Qualitative evidence synthesis and conceptual development

Qualitative evidence syntheses (QES) have increased in prominence and profile over the last decade as a discrete set of methodologies to undertake systematic reviews of primary qualitative research in health and social care and in education. The findings from a qualitative evidence synthesis can enable a richer interpretation of a particular phenomenon, set of circumstances, or experiences than single primary qualitative research studies can achieve. Qualitative evidence synthesis methods were developed in response to an increasing demand from health and social professionals, policy makers, guideline developers and educationalists for review evidence that goes beyond “what works” afforded by systematic reviews of effectiveness. The increasing interest in the synthesis of qualitative research has led to methodological developments documented across a plethora of texts and journal articles. This “State of the Method” paper aims to bring together these methodological developments in one place, contextualizing advances in methods with exemplars to support readers in making choices in approach to a synthesis and aid understanding. The paper clarifies what a “qualitative evidence synthesis” is and explores its role, purpose and development. It details the kind of questions a QES can explore, the processes associated with a QES, including the methods for synthesis. The rational and methods for integrating a QES with systematic reviews of effectiveness are also detailed. Finally approaches reporting and recognition of what a “good” or rigorous QES look like are provided.

To explore factors influencing the implementation of a nursing care delivery model in a hospital setting. A qualitative evidence synthesis with a thematic synthesis was conducted. The search string consisted of four 'cluster topics': (1) nursing, (2) care delivery models, (3) hospital setting, (4) qualitative and mixed methods designs. Four electronic databases were searched from January 2000 until July 2024: MEDLINE (PubMed interface), Embase (embase.com interface), CINAHL (EBSCOhost interface) and Web of Science. A thematic synthesis was conducted consisting of the following steps; the 'line-by-line' coding of the text, the development and allocation of 'descriptive themes' and the generation of 'analytical themes'. In total, 3976 references were screened, of which 25 were included in the qualitative evidence synthesis. Eight analytical themes were generated that influence the implementation of a nursing care delivery model in a hospital setting: shared understanding of the care delivery model, ownership of the change, scope of practice and role clarity, collaboration, communication, responsibility, a double-loop process and aggregated recommendations. The themes were categorised on four different levels: vision, process, interactional factors and contextual factors. The eight themes identified in this qualitative evidence synthesis showed that during the implementation of a nursing care delivery model, a clear implementation strategy is often missing. It is advised that future implementation processes have a clear guide and goal. The analytical themes can guide the future implementation of a new nursing care delivery model in a hospital setting. This review can support nurses, researchers, hospital management and policymakers when implementing organisational alternatives to reorganise nursing care in a hospital setting. The qualitative evidence synthesis was reported according to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. No patient or public contribution.

Systematic reviews of qualitative research (‘qualitative evidence syntheses’) are increasingly popular and represent a potentially important source of information about people’s views, needs and experiences. Since 2013, Cochrane has published qualitative evidence syntheses, and the Cochrane Effective Practice and Organisation of Care group has been involved in the majority of these reviews. But more guidance is needed on how to prepare these reviews in an environment that is more familiar with reviews of quantitative research. In this paper, we describe and reflect on how Cochrane qualitative evidence syntheses differ from reviews of intervention effectiveness and how these differences have influenced the guidance developed by the EPOC group. In particular, we discuss how it has been important to display to end users, firstly, that qualitative evidence syntheses are carried out with rigour and transparency, and secondly, that these quality standards need to reflect qualitative research traditions. We also discuss lessons that reviews of effectiveness might learn from qualitative research.

