Asking More of Qualitative Synthesis: A Response to Sally Thorne

Rapid reviews methods series: guidance on rapid qualitative evidence synthesis

This paper forms part of a series of methodological guidance from the Cochrane Rapid Reviews Methods Group and addresses rapid qualitative evidence syntheses (QESs), which use modified systematic, transparent and reproducible methodsu to accelerate the synthesis of qualitative evidence when faced with resource constraints. This guidance covers the review process as it relates to synthesis of qualitative research. 'Rapid' or 'resource-constrained' QES require use of templates and targeted knowledge user involvement. Clear definition of perspectives and decisions on indirect evidence, sampling and use of existing QES help in targeting eligibility criteria. Involvement of an information specialist, especially in prioritising databases, targeting grey literature and planning supplemental searches, can prove invaluable. Use of templates and frameworks in study selection and data extraction can be accompanied by quality assurance procedures targeting areas of likely weakness. Current Cochrane guidance informs selection of tools for quality assessment and of synthesis method. Thematic and framework synthesis facilitate efficient synthesis of large numbers of studies or plentiful data. Finally, judicious use of Grading of Recommendations Assessment, Development and Evaluation approach for assessing the Confidence of Evidence from Reviews of Qualitative research assessments and of software as appropriate help to achieve a timely and useful review product.

Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol

BACKGROUND

Surgical specialities use extensive amounts of antimicrobials, and misuse has been widely reported, making them a key target for antimicrobial stewardship initiatives. Interventions informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to successfully improve practice. However, this approach has been under utilised. Our aim is to synthesise qualitative studies on surgical antimicrobial prescribing behaviour (APB) in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new theory to advance understanding and identify knowledge gaps to inform further research.

METHODS

The meta-ethnography will follow the seven-phase method described by Noblit and Hare. We will conduct a comprehensive search using eight databases (AMED, CINAHL, EMBASE, MEDLINE, MEDLINE-in-process, Web of Science, Cochrane Library and PsycINFO) with no date restrictions; forwards and backwards citation searches; and contacting first authors of relevant papers. Studies will be dual screened and included if they use recognised qualitative methods and analysis; focus on contextual factors associated with surgical APB within hospital settings; are available in full in English; and are relevant to the research question. Any disagreements between reviewers will be resolved through discussion to reach consensus. Included studies will be read repeatedly to illuminate key concepts and the relationship between key concepts across studies. Then, key concepts will be sorted into conceptual categories or 'piles' which will be further abstracted to form a conceptual framework explaining surgical APB. During the synthesis, emerging interpretations will be discussed with stakeholders (including authors of included studies where possible; surgical and stewardship practitioners; and patient representatives) to ensure new knowledge is meaningful.

DISCUSSION

This research has several strengths: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team bring varied interpretative repertoires and relevant methodological skills; and (3) stakeholders will be involved to ensure that findings are relevant, and disseminated via suitable channels, to support improved patient care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020184343.

Situating Preventive Action in a Moral and Clinical Context: A Qualitative Synthesis on Fall Prevention

The prevention of falls is an integral part of the safety culture of health institutions with mandatory fall prevention programs set within health care facilities. Care providers are key in identifying the risks of falls and in implementing strategic actions to prevent them. With the aim to better understand practices of fall prevention, we conducted a synthesis of qualitative evidence on care providers' practices to prevent older people from falling in health care facilities. This synthesis is part of an integrative review of the role of care providers in fall prevention of adults aged 65 years and above. Primary studies were synthesized with the emerging core category of "a complex decision" and described by four emerging conditions that make that decision complex: (a) permanent threat of a fall, (b) continuous flow of information, (c) lack of control, and (d) ethical dilemmas and moral issues over the course of action. The present synthesis shows that before implementing preventive actions, care providers consider the conditions in which they are immersed, in this way situating their preventive actions in a clinical and a moral context.

A typology of systematic reviews for synthesising evidence on health care

OBJECTIVES

The objectives of this paper are to (a) Review published references to systematic reviews; (b) offer a typology of systematic reviews for synthesising evidence on health care; and (c) summarise the guides for designing, reporting and appraising the reviews.

BACKGROUND

Systematic reviews play a role in finding, synthesising, transferring and implementing evidence for healthcare policy, practice guidelines and allocation of health resources. They have been particularly successful in confirming or synthesising evidence for health care by meta-analysing aggregated data from multiple randomised controlled trials. However, concerns about the limitations of evidence from controlled trials have prompted interest in other review methods capable of locating and appraising evidence from more diverse, and possibly more realistic, healthcare situations.

METHODS

An iterative citation-tracking process with Google Search and grey literature identified 204 papers on previous typologies and methods of systematic reviews.

RESULTS AND CONCLUSIONS

There are six types of systematic reviews: narrative; meta-analysis; scoping; qualitative; umbrella; and realist. Each type has distinct objectives, characteristics and attributes, but with much overlapping of methods and guides. Sensitivity to the need for qualitative evidence on complex human responses to ill-health and health care has broadened the objectives and methods of health-related systematic reviews to find, appraise and synthesis useful evidence for practice guidelines, healthcare policy and allocation of health resources.

