Nursing research priorities based on CINAHL database: A scoping review

Abstract Aim To analyse nursing research based on the CINAHL database to identify research priorities for nursing. Design A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012–2018. Methods Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method. Results A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta‐synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.


| INTRODUC TI ON
Building a research strategy for nursing is vitally important to give the necessary direction for the future. Strategic planning enables us to examine the forthcoming nursing and healthcare research in a systematic way and find areas that need to be further studied.
Moreover, nursing strategies help us to implement the necessary procedures and actions to obtain that future. (National Institute of Nursing Research [NINR], 2016, pp. 3-9.) To develop a current, relevant and applicable nursing research strategy, we need to know what the nursing research priorities are locally, nationally and internationally. However, identifying nursing research priorities on different levels can be challenging.
The significance of this review is threefold. First, there seems to be a lack of reviews synthesizing nursing research priorities on a general level. Therefore, it is essential to carry out a scoping review of the literature, which describes current research topics covering different sectors in nursing. Second, the CINAHL database is claimed to be an extremely important electronic database for nurses and nurse researchers (CINAHL databases, 2019). Therefore, it is crucial to summarize the literature on nursing research priorities available in the named database. Third, research priorities are quite often recognized by applying the Delphi technique method. However, broader reviews are also required since they give a wider standpoint by analysing and reflecting the priority areas overall. In addition to the previously described reports and strategy plans, several studies on research priorities in different fields of nursing have been published in scientific databases. Many of these studies have applied the Delphi technique with a varying number of survey rounds to define the priorities (Cowman et al., 2012;Wynaden et al., 2014). Furthermore, the topics of the research priority studies vary from pressure injuries (Haesler, Carville, & Haesler, 2018) to children's nursing (Brenner et al., 2014) and mental health nursing (Wynaden et al., 2014). Despite the considerable number of research priority publications, limited efforts have been made to understand the big picture of nursing research priorities worldwide and, thus, to describe the essential topics of current research in nursing. Therefore, this review aims to give a synthesis of current identified nursing research priorities by applying a scoping review.

| Aim
The aim of this review was to analyse nursing research to identify global research priorities for nursing and its future directions. An additional purpose is to give a synthesis of current nursing research priorities for a future Delphi study. This review also reflects what can be found in CINAHL, one of the largest nursing research databases, about nursing research priorities. The review question addressed was "What are the research priorities for nursing research based on the CINAHL database?"

| Design
The scoping review was chosen as a method for its suitability to identify the scope or coverage of a body of literature on a topic (Arksey & O'Malley, 2005). As Peters et al. (2015) have stated, a scoping review is useful when a body of literature has not yet been comprehensively reviewed or exhibits a complex or heterogeneous nature of the evidence. With respect to this review's topic, nursing research priorities, it can be defined as a broad area of interest with a scattered body of literature. In addition, scoping reviews do not aim to produce answers to particular questions but rather to give an overview of the evidence, which is one of the aims of this review. Scoping reviews also have a broader scope than traditional systematic reviews. (Munn et al., 2018;Tricco et al., 2018) This scoping review outlines a preliminary step in the synthesis of the broad literature on nursing research priorities.

| Search methods, outcomes and data abstraction
The search of the relevant literature was conducted in the CINAHL Plus (EBSCO) with Full Text (The Cumulative Index to Nursing and Allied Health Literature) database at the end of 2018. The database was selected as it is the largest source for nursing and allied health peer-reviewed journals and publications in the world and In total, 1,522 publications were identified by the electronic search. A review team with three experts was formed to conduct the selection strategy. In all the following stages, two of the experts,

| Quality appraisal of the included publications
Even though it is not necessary to conduct the critical appraisal procedure in scoping reviews (Munn et al., 2018;Tricco et al., 2018), the Joanna Briggs Institute's (JBI) Critical appraisal tools (2017) were chosen to determine the methodological quality and general adequacy of the publications included in this review. The JBI checklists were selected as they are intended for nursing and healthcare studies specifically.
In the critical appraisal procedure, two independent reviewers evaluated the 96 full-text publications for their quality. The design and methodology of each publication were paired with the appropriate JBI checklist, and thus, the following tools were used for the evaluation: analytic cross-sectional studies, systematic reviews, qualitative studies and text and opinion. The decision about the scoring system and the cut-off for the inclusion of a publication were made in advance and was agreed on by both participating reviewers before critical appraisal commenced. It was decided that the publication had to fulfil 50% of the assessment criteria and as every JBI checklist has a different assessment item range, the exact cutoff scores that were applied are illustrated in Table 2. As for Delphi studies, which often use a variety of methods, the tool of analytic cross-sectional studies was used in most cases. In terms of argumentative, discussion and contemporary issues papers, strategic and policy papers and editorials, the text and opinion checklist were employed.
After the independent appraisals, the reviewers discussed the cases where their evaluations differed to reach consensus.
Eventually, five publications were excluded from the synthesis for having low quality, leaving 91 articles for the review. Figure 1 shows the flow diagram of the literature search.

