevance and
validity of the studies found; collection, synthesis and
interpretation of data from research(2).
Lastly, integrative review is the most comprehensive
methodological approach of reviews, and it allows
including experimental and non-experimental studies
to fully understand the phenomenon analyzed. It also
combines data from theoretical and empirical literature,
and has a wide range of purposes, such as definition of
concepts, review of theories and evidence, and analysis
of methodological problems of a particular topic. The
broad sample, together with multiple proposals, should
create a consistent and comprehensive panorama of
complex concepts, health theories or problems that are
relevant for nursing(3).
Considering this information and aiming to provide
subsidies for construction and/or application of
integrative reviews in the field of nursing, the purpose
of this article is to present the phases of an integrative
review and the relevant aspects to be taken into account
when using this important methodological resource.
It is a study with data collected from secondary
sources through a bibliographic search and based on
the experience of the authors when performing an
Bibliographical survey is one of the best ways
to initiate a study, searching for similarities and
differences among the articles found in the references.
The electronic compilation of information is a major
advance for researchers for it democratizes access
and provide frequent update(4). The general objective
of a literature review is to gather knowledge about
a topic, thus assisting to set the foundations for a
significant study on nursing. This task is crucial for
To survey articles in the literature, the following
databases were used: Latin-American and Caribbean
Health Sciences Literature (LILACS) and Medical
Literature Analysis and Retrieval System on-line
The descriptors, and their combinations in
Portuguese and English, employed to search articles
were as follows: “Methodology”, “Method”, “Literature
review as subject”, “Research in nursing” and “Evidence-
The inclusion criteria defined to select articles
were: articles published in Portuguese, English and
Spanish; full articles addressing integrative review and
articles published and indexed in the above-mentioned
databases in the last ten years.
The analysis of the studies selected in terms of
research design was based on Polit, Beck, Hungler(5) and
Lo Biondo-Wood, Haber(6). Both analysis and synthesis
of data extracted from the articles were carried out in a
descriptive fashion, allowing to observe, count, describe
and classify data in order to gather knowledge produced
on the topic addressed in this review.
The final sample of this review comprised five scientific
articles, selected according to the inclusion criteria
previously established. One article was found in the
database LILACS and four in the Medline. The chart 1
represents the specifications of each article.
Hence, scarcity of published scientific articles
on integrative review was observed, since it is a
methodology derived from Evidence-based Practice,
which is increasingly developing in nursing, as well as in
all other areas in the field of health.
Within this context, the concept and the phases of
an integrative review are addressed as an EBP tool.
Integrative review determines current knowledge about
a specific topic because it is carried out to identify,
analyze and synthesize results of independent studies
on the same subject, thus contributing to a possible
beneficial repercussion on quality of care delivered to
patients(1). It is noteworthy mentioning that the use of
integrative review impacts not only in development of
policies, protocols and procedures, but also in critical
assessment that the daily practice demands(7).
einstein. 2010; 8(1 Pt 1):102-6
104Souza MT, Silva MD, carvalho R
Next, the six phases of the process of preparing an
integrative review are briefly presented(8).
1st phase: preparing the guiding question
Defining the guiding question is the most important
phase of the review, because it determines which
studies will be included, the means adopted for
identification and information gathered in each
selected study. Hence, it includes the definition of
participants, the interventions to be evaluated and
the results to be measured(2). It should be clearly and
specifically prepared, and related to a theoretical
principle that comprises theories and rationale
learned by the researcher(1,9).
2nd phase: searching or sampling the literature
Intrinsically related to the previous phase, the search in
databases should be broad and diverse, including search
in electronic databases, manual search in journals, the
references described in the selected studies, contact with
researchers and the use of unpublished material(2). The
sampling criteria must assure representativeness of the
sample, and they are important indicators of reliability
and veracity of the results. The ideal procedure is to
include all the studies found or a randomized selection
of them; however, if both choices are not feasible due to
the amount of works, the inclusion and exclusion criteria
adopted for the articles must be clearly explained and
discussed(8). Thus, determining the criteria should be
performed in agreement with the guiding question,
considering the participants, the intervention and the
results of interest.
