The importance of STROBE checklist adherence in reporting of observational studies: Not just a tick box exercise

With increasing interest in the quality of published research within the scientific community, inadequate reporting has been identified as a widespread issue in biomedical research for several years (Glasziou et al., 2014). Poor reporting of research is unethical, it wastes time and valuable resources and can be potentially detrimental to patient care (Moher, 2018). Poor, or insufficient, reporting may hinder the possibility of nurses being able to effectively translate the findings of a nursing observational study into practice-based improvements. If an author forgets or neglects to report important information about their study, it can lead to a delay in the publication of the paper, reduce the chances of the study being cited and potentially prevent it from being included in evidence-synthesis studies. If a study has not been reported clearly, completely and transparently, replication can be near impossible. Insufficient attention to reporting may also make it difficult for the reader to fully assess the strengths and weaknesses of a study. To deal with all these issues, the EQUATOR Network (Enhancing the QUAlity and Transparency Of health Research; 2020, www.equator-network.org), an international initiative that aims to systematically address issues of poor reporting in biomedical research, was established in 2006. EQUATOR provides robust guidelines that confirm that academic papers are rigorously and transparently reported. Within nursing research, high-quality observational studies can provide the answers to important research questions, these studies can be descriptive, comparative and analytical. As part of the EQUATOR Network, the Strengthening of Reporting of Observational Studies in Epidemiology (STROBE) guidelines were originally formulated in 2007 (von Elm et al., 2007). Constantly evolving since its inception, STROBE was developed to improve the transparency and accuracy in the reporting of observational studies, across cohort, case−control and cross-sectional studies. The 22-item STROBE checklist which relates to the conventional sections of an academic research paper can be found on the STROBE website www.strobe-statement.org. An explanatory and elaborative paper outlining the meaning and rationale of the STROBE accompanies the checklist (Vandenbroucke et al., 2014). STROBE has increasingly become a requisite for authors wishing to publish observational studies in biomedical journals. STROBE adherence can greatly enhance the quality and transparency in observational research, an important ethical obligation in publication. In this editorial, we examine the use and misuse of STROBE in nursing research. Specific attention is given to the need for greater guideline awareness to ensure better adherence, with focus on the importance of reporting of confounding in observational research. At the Journal of Advanced Nursing, we require authors of observational research to adhere to the STROBE guidelines. When applied appropriately, we believe that STROBE can have a positive impact on the quality of reporting an observational study. Therefore, we encourage researchers to become familiar with STROBE as early as possible, from the study design phase through to the reporting stages of an observational study. However, even when academic journals mandate responsible reporting practices, it does not imply that authors will necessarily appreciate their importance. Worryingly, in one study of quality of reporting in observational research, Pouwels et al. (2016) reported that many authors were often unaware of the use of STROBE or its existence. Despite its strengths, the STROBE checklist does come with limitations, it is only limited to three main types of observational study design; however, several extensions now exist. The checklist was originally conceived as ‘a life jacket not a strait jacket’, as such, it was not intended to be a strict and rigid method of reporting findings, it merely provides guidance on the most important items that need to be considered in a manuscript. However, some authors believe that the constraints of STROBE are too rigid, adhering to the level of methodological rigour required can be very challenging (Larsson, 2022). If inadequate attention is given to publication reporting in observational research, there is always the potential risk of bias, including confounding. In observational studies, addressing bias that is related to confounding is of great importance. Confounders, which are extraneous variables that can distort the distinction between exposure and outcome can be common in observational research, mainly due to lack of randomization which is not applicable in this type of research. Confounders can lead to the masking of a true effect or association or can make it appear that there is an association between the exposure and outcome when no true association exists. Within the psychiatric specialty journals, Munkholm et al. (2020) identified poor quality of reporting of confounding to be widespread and potentially problematic as bias related to confounding may present as a major limitation in observational research. Specifically, they noted the term ‘confounding’ was only mentioned in the abstract or discussion of around half (55%) of identified papers and only around a fifth of authors gave any acknowledgement of confounding in their findings. With multiple items