| Data analysis
The data were analysed by using the thematic analysis described by Braun and Clarke (2006). First, 91 articles were read through and the results or main content from each article were extracted into a table.
Furthermore, the types of the included publications were identified and the results are shown in Table 3. Second, codes were generated and clustered into sub-themes that were related. The theme was defined as a coherent integration of the different pieces of data that constitute the findings. The idea of the theme was that it captured something significant about the data in relation to research question and aim and it represented a pattern or meaning in the data set. After clustering initial codes into sub-themes, themes were identified, defined and named. Lastly, the key themes were refined with regard to aim and overall meaning of the review. To increase the verification of the analysis, peer debriefing was applied during the coding process. In practice, two members of the research team regularly discussed their personal insight and perception of all the aspects of the analysed data. This helped us to examine how our thoughts and ideas evolved as we engaged more deeply with the analysis process. (Braun & Clarke, 2006

| Ethics
Ethical approval was not required. The review was conducted according to good scientific integrity.

| RE SULTS
Almost a third (26) of the selected publications were systematic or other types of literature reviews, and a little over fourth (24) were discussion/contemporary issues articles. The research articles were mostly conducted with Delphi or other consensus-building methods (16) and a minority with quantitative (5) or qualitative methods (3).
The rest of the publications were policy papers (12) and editorials (5) (see Table 3). More than half (53)

| Nursing theory development
Several nursing researchers have emphasized that continuing research and in-depth academic discussion should be carried out in the area of nursing theory development (Im, 2014a;Jairath, Peden-McAlpine, Sullivan, Vessey, & Henly, 2018;Turkel et al., 2018). In particular, the theories that are strongly based on practice such as situation-specific theories and middle-range theories need to be further developed. Furthermore, nursing theories should be evaluated frequently in nursing practice (Im, 2014b.). Researchers (Im, 2014a;Turkel et al., 2018) warn that unless more emphasis is put on theory Included development and evaluation, theories can silently be erased from nursing science. Jairath et al. (2018) underlined that nursing metaparadigms (health, person, nursing and environment) need revision in the current scientific and practice climates. According to Jairath et al. (2018) and Rolfe (2016), the gap between research and theory is growing and, therefore, building practices based on theories as well as constant evaluation of nursing theories are crucial areas in current nursing science. That is, constant re-examination of nursing theories is needed to clarify the domain of nursing and to guide nursing practice and science. Some scholars even claim that nursing science is at a critical point in its development and nursing theories should guide nursing practice in terms of individualized holistic care (Turkel et al., 2018). As Kelly, Kent, McMahon, Taylor, and Traynor (2016) argue, attention needs to be focused on how to ensure that the impact of nursing research and research on nursing is captured and celebrated.
The impact of nursing research and its role in theory development should be fully recognized now and in future (Kelly et al., 2016).

| Methodology of nursing research
Nursing science researchers are of the opinion that more randomized controlled trial (RCT) studies, meta-synthesis, experimental and intervention studies are needed (Baldi et al., 2014;Richards, Coulthard, & Borglin, 2014 More importance should also be attached to the appropriate methods of conducting evidence-based nursing research (Zhao et al., 2018).
Behavioural science such as big data and quantitative science as well as patient-reported outcomes and health economics are relevant to nursing research, and more stress should be put on these areas and data Big data with large data set analysis from the nursing perspective has the potential to give a better understanding of patient phenomena and in tailoring interventions that are personalized to the patient (Brennan & Bakken, 2015).
In terms of implementation science, Curtis, Fry, Shaban, and Considine (2017)  Delphi/consensus-building study 16 Strategic and policy paper 12 Editorial 5 Empirical quantitative study 5 Empirical qualitative study 3

2018). Overall, researchers have stated that the impact of nursing
research is now hidden, and it must be recognized by conducting scientifically sound studies with generalizable results (Baldi et al., 2014;Kim, Sefcik, & Bradway, 2017;Muntlin, 2018;Richards et al., 2014).
When the state of European nursing research is exposed, it shows that research in the leading nursing journals is largely descriptive and poorly described (Richards et al., 2014).