To systematically synthesize undergraduate student nurses' experience of online, blended or distance learning during Covid-19 pandemic. A qualitative evidence synthesis (QES). A QES. Themes were organized using the 'best fit' framework approach. Methodological limitations and confidence in the review findings were informed by GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). Qualitative literature from five databases including CINAHL, PubMed, Medline, Education Full Text (H.W. Wilson) and ERIC were searched from March 2020 to November 2021. Nine qualitative and two mixed method studies were included in this 'best fit' framework using Chickering and Gamson's Seven Principles for Good Practice in Undergraduate Education. Importance of the social presence of the teacher through effective communication and interpersonal relationships is highlighted. Clinical placement and in-person practical skills training are needed for effective nursing education. This review highlighted that online content can be developed into efficient and high-quality learner-centred education within blended undergraduate nursing programmes incorporating essential face-to-face and practical components. Various supporting measures are required for both students and faculty. We suggest an adaptation of a 'Blending with Purpose: The Multimodal Model' with key considerations for undergraduate nursing programmes where pedagogical objectives and activities drive the approaches to achieve intended learning outcomes and student satisfaction. Well-designed online programmes using digital tools that support interaction and teamwork are required for undergraduate nursing education. Blended learning approaches offer more flexibility than online learning alone which leads to improved student engagement. Clinical placement and in-person practical skills training are needed for effective nursing education. REPORTING METHOD: 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) for QES. No Patient or Public Contribution.

BackgroundThe syntheses of multiple qualitative studies can pull together data across different contexts, generate new theoretical or conceptual models, identify research gaps, and provide evidence for the development, implementation and evaluation of health interventions. This study aims to develop a framework for reporting the synthesis of qualitative health research.MethodsWe conducted a comprehensive search for guidance and reviews relevant to the synthesis of qualitative research, methodology papers, and published syntheses of qualitative health research in MEDLINE, Embase, CINAHL and relevant organisational websites to May 2011. Initial items were generated inductively from guides to synthesizing qualitative health research. The preliminary checklist was piloted against forty published syntheses of qualitative research, purposively selected to capture a range of year of publication, methods and methodologies, and health topics. We removed items that were duplicated, impractical to assess, and rephrased items for clarity.ResultsThe Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement consists of 21 items grouped into five main domains: introduction, methods and methodology, literature search and selection, appraisal, and synthesis of findings.ConclusionsThe ENTREQ statement can help researchers to report the stages most commonly associated with the synthesis of qualitative health research: searching and selecting qualitative research, quality appraisal, and methods for synthesising qualitative findings. The synthesis of qualitative research is an expanding and evolving methodological area and we would value feedback from all stakeholders for the continued development and extension of the ENTREQ statement.

Introduction:The growth of the evidence-based policy movement sought to determine how to better assess and incorporate qualitative evidence in clinical practice and policy development. The question engendered was not whether qualitative research is valuable but how researchers can enhance its rigor. From this discussion arose over one hundred appraisal tools for the quality appraisal process of qualitative studies. For those without a deep familiarity with the qualitative research paradigm, navigating through the breadth of tools to find the most suitable tool for the task is a cumbersome process. This presentation will review the descriptive characteristics of available quality appraisal tools for assessing the quality of primary qualitative studies in qualitative evidence syntheses (QES). This presentation will also offer a critical discussion on the use of reflexivity as a de facto quality criterion, and how methodological reporting may influence the application of quality criteria in QES.Methods:We conducted a systematic search to identify quality appraisal tools of qualitative research designed for use in QES. This search built upon the work of Santiago-Delefosse and colleagues by extending their search to 2016.Results:We identified eight appraisal tools intended for use in the quality appraisal process of a QES. We provide a description of the structure, content, objectives, and philosophies of tools followed by considerations concerning their historical antecedents, common patterns regarding structure, content, and purpose, and the implications of these patterns on the QES process.Conclusions:Quality appraisal of qualitative research is an important step in QES, and there have been a proliferation of tools for this purpose. By providing an overview of available tools detailing their intent and strengths, this presentation will assist those engaging in QES to choose an appropriate tool for their work.

