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Introduction

This The following section provides an introductory perspective on qualitative synthesis, the relationship between evidence, qualitative evidence and health care practice and sets out a framework for considering the philosophic traditions associated with forms of research. A brief outline of some of the debates regarding qualitative synthesis is presented, although not with the intent of comprehensively addressing the significant variety of positions, but rather to assist in situating meta aggregation (the JBI approach to qualitative synthesis) as a methodology and where it sits within the wider debates.Importantly, key operational assumptions have been included in this section, as have the definitions of core terms for the process of extracting and synthesizing qualitative data. These definitions inform meta aggregation and represent a distinctive difference from other methods of qualitative synthesis that rely on the reviewer to re-interpret literature. The term meta aggregation is the formal name of the methodology, however, aggregative review, aggregative synthesis or meta synthesis are used interchangeably in this manual.

What is qualitative research?

Qualitative evidence or qualitative data allows researchers to analyze human experience and cultural and social phenomena (Jordan 2006). Qualitative evidence has its origins in research methods from the humanities and social sciences and seeks to analyze the complexity of human phenomena in naturalistic settings and from a holistic perspective (Ailinger 2003). The term ‘qualitative’ refers to various research methodologies including ethnography, phenomenology, qualitative inquiry, action research, discourse analysis and grounded theory. Research methods include interviews, whether group or individual and observation (either direct or indirect). Researchers who use qualitative methodologies seek a deeper understanding, aiming to “study things in their natural setting, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them” (Denzin 2005).

In the healthcare or medical context, qualitative research:

“...seeks to understand and interpret personal experiences, behaviors, interactions, and social contexts to explain the phenomena of interest, such as the attitudes, beliefs, and perspectives of patients and clinicians; the interpersonal nature of caregiver and patient relationships; the illness experience; or the impact of human suffering”. (Wong and Haynes 2004).

Qualitative evidence has a particular role in exploring and explaining why interventions are or are not effective from a person centered perspective, and address questions related to the usability, meaningfulness, feasibility and appropriateness of interventions. Similarly, qualitative evidence is able to explain and explore why an intervention is not adopted in spite of evidence of its effectiveness (Black 1994).  The strength of qualitative research lies in its credibility (i.e. close proximity to the truth), using selected data collection strategies that “touch the core of what is going on rather than just skimming the surface” (Greenhalgh 1997).

Qualitative Evidence and Healthcare

Qualitative methods and data are increasing in usage in evidence-based healthcare research. Instead of quantifying or statistically portraying the data or findings, qualitative research focuses on individuals and gives voice to the patient/client or provider in the healthcare decision-making process. As an example, the question: ‘What proportion of smokers have tried to give up?’ leads to statistical answers while the question ‘Why do people continue to smoke?’, leads the researcher into exploring the ideas and concerns people who smoke tobacco may have about their smoking habits (Greenhalgh 1997).

Qualitative research is undertaken because it:

“...has an important role in evidence-based health care, in that it represents the human dimensions and experiences of the consumers of health care. This type of research does not answer questions concerning the effectiveness of health care; rather it provides important information about such things as the appropriateness of care and the impact of illness. It also provides a means of giving consumers a voice in the decision-making process through the documentation of their experiences, preferences, and priorities...” (Evans 2002).

Qualitative research plays a significant role in understanding how individuals and communities perceive health, manage their own health and make decisions related to health service usage. It can assist to understand the culture of communities, in relation to implementing changes and overcoming barriers. It can also inform planners and policy makers about the manner in which service users experience health as well as illness, and can be used to evaluate activities of health services such as health promotion and community development.

Acknowledgement of the contribution that qualitative research findings make in improving the quality and relevance of healthcare conditions is increasing. As an example, Systematic reviews. CRD's guidance for undertaking reviews in health care published by the Centre for Reviews and Dissemination at the University of York states that ‘There is growing recognition of the contribution that qualitative research can make to reviews of effectiveness’ as it helps to develop an understanding of the people, the practices and the policies behind the mechanisms and interventions (CRD 2009).

