Background

Nurses and midwives constitute almost 90% of health workers and provide up to 50% of health services worldwide.1 As the frontline of health services delivery, midwives and nurses are critical to the localized successes of global interventions and strategies to promote health and human development in resource-limited settings.2 Nurses form an integral part of the health system through their prolonged engagement with patients and their families during care delivery and disease management. Midwives and nurses are also disproportionately represented among healthcare leaders and decision makers in low- and middle-income countries (LMICs).3 In most of these settings, including in Nigeria, midwives and nurses are often the only healthcare professionals working in rural and remote areas where economic deprivation along with morbidity and mortality rates due to preventable and/or treatable conditions are disproportionately high.4 In view of their critical position on the frontline of care delivery, the importance of nurses' involvement in the success of health sector reform has been acknowledged in countries such as South Africa.5 Moreover, the benefits of nurses and midwives' involvement in research production and leadership extend beyond improved patient care to include the health system as a whole.6

Nonetheless, the evidence suggests that midwives and nurses are only marginally involved in research production and policy development in and about LMICs.7 Current research reveals that nurses' primary involvement in research production centers on data collection (as research/field assistants or facilitators) and seldom as principal- or co-investigators.8,9 Nurses in some African countries including those in leadership positions are often unaware or have limited knowledge of various health sector policies.6,10 Yet, these policies are often informed by local research and have the potential to positively impact their daily work.6,10 The evidence further suggests that nurses have limited involvement in international grants, awards and training programs to support research in and about LMICs.10 This situation likely predisposes nurses and midwives to lesser opportunities for collaboration or partnerships at the appropriate decision making levels necessary to influence change in primary healthcare delivery.11 In the face of these challenges, midwives and nurses face limited involvement in the development of healthcare and health system policies that impact healthcare practices in LMICs.12-15 This may further constrain their potential contributions to the development and successful translation of policy into practice. Limited involvement of nurses and midwives in health research production in and about LMICs might also hamper the uptake of proven interventions in care delivery and undermine projected improvements in population health and development outcomes in LMICs, particularly in underserved areas.11

Several studies conducted in developing countries suggest minimal involvement of midwives and nurses in health research production. Edwards et al.9 conducted a five year, collaborative international research program that explored and promoted nurses' involvement in HIV research and policy development in five LMICs (three in sub-Saharan Africa and two in the Caribbean), each with a high HIV disease burden.9 The core component of the program was to strengthen the research capacity, particularly, qualitative capacity, of nurses through the use of mentorship, role-modeling and enhanced institutional support. In another example, Mill et al.7 found that while some nurse-researchers on their team had limited experience conducting qualitative research, others expressed skepticism about the value of qualitative research being "real" research. The authors noted that such skepticism may be the result of the emphasis placed on quantitative research methodologies in nursing and epidemiological training, and of the values instilled during training at nurse-researchers' institutions.7 They suggested that this may have resulted from misconceptions about the discipline of qualitative research and other common barriers such as a lack of opportunities for meaningful engagement. The proposed review would be instrumental in identifying potential gaps or hindrances to midwives' and nurses' involvement in research. A Nigerian study led by members of the team proposing this review examined research involvement among nurses and midwives in a local municipality and lends further support to the relevance of this review.15 The authors found that while the majority of midwives and nurses interviewed (74%) considered research essential to further advancement in their profession, only 30% of the participants reported ever having been involved in research activities.15 On the other hand, a review of health literature authored by nurses in the Latin American and Caribbean region revealed a high proportion of descriptive (55%) or qualitative research (30%) designs among health research studies conducted in the region.16 However, among these, nursing care emerged as the most common research topic, while topics related to health systems and services were the least studied areas. This evidence attests to the lack of optimal engagement in, and a loss of potential opportunities for contribution to, critical areas that are shaping the health sector agenda in developing countries, even among leading nurse researchers in these settings. Given their representation in health services provision, midwives and nurses have a critical role to play in organizational learning. A qualitative study conducted among nurses in Iranian hospitals identified hitherto little known factors that hindered their participation in organizational learning.17 This proposed review is timely for highlighting the importance of midwives' and nurses' involvement in research production and identifying contributions made by midwives and nurses to pertinent health services issues.