3rd phase: data collection
To extract data from the articles selected, it is necessary
to use a previously prepared instrument that is able to
assure collection of all relevant data, to minimize the
risk of errors in transcription, to guarantee precision
when checking information and to serve as a record.
The data should include definition of the subjects,
methodology, size of the sample, measuring variables,
method of analysis and concepts used as bases is the
Appendix 1 is a model of an instrument to be used in
4th phase: critical analysis of the studies included
Similar to data analysis in conventional research, this
phase demands an organized approach to weigh rigor
and characteristics of each study. The clinical experience
of the researcher contributes to check validity of the
methods and results, and helps determining their
usefulness in practice(1,9).
Differently, the Evidence-based Practice (EBP)
focus on evidence classification systems, which
are hierarchically characterized depending on the
methodological approach adopted. To assist in choosing
the best possible evidence, a hierarchy of evidence is
proposed, based on the design of the research, which is
one of the items to be analyzed in this phase(7).
- Level 1: evidence resulting from meta-analysis of
multiple randomized controlled clinical trials;
- Level 2: evidence from individual studies with
- Level 3: evidence from quasi-experimental studies;
- Level 4: evidence of descriptive (non-experimental)
studies or with a qualitative approach;
- Level 5: evidence from case reports or from
- Level 6: evidence based on opinions of specialists.
5th phase: discussion of results
In this stage, based on interpretation and synthesis of
results, the data demonstrated in the analysis of the
Chart 1. Articles surveyed in the databases LILACS and MEDLINE on integrative review.
Origin Title of the article
MedlineWriting an integrative review.
Beyea S, Nicoll LH.
Journal (volume, number, page, year)
AORN J. 67(4): 877-80, abr 1998.
Considerations / Subject
It defines integrative review as an
efficient methodological approach and
gives directions on how to conduct it.
LILAcS Revisão integrativa de pesquisa
aplicada à enfermagem.
combining evidence in nursing
research: methods and
An overview of the integrative
The integrative review: up date
Roman AR, Friedlander MA. cogitare Enferm. 3(2):109-12, jul/dez 1998. It determines integrative review, presents
its purposes and describes its phases.
It analyzes, synthesizes and differentiates
all the review methods, including
It displays the benefits of integrative
review and describes its phases.
It distinguishes integrative review from
other review methods and presents
strategies to increase methodological
rigor in this type of methodology.
MedlineWhittemore R. Nurs Res. 54(1): 56-62, jan/fev 2005.
MedlineRussel cL.Prog Transplant. 15(1):8-12, mar 2005.
MedlineWhittemore R, Kanafl K. J Adv. 52(5):546-53, dez 2005.
einstein. 2010; 8(1 Pt 1):102-6
Integrative review: what is it? How to do it?105
articles are compared to the theoretical reference. In
addition to identifying eventual gaps in knowledge,
it is possible to set priorities for future studies.
Nonetheless, to protect validity of the integrative
review, the investigators must stress their conclusions
and inferences, and also explain the biases(9).
6th phase: presentation of the integrative review
The presentation of the review must be clear and
complete to enable the reader to critically assess the
results. It should contain relevant and detailed pieces
of information based on contextualized methodologies,
without omission of any related evidence(1,9).
In integrative review, the combination of several
methodologies may contribute to lack of rigor,
inaccuracy and bias; thus, it should be conducted within
the methodological rigor standards(3). It is therefore
imperative to make punctual considerations about
some phases of the process, namely collection, analysis
and discussion of data.
One of the methods to analyze data of a qualitative
research concerns variety of findings of integrative
review(3). It consists of reduction, presentation and
comparison of data, as well as conclusion and verification
Reducing data involves determining the general
classification system to manage diverse methodologies.
First, the studies should be divided into subgroups
according to a previously established classification,
aiming to facilitate the analysis. In integrative reviews,
for instance, the categorization may be based on the type
of incidence, chronology or characteristics of the sample,
or on some predetermined conceptual classification.