Patients' and nurses' experiences of fundamental nursing care: A systematic review and qualitative synthesis

AIMS AND OBJECTIVES

To systematically identify, appraise and synthesise patients', residents' and nurses' experiences of fundamental nursing care for nutrition, elimination, mobility and hygiene.

BACKGROUND

The evidence base for effective nursing behaviours to assist people with their fundamental care needs is sparse, hampering the development of effective interventions. Synthesising data on patients' and nurses' experiences of fundamentals of nursing care could contribute to the development of such an intervention.

METHODS

Systematic review and synthesis of qualitative data from qualitative studies on patients' and nurses' experiences of fundamental nursing care behaviours addressing peoples' nutrition, elimination, mobility and hygiene needs. We appraised study quality and relevance and used a narrative approach to data synthesis, fulfilling PRISMA criteria (Appendix S2).

RESULTS

We identified 22,374 papers, and 47 met our inclusion criteria. Most papers were of low quality. Sixteen papers met our quality and relevance criteria and were included for synthesis. Papers were about nutrition (2) elimination (2), mobility (5), hygiene (5) and multiple care areas (2). We found nurses and patients report that fundamental nursing care practices involve strong leadership, collaborative partnerships with patients and cohesive organisational practices aligned to nursing care objectives and actions.

CONCLUSIONS

To improve fundamental care and interventions suitable for testing may require attention to leadership, patient-nurse relationships and organisational coherence plus the fundamentals of care nursing interventions themselves.

RELEVANCE TO CLINICAL PRACTICE

More rigorous mixed methods research about fundamental nursing care is needed to inform nursing practice and improve patient's experience. Nursing interventions should include effective nurse leadership and nurse-patient collaboration and a focus on fundamental care by the host organisation.

Is meta-synthesis turning rich descriptions into thin reductions? A criticism of meta-aggregation as a form of qualitative synthesis

Meta-synthesis of qualitative research can be an important way to consolidate and grow nursing knowledge and theory. However, from recent readings of such works in the nursing literature, one can observe that there is increasing use of meta-synthesis being used as a way to simply aggregate qualitative research findings in a manner claimed to be similar to quantitative meta-research while also remaining compatible with the qualitative research tradition. The aim of this paper is to discuss whether this meta-aggregation form of research has a sound epistemological foundation and should be considered a viable form of meta-synthesis. The conclusion drawn is that meta-aggregation falls short of being a sound method and is not compatible with the qualitative research philosophy. It is also concluded that meta-aggregation should not be seen as a form of qualitative meta-synthesis. Meta-synthesis is best understood as a way to re-interpret, compare and translate disparate qualitative studies using different conceptual apparatus into a consolidated knowledge of fundamental importance to nursing care practitioners. To conclude, aggregating qualitative research tends to turn rich descriptions into thin abstractions that are of little use to nursing practice knowledge and does not advance nursing science.

When Health Care is Displaced by State Interests: Building Dialogue Through Shared Findings

Health sociologists interested in how macro state influences affect micro health care practices have much to gain from meta-ethnography research. In this article, we bring together insights from two separate empirical studies on state health care services involving HIV/AIDS as a way to speak to larger issues about the organization and production of medical expertise and governance in health care systems. We use Noblit and Hare's meta-ethnography approach to bring these studies into conversation and identify six shared "organizers" of health care encounters. The organizers illustrate how state health interests operate across institutional contexts and impact the work of providers in seemingly unrelated health care settings. On the basis of this synthesis, we conclude that state interests both structure and create conflict in health care settings. We believe this perspective offers the potential to advance the goals of health sociology and the field of qualitative health research in general.

Researching and Designing Health Care Environments: A Systematized Review of Creative Research Methods

In research and design, Creative Research Methods (CRMs) are useful to gain insight into user perspectives. Reviews suggest that CRMs offer potential to engage people, yet little detail is available regarding their use in relation to built health care environments. Consider environments for cancer care, where patients are confronted with particular physical and emotional challenges. This review aims to synthesize what is known from existing literature about CRMs exploring user experience when researching and designing (cancer) care environments. Based on 16 items, we evaluate the potential of CRMs, offering insight into why, how, where, and when they are employed. Generally little consideration is shown for participants' abilities and limitations. Our analysis further emphasizes the importance of reflecting on visual methods, and the need to report research approaches transparently including where CRMs are used. A sophisticated research approach can leverage CRMs' potential to study experience and carry artifacts forward to inform design(ers).

The Impact of Evidence-Based Medicine on Qualitative Metasynthesis: Benefits to be Harvested and Warnings to be Given

Qualitative metasynthesis, developed as an interpretative and inductive methodology, is increasingly influenced by standards from evidence-based medicine, established as a strategy to support policy decisions and guidelines. Currently, principles and procedures from the format developed for systematic reviews are often applied for review and synthesis of all kinds of evidence, including results from qualitative studies. In this article, I substantiate these claims, discussing benefits to be harvested and warnings to be given when qualitative metasynthesis approaches the evidence-based medicine methodology. Situating my exploration in the context of clinical practice, I contrast missions and values of these methodologies regarding review and synthesis of research literature, highlighting potential mismatches between ontology and epistemology, emphasizing challenges regarding sample, analysis, and transferability. Approving systematic and transparent strategies as generic for such purposes, I warn against the idea that methodology developed for evidence-based medicine is a universal gold standard for synthesis of research evidence.

