Kate Flemming

Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ

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.

Asking answerable questions

Nurses have had to deal with many changes in recent years, one of which is the increased expectation that they will keep their practice up to date by reading vast numbers of publications. This expectation and the pressures of maintaining continuing education requirements come alongside ever increasing workloads and diminishing study time. So what can be done to ease some of the pressure? Evidence-based nursing (EBN) offers at least some of the answers. In a nutshell, the aim of EBN is to make it easier to include current best evidence from research in clinical and healthcare decisions. EBN is a 5 stage process: The purpose of this paper is to work through stage 1: the formulation of structured, focused questions. The types of information needs that arise regularly from our clinical practice are those questions such as Why do we do it this way? or Whats the best way of ....? for which neither you nor your colleagues have a ready answer. If you are able to go to the library, what strategies can you use to find answers to this type of question efficiently? How do you find good quality, relevant research without wading through hundreds of papers? Framing the question in a way which lends itself to searching while still reflecting the specific patient or service focus is an important stage to get right. That way, when you begin …

Smoking in pregnancy: a systematic review of qualitative research of women who commence pregnancy as smokers

AIM To provide evidence on how womens circumstances and experiences influence their smoking behaviour in pregnancy, including their attempts to quit. BACKGROUND Women in disadvantaged circumstances are more likely to smoke prior to pregnancy; they are also less likely to quit in pregnancy and, among those who quit, more likely to resume smoking after birth. Although there is a rich seam of qualitative research on their experiences, it has yet to be bought together and synthesized. DESIGN The synthesis was conducted using meta-ethnography. DATA SOURCES A comprehensive search of five electronic databases (inception to May 2012) was completed to identify qualitative research exploring pregnant womens experiences of smoking in pregnancy. REVIEW METHODS Following critical appraisal, 26 studies reported in 29 papers were included in the review. Over 640 pregnant women were represented, the majority drawn from disadvantaged groups. We carried out the synthesis using meta-ethnography. RESULTS Four dimensions of womens circumstances and experiences of smoking in pregnancy were highlighted: the embeddedness of smoking in womens lives, questioned only because of pregnancy; quitting for pregnancy rather than for good; quitting had significant costs for the woman and cutting down was a positive alternative; the role of partners and the broader dynamics of the couples relationship in influencing womens smoking habits. CONCLUSION Syntheses of qualitative research have an important role to play in producing the evidence base for midwifery, nursing, and public health policy and practice. The four dimensions identified in this review have implications for the design and delivery of interventions to support women to quit smoking in pregnancy.

The Use of Morphine to Treat Cancer-Related Pain: A Synthesis of Quantitative and Qualitative Research

Morphine is the most commonly used opioid for severe cancer-related pain. Despite its established effectiveness, it is often used cautiously in clinical practice, particularly outside specialist palliative care. This review identifies the key social, contextual, and physical concerns held by patients, carers, and health care professionals when using morphine, which might explain the caution taken in its use. The review used an approach called critical interpretive synthesis (CIS), which combines conventional systematic review techniques with methods for interpretative synthesis of qualitative research. An existing review examining the effectiveness of morphine and a guideline on its use were synthesized with 19 qualitative articles to establish understanding of how context of use can affect the established effectiveness of morphine. The article argues for the appropriateness of CIS for answering questions of this type. The results demonstrate that using morphine is a balancing act and a trade-off between pain relief and adverse effects. Deep-seated concerns regarding the symbolism of morphine, addiction, and tolerance are held by patients, carers, and clinicians, which influence prescription and use. Cancer pain is a referent for disease status and has existential meaning, with the introduction of morphine becoming a metaphor for impending death. Cancer pain is intersubjective, with its perception and reporting influenced by those with whom the patient interacts. By understanding the context and social meaning surrounding the use of morphine to treat cancer pain, health care professionals can begin to anticipate, acknowledge, and address some of the barriers to its use, thereby enhancing pain control.

Improving the effectiveness of interventions in palliative care: the potential role of qualitative research in enhancing evidence from randomized controlled trials

Evaluating interventions in palliative care using randomized controlled trials (RCTs) has helped advance the specialty and create an evidence base for the delivery of care. RCTs, however, are notoriously difficult to conduct in palliative care, raising a variety of practical, ethical and moral dilemmas. Mixed-methods research, which combines qualitative research and RCTs, offers a potential solution to these problems. This paper begins by examining the theoretical basis for combining the two approaches, before reviewing the specific role qualitative research could play in planning, conducting and implementing trials. The paper then goes on to explore how palliative care research currently uses the mixed-methods approach, by searching the trials included in six Cochrane Systematic Reviews (n = 146) on the incorporation of qualitative research. Only one trial undertook qualitative research. These findings reflect some of the challenges facing mixed-methods research, which include lack of experience in a research team, the problems of obtaining funding and difficulties in publishing. The paper concludes that while combining qualitative and quantitative research is not a panacea for methodological problems in palliative care research, with careful planning and integration, the approach may enhance the clinical and ethical utility of trial findings, which in turn will improve patient care.

The Knowledge Base for Evidence-based Nursing A Role for Mixed Methods Research?