According to the Institute of Medicine18 Advancing Nursing: Leading Change Report, nurses need to be equal partners in healthcare redesign including visibility from front lines to the policy arena. This order of change is necessary to establish sustainable improvements in healthcare delivery in LMICs.19-21,24 However, the irony is that midwives and nurses are strategically positioned to influence the uptake of evidence-based practice (EBP) and are yet barely involved in research that informs this process. This is demonstrated in a recent study of factors affecting the uptake of EBP among nurses working in four Iranian teaching hospitals.22 As many as 80% of the participating nurses had never been involved in any research activities; most had unfavorable attitudes toward EBP and demonstrated weak self-efficacy in carrying out EBP. This cross-sectional, descriptive and quantitative study also highlights the importance of qualitative studies that investigate the underlying determinants of negative attitudes or perceptions among midwives and nurses that potentially hinder their engagement in research designed to improve practice. Various approaches to remedy this situation are being explored in LMIC settings, an example being a recent qualitative study in Nigeria which employed a participatory action research model to explore nurses' involvement in research and policy development relating to vertical transmission of HIV.23 This systematic review will provide a timely synthesis of the available evidence to better inform remedial strategies.

The Institute of Medicine18 has suggested that, although nurses are well positioned to lead positive change and advance health, constraints such as the scarcity of nurse researchers with doctoral-level training preclude nurses from effectively responding to the ever-changing needs of health care. To better assess and address such constraints and to improve clinical practice and health outcomes, this large segment of the health workforce in LMICs requires targeted effort. Generating evidence to increase current understanding of their experiences in terms of involvement in research studies that inform health and healthcare decisions is essential. The findings of this systematic review have the potential to contribute to the development of appropriate interventions that may enhance nurses' and midwives' active involvement in research production in LMICs. This will ultimately strengthen healthcare and delivery systems in these settings. With the end of 2015 having drawn the curtain on the millennium development goals, reorganization of human resources for health is a priority strategy to meet outstanding global health targets in many LMICs. The feasibility of the recently introduced sustainable development goals, such as universal health coverage in LMICs, requires task shifting with midwives and nurses taking on care-giving roles and responsibilities previously assigned to physicians.5,25 A review of their current engagement in research production toward better health system strengthening is timely to inform health system reorganization in LMICs. Such evidence will also help to explicate how midwives and nurses may be usefully engaged in the production and uptake of evidence-informed practice standards to enable and to sustain quality care in LMICs.

A preliminary search of MEDLINE/PubMed, CINAHL, Epistemonikos, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports revealed that there is currently no existing systematic review on the topic.

Inclusion criteria

Type of participants

The systematic review will focus on midwives and nurses who are registered and licensed to practise midwifery and/or nursing by an accredited and authoritative organization in LMICs and are involved in research. This systematic review will consider studies that include one or both of two types of participants (nurses/midwives) based on LMICs, regardless of age, gender or cultural identity.

Phenomenon of interest

The phenomena of interest are midwives' and nurses' experiences of participation in research production in LMICs. This systematic review will also focus on identified activities relevant to research production in the retrieved literature. Involvement in research production refers to their participation in research activities and processes such as the design, planning, decision making, implementation, collaboration, dissemination and knowledge uptake.

Context

The current review will consider qualitative studies that have explored the experiences of nurses and/or midwives' involvement in research production in LMICs.26 Areas where research production occurs may include, but are not limited to, settings specific to care delivery (hospitals, clinics and communities), professional and government organizations, and academic settings. Examples of research production include, but are not limited to, involvement in research design, planning, decision making, implementation, collaborating, disseminating and participating in knowledge uptake.

