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  • Published: 10 July 2008

Methods for the thematic synthesis of qualitative research in systematic reviews

  • James Thomas 1 &
  • Angela Harden 1  

BMC Medical Research Methodology volume  8 , Article number:  45 ( 2008 ) Cite this article

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There is a growing recognition of the value of synthesising qualitative research in the evidence base in order to facilitate effective and appropriate health care. In response to this, methods for undertaking these syntheses are currently being developed. Thematic analysis is a method that is often used to analyse data in primary qualitative research. This paper reports on the use of this type of analysis in systematic reviews to bring together and integrate the findings of multiple qualitative studies.

We describe thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion research. Thematic synthesis has three stages: the coding of text 'line-by-line'; the development of 'descriptive themes'; and the generation of 'analytical themes'. While the development of descriptive themes remains 'close' to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewers 'go beyond' the primary studies and generate new interpretive constructs, explanations or hypotheses. The use of computer software can facilitate this method of synthesis; detailed guidance is given on how this can be achieved.

We used thematic synthesis to combine the studies of children's views and identified key themes to explore in the intervention studies. Most interventions were based in school and often combined learning about health benefits with 'hands-on' experience. The studies of children's views suggested that fruit and vegetables should be treated in different ways, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective. Thematic synthesis enabled us to stay 'close' to the results of the primary studies, synthesising them in a transparent way, and facilitating the explicit production of new concepts and hypotheses.

We compare thematic synthesis to other methods for the synthesis of qualitative research, discussing issues of context and rigour. Thematic synthesis is presented as a tried and tested method that preserves an explicit and transparent link between conclusions and the text of primary studies; as such it preserves principles that have traditionally been important to systematic reviewing.

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The systematic review is an important technology for the evidence-informed policy and practice movement, which aims to bring research closer to decision-making [ 1 , 2 ]. This type of review uses rigorous and explicit methods to bring together the results of primary research in order to provide reliable answers to particular questions [ 3 – 6 ]. The picture that is presented aims to be distorted neither by biases in the review process nor by biases in the primary research which the review contains [ 7 – 10 ]. Systematic review methods are well-developed for certain types of research, such as randomised controlled trials (RCTs). Methods for reviewing qualitative research in a systematic way are still emerging, and there is much ongoing development and debate [ 11 – 14 ].

In this paper we present one approach to the synthesis of findings of qualitative research, which we have called 'thematic synthesis'. We have developed and applied these methods within several systematic reviews that address questions about people's perspectives and experiences [ 15 – 18 ]. The context for this methodological development is a programme of work in health promotion and public health (HP & PH), mostly funded by the English Department of Health, at the EPPI-Centre, in the Social Science Research Unit at the Institute of Education, University of London in the UK. Early systematic reviews at the EPPI-Centre addressed the question 'what works?' and contained research testing the effects of interventions. However, policy makers and other review users also posed questions about intervention need, appropriateness and acceptability, and factors influencing intervention implementation. To address these questions, our reviews began to include a wider range of research, including research often described as 'qualitative'. We began to focus, in particular, on research that aimed to understand the health issue in question from the experiences and point of view of the groups of people targeted by HP&PH interventions (We use the term 'qualitative' research cautiously because it encompasses a multitude of research methods at the same time as an assumed range of epistemological positions. In practice it is often difficult to classify research as being either 'qualitative' or 'quantitative' as much research contains aspects of both [ 19 – 22 ]. Because the term is in common use, however, we will employ it in this paper).

When we started the work for our first series of reviews which included qualitative research in 1999 [ 23 – 26 ], there was very little published material that described methods for synthesising this type of research. We therefore experimented with a variety of techniques borrowed from standard systematic review methods and methods for analysing primary qualitative research [ 15 ]. In later reviews, we were able to refine these methods and began to apply thematic analysis in a more explicit way. The methods for thematic synthesis described in this paper have so far been used explicitly in three systematic reviews [ 16 – 18 ].

The review used as an example in this paper

To illustrate the steps involved in a thematic synthesis we draw on a review of the barriers to, and facilitators of, healthy eating amongst children aged four to 10 years old [ 17 ]. The review was commissioned by the Department of Health, England to inform policy about how to encourage children to eat healthily in the light of recent surveys highlighting that British children are eating less than half the recommended five portions of fruit and vegetables per day. While we focus on the aspects of the review that relate to qualitative studies, the review was broader than this and combined answering traditional questions of effectiveness, through reviewing controlled trials, with questions relating to children's views of healthy eating, which were answered using qualitative studies. The qualitative studies were synthesised using 'thematic synthesis' – the subject of this paper. We compared the effectiveness of interventions which appeared to be in line with recommendations from the thematic synthesis with those that did not. This enabled us to see whether the understandings we had gained from the children's views helped us to explain differences in the effectiveness of different interventions: the thematic synthesis had enabled us to generate hypotheses which could be tested against the findings of the quantitative studies – hypotheses that we could not have generated without the thematic synthesis. The methods of this part of the review are published in Thomas et al . [ 27 ] and are discussed further in Harden and Thomas [ 21 ].

