Francine Toye

'Trying to pin down jelly' - exploring intuitive processes in quality assessment for meta-ethnography

BackgroundStudies that systematically search for and synthesise qualitative research are becoming more evident in health care, and they can make an important contribution to patient care. However, there is still no agreement as to whether, or how we should appraise studies for inclusion. We aimed to explore the intuitive processes that determined the ‘quality’ of qualitative research for inclusion in qualitative research syntheses. We were particularly interested to explore the way that knowledge was constructed.MethodsWe used qualitative methods to explore the process of quality appraisal within a team of seven qualitative researchers funded to undertake a meta-ethnography of chronic non-malignant musculoskeletal pain. Team discussions took place monthly between October 2010 and June 2012 and were recorded and transcribed. Data was coded and organised using constant comparative method. The development of our conceptual analysis was both iterative and collaborative. The strength of this team approach to quality came from open and honest discussion, where team members felt free to agree, disagree, or change their position within the safety of the group.ResultsWe suggest two core facets of quality for inclusion in meta-ethnography - (1) Conceptual clarity; how clearly has the author articulated a concept that facilitates theoretical insight. (2) Interpretive rigour; fundamentally, can the interpretation ‘be trusted?’ Our findings showed that three important categories help the reader to judge interpretive rigour: (ii) What is the context of the interpretation? (ii) How inductive is the interpretation? (iii) Has the researcher challenged their interpretation?ConclusionsWe highlight that methods alone do not determine the quality of research for inclusion into a meta-ethnography. The strength of a concept and its capacity to facilitate theoretical insight is integral to meta-ethnography, and arguably to the quality of research. However, we suggest that to be judged ‘good enough’ there also needs to be some assurance that qualitative findings are more than simply anecdotal. Although our conceptual model was developed specifically for meta-ethnography, it may be transferable to other research methodologies.

Meta-ethnography 25 years on: challenges and insights for synthesising a large number of qualitative studies

Studies that systematically search for and synthesise qualitative research are becoming more evident in health care, and they can make an important contribution to patient care. Our team was funded to complete a meta-ethnography of patients’ experience of chronic musculoskeletal pain. It has been 25 years since Noblit and Hare published their core text on meta-ethnography, and the current health research environment brings additional challenges to researchers aiming to synthesise qualitative research. Noblit and Hare propose seven stages of meta-ethnography which take the researcher from formulating a research idea to expressing the findings. These stages are not discrete but form part of an iterative research process. We aimed to build on the methods of Noblit and Hare and explore the challenges of including a large number of qualitative studies into a qualitative systematic review. These challenges hinge upon epistemological and practical issues to be considered alongside expectations about what determines high quality research. This paper describes our method and explores these challenges. Central to our method was the process of collaborative interpretation of concepts and the decision to exclude original material where we could not decipher a concept. We use excerpts from our research team’s reflexive statements to illustrate the development of our methods.

'Could I be imagining this?' - the dialectic struggles of people with persistent unexplained back pain.

Purpose. To explore how patients with persistent unexplained pain interpret and utilise the biopsychosocial model. This might have an impact on the outcome from treatment programmes that adopts a biopsychosocial approach. Method. We conducted three interviews with 20 patients attending a pain management programme for persistent unexplained back pain; prior to attending the course, immediately following the course and at 1 year. We used the methods of grounded theory. Results. Patients battled through several dialectic tensions in an attempt to legitimise their pain: First, patients wanted a medical diagnosis but also recognised that psychosocial factors contributed to their pain. Second, although the outward appearance of pain was important to legitimacy, it was also important not to appear ‘too ill’. Third, meeting others with unexplained pain reinforced credibility, but patients also described how they were not ‘like the others’. Finally, although holding on to ones self was important, patients also described an acceptance of loss. Conclusions. These dialectic tensions are likely to have an impact on a persons decision to embrace the biopsychosocial model, and might therefore effect their outcome. Health care professionals should be sensitive to the cultural ambiguity of patients with persistent unexplained pain.

‘I can’t see any reason for stopping doing anything, but I might have to do it differently’ – restoring hope to patients with persistent non-specific low back pain – a qualitative study

Purpose: To explore the differences in narrative between patients with persistent non-specific low back pain (PLBP) who benefited from a pain management programme, and those who did not benefit. Method: We conducted interviews with 20 patients attending a pain management programme; prior to attending the programme, immediately following the programme and at one year. Our analysis focused on a theoretical sample of patients who either described dramatic life improvements at one year, and who described themselves as much worse. We used the methods of grounded theory. Results: We found that finding hope was central to good outcome. Patients restored hope by making certain changes; (a) deconstructing specific fears, (b) constructing an acceptable explanatory model (c) reconstructing self identity by making acceptable changes. Those who had not restored hope retained fears of loss of self, remained committed to the biomedical model and were unable to make acceptable changes. Conclusions: Our findings may help to operationalise the restoration of hope in patients with PLBP. Firstly, health care professionals need to identify and resolve any specific fears of movement. Secondly, patients need an acceptable explanatory model that fits their experience and personal narrative. Finally our study confirms the centrality of self concept to recovery. Implications for Rehabilitation Explanatory models are likely to have an impact on recovery following pain rehabilitation. Adherence to a biomedical model may have a negative impact on recovery. Patients need an acceptable explanatory model that fits their experience. Defining an acceptable self concept is integral to recovery.

Chronic disease management programme in people with severe knee osteoarthritis: efficacy and moderators of response:

Aims: To establish (1) the efficacy of a six-week chronic disease management programme for knee osteoarthritis and (2) whether previous physiotherapy or being wait listed for surgery moderated the outcome of the programme. Design: A pretest, posttest design with multivariate statistical modelling. Participants: One hundred and twenty-one people with severe osteoarthritis who were waiting, or being considered, for surgery. Methods and measures: Western Ontario Osteoarthritis Index (WOMAC) scores, arthritis self-efficacy, distress and a patient-rated global indicator of response were collected at baseline, 6 and 12 weeks. History of previous physiotherapy, waiting list status, symptom duration, New Zealand disease severity score, radiographic changes and self-perceived need for surgery were recorded at baseline. Results: There were moderate improvements in most outcomes; WOMAC function decreased by 0.29, WOMAC pain by 0.27, pain self-efficacy by 4.4, function self-efficacy by 5.6 and visual analogue scale (VAS) distress by 0.2 (effect sizes ranging from 0.3 to 0.5 at 12 weeks). Waiting list status was a significant modifier for function, pain, distress and self-related outcomes. Participants on the waiting list for surgery experienced lesser improvements. Previous physiotherapy was associated with greater improvements in WOMAC scores at six weeks, but not at 12 weeks. Conclusion: The chronic disease management programme could be considered for people with severe knee osteoarthritis, but should be given prior to referral and placement on the waiting list for surgery. Previous physiotherapy should not preclude people from participating in a chronic disease management programme.

‘It makes you think’ – exploring the impact of qualitative films on pain clinicians

Background: Researchers need to consider the impact and utility of their findings. Film is an accessible medium for qualitative research findings and can facilitate learning through emotional engagement. Aim: We aimed to explore the usefulness of a short film presenting findings from a published qualitative synthesis of adults’ experience of chronic musculoskeletal pain for pain education. In particular, we were interested in the impact of the film on clinician’s understanding of patients’ experience of chronic pain and how this knowledge might be used for improved healthcare for people with pain. Methods: Focus groups with healthcare professionals enrolled in a pain management foundation course explored healthcare professionals’ experience of watching the film. A constructivist grounded theory approach was adopted by the researchers. Findings: This article presents one thematic exemplar from a wider study. Participants reflected upon the pitfalls of judging by appearances and the value of seeing the person beneath his or her performance. Conclusion: There is a danger that the impact of qualitative findings is under-valued in clinical education. We present one exemplar from a study exploring knowledge mobilisation, which demonstrates that qualitative research, specifically qualitative films, can make us think about the care that we provide to people with chronic pain.

A validation study of the new Zealand score for hip and knee surgery

In the absence of consensus over criteria for performing total knee arthroplasty, the variability of symptom burden, and limited resources, some ways to prioritize whether and when to treat would be useful. In the UK, some payers use the New Zealand score to determine access to an orthopaedic surgeon despite limited validation. We tested convergent validity of this score and ascertained its ability to discriminate between groups of patients with high or low disease burden as determined by a validated disease-specific measure. The sample included patients being considered for total knee arthroplasty at one hospital. Convergent validity was tested against the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The ability of the New Zealand score to discriminate between high and low disease burdens was tested by plotting a receiver operating characteristic curve. Correlations between the New Zealand score and WOMAC pain and function were moderate (0.5 and 0.54, respectively). The area under the receiver operating characteristic curve was 0.77, suggesting the New Zealand score was able to discriminate. This study supports the validity of the New Zealand score. However, additional multisite and extended evaluations are needed before we would recommend widespread implementation.Level of Evidence: Level I, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.