Types of studies

The current review will consider English language studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, case studies and feminist research. In the absence of research studies, other text such as opinion papers and reports will be considered.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies as well as Scopus, Google Scholar and Web of Science will be used to identify articles that cite the identified reports. Studies published beginning with the date of inception of each of the databases will be considered for inclusion in this review.

The databases to be searched include:

Medline, CINAHL, Embase, PsycINFO, Scopus, Sociological Abstracts, Web of Science, ProQuest Nursing and Allied Health Source, TRIP: Turning research into practice, Latin American and Caribbean Health Sciences Literature, and African Index Medicus.

The search for unpublished studies will include:

Google (country specific)

Angola - Associacao Nacional de Enfermeiros de Angola

Botswana - The Nurses Association of Botswana

Burkina Faso - Association Professionnelle des Infirmiers/eres du Burkina

Rep. democratique du Congo - Association des Infirmiers du Congo

Ethiopia - Ethiopian Nurses Association

Gambia - The Gambia Nurses Association

Ghana - Ghana Registered Nurses Association

Guyana - Guyana Nurses Association

Kenya - National Nurses Association of Kenya

Lesotho - Lesotho Nurses Association

Liberia - Liberia Nurses Association

Malawi - National Association of Nurses of Malawi

Morocco - Association Marocaine des Sciences Infirmieres et Techniques Sanitaires

Mozambique - Asociacao Nacional dos Enfermeiros de Mozambique

Namibia - Namibian Nursing Association

Nigeria - National Association of Nigeria Nurses and Midwives

Sao Tome & Principe - Associacao Nacional dos Enfermeiros y Parteiras de Sao Tome e Principe

Sierra Leone - Sierra Leone Nurses Association

South Africa DENOSA

Swaziland - Swaziland Nursing Association

Tanzania - Tanzania Registered Nurses' Association

Togo - Association nationale des infirmiers/eres du Togo

Uganda - Uganda National Association for Nurses & Midwives

Zambia - Zambia Nurses Association

Zimbabwe - Zimbabwe Nurses Association

World Health Organization (WHO), OAIster (through WorldCat), ProQuest Dissertations and Theses Virginia Henderson International Nursing Library

Initial keywords to be used will be Nurs*, Midwi*, Nurse-Midwives, LMICs, healthcare, qualitative research, investigators; capacity building, research productivity

Initial MeSH terms to be used will be Nursing research, Health Services Research, Research support as topic, Developing countries

The search strategy will be adapted to the features and vocabulary of each database searched to ensure that a wide body of relevant literature is captured. A LMIC search filter developed by the Norwegian Satellite of the Cochrane Effective Practice and Organisation of Care Group will be tested and adjusted as needed for this search (http://epocoslo.cochrane.org/lmic-filters). The search will be conducted by a library scientist.

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

In the absence of research studies, textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Qualitative data from papers included in the review will be extracted by two independent reviewers and by using the standardized data extraction tool from JBI-QARI (Appendix III). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Levels of credibility will be assigned to qualitative findings as unequivocal, credible or unsupported. Primary authors will be consulted for any missing information.

In the absence of research studies, textual data will be extracted from papers included in the review using the standardized data extraction tool from JBI-NOTARI (Appendix IV). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Levels of credibility will be assigned to qualitative findings as unequivocal, credible or unsupported. Primary authors will be consulted for any missing information.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for EBP. Where textual pooling is not possible, the findings will be presented in narrative form.

In the absence of research studies, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity of meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for EBP. Where textual pooling is not possible, the conclusions will be presented in narrative form.

Acknowledgments

We wish to gratefully acknowledge the Queens University Joanna Briggs Collaboration for Patient Safety especially the 2014 Institute Faculty for their support and feedback in the development of this protocol.

Appendix I: QARI critical appraisal instrument

Appendix II: NOTARI critical appraisal instrument

Appendix III: QARI data extraction instrument

Appendix IV: NOTARI data extraction instrument

References