Qualitative research and systematic reviews

The act of seeking to synthesise qualitative research means stepping into more complex and contested territory than is the case when only RCTs are included in a review. First, methods are much less developed in this area, with fewer completed reviews available from which to learn, and second, the whole enterprise of synthesising qualitative research is itself hotly debated. Qualitative research, it is often proposed, is not generalisable and is specific to a particular context, time and group of participants. Thus, in bringing such research together, reviewers are open to the charge that they de-contextualise findings and wrongly assume that these are commensurable [ 11 , 13 ]. These are serious concerns which it is not the purpose of this paper to contest. We note, however, that a strong case has been made for qualitative research to be valued for the potential it has to inform policy and practice [ 11 , 28 – 30 ]. In our experience, users of reviews are interested in the answers that only qualitative research can provide, but are not able to handle the deluge of data that would result if they tried to locate, read and interpret all the relevant research themselves. Thus, if we acknowledge the unique importance of qualitative research, we need also to recognise that methods are required to bring its findings together for a wide audience – at the same time as preserving and respecting its essential context and complexity.

The earliest published work that we know of that deals with methods for synthesising qualitative research was written in 1988 by Noblit and Hare [ 31 ]. This book describes the way that ethnographic research might be synthesised, but the method has been shown to be applicable to qualitative research beyond ethnography [ 32 , 11 ]. As well as meta-ethnography, other methods have been developed more recently, including 'meta-study' [ 33 ], 'critical interpretive synthesis' [ 34 ] and 'metasynthesis' [ 13 ].

Many of the newer methods being developed have much in common with meta-ethnography, as originally described by Noblit and Hare, and often state explicitly that they are drawing on this work. In essence, this method involves identifying key concepts from studies and translating them into one another. The term 'translating' in this context refers to the process of taking concepts from one study and recognising the same concepts in another study, though they may not be expressed using identical words. Explanations or theories associated with these concepts are also extracted and a 'line of argument' may be developed, pulling corroborating concepts together and, crucially, going beyond the content of the original studies (though 'refutational' concepts might not be amenable to this process). Some have claimed that this notion of 'going beyond' the primary studies is a critical component of synthesis, and is what distinguishes it from the types of summaries of findings that typify traditional literature reviews [e.g. [ 32 ], p209]. In the words of Margarete Sandelowski, "metasyntheses are integrations that are more than the sum of parts, in that they offer novel interpretations of findings. These interpretations will not be found in any one research report but, rather, are inferences derived from taking all of the reports in a sample as a whole" [[ 14 ], p1358].

Thematic analysis has been identified as one of a range of potential methods for research synthesis alongside meta-ethnography and 'metasynthesis', though precisely what the method involves is unclear, and there are few examples of it being used for synthesising research [ 35 ]. We have adopted the term 'thematic synthesis', as we translated methods for the analysis of primary research – often termed 'thematic' – for use in systematic reviews [ 36 – 38 ]. As Boyatzis [[ 36 ], p4] has observed, thematic analysis is "not another qualitative method but a process that can be used with most, if not all, qualitative methods..." . Our approach concurs with this conceptualisation of thematic analysis, since the method we employed draws on other established methods but uses techniques commonly described as 'thematic analysis' in order to formalise the identification and development of themes.

We now move to a description of the methods we used in our example systematic review. While this paper has the traditional structure for reporting the results of a research project, the detailed methods (e.g. precise terms we used for searching) and results are available online. This paper identifies the particular issues that relate especially to reviewing qualitative research systematically and then to describing the activity of thematic synthesis in detail.

When searching for studies for inclusion in a 'traditional' statistical meta-analysis, the aim of searching is to locate all relevant studies. Failing to do this can undermine the statistical models that underpin the analysis and bias the results. However, Doyle [[ 39 ], p326] states that, "like meta-analysis, meta-ethnography utilizes multiple empirical studies but, unlike meta-analysis, the sample is purposive rather than exhaustive because the purpose is interpretive explanation and not prediction" . This suggests that it may not be necessary to locate every available study because, for example, the results of a conceptual synthesis will not change if ten rather than five studies contain the same concept, but will depend on the range of concepts found in the studies, their context, and whether they are in agreement or not. Thus, principles such as aiming for 'conceptual saturation' might be more appropriate when planning a search strategy for qualitative research, although it is not yet clear how these principles can be applied in practice. Similarly, other principles from primary qualitative research methods may also be 'borrowed' such as deliberately seeking studies which might act as negative cases, aiming for maximum variability and, in essence, designing the resulting set of studies to be heterogeneous, in some ways, instead of achieving the homogeneity that is often the aim in statistical meta-analyses.

However you look, qualitative research is difficult to find [ 40 – 42 ]. In our review, it was not possible to rely on simple electronic searches of databases. We needed to search extensively in 'grey' literature, ask authors of relevant papers if they knew of more studies, and look especially for book chapters, and we spent a lot of effort screening titles and abstracts by hand and looking through journals manually. In this sense, while we were not driven by the statistical imperative of locating every relevant study, when it actually came down to searching, we found that there was very little difference in the methods we had to use to find qualitative studies compared to the methods we use when searching for studies for inclusion in a meta-analysis.

Quality assessment

Assessing the quality of qualitative research has attracted much debate and there is little consensus regarding how quality should be assessed, who should assess quality, and, indeed, whether quality can or should be assessed in relation to 'qualitative' research at all [ 43 , 22 , 44 , 45 ]. We take the view that the quality of qualitative research should be assessed to avoid drawing unreliable conclusions. However, since there is little empirical evidence on which to base decisions for excluding studies based on quality assessment, we took the approach in this review to use 'sensitivity analyses' (described below) to assess the possible impact of study quality on the review's findings.