Qualitative evidence comprises data that is expressed in terms of the meaning or experiences of acts or events rather than in terms of a quantitative measurement. (Barbour 1999, Moffatt et al. 2006, Forman et al. 2008) Arguably one of the best features of its contribution to research inquiry lies in its stories and accounts of living and its richness of meanings within its words (Forman et al. 2008).

Philosophical perspectives, research methodologies and methods

A philosophical perspective encompasses our assumptions of the theory and the research methodologies that guide research. There are three prevailing philosophical or guiding paradigms in current western health care research. The first is the positivist – or empirico- analytical –paradigm, often associated with quantitative evidence (see Chapter 3) while the other two, the interpretive and critical paradigms, are largely associated with qualitative evidence. In the interpretive paradigm, theory is inductive and concerned with exposing implicit meaning; it aims at understanding. The critical paradigm, like the interpretive, is inductive, however it aims to emancipate knowledge and practice. Each paradigm is encompasses a diversity of research methodologies and methods (methods being the specific approach to data collection).

An outline of the key research methodologies and methods associated with the interpretive and critical paradigms is shown in Table 2.1.

Table 2.1: A summary of qualitative philosophy, methodologies and methods.

Methodologies

Data Collection Methods

Interpretivism

Seeks to understand. Sees knowledge in the possession of the people.

Phenomenology

Seeks to understand people’s individual subjective experiences and interpretations of the world.

Ethnography

Seeks to understand the social meaning of activities, rituals and events in a culture.

Grounded Theory

Seeks to generate theory that is grounded in the real world. The data itself defines the boundaries and directs development of theory.

Interviews.

Focus groups Observations.

Field work. (Observations, Interviews) Interviews.
Field observations. Purposeful interviews Textual analysis.

Critical enquiry

Seeks to change.

Action research

Involves researchers participating with the researched to effect change.

Feminist research

Seeks to create social change to benefit women.

Discourse Analysis

assumes that language socially and historically constructs how we think about and experience ourselves, and our relationships with others.

Participative group work Reflective Journals. (Quantitative methods can be used in addition to qualitative methods).

Qualitative in-depth interviews.
Focus Groups. (Quantitative methods can be used in addition to qualitative methods).

overview of the key information related to step 1 of the framework, including identifying the practice area, gaining consensus from stakeholders, establishing a working party and engaging stakeholders.

Identify the practice area

There are many important considerations when looking to change policy and practice, particularly when it comes to implementation. Implementation is far more likely to be successful when the questions being answered are relevant to key stakeholder groups (be they policy makers, managers, clinicians, patients/consumers) (Pearson, Jordan & Munn 2012). This is a key argument for why changes in policy or practice should be led by those who work in the area, rather than by external agencies. Clinicians and those supporting clinical practice are well situated to consider changes to the structures and processes of care. The context-rich knowledge practitioners bring has immense significance to policy or practice change processes.

Working in clinical practice and the management or administrative aspects of health service delivery raises many questions about how we might act to improve the provision of care. Sometimes these questions come from our own observations, from colleagues or from the people we care for. There are many valid and useful approaches to identifying areas of concern where practice might not be based on good evidence, or where there is a known problem or issue (Institute for Healthcare Improvement 2003). The first step is to ask as a team, “What are we trying to accomplish?” (Institute for Healthcare Improvement 2003; Langley et al. 1996). Topic identification may be supported by data such as hospital reports, adverse events, clinical pathway variance reports, morbidity and mortality data. Additionally, team members may know of better results occurring elsewhere for the same issue and be aware that evidence-based practice is not being followed (Institute for Healthcare Improvement 2003). Some approaches for identifying topic areas for evidence-based implementation projects include aspects of care that are:

• High cost
• High frequency (regardless of cost)
• High risk (known poor process or outcome)
• Topic of local concern
• Known variability in practice
• Flagged through critical incident review
• Practice area addressed by recent evidence-based guidelines

Sometimes it is helpful to review a process of care simply because it has been an accepted routine procedure or process, and no one has previously considered whether current practice is best practice, potentially making no difference or even causing harm.