| Expertise in advanced nursing
In strategies and teaching methods that support competence development of nurses need to be examined. In particular, the focus ought to be on how skills and competencies are acquired in professional nursing practice and how they can be effectively taught to nurses (Johnson et al., 2013). The focus of nursing research should also be on how to best meet the educational needs of nurses at different stages of development (Ramelet & Gill, 2012).
Effective strategies and models that specialists can use in practice, such as critical thinking and clinical reasoning models, have not been studied enough in nursing science. More research attention than previously granted ought to be put on models for healthcare work processes and inter-professional collaboration (Garcia et al., 2015). According to multiple researchers, the area of professional de-

| Professional nursing practice
The fourth key theme, professional nursing practice, contains three domains where more research is warranted: nursing phenomena, clinical nursing and diseases and specific fields from the nursing perspective.

| Nursing phenomena
Regarding the first phenomenon, long-term care (Brazil,  Improving the quality of life of individuals with chronic conditions (Grady & Gullatte, 2014), patient-level outcome measures (Davis, Morgans, & Stewart, 2016), patient self-management (Grady, 2017), personalized health strategies, health promotion and patient education are topics that need further research (Foster et al., 2018;Grady & Gough, 2015). Grady and Gullatte (2014;also Grady, 2017) state that increasing numbers of people are currently living with chronic conditions and managing long-term illnesses is shifting from health professionals to individuals and their families; consequently, these nursing phenomena ought to be investigated in greater depth. Zwakhalen et al. (2018) proposed a research programme to be developed that aims to create awareness and expand knowledge of evidence-based basic nursing care by addressing four basic nursing areas: bathing and dressing, communication, mobility and nutrition.
They further claim that reassessing these essential nursing activities not only positively influences patient outcomes but has an impact on staff outcomes and organizational outcomes as well (Zwakhalen et al., 2018).
Veteran nursing care (De Jong, 2015;Struwe et al., 2018) and chaplaincy care (Damen, Delaney, & Fitchett, 2018) are also phenomena where research is lacking from the nursing point of view.
Furthermore, public health, occupational health and environmental health are considered as fields with a limited number of nursing studies available (Edwards, Porr, & Rieck Buckley, 2015;Issel, Bekemeier, & Kneipp, 2012;McCauley, 2012;Rehfuess et al., 2016). According to Issel et al. (2012), more research ought to be conducted in the area of public health nursing interventions, models and the effectiveness of public health nursing outcomes. Regarding environmental health nursing research, it is recommended that environmental exposures, risk perception, second-hand smoking and health education on environmental issues need to be the focus of current nursing research (Polivka & Chaudry, 2018). Last, more focus ought to be placed on planning and conducting nursing research in low-and middle-income countries (Rehfuess et al., 2016).

| Clinical nursing
Regarding the second domain, nursing research is prioritized focusing on the following clinical areas: paediatric nursing (Brenner et al., 2014;Downing, Knapp, Muckaden, Fowler-Kerry, & Marston, 2015;Sawin et al., 2012), critical care (Deutschman et al., 2012;Olson et al., 2012), emergency nursing (Hansoti et al., 2017), mental health (Wynaden et al., 2014), oncology nursing (Jarrett et al., 2013;Knobf et al., 2015;Lee, Chung, Chun, Oh, & Cho, 2013;Majidi et al., 2017;Maree, Herbert, & Huiskamp, 2017;Matthews, Danaher Hacker, Otte, & Dean, 2018;Mayer, 2015;Medlow & Patterson, 2015), nephrology nursing (Hewitson, 2014) and medical-surgical nursing (Davis et al., 2016). In terms of paediatric nursing, the palliative care of paediatric population is one of the topics that needs more attention in nursing research. Children's understanding of death and dying, child and families' needs assessment and best practices at the end of life are examples of topics that need to be paid attention in nursing science (Brenner et al., 2014;Downing et al., 2015;Ramelet & Gill, 2012). In the Delphi study of mental health nursing (Wynaden et al., 2014), professional issues such as nurses' job satisfaction and skills and knowledge acquired when working with mental health patients were discovered to be the most important research areas. On the other hand, research should also be focused on clinical issues such as the application of nursing models in mental health (Wynaden et al., 2014). For oncology nursing, research priorities are focusing on clinical issues such as pain management, the identification and relief strategies of symptoms and their associated outcomes (Maree et al., 2017;Mayer, 2015). In addition, living with cancer throughout the trajectory of the disease and cancer prevention interventions should be explored in more detail (Jarrett et al., 2013;Maree et al., 2017).