In our example review we assessed our studies according to 12 criteria, which were derived from existing sets of criteria proposed for assessing the quality of qualitative research [ 46 – 49 ], principles of good practice for conducting social research with children [ 50 ], and whether studies employed appropriate methods for addressing our review questions. The 12 criteria covered three main quality issues. Five related to the quality of the reporting of a study's aims, context, rationale, methods and findings (e.g. was there an adequate description of the sample used and the methods for how the sample was selected and recruited?). A further four criteria related to the sufficiency of the strategies employed to establish the reliability and validity of data collection tools and methods of analysis, and hence the validity of the findings. The final three criteria related to the assessment of the appropriateness of the study methods for ensuring that findings about the barriers to, and facilitators of, healthy eating were rooted in children's own perspectives (e.g. were data collection methods appropriate for helping children to express their views?).

Extracting data from studies

One issue which is difficult to deal with when synthesising 'qualitative' studies is 'what counts as data' or 'findings'? This problem is easily addressed when a statistical meta-analysis is being conducted: the numeric results of RCTs – for example, the mean difference in outcome between the intervention and control – are taken from published reports and are entered into the software package being used to calculate the pooled effect size [ 3 , 51 ].

Deciding what to abstract from the published report of a 'qualitative' study is much more difficult. Campbell et al . [ 11 ] extracted what they called the 'key concepts' from the qualitative studies they found about patients' experiences of diabetes and diabetes care. However, finding the key concepts in 'qualitative' research is not always straightforward either. As Sandelowski and Barroso [ 52 ] discovered, identifying the findings in qualitative research can be complicated by varied reporting styles or the misrepresentation of data as findings (as for example when data are used to 'let participants speak for themselves'). Sandelowski and Barroso [ 53 ] have argued that the findings of qualitative (and, indeed, all empirical) research are distinct from the data upon which they are based, the methods used to derive them, externally sourced data, and researchers' conclusions and implications.

In our example review, while it was relatively easy to identify 'data' in the studies – usually in the form of quotations from the children themselves – it was often difficult to identify key concepts or succinct summaries of findings, especially for studies that had undertaken relatively simple analyses and had not gone much further than describing and summarising what the children had said. To resolve this problem we took study findings to be all of the text labelled as 'results' or 'findings' in study reports – though we also found 'findings' in the abstracts which were not always reported in the same way in the text. Study reports ranged in size from a few pages to full final project reports. We entered all the results of the studies verbatim into QSR's NVivo software for qualitative data analysis. Where we had the documents in electronic form this process was straightforward even for large amounts of text. When electronic versions were not available, the results sections were either re-typed or scanned in using a flat-bed or pen scanner. (We have since adapted our own reviewing system, 'EPPI-Reviewer' [ 54 ], to handle this type of synthesis and the screenshots below show this software.)

Detailed methods for thematic synthesis

The synthesis took the form of three stages which overlapped to some degree: the free line-by-line coding of the findings of primary studies; the organisation of these 'free codes' into related areas to construct 'descriptive' themes; and the development of 'analytical' themes.

Stages one and two: coding text and developing descriptive themes

In our children and healthy eating review, we originally planned to extract and synthesise study findings according to our review questions regarding the barriers to, and facilitators of, healthy eating amongst children. It soon became apparent, however, that few study findings addressed these questions directly and it appeared that we were in danger of ending up with an empty synthesis. We were also concerned about imposing the a priori framework implied by our review questions onto study findings without allowing for the possibility that a different or modified framework may be a better fit. We therefore temporarily put our review questions to one side and started from the study findings themselves to conduct an thematic analysis.

There were eight relevant qualitative studies examining children's views of healthy eating. We entered the verbatim findings of these studies into our database. Three reviewers then independently coded each line of text according to its meaning and content. Figure 1 illustrates this line-by-line coding using our specialist reviewing software, EPPI-Reviewer, which includes a component designed to support thematic synthesis. The text which was taken from the report of the primary study is on the left and codes were created inductively to capture the meaning and content of each sentence. Codes could be structured, either in a tree form (as shown in the figure) or as 'free' codes – without a hierarchical structure.

figure 1

line-by-line coding in EPPI-Reviewer.

The use of line-by-line coding enabled us to undertake what has been described as one of the key tasks in the synthesis of qualitative research: the translation of concepts from one study to another [ 32 , 55 ]. However, this process may not be regarded as a simple one of translation. As we coded each new study we added to our 'bank' of codes and developed new ones when necessary. As well as translating concepts between studies, we had already begun the process of synthesis (For another account of this process, see Doyle [[ 39 ], p331]). Every sentence had at least one code applied, and most were categorised using several codes (e.g. 'children prefer fruit to vegetables' or 'why eat healthily?'). Before completing this stage of the synthesis, we also examined all the text which had a given code applied to check consistency of interpretation and to see whether additional levels of coding were needed. (In grounded theory this is termed 'axial' coding; see Fisher [ 55 ] for further discussion of the application of axial coding in research synthesis.) This process created a total of 36 initial codes. For example, some of the text we coded as "bad food = nice, good food = awful" from one study [ 56 ] were:

'All the things that are bad for you are nice and all the things that are good for you are awful.' (Boys, year 6) [[ 56 ], p74]

'All adverts for healthy stuff go on about healthy things. The adverts for unhealthy things tell you how nice they taste.' [[ 56 ], p75]

Some children reported throwing away foods they knew had been put in because they were 'good for you' and only ate the crisps and chocolate . [[ 56 ], p75]

Reviewers looked for similarities and differences between the codes in order to start grouping them into a hierarchical tree structure. New codes were created to capture the meaning of groups of initial codes. This process resulted in a tree structure with several layers to organize a total of 12 descriptive themes (Figure 2 ). For example, the first layer divided the 12 themes into whether they were concerned with children's understandings of healthy eating or influences on children's food choice. The above example, about children's preferences for food, was placed in both areas, since the findings related both to children's reactions to the foods they were given, and to how they behaved when given the choice over what foods they might eat. A draft summary of the findings across the studies organized by the 12 descriptive themes was then written by one of the review authors. Two other review authors commented on this draft and a final version was agreed.

figure 2

relationships between descriptive themes.