Next, data are extracted from the primary sources
using the prepared instrument to simplify, summarize
and organize the findings, so that each study is reduced
to one page with relevant content (Appendix 1). Such
approach, in addition to enabling a brief organization
of data, facilitates comparison among studies in specific
topics, such as problems, variables and characteristics
of the sample.
The following step is the visualization of data,
that is, converting the findings into a visual form of
subgroups. The visualization modes may be depicted
in tables, graphs or charts, in which all selected studies
can be compared. Moreover, identification of patterns,
differences and redistribution of these topics may be
included as part of the general discussion.
Any statements regarding relations or conclusions
demand verifying the primary source to avoid premature
conclusions or exclusion of relevant evidence during the
Considering the need to assure care based on scientific
evidence, the integrative review has been identified as a
unique tool in healthcare for synthesizing investigations
available on the given topic and for directing practice
based on scientific knowledge. Although combining
data of investigations with diverse design is quite
complex and challenging, performing integrative
review, based on inclusion of a systematic and rigorous
approach of the process, particularly data analysis,
results in reduced biases and errors. For this reason, it
is imperative to establish integrative review as a valid
instrument of Evidence-based Practice, primarily in the
current scenario of Brazilian nursing.
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evidências [dissertation]. Ribeirão Preto: Universidade de São Paulo, Escola de
Enfermagem de Ribeirão Preto; 2005.
2. Galvão cM, Sawada NO, Trevizan MA. Revisão sistemática: recurso que
proporciona a incorporação das evidências na prática da enfermagem. Rev
Latino-Am Enfermagem. 2004;12(3):549-56.
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4. Brevidelli MM, De Domenico EB. Trabalho de conclusão de curso: guia prático
para docentes e alunos da área da saúde. 2a ed. São Paulo: Iátria; 2008.
5. Polit DF, Beck cT, Hungler BP. Fundamentos de pesquisa em enfermagem:
métodos, avaliação e utilização. 5a ed. Porto Alegre (RS): Artmed, 2004.
6. Lo Biondo-Wood G, Haber J. Pesquisa em enfermagem: métodos, avaliação
crítica e utilização. 4a ed. Rio de Janeiro: Guanabara Koogan; 2001.
7. Stetler cB, Morsi D, Rucki S, Broughton S, corrigan B, Fitzgerald J, et al.
Utilization-focused integrative reviews in a nursing service. Appl Nurs Res.
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einstein. 2010; 8(1 Pt 1):102-6
106 Souza MT, Silva MD, carvalho R
APPeNDiX 1. Example of a data collection instrument (validated by Ursi, 2005).
Title of the article
Title of the journal
Authors Name _______________________________________________________________________
Year of publication
B. Institution holding the study
No identification of setting
C. Type of publication
Publication in another area of health. Which area?
D. Methodological characteristics of the study
1. Type of publication 1.1 Research
( ) Quantitative approach
( ) Experimental design
( ) Quasi-experimental design
( ) Non-experimental design
( ) Qualitative approach
1.2 Non research
( ) Literature review
( ) Report of experience
( ) Others _____________________________________________________________________
2. Objective or investigation question
3. Sample 3.1 Selection
( ) Random
( ) convenience
( ) Other ______________________________________________________________________
3.2 Size (n)
( ) Initial ______________________________________________________________________
( ) Final ______________________________________________________________________
Sex: M ( ) F ( )
Type of surgery _________________________________________________________________
3.4 Inclusion/exclusion criteria of subjects ______________________________________________
4. Treatment of data
5. Interventions performed5.1 Independent variable __________________________________________________________
5.2 Dependent variable ___________________________________________________________
5.3 control group: yes ( ) no ( )
5.4 Measurement instrument: yes ( ) no ( )
5.5 Duration of the study __________________________________________________________
5.6 Methods employed to measure the intervention _______________________________________
7. Analysis7.1 Statistical treatment __________________________________________________________
7.2 Significance level ____________________________________________________________
8.1 The conclusions are justified based on the results______________________________________
8.2 What are the recommendations of the authors? _______________________________________
9. Evidence level
E. Assessing methodological rigor
clarity to identify the methodological steps in the text (method
employed, participating subjects, inclusion/ exclusion criteria,
Identification of restrictions or biases