Defining the process to literature searching in systematic reviews: a literature review of guidance and supporting studies

BACKGROUND

Systematic literature searching is recognised as a critical component of the systematic review process. It involves a systematic search for studies and aims for a transparent report of study identification, leaving readers clear about what was done to identify studies, and how the findings of the review are situated in the relevant evidence. Information specialists and review teams appear to work from a shared and tacit model of the literature search process. How this tacit model has developed and evolved is unclear, and it has not been explicitly examined before. The purpose of this review is to determine if a shared model of the literature searching process can be detected across systematic review guidance documents and, if so, how this process is reported in the guidance and supported by published studies.

METHOD

A literature review. Two types of literature were reviewed: guidance and published studies. Nine guidance documents were identified, including: The Cochrane and Campbell Handbooks. Published studies were identified through 'pearl growing', citation chasing, a search of PubMed using the systematic review methods filter, and the authors' topic knowledge. The relevant sections within each guidance document were then read and re-read, with the aim of determining key methodological stages. Methodological stages were identified and defined. This data was reviewed to identify agreements and areas of unique guidance between guidance documents. Consensus across multiple guidance documents was used to inform selection of 'key stages' in the process of literature searching.

RESULTS

Eight key stages were determined relating specifically to literature searching in systematic reviews. They were: who should literature search, aims and purpose of literature searching, preparation, the search strategy, searching databases, supplementary searching, managing references and reporting the search process.

CONCLUSIONS

Eight key stages to the process of literature searching in systematic reviews were identified. These key stages are consistently reported in the nine guidance documents, suggesting consensus on the key stages of literature searching, and therefore the process of literature searching as a whole, in systematic reviews. Further research to determine the suitability of using the same process of literature searching for all types of systematic review is indicated.

How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis

We conducted a study to explore how people diagnosed with first-episode psychosis experienced their contact with early intervention services for psychosis and the way these experiences relate to their recovery processes. Our aim was to integrate and describe the service users' experiences in a rigorous and comprehensive way. A broad literature search was performed in June and July 2016. After screening, 17 qualitative studies were included. We analyzed the findings in two main steps: (a) translating studies into one another and (b) synthesizing the findings from the studies. Through these interpretative processes, we found five new and overarching themes: (a) something is wrong, (b) do for myself, (c) it's about people, (d) a price to pay, and (e) ongoing vulnerability. We describe these themes as a process that service users' maneuver through in their contact with the services. Our findings are discussed in light of relevant research.

"Trapped in an Empty Waiting Room"-The Existential Human Core of Loneliness in Old Age: A Meta-Synthesis

Loneliness in old age has a negative influence on quality of life, health, and survival. To understand the phenomenon of loneliness in old age, the voices of lonely older adults should be heard. Therefore, the purpose of this meta-synthesis was to synthesize scientific studies of older adults' experiences of loneliness. Eleven qualitative articles that met the inclusion criteria were analyzed and synthesized according to Noblit and Hare's meta-ethnographic approach. The analysis revealed the overriding meaning of the existential human core of loneliness in old age expressed through the metaphor "trapped in an empty waiting room." Four interwoven themes were found: (a) the negative emotions of loneliness, (b) the loss of meaningful interpersonal relationships, (c) the influence of loneliness on self-perception, and (d) the older adults' endeavors to deal with loneliness. The joint contribution of family members, health care providers, and volunteers is necessary to break the vicious circle of loneliness.

Advancing the Field of Synthesis Scholarship: A Response to Nicky Britten and Colleagues

Continuing the dialogue and debate on the relevance and value of qualitative metasynthesis research for the health fields, Thorne comments on some of the ideas raised by Britten and colleagues in response to her January 2017 Qualitative Health Research editorial on Metasynthetic Madness. Here she extends the debate on the terminology with which we refer to this kind of scholarly work and the kinds of research synthesis that hold potential for adding value to existing knowledge about matters of health and illness. In the spirit of engaging an ongoing critical conversation, she proposes that the kinds of metasynthesis products that get published ought to be those capable of demonstrating actual relevance. She reminds us that the procedural steps that have come to be associated with metasynthesis in many of the recently published reports are merely the stage-setting one does in order to prepare the way for the actual intellectual work of synthesis. By whatever name it is known, if qualitative synthesis is to make a meaningful scholarly contribution in the health domain, Thorne argues that it must demonstrate the kind of thoughtfully critical and interpretive intellectual engagement that takes our understanding of phenomena significantly beyond what we could have known on the basis of an ordinary kind of literature review, offering us an original form of insight that would not have been otherwise accessible.