Stage three: generating analytical themes

Up until this point, we had produced a synthesis which kept very close to the original findings of the included studies. The findings of each study had been combined into a whole via a listing of themes which described children's perspectives on healthy eating. However, we did not yet have a synthesis product that addressed directly the concerns of our review – regarding how to promote healthy eating, in particular fruit and vegetable intake, amongst children. Neither had we 'gone beyond' the findings of the primary studies and generated additional concepts, understandings or hypotheses. As noted earlier, the idea or step of 'going beyond' the content of the original studies has been identified by some as the defining characteristic of synthesis [ 32 , 14 ].

This stage of a qualitative synthesis is the most difficult to describe and is, potentially, the most controversial, since it is dependent on the judgement and insights of the reviewers. The equivalent stage in meta-ethnography is the development of 'third order interpretations' which go beyond the content of original studies [ 32 , 11 ]. In our example, the step of 'going beyond' the content of the original studies was achieved by using the descriptive themes that emerged from our inductive analysis of study findings to answer the review questions we had temporarily put to one side. Reviewers inferred barriers and facilitators from the views children were expressing about healthy eating or food in general, captured by the descriptive themes, and then considered the implications of children's views for intervention development. Each reviewer first did this independently and then as a group. Through this discussion more abstract or analytical themes began to emerge. The barriers and facilitators and implications for intervention development were examined again in light of these themes and changes made as necessary. This cyclical process was repeated until the new themes were sufficiently abstract to describe and/or explain all of our initial descriptive themes, our inferred barriers and facilitators and implications for intervention development.

For example, five of the 12 descriptive themes concerned the influences on children's choice of foods (food preferences, perceptions of health benefits, knowledge behaviour gap, roles and responsibilities, non-influencing factors). From these, reviewers inferred several barriers and implications for intervention development. Children identified readily that taste was the major concern for them when selecting food and that health was either a secondary factor or, in some cases, a reason for rejecting food. Children also felt that buying healthy food was not a legitimate use of their pocket money, which they would use to buy sweets that could be enjoyed with friends. These perspectives indicated to us that branding fruit and vegetables as a 'tasty' rather than 'healthy' might be more effective in increasing consumption. As one child noted astutely, 'All adverts for healthy stuff go on about healthy things. The adverts for unhealthy things tell you how nice they taste.' [[ 56 ], p75]. We captured this line of argument in the analytical theme entitled 'Children do not see it as their role to be interested in health'. Altogether, this process resulted in the generation of six analytical themes which were associated with ten recommendations for interventions.

Six main issues emerged from the studies of children's views: (1) children do not see it as their role to be interested in health; (2) children do not see messages about future health as personally relevant or credible; (3) fruit, vegetables and confectionery have very different meanings for children; (4) children actively seek ways to exercise their own choices with regard to food; (5) children value eating as a social occasion; and (6) children see the contradiction between what is promoted in theory and what adults provide in practice. The review found that most interventions were based in school (though frequently with parental involvement) and often combined learning about the health benefits of fruit and vegetables with 'hands-on' experience in the form of food preparation and taste-testing. Interventions targeted at people with particular risk factors worked better than others, and multi-component interventions that combined the promotion of physical activity with healthy eating did not work as well as those that only concentrated on healthy eating. The studies of children's views suggested that fruit and vegetables should be treated in different ways in interventions, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective than those which were not.

Context and rigour in thematic synthesis

The process of translation, through the development of descriptive and analytical themes, can be carried out in a rigorous way that facilitates transparency of reporting. Since we aim to produce a synthesis that both generates 'abstract and formal theories' that are nevertheless 'empirically faithful to the cases from which they were developed' [[ 53 ], p1371], we see the explicit recording of the development of themes as being central to the method. The use of software as described can facilitate this by allowing reviewers to examine the contribution made to their findings by individual studies, groups of studies, or sub-populations within studies.

Some may argue against the synthesis of qualitative research on the grounds that the findings of individual studies are de-contextualised and that concepts identified in one setting are not applicable to others [ 32 ]. However, the act of synthesis could be viewed as similar to the role of a research user when reading a piece of qualitative research and deciding how useful it is to their own situation. In the case of synthesis, reviewers translate themes and concepts from one situation to another and can always be checking that each transfer is valid and whether there are any reasons that understandings gained in one context might not be transferred to another. We attempted to preserve context by providing structured summaries of each study detailing aims, methods and methodological quality, and setting and sample. This meant that readers of our review were able to judge for themselves whether or not the contexts of the studies the review contained were similar to their own. In the synthesis we also checked whether the emerging findings really were transferable across different study contexts. For example, we tried throughout the synthesis to distinguish between participants (e.g. boys and girls) where the primary research had made an appropriate distinction. We then looked to see whether some of our synthesis findings could be attributed to a particular group of children or setting. In the event, we did not find any themes that belonged to a specific group, but another outcome of this process was a realisation that the contextual information given in the reports of studies was very restricted indeed. It was therefore difficult to make the best use of context in our synthesis.