A qualitative systematic review of patients’ experience of osteoporosis using meta-ethnography

SummaryWe aimed to systematically review qualitative studies exploring the experience of living with osteoporosis to develop new conceptual understanding. We identified themes about the invisibility/visibility of osteoporosis, the experience of uncertainty of living with osteoporosis (OP) and living with an ageing body and the place of gender.PurposeThe aim of this review was to systematically review the body of qualitative studies exploring the experience of living with either osteoporosis or osteopenia and to use meta-ethnography to develop new conceptual understanding.MethodsWe systematically reviewed and integrated the findings of qualitative research from four bibliographic databases (Medline, Embase, Cinahl, Psychinfo) to September 2015 in order to increase our conceptual understanding of the lived experience of osteoporosis and osteopenia. Articles were appraised for quality; each was independently read by two researchers to identify concepts which were compared and developed into a conceptual model.ResultsOur findings demonstrate that coming to terms with a diagnosis of osteoporosis is linked to its relative visibility or invisibility. For some, OP has not become manifest and self-identity is intact (biographical integrity). For others, OP is profoundly manifest and self-identity is no long intact (biographical fracture). We also demonstrate that overwhelming uncertainty pervades the experience of OP. Our final theme demonstrates how the experience of OP is set within a cultural context with certain views about ageing and gender.ConclusionsOur synthesis has highlighted the wealth of qualitative data about osteoporosis and osteopenia. Despite the increasing body of literature on the subject, there remains a need to adjust our interactions with patients. This will allow clinicians to understand how patients can be helped to receive and understand their diagnosis and move forward in partnership with healthcare providers to promote optimal management of the disease.

Physiotherapists' experiences of activity pacing with people with chronic musculoskeletal pain: an interpretative phenomenological analysis.

Abstract Purpose: Activity pacing is a strategy used by physiotherapists treating people with chronic pain. Questions as to the usefulness of activity pacing with people with chronic pain have been raised clinically and in research. This study explores physiotherapists’ experiences of using activity pacing with people with chronic musculoskeletal pain. Method: We interviewed six physiotherapists and used the methods of Interpretative Phenomenological Analysis (IPA) to explore the meaning of pacing. Results: We identified three master themes. First, activity pacing was perceived as part of a process whereby patients came to realize that change is possible, and that life could be different. Second, in order to use activity pacing effectively the physiotherapist needs to shift from a “fix it” to a “sit with” approach to the treatment. Third physiotherapists described how they used many combined therapeutic approaches in managing chronic pain. Conclusions: This study increases our understanding of activity pacing and will help to make the best use of activity pacing in clinical practice, and optimize outcomes for the patients. These findings suggest that physiotherapists need to develop reflective listening skills, and use an experiential learning approach to facilitate activity pacing.

Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention - ISRCTN89936343

BackgroundRheumatoid Arthritis (RA) commonly affects the hands and wrists with inflammation, deformity, pain, weakness and restricted mobility leading to reduced function. The effectiveness of exercise for RA hands is uncertain, although evidence from small scale studies is promising. The Strengthening And Stretching for Rheumatoid Arthritis of the Hand (SARAH) trial is a pragmatic, multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of adding an optimised exercise programme for hands and upper limbs to best practice usual care for patients with RA.Methods/design480 participants with problematic RA hands will be recruited through 17 NHS trusts. Treatments will be provided by physiotherapists and occupational therapists. Participants will be individually randomised to receive either best practice usual care (joint protection advice, general exercise advice, functional splinting and assistive devices) or best practice usual care supplemented with an individualised exercise programme of strengthening and stretching exercises. The study assessors will be blinded to treatment allocation and will follow participants up at four and 12 months. The primary outcome measure is the Hand function subscale of the Michigan Hand Outcome Questionnaire, and secondary outcomes include hand and wrist impairment measures, quality of life, and resource use. Economic and qualitative studies will also be carried out in parallel.DiscussionThis paper describes the design and development of a trial protocol of a complex intervention study based in therapy out-patient departments. The findings will provide evidence to support or refute the use of an optimised exercise programme for RA of the hand in addition to best practice usual care.Trial registrationCurrent Controlled Trials ISRCTN89936343