| Diseases and specific fields from the nursing perspective
The third domain encompasses diseases where nursing research is scarce, and as a result, more research is urgently called for. Stroke (Lightbody, 2017;Rowat et al., 2016), heart failure (Stamp et al., 2018), Parkinson's disease (Shin & Habermann, 2016), osteoarthritis (Robbins & Kulesa, 2012), diabetes (Graue et al., 2013;Iversen et al., 2016) and stoma (Hubbard et al., 2017) are considered to be the above-mentioned areas of diseases. With respect to nursing research on diabetes, Iversen et al. (2016) believe that future research may benefit from larger nurse-led research programmes organized into networks to share knowledge and expertise across national groups.
Autism and developmental disabilities are regarded as specific fields where additional nursing research should be conducted (Tomlinson et al., 2014). Furthermore, wound management and pressure injury (Cowman et al., 2012;Haesler et al., 2018) seem to be specific fields that have a very limited amount of nursing research at the moment.
All these areas require more inquiry from the nursing perspective.

| D ISCUSS I ON
In this scoping review, we explored the nursing research priority topics globally. To accomplish this, we identified 91 publications extracted from the CINAHL database that met the inclusion criteria, performed a quality appraisal following the JBI guidelines and analysed the data focusing on research topics of nursing. Overall, four key themes were identified with three additional domains. Here, we highlight a few points of view about the results.
According to our findings, nurse researchers state that a strong emphasis should be put on the development and evaluation of nursing theories. Particularly, middle-range and situation-specific theories that link theory to practice need to be generated more actively in nursing science. Some of this concern is well grounded. For example, only a few indications about nursing theory development or nursing theories overall are contained in current nursing research strategies and policy papers (ENRF, n.d.;NINR, 2016). However, there are several textbooks on nursing theories currently available for students and professionals where nursing's theoretical roots are described, different types of theories are presented and their applicability in practice is discussed (Fawcett, 2017;McKenna, Pajnkihar, & Murphy, 2014

| Strengths and limitations
Several researchers suggest that a formal quality assessment of the included publications is not necessary for a scoping review (Munn et al., 2018;Peters et al., 2015;Tricco et al., 2018). Despite this, we applied standardized critical appraisal guidelines (JBI) for the assessment of retrieved publications believing that these actions minimize the opportunity that articles with weak methodological or overall quality were included in the review (Porritt, Gomersall, & Lockwood, 2014). Furthermore, to ensure a more reliable review of included publications, we used an additional research expert to perform the critical appraisal together with one of the authors.
The weakness of this review is that we used one database, CINAHL, for the identification of potentially eligible studies. This was, however, a well-considered and thoughtful decision as the aim of our review was to analyse and synthetize the research topics of nursing research worldwide and the chosen database is known for being the world's largest source of full-text nursing and allied health journals at the moment.

| Conclusion
Development of nursing theories and usage of robust methods in nursing research were identified as current priorities in nursing science. Expertise in nursing and professional nursing practice with different nursing areas was also recognized as warranting further investigation. These insights can give important information for nursing science faculties to extend the discussion and to strengthen collaboration on nursing research priorities on the local, national and international levels in the future. After all, universities have a special responsibility to produce basic science research, develop and test theories and conduct sound research that generates robust evidence. Based on this review, it appears, however, that the roles are not clear between the professional nursing bodies, research organizations and universities for defining nursing research priorities.
It is worth pondering whether professional networks such as the ICN (International Council of Nurses) network for advanced nursing practice could play a significant role in facilitating communication around mutual research interests with universities and, consequently, formulate topics that need to be included in research strategies and action plans.
Nevertheless, research priority setting is a highly essential process and, thus, these results may increase awareness on the current situation of nursing research and will help to identify priority areas that will advance nursing and nursing science for its part in the years to come. Moreover, the results can serve as a basis for the development of nursing research agenda and enable discussion on the status of nursing research.

| Recommendations
Based on the results, the following recommendations are suggested.
First, a comprehensive systematic review ought to be conducted on nursing research priorities including several relevant databases used in nursing. Since scoping reviews are being used as a precursor to a systematic review, findings of this review can be used as the basis for further systematic review studies. Second, findings of this review can be used as valuable input and resource for nursing research faculties as well as research organizations to form more comprehensive agendas for future research. In addition to faculty research staff, nursing science students may also find these results useful for their studies.

ACK N OWLED G EM ENTS
We would like to thank specialist Jonna Reinikainen for her assistance in this research.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

AUTH O R CO NTR I B UTI O N S
HH and JH: have made substantial contributions to conception and design or acquisition of data, analysis and interpretation of data, gave final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; HH: involved in drafting the manuscript; JH: revised the manuscript critically for important intellectual content.