In checking that we were not translating concepts into situations where they did not belong, we were following a principle that others have followed when using synthesis methods to build grounded formal theory: that of grounding a text in the context in which it was constructed. As Margaret Kearney has noted "the conditions under which data were collected, analysis was done, findings were found, and products were written for each contributing report should be taken into consideration in developing a more generalized and abstract model" [[ 14 ], p1353]. Britten et al . [ 32 ] suggest that it may be important to make a deliberate attempt to include studies conducted across diverse settings to achieve the higher level of abstraction that is aimed for in a meta-ethnography.

Study quality and sensitivity analyses

We assessed the 'quality' of our studies with regard to the degree to which they represented the views of their participants. In doing this, we were locating the concept of 'quality' within the context of the purpose of our review – children's views – and not necessarily the context of the primary studies themselves. Our 'hierarchy of evidence', therefore, did not prioritise the research design of studies but emphasised the ability of the studies to answer our review question. A traditional systematic review of controlled trials would contain a quality assessment stage, the purpose of which is to exclude studies that do not provide a reliable answer to the review question. However, given that there were no accepted – or empirically tested – methods for excluding qualitative studies from syntheses on the basis of their quality [ 57 , 12 , 58 ], we included all studies regardless of their quality.

Nevertheless, our studies did differ according to the quality criteria they were assessed against and it was important that we considered this in some way. In systematic reviews of trials, 'sensitivity analyses' – analyses which test the effect on the synthesis of including and excluding findings from studies of differing quality – are often carried out. Dixon-Woods et al . [ 12 ] suggest that assessing the feasibility and worth of conducting sensitivity analyses within syntheses of qualitative research should be an important focus of synthesis methods work. After our thematic synthesis was complete, we examined the relative contributions of studies to our final analytic themes and recommendations for interventions. We found that the poorer quality studies contributed comparatively little to the synthesis and did not contain many unique themes; the better studies, on the other hand, appeared to have more developed analyses and contributed most to the synthesis.

This paper has discussed the rationale for reviewing and synthesising qualitative research in a systematic way and has outlined one specific approach for doing this: thematic synthesis. While it is not the only method which might be used – and we have discussed some of the other options available – we present it here as a tested technique that has worked in the systematic reviews in which it has been employed.

We have observed that one of the key tasks in the synthesis of qualitative research is the translation of concepts between studies. While the activity of translating concepts is usually undertaken in the few syntheses of qualitative research that exist, there are few examples that specify the detail of how this translation is actually carried out. The example above shows how we achieved the translation of concepts across studies through the use of line-by-line coding, the organisation of these codes into descriptive themes, and the generation of analytical themes through the application of a higher level theoretical framework. This paper therefore also demonstrates how the methods and process of a thematic synthesis can be written up in a transparent way.

This paper goes some way to addressing concerns regarding the use of thematic analysis in research synthesis raised by Dixon-Woods and colleagues who argue that the approach can lack transparency due to a failure to distinguish between 'data-driven' or 'theory-driven' approaches. Moreover they suggest that, "if thematic analysis is limited to summarising themes reported in primary studies, it offers little by way of theoretical structure within which to develop higher order thematic categories..." [[ 35 ], p47]. Part of the problem, they observe, is that the precise methods of thematic synthesis are unclear. Our approach contains a clear separation between the 'data-driven' descriptive themes and the 'theory-driven' analytical themes and demonstrates how the review questions provided a theoretical structure within which it became possible to develop higher order thematic categories.

The theme of 'going beyond' the content of the primary studies was discussed earlier. Citing Strike and Posner [ 59 ], Campbell et al . [[ 11 ], p672] also suggest that synthesis "involves some degree of conceptual innovation, or employment of concepts not found in the characterisation of the parts and a means of creating the whole" . This was certainly true of the example given in this paper. We used a series of questions, derived from the main topic of our review, to focus an examination of our descriptive themes and we do not find our recommendations for interventions contained in the findings of the primary studies: these were new propositions generated by the reviewers in the light of the synthesis. The method also demonstrates that it is possible to synthesise without conceptual innovation. The initial synthesis, involving the translation of concepts between studies, was necessary in order for conceptual innovation to begin. One could argue that the conceptual innovation, in this case, was only necessary because the primary studies did not address our review question directly. In situations in which the primary studies are concerned directly with the review question, it may not be necessary to go beyond the contents of the original studies in order to produce a satisfactory synthesis (see, for example, Marston and King, [ 60 ]). Conceptually, our analytical themes are similar to the ultimate product of meta-ethnographies: third order interpretations [ 11 ], since both are explicit mechanisms for going beyond the content of the primary studies and presenting this in a transparent way. The main difference between them lies in their purposes. Third order interpretations bring together the implications of translating studies into one another in their own terms, whereas analytical themes are the result of interrogating a descriptive synthesis by placing it within an external theoretical framework (our review question and sub-questions). It may be, therefore, that analytical themes are more appropriate when a specific review question is being addressed (as often occurs when informing policy and practice), and third order interpretations should be used when a body of literature is being explored in and of itself, with broader, or emergent, review questions.

This paper is a contribution to the current developmental work taking place in understanding how best to bring together the findings of qualitative research to inform policy and practice. It is by no means the only method on offer but, by drawing on methods and principles from qualitative primary research, it benefits from the years of methodological development that underpins the research it seeks to synthesise.