within the STROBE checklist devoted to confounding, attention has been given to assess whether reporting of confounding can be enhanced with STROBE adherence. Using STROBE, authors are encouraged to provide a clear rationale for their choice of statistical covariates, all confounders should be identified and defined. In relation to precision, STROBE requests that due attention is given to providing unadjusted and adjusted confounder-adjusted estimates. It has been suggested that even when STROBE is applied appropriately, the standard of reporting studies can remain sub-optimal (Sharp et al., 2019). Despite noting improvements in the reporting of confounding, Pouwels et al. (2016) found little difference in reporting quality between those journals that endorsed STROBE, and those that did not, this may be potentially related to STROBE misuse. For several years, concerns have been raised about the misuse of STROBE, it has commonly been used as a tool to assess methodological quality of a study or as a template for study design, despite clear indication for the developers that it is a guide to reporting research (da Costa et al., 2011). As confounding can be a major limitation of observational research, closer attention, with careful interpretation of study findings, needs to be given to this issue in nursing research, addressing confounding and other aspects of bias. More than just endorsing STROBE reporting guidelines, we feel that is timely and important for our authors to have a greater awareness of STROBE and ways to adhere to it. It is important for prospective authors to realize that STROBE adherence is much more than just a ‘tick box’ exercise, but that appropriate time and consideration are needed to ensure that they have correctly interpreted and applied the tool. In our experience, this may not always be clearly apparent. At the Journal of Advanced Nursing, authors of observational studies are strongly encouraged to dedicate sufficient time to familiarize themselves with STROBE guidelines and to complete the checklist thoroughly and correctly, this requires more than just stating page numbers. So how can our potential authors enhance STROBE adherence? Although vital, endorsing reporting guidelines within journal author guidelines may not be enough. Some journals, like PLOS Medicine, have gone one step further and require authors not only to submit a completed checklist, but they also require authors to submit text from their manuscript to provide justification for their responses to the checklist questions (PLOS Medicine Editors, 2014). Merely attaching a STROBE checklist with a manuscript does not demonstrate adherence within a study, and at the Journal of Advanced Nursing, we also request that reference should be made to the checklist in the abstract and in the main body of the text within the methods section. Appropriate completion of the checklist allows reviewers and readers a greater appreciation on key aspects of an observational study, like issues of bias, confounding and generalizability. In addition to the checklist, we also encourage our authors to take the time to consult the explanatory and elaborative paper, outlining the meaning, rationale and use of the STROBE checklist (Vandenbroucke et al., 2014). Authors should also provide key information about their study design and population providing clear definition of outcomes predictors and potential confounders. Any attempts to eliminate or reduce bias should be clearly outlined by the author in the methods section of the paper. The integrity and validity of journal publications in any academic discipline are dependent on a high-quality peer review process (Smith & Jackson, 2022). Awareness of reporting guidelines may also help peer reviewers in their assessment of a manuscript. At the Journal of Advanced Nursing, reviewers are strongly encouraged to refer to STROBE reporting guidelines to ensure methodological rigour in observational studies. It has been suggested that training and education on the use of reporting checklists, including STROBE, should be incorporated within postgraduate nursing education (McEvoy et al., 2022). We advocate the core teaching of all reporting guidelines, including STROBE, at an early stage of postgraduate research training to ensure awareness of the existence and importance of these checklists and guidelines. In the communication and dissemination phases of the research process, students could be taught about the ways to achieve STROBE adherence, leading to the enhancement of the quality of their manuscript, rather than just being seen as an onerous administrative task. Although time consuming to complete, when used appropriately, STROBE guidelines can improve the overall quality of an observational paper, potentially enhancing the chances of publication acceptance. At the Journal of Advanced Nursing, we aim to publish the highest quality nurse research papers for our readership and require that reporting guidelines are precisely followed to ensure that our publications, including observational studies, have transparency and can be judged appropriately by our readers. Although using this guideline does not reflect the methodological quality of a study, greater effort needs to be given to ways to encourage nursing authors to fully adhere to STROBE reporting guidelines when reporting observational research. All authors contributed to the writing and revisions of this editorial. The authors declare no conflicts of interest.