The importance of teamwork cannot be over stressed in determining the long-term success/ sustainability of an implementation project.

It is important to choose a topic relevant to your clinical area of interest to which the clinical team can relate.  If you do not have the support of the team (and broadly across the organization) from the outset, the likelihood of achieving sustainable change will be challenging at best.  All evidence implementation projects are soundly grounded in a multidisciplinary team effort. No single healthcare professional group is responsible for excellent patient care. The first activity to be completed during this step is to construct a rationale, using the data that you have gathered, to demonstrate that the lack of evidence implementation within the organization is causing a problem. By providing this data to key stakeholders, you will hopefully be able to achieve the critical buy–in from both your key stakeholders and your executive leadership group.

Gaining consensus with key stakeholders

Healthcare delivery is a collaborative activity, with people working in teams, units, departments and divisions in order to bring together different strengths, skills and expertise to best serve the needs of particular groups of people. As such, identifying areas for improvement should be a collaborative process (Cranley et al. 2012). Consider who the key stakeholders are for the area of care; the patients (or clients or residents) who may be impacted by the change; the identification of relevant leaders and leadership skills that need to be accepting and engaged; and the organizational communications channels, committees and reporting requirements. This identification process means considering the trajectory of a project from start to finish, and knowing (or learning) the organizational pathways or processes to facilitate the successful completion of an evidence implementation study. Modern healthcare provision is team-based, multidisciplinary and integrative, bringing together organizational resources to efficiently and effectively meet healthcare needs.

Establishing a working group

When preparing to undertake an implementation project, consideration needs to be given to the human as well as the technical resources needed to complete the project.  A project of this nature will require a team of people to engage with others and enact a process of change and change management. It is recommended that this team is established well before confirmation of the project topic, scope and direction to ensure the project is feasible and will be accepted across the organization.

The degree to which engaging with stakeholders influences a project or process may vary, from being passively informed through to being truly active partners. A dominant theme in all literature about change management, and therefore implementation science, is the acknowledgment that leadership support is essential—particularly when it comes to large, complex organizations such as hospitals (Redfern & Christian 2003; Salmela, Eriksson & Fagerström 2012; Kitson, Alison et al. 1996; Redfern & Christian 2003; McGrath et al. 2008; Shanley 2007). Informing and persuading leadership of the need for change is critical to the long-term success of the project. The executive leadership support becomes invaluable in the constructive management of the identified barriers to the proposed change. Once you have leadership support, they will be able to direct you to the key stakeholders who should be involved. The identification of a project team that reflects the key stakeholders impacted by the project is a crucial activity during this phase of the project. The key principles governing the working party for an evidence implementation project are as follows:

• Establishing clear goals, aims or objectives
• Obtaining support (and representation where possible) from executive leadership
• Creating a clear communications strategy for the organization
• Including representatives from all sites across the organization or where the implementation will take place
• Ensuring an interprofessional team
• Selecting key opinion leaders, as well as representatives with knowledge in areas such as evidence-based practice, quality improvement and the evidence implementation project topic

Stakeholder engagement

Stakeholders reflect those who are involved in all aspects of clinical practice (generating policy on delivering and receiving care). The methods used to engage members of the stakeholder group should be transparent and allow the sharing of ideas in ways that permit ongoing feedback. When seeking stakeholder involvement, the agenda should be focused and the purpose and outcomes should be transparent and clearly articulated. Table 2 presents the core principles of stakeholder engagement.

Table 2: Core Principles of Stakeholder Engagement

Stakeholder engagement can be facilitated by the following methods:

• Establishing a project steering committee
• Ensuring representative working group membership
• Ensuring all people who will be affected by the project have a chance to provide input and feedback
• Ensuring the project is transparent
• Ensuring feedback is provided frequently