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Acknowledgements

The authors would like to thank Elaine Barnett-Page for her assistance in producing the draft paper, and David Gough, Ann Oakley and Sandy Oliver for their helpful comments. The review used an example in this paper was funded by the Department of Health (England). The methodological development was supported by Department of Health (England) and the ESRC through the Methods for Research Synthesis Node of the National Centre for Research Methods. In addition, Angela Harden held a senior research fellowship funded by the Department of Health (England) December 2003 – November 2007. The views expressed in this paper are those of the authors and are not necessarily those of the funding bodies.

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The webinar began by outlining the key features of thematic synthesis and how it relates to other synthesis methods. It then illustrated the steps involved using worked examples. The different ways it has been used were highlighted and the value of descriptive and analytical themes was discussed. The webinar then moved onto a discussion of rigour in thematic synthesis and key issues to consider when planning a thematic synthesis.

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Professor Angela Harden is Professor of Health Sciences at City, University of London. She is a social scientist and currently leads interdisciplinary and interprofessional collaborative research testing interventions tackling the wider determinants of health across the life course. She is interested in the development of both primary and systematic review methods to better develop and evaluate complex interventions and generate evidence for decision-makers. Angela also builds research capacity in applied research through her role as the Academy Director of the NIHR North Thames ARC. She has been a Co-convenor of the Cochrane Qualitative and Implementation Methods group since 2008. 

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"Similar to analysis of primary qualitative datasets, thematic synthesis involves the systematic coding of data and generating of descriptive and analytical themes" (Nicholson et al, 2016 ).

Further Reading/Resources

Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: a critical review. BMC medical research methodology , 9 (1), 1-11. Full Text Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology , 8 (1), 1-10. Full Text  

Caskurlu, S., Richardson, J. C., Maeda, Y., & Kozan, K. (2021). The qualitative evidence behind the factors impacting online learning experiences as informed by the community of inquiry framework: A thematic synthesis. Computers & Education , 165 , 104111. Full Text

References Nicholson, E., Murphy, T., Larkin, P., Normand, C., & Guerin, S. (2016). Protocol for a thematic synthesis to identify key themes and messages from a palliative care research network. BMC research notes , 9 (1), 1-5. Full Text

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A qualitative systematic review and thematic synthesis exploring the impacts of clinical academic activity by healthcare professionals outside medicine

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There are increasing opportunities for healthcare professionals outside medicine to be involved in and lead clinical research. However, there are few roles within these professions that include time for research. In order to develop such roles, and evaluate effective use of this time, the range of impacts of this clinical academic activity need to be valued and understood by healthcare leaders and managers. To date, these impacts have not been comprehensively explored, but are suggested to extend beyond traditional quantitative impact metrics, such as publications, citations and funding awards.

Ten databases, four grey literature repositories and a naïve web search engine were systematically searched for articles reporting impacts of clinical academic activity by healthcare professionals outside medicine. Specifically, this did not include the direct impacts of the research findings, rather the impacts of the research activity. All stages of the review were performed by a minimum of two reviewers and reported impacts were categorised qualitatively according to a modified VICTOR (making Visible the ImpaCT Of Research) framework.

Of the initial 2704 identified articles, 20 were eligible for inclusion. Identified impacts were mapped to seven themes: impacts for patients; impacts for the service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic.

Conclusions

Several overlapping sub-themes were identified across the main themes. These included the challenges and benefits of balancing clinical and academic roles, the creation and implementation of new evidence, and the development of collaborations and networks. These may be key areas for organisations to explore when looking to support and increase academic activity among healthcare professionals outside medicine. The modified VICTOR tool is a useful starting point for individuals and organisations to record the impact of their research activity. Further work is needed to explore standardised methods of capturing research impact that address the full range of impacts identified in this systematic review and are specific to the context of clinical academics outside medicine.

Peer Review reports

There is compelling evidence that research active healthcare organisations have improved care performance compared to their non-research active counterparts [ 1 ]. Examples include patients feeling better informed about their condition and medication, having greater confidence in their healthcare staff [ 2 ], greater staff adherence to treatment guidelines [ 3 ] and lower mortality rates [ 3 , 4 ]. In the UK, this has resulted in correlation between research activity and the national healthcare inspection rating [ 4 ].

Traditionally, healthcare research has been associated with medical professionals (doctors), with approximately 5% of UK medical consultants working in clinical academic roles [ 5 , 6 ]. Clinical academics engage in clinical practice and also conduct and lead programmes of applied health and/or social care research, often directly aimed at improving patient care and care pathways [ 7 ].

Healthcare professionals outside medicine are increasingly developing the expertise to lead clinically relevant research, with the aim of 1% of this workforce being employed in clinical academic roles by 2030 [ 8 ]. Healthcare professions outside medicine include: nursing, midwifery, the allied health professions (art therapists, dietitians, drama therapists, music therapists, occupational therapists, orthoptists, operating department practitioners, osteopaths, podiatrists, prosthetists/orthotists, paramedics, physiotherapists, radiographers, and speech and language therapists), clinical psychologists, healthcare scientists and pharmacists. Within the UK, the drive to increase the clinical academic workforce is supported by a targeted Health Education England/National Institute for Health Research funding stream specifically for these professions [ 9 ], and through fellowship funding from a number of national health charities. Similar schemes exist elsewhere [ 10 , 11 , 12 , 13 ].

As clinical academic activity increases, there is a need to evaluate its impact at both individual and organisational levels, and across the short to longer term. Several frameworks have been designed to guide impact assessments for healthcare research and these have recently been systematically reviewed to create a summary framework [ 14 ]. However, the focus is on evaluating individual programmes of research, rather than the impact of collective research activity within an organisation. This is also the case with other research impact assessment tools [ 15 ].