Evidence-based nursing is central to the knowledge base for nursing practice. Critics of evidence-based nursing dislike the central role that randomized controlled trials (RCTs) take in providing evidence for nursing, claiming that the context and experience of nursing care are removed from evaluation. Many nursing decisions involve questions regarding the effectiveness of interventions, best evaluated by RCTs. This article explores the epistemological and practical feasibility of combining qualitative research with RCTs (mixed methods research) in evaluations of nursing practice. Through theoretical and practical examples, it proposes that mixed methods research has the potential to enhance the evidence base for nursing.

The synthesis of qualitative research and evidence-based nursing

Readers of Evidence-Based Nursing will be familiar with “review articles.” They are among the most common types of research abstracted for the journal, and although systematic reviews of randomised controlled trials (RCTs) predominantly feature in the Treatment section, reviews that address questions of assessment, causation, quality improvement, prognosis, and quality assessment have also been abstracted. Reviews of qualitative research have been abstracted less frequently—7 times since the journal began in 1998. Qualitative research is an important component of the evidence base for nursing. Almost one quarter of all abstracts published in Evidence-Based Nursing (n = 205) have been primary qualitative research articles, and they have examined several areas of nursing practice. Like quantitative researchers, qualitative researchers have become interested in synthesising qualitative research in order to develop new cumulative knowledge.1 This notebook will explore how syntheses of qualitative research may contribute to the practice of evidence-based nursing. Systematic reviews and meta-analyses of RCTs are at the top of the hierarchy for providing evidence of the effectiveness of interventions. This is because all individual trials have limitations, such as low statistical power, researcher or expert bias, and contextual variability.2 Similarly, single qualitative studies can be heavily influenced by specific issues of context and generalisability. By synthesising qualitative research, these difficulties can potentially be overcome. Several methodological approaches have been developed to synthesise qualitative research over the past 2 decades. Some have been adapted from methods used to analyse primary qualitative research, whereas others have been specifically developed for this purpose.3 Qualitative synthesis is being promoted by a number of organisations based on the recognition that providing health care involves complex, multifactorial decisions that require a range of evidence. Qualitative synthesis complements the “rationalist” model of synthesis provided by traditional systematic review methods.4 One such organisation is the Cochrane Qualitative …

Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth

AIM To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies. BACKGROUND The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed. DESIGN A synthesis of qualitative research using meta-ethnography. DATA SOURCES Five electronic databases (January 1990-May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the reviews aims. REVIEW METHODS Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups. RESULTS Four factors were identified that acted both as barriers and facilitators to womens ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking. CONCLUSION The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting.

Education in cancer pain management.

Purpose of reviewTo describe the current position of educational interventions within the context of cancer pain management. Recent findingsBarriers to good cancer pain control exist within patients and professionals and centre on lack of knowledge or poor attitudes towards pain and opioid analgesia. Education provided to healthcare professionals increases knowledge and improves attitudes but this does not necessarily translate into improvements in patient outcomes. However, targeted interventions that modify professional behaviour are effective. Educational interventions directed at patients result in improved patient outcomes, although the mechanisms by which these improvements occur are not yet clear. SummaryOverall, educational interventions directed at patients or professionals can result in significant but modest clinical benefit which is similar in magnitude to that achieved by some analgesics. Educational interventions should be part of routine clinical practice alongside optimal oncological and analgesic management. Further work is needed on how best to implement multicomponent interventions within clinical services, including the identification of which combinations are most cost effective.

Health professionals’ perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research

BackgroundReducing smoking in pregnancy is a policy priority in many countries and as a result there has been a rise in the development of services to help pregnant women to quit. A wide range of professionals are involved in providing these services, with midwives playing a particularly pivotal role. Understanding professionals’ experiences of providing smoking cessation support in pregnancy can help to inform the design of interventions as well as to improve routine care.MethodsA synthesis of qualitative research of health professionals’ perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and the post-partum period was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2015 using terms for maternity health professionals and smoking cessation advisors, pregnancy, post-partum, smoking, and qualitative in seven electronic databases. The review was reported in accordance with the ‘Enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement.ResultsEight studies reported in nine papers were included, reporting on the views of 190 health professionals/key informants, including 85 midwives and health visitors. The synthesis identified that both the professional role of participants and the organisational context in which they worked could act as either barriers or facilitators to an individual’s ability to provide smoking cessation support to pregnant or post-partum women. Underpinning these factors was an acknowledgment that the association between maternal smoking and social disadvantage was a considerable barrier to addressing and supporting smoking cessationConclusionsThe review identifies a role for professional education, both pre-qualification and in continuing professional development that will enable individuals to provide smoking cessation support to pregnant women. Key to the success of this education is recognising the centrality of the professional-client/patient relationship in any interaction. The review also highlights a widespread professional perception of the barriers associated with helping women give up smoking in pregnancy, particularly for those in disadvantaged circumstances. Improving the quality and accessibility of evidence on effective healthcare interventions, including evidence on ‘what works’ to support smoking cessation in disadvantaged groups, should therefore be a priority.PROSPERO 2013CRD42013004170.