There is limited understanding of which factors most influence take-up of DRR behaviour in the general population. This evidence gap may limit the effectiveness of DRR implementation and, hence, impede translation of increasing evidence for DRR1 into real-world public health benefits.Reviews of quantitative studies have identified poor knowledge and persistence of myths about ageing2,3 as important. However, these findings are limited by the scope of included questionnaires.Qualitative literature reporting the perspectives of the general public offers an opportunity to increase this understanding. Qualitative studies can examine poorly understood phenomena in greater depth and with fewer a priori assumptions. Qualitative evidence synthesis (QES) is increasingly recognised as valuable, particularly in relation to complex interventions like DRR.We will present a QES regarding the perspectives of dementia- free members of the general public towards DRR. Searches indicate that no QES for this topic currently exists.Systematic searches of Medline, PsycINFO, Embase and CINAHL for studies published since 1995 that have used qualitative methods to explore DRR perspectives in the general public were undertaken, supplemented by hand searches of included studies’ reference lists. Following independent screening by two reviewers, 41 publications based on 37 individual studies meeting inclusion criteria have been identified.Data will be analysed using thematic synthesis, as outlined by Thomas and Harden (2008)4 and recommended for QES regarding complex health interventions5. ‘Line-by-line’ inductive coding and development of descriptive themes across studies will produce a summary of the perspectives of the general public for DRR. A conceptual framework explaining the relationships between key themes and considering the implications for implementation will be proposed.The Critical Appraisal Skills Programme (CASP) tool will be used to appraise included studies. Rather than imposing an arbitrary quality cut-off point for inclusion, sensitivity analyses will be used to examine the influence of lower quality studies on review findings. Finally, the Confidence in the Evidence from Qualitative Reviews (CERQual) approach will facilitate assessment of confidence in review findings to aid future use. Data extraction is ongoing.Findings from this synthesis will support better targeted quantitative examination of DRR implementation determinants and more strategic intervention design. 1.World Health Organisation. Risk reduction of cognitive decline and dementia: WHO guidelines. World Health Organisation. 2019. Geneva. Licence CC BY-NC-SA 3.0 IGO2.Cahill, S., Pierce, M., Werner, P., Darley, A., Bobersky, A. A systematic review of the public’s knowledge and understanding of Alzheimer’s disease and dementia. Alz Dis Assoc Disord. 2015; 29:255-2753.Cations, M., Radisic, G., Crotty, M., Laver, K.E. What does the general public understand about prevention and treatment of dementia? A systematic review of population-based surveys. PLoS One. 2018, 13(4):e01960854.Thomas, J. and Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews, BMC Medical Research Methodology. 2008 July; 8:45. doi 10.1186/1471-2288-8-455.Noyes, J., Booth, A., Cargo, M., et al. (2018). Cochrane Qualitative and Implementation Methods Group guidance series – paper 1: introduction. J of Clin Epidemiol. 2018; 97:35-38

PurposeMetastatic breast cancer [MBC] is the leading cause of cancer death in women globally with no cure. Women diagnosed with MBC endure a catastrophic upheaval to multiple aspects of their life and a radically transformed future landscape. Evidence suggests that the provision of care for women living with metastatic breast cancer is inadequate, socially isolating and stigmatising. To date, this topic has received little research attention. To increase understanding of the experiences of women living with MBC, a synthesis of current evidence is required. This paper presents a review of qualitative evidence on women’s experiences of MBC.MethodsA qualitative evidence synthesis [QES] was conducted to synthesise primary qualitative research on the experiences of women living with MBC. Searches were performed of electronic databases Medline, Medline Ovid, PsycINFO, Psych articles, PubMED, CINAHL Complete, Scopus and grey literature databases. The methodological quality of the included studies was appraised using a modified version of the Critical Appraisal Skills Programme [CASP]. Title, abstract, and full-text screening were undertaken. A ‘best fit’ framework approach using the ARC [Adversity, Restoration, Compatibility] framework was used to guide data extraction and synthesis. Confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation, Confidence in the Evidence from Reviews of Qualitative research [GRADE-CERQual].Results28 papers from 21 research studies containing 478 women’s experiences of living with MBC were deemed suitable for inclusion in this qualitative evidence synthesis. Findings are presented in a new conceptual framework RAAW [adapted from ARC] for women living with MBC under themes: Reality, Adversity, Adjustment and Wellbeing. Findings revealed that a diagnosis of MBC impacted every aspect of women’s lives; this is different to a diagnosis of early breast cancer. An overarching theme of lack of support extended across various facets of their lives. A lack of psychological, emotional, and psychosocial support was evident, with a critical finding that models of care were not fit for purpose. Deficits included a lack of information, knowledge, inclusion in shared decision-making and MDT support, specifically the need for palliative care/oncology support access. Some women living with MBC wanted to be identified as having a chronic illness not a life-limiting illness. Culture and socioeconomic standing influenced the availability of various types of support. The impact of treatment and symptoms had an adverse effect on women’s quality of life and affected their ability to adjust.ConclusionThis review synthesised the qualitative literature on the experiences of women living with MBC. The ARC framework used in the synthesis was adapted to develop a revised conceptual framework titled RAAW to represent the evidence from this review on experiences for women living with MBC; Reality & Adversity: A diagnosis of MBC; Adjustment: Living with MBC; Wellbeing: Awareness, meaning, engagement [RAAW; MBC].

This paper introduces models and techniques for synthesizing multiple qualitative studies on a topic. Qualitative research synthesis is a diverse set of methods for combining the data or the results of multiple studies on a topic to generate new knowledge, theory and applications. Use of qualitative research synthesis is rapidly expanding across disciplines. Aggregative and interpretive models of qualitative research synthesis are defined and distinguished. Several interpretive models are detailed. Their strengths are identified, and their limitations and areas of methodological ambiguity are critically examined. The steps of qualitative research synthesis are discussed and challenges specific to doing qualitative synthesis are identified and explored.

BackgroundThe GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation.CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on CERQual’s methodological limitations component.MethodsWe developed the methodological limitations component by searching the literature for definitions, gathering feedback from relevant research communities and developing consensus through project group meetings. We tested the CERQual methodological limitations component within several qualitative evidence syntheses before agreeing on the current definition and principles for application.ResultsWhen applying CERQual, we define methodological limitations as the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding. In this paper, we describe the methodological limitations component and its rationale and offer guidance on how to assess methodological limitations of a review finding as part of the CERQual approach. This guidance outlines the information required to assess methodological limitations component, the steps that need to be taken to assess methodological limitations of data contributing to a review finding and examples of methodological limitation assessments.ConclusionsThis paper provides guidance for review authors and others on undertaking an assessment of methodological limitations in the context of the CERQual approach. More work is needed to determine which criteria critical appraisal tools should include when assessing methodological limitations. We currently recommend that whichever tool is used, review authors provide a transparent description of their assessments of methodological limitations in a review finding. We expect the CERQual approach and its individual components to develop further as our experiences with the practical implementation of the approach increase.

In the UK, epilepsy care involves both specialists (for example, neurologists) and generalists (for example, GPs). Policymakers typically consider that epilepsy care should be integrated and involve both specialists and generalists. However, few understand exactly how patients view and compare specialist and generalist care. To explore patient perspectives of specialist care and generalist care for epilepsy in a qualitative evidence synthesis. A systematic review of patient perspectives of epilepsy care. A qualitative evidence synthesis was conducted using an identified framework. Systematic searches in five databases retrieved 17 eligible studies. Data were extracted and synthesised using framework analysis informed by the 'United Model of Generalism'. The following three themes were developed: 'Epilepsy care can be burdensome' (for example, through care fragmentation); 'Patients' experiences of care is that care is not always accessible' (for example, lack of a continuum between standardised and interpretive care); and 'How care could change for people with epilepsy' (for example, clinicians currently have insufficient time to deviate from protocol-driven care to address psychosocial needs). People with epilepsy frequently observe that generalists lack expertise in epilepsy management. This synthesis of patient experiences indicates recommendations should focus on improving communication and integration between specialists and generalists for epilepsy care. Patient experiences indicate specialist care risks being burdensome and generalist knowledge insufficient, requiring enhanced primary care clinician skills and improved awareness of patient psychosocial needs. The findings argue in favour of healthcare policies, materials, and tools to continually support patient perspectives in developing epilepsy services.

Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence

BackgroundGeneral practice has a key role in reducing inequity in access to care relating to sexual and reproductive health (SRH). Unplanned pregnancy, abortion, and sexually transmitted infections are increasing and disproportionately affect deprived communities and minoritised ethnic groups. The Candidacy Framework is a practical and theoretical framework for understanding the complex interactional processes of access to SRH care in general practice.AimTo use the Candidacy Framework to explore access to SRH care in general practice. The seven interaction stages are: identification of need; navigation of services; permeability of services; appearing and asserting need; adjudication by healthcare professional (HCP); offers or resistance of offer; and the local operating conditions or local production of candidacy.Design & settingSystematic review with qualitative evidence synthesis using a framework approach.MethodA systematic search of MEDLINE, Embase, PubMed, and the Web of Science was conducted to identify primary qualitative research exploring access to SRH care in general practice from practitioner, public, and patient perspectives in countries with universal health care. The Candidacy Framework was used to synthesise the findings.ResultsAnalysis of 42 studies revealed the impact of stigma, shame, and embarrassment among individuals, communities, and HCPs. Findings showed limited inclusion of demographics, such as ethnicity and socioeconomic status. Barriers to access were more evident for those from lower socioeconomic communities, minoritised ethnic groups, and the LGBTQ+ community. There are multiple barriers, which include the behaviours of HCPs, who have a crucial role in recognising an individual’s SRH need.ConclusionGeneral practice offers a cradle-to-grave healthcare service that should have SRH as a priority area of provision. Further understanding is needed about the impact of historic harms by medicine and health care on racialised individuals and minoritised genders.

This chapter looks at some of the main methods of synthesis that have been applied to qualitative research in the health care field, as well as methods for synthesis of qualitative and quantitative research. Synthesis can be conducted for different reasons with different sorts of outputs in mind. It can be conducted to summarise the implications of the qualitative evidence as part of a broader review process that includes a systematic review or other analyses of quantitative evidence. The chapter considers four main methods that can be used to synthesise qualitative research: narrative synthesis; framework synthesis; cross-case analysis; and meta-ethnography. These are followed by a brief overview of methods for mixed, qualitative, and quantitative synthesis. In general, qualitative synthesis is more iterative and less strictly linear in execution than quantitative synthesis. However, all the methods depend on a number of generic synthesis activities.

Healthcare decision makers are increasingly demanding that health technology assessment (HTA) is patient focused, and considers data about patients' perspectives on and experiences with health technologies in their everyday lives. Related data are typically generated through qualitative research, and in HTA the typical approach is to synthesize primary qualitative research through the conduct of qualitative evidence synthesis (QES). Abbreviated HTA timelines often do not allow for the full 6-12 months it may take to complete a QES, which has prompted the Canadian Agency for Drugs and Technologies in Health (CADTH) to explore the concept of "rapid qualitative evidence synthesis" (rQES). In this paper, we describe our experiences conducting three rQES at CADTH, and reflect on challenges faced, successes, and lessons learned. Given limited methodological guidance to guide this work, our aim is to provide insight for researchers who may contemplate rQES. We suggest several lessons, including strategies to iteratively develop research questions and search for eligible studies, use search of filters and limits, and use of a single reviewer experienced in qualitative research throughout the review process. We acknowledge that there is room for debate, though believe rQES is a laudable goal and that it is possible to produce a quality, relevant, and useful product, even under restricted timelines. That said, it is vital to recognize what is lost in the name of rapidity. We intend our paper to advance the necessary debate about when rQES may be appropriate, and not, and enable productive discussions around methodological development.