Outside the medical professions, the impacts of dedicated allied health professional (AHP) research roles have been systematically reviewed to explore their outcomes in terms of building research capacity and culture. Wenke and Mickan described varied roles, but most often these centred on the development of researchers’ own research projects and their dissemination [ 10 ]. Additional responsibilities included supervising others and developing strategies to promote research activity. These roles were found to have positive impacts on individual research skills, research outputs and research culture, however other areas of impact were not assessed, such as patient outcomes, changes to clinical training or practice guidelines, or increased investment. Importantly, only one study described practising clinicians with dual clinical and research roles, and other non-medical professionals, such as nurses and midwives, were excluded from the review.

Existing reviews have only included published research studies, thus overlooking impact reports that have been compiled by individual healthcare organisations or collaborations [ 16 , 17 ]. Such documents contain valuable insights and reflections on clinical academic programmes, often in the form of case studies, and are useful for other healthcare providers supporting or developing their own clinical academic strategies.

The current systematic review was developed in order to understand the full range of impacts of non-medical clinical academic roles. A cross-disciplinary approach was taken to include clinical academic activity among nurses, midwives, AHPs and other non-medical healthcare professionals.

The review protocol was pre-registered with the Open Science Foundation [ 18 ] and followed the PRISMA protocol reporting guidelines [ 19 ]. The primary review question was: what are the reported impacts of clinical academic activity among practising healthcare professionals outside medicine?

Selection criteria

Impact was not pre-defined for the purposes of this review, and eligible articles were those reporting any form of impact that was attributed to clinical academic activity carried out by non-medical healthcare professionals. This did not include the reported outcomes of clinical research studies, rather the impact of these individuals being involved in research activity. Clinical academic activity was defined as the review intervention, and was the involvement of practising clinicians in research. This included specific research roles, such as research fellowships or combined clinical academic positions, in addition to other protected research time or opportunities to be involved in research. The review population was defined as healthcare professionals outside medicine. Full eligibility criteria, including the list of eligible healthcare professions, are provided in Table  1 .

Search strategy

Ten healthcare databases and four grey literature repositories were individually searched by the lead author between December 2019 and January 2020. Search locations are shown in Fig.  1 . The example search strategy for Medline is provided in Additional File  1 , which included i) terms for the different non-medical clinical disciplines, and ii) terms for clinical academic activity, combined with iii) terms for impact. The search strategy was developed and piloted by LN, CMA and MW, with additional assistance from a healthcare librarian (LG). There were no restrictions for country of publication, but due to time and resource limitations, articles were restricted to those available in the English language. An additional Google search for ‘impact of clinical academic nursing, midwifery and allied health’ was conducted in a naïve browser and the first 50 hits recorded.

figure 1

PRISMA flowchart

Eligibility assessment

Identified references were exported into Covidence ( Covidence.org ) and duplicates removed. Title and abstract screening were performed in two stages. Firstly, the lead author and two members of the review team (JC and OFC) independently screened out those articles which clearly met the exclusion criteria. Any disagreements were resolved by discussion. Secondly, the lead author and two members of the review team (LS and LB) independently screened the remaining articles against both the inclusion and exclusion criteria. Again, any disagreements were resolved by discussion. Full text screening was independently performed by LN and one of five members of the review team (AA, MC, LS, OFC and LBS); disagreements were resolved by MW and CMA.

Quality assessment

The mixed methods appraisal tool (MMAT) was used to evaluate the quality of the included studies [ 20 ]. The assessment form was piloted prior to use and modified to include key components of the qualitative checklist proposed by Walsh et al. [ 21 ]. The quality assessment form template is provided in Additional File  2 . Quality assessment was conducted independently by LN and one of eight members of the review team (AA, LBS, CL, LS, MC, JJ, LB and JC). Disagreements were resolved by discussion. All relevant studies were included regardless of their MMAT score.

Data extraction

Data extraction was completed independently by LN and one of the eight members of the review team, listed above, and was conducted in parallel to the quality assessment. Data items were extracted using a pre-piloted electronic form under the headings listed in Table  2 . The two independent data extraction forms for each article were compared and harmonised by MS and CH, who referred back to the original articles where disagreement occurred. The impacts of the clinic academic activity were broadly characterised using the section headings from the VICTOR (making Visible the ImpaCT Of Research) framework [ 22 ]. The VICTOR framework was developed for individual research teams to record the impact of their study and is endorsed by the UK National Institute for Health Research [ 23 ]. It comprises a series of open ended questions categorised under seven sections: health benefits, safety and quality improvements for research participants and carers during the study; service and workforce impacts; research profile of the organisation and research capacity; economic impacts; organisation’s influence and reputation; knowledge generation and exchange. Following piloting for this systematic review, the headings were modified to include a section for impacts to the individual, and research profile and research capacity and the organisation’s influence and reputation were merged.

Data synthesis

Extracted data for each of the pre-identified categories of impact (Table 2 ) were independently analysed by two members of the review team (LN and one of CH, AA, MS, JC, LSB, MC and LB) to create a thematic synthesis. This involved independently coding the data to identify recurring, unique and contradictory content and using the codes to independently summarise the content of the theme in a series of sub-themes [ 24 ]. The findings were discussed and agreed together by the two independent reviewers for each category of impact. The final analysis for all categories of impact was discussed and refined by CMA, MW and LN.

Study characteristics

A total of 2704 articles were identified after removal of duplicates, of which 20 met the review eligibility criteria (Fig. 1 ) [ 13 , 16 , 17 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. The most common reasons for exclusion were that the study population did not involve clinical academics, that is clinicians who were also involved in research activity; or the study assessed the amount of research interest/activity, rather than the impacts of this activity (Additional File  3 ). Of the included articles, nine reported qualitative data [ 17 , 25 , 29 , 30 , 31 , 33 , 36 , 38 , 41 ], three reported quantitative data [ 28 , 35 , 37 ] and eight reported a mixture of both [ 13 , 16 , 26 , 27 , 32 , 34 , 39 , 40 ]. Sixteen were peer reviewed journal articles and four were organisational reports. Publication dates ranged from 2003 to 2019 and the geographical distribution was: Europe (including the UK) 10; North America 5; Australasia 4; Middle East 1 (Table  3 ).

Participants

A variety of healthcare professions outside medicine were included. Eight articles involved mixed professional groups, most commonly nursing, midwifery and one or more of the allied health professions. Nine articles were specific to nursing, two to allied health professions and one to pharmacy. The nature of the clinical academic activity was not consistent. All articles discussed clinicians conducting research in clinical practice, however some also incorporated formal educational components at masters or doctoral level and others involved short programmes of research training and/or mentorship (Table 3 ).

Methodological assessment

Outcomes of the MMAT assessment [ 20 ] are shown in Fig.  2 and are available in full via the Open Science Framework [ 18 ]. No articles met all quality assessment criteria, although three qualitative studies were rated as having a single area of concern [ 31 , 38 , 41 ]. Common issues with study quality and risk of bias for qualitative and mixed methods studies were a lack of clarity in how the findings were derived from the data and a lack of coherence between data, analysis and interpretation. Common issues with quantitative and mixed methods studies were a lack of information about the measurement tools/methods and a lack of consideration of response bias. Common issues across all study types were inadequate sampling methods and a lack of reporting of ethics/other approvals.

figure 2

Quality assessment scores for included articles using the Mixed Methods Assessment Tool

Reported impacts of clinical academic activity

Reported impacts were categorised into seven main themes based on the modified section headings for the VICTOR framework (Table 2 ). The distribution of the reported impact themes across the articles included in this review are presented in Table  4 . Extracted and coded data for each theme was used to generate the sub-themes, which are described below and presented with illustrative excerpts from the included articles. The full framework of themes, sub-themes and additional quotes is provided in Additional File  4 . Most of the extracted impacts were positive in nature, reflecting the aims of the included papers (Table 3 ), however challenges for the individual clinical academics and their healthcare teams were also described.

Impacts for patients

The reported impacts for patients focused on beneficial changes to service provision that arose as a result of local clinical academic activity, and wider access to evidence-based healthcare as a result of the promotion of evidence-based practice across research-active teams and departments:

“This project demonstrated significant improvements in the neutropenic patient pathway, enhancing experience and outcomes for patients and a reduction in unnecessary admissions.” [ 27 ]
“Behaviours learned during the programmes provided benefits for improving the quality of care delivered within services … Respondents reported they discussed evidence with colleagues, searched the literature for evidence updates, questioned and used evidence to inform their practice following completion of the programme.” [ 16 ]

It was suggested that these practice-changes were associated with improved patient/carer experiences, particularly because clinical academic research was directed at issues that were meaningful to patients and focused on patient experience in addition to clinical outcomes:

“My research has demonstrated the benefits of these kinds of approaches both to patients’ quality of life, and patients, carers, friends and families’ experience of palliative care services.” [ 36 ]
"[It is a] synergistic relationship, as research knowledge improves the care I provide, but the close patient contact allows me to identify areas that require further research." [ 29 ]

Furthermore, clinical academics reported a drive to challenge and improve their own clinical practice and that of their team, with the goal of improving all aspects of patient care:

“Participants expressed how their involvement in the innovation increased their observation of their own clinical practice, brought the research back to practice, enhanced practice development and the clinical role overall while contributing to improved patient care.” [ 34 ]

Impacts on service provision and workforce

I. clinical service provision.

In addition to the identified impacts to patients (theme 1), changes in practice as a result of the clinical academic activity were also regarded as beneficial to the clinical service through improved care delivery and pathways . This included the introduction of new equipment, better integration of clinical teams, efficiencies, cost-savings and securing new clinical funding:

“Research positions supported projects that led to changes in service delivery models, with [one] manager commenting, ‘ … it’s amazed me that through the research grant that she got for that project, she has now generated for the Health Service recurrent money for the full time [implementation of the] … rural allied health model’.” [ 41 ]
“One participant’s intervention removes the need for GPs’ referral for physiotherapy, potentially saving ‘multimillion pounds’ across the NHS [National Health Service], and has subsequently been recognised in the NHS long-term plan.” [ 39 ]

It was reported that clinical academics remained up to date with the relevant literature and clinical guidelines and were able to translate research into practice and implement the evidence . They were also able to share these skills with their clinical team to support their colleagues in the delivery of high-quality care:

“As a clinical academic midwife my aim is to bring more evidence into practice and assist other midwives in doing the same.” [ 29 ]
“Most of this reported activity focused on reviewing published evidence in relation to clinical practice but participants also reported involvement in facilitating/enhancing research skills in other clinicians.” [ 37 ]

The need to find backfill was reported as a negative consequence of releasing clinical staff for research . In some instances, it was not possible to find backfill at the same clinical grade as the clinical academic, potentially leaving a deficit in the clinical service. However, backfill posts were also seen as opportunities for other clinicians to gain experience by acting-up into the role:

“Release from the workplace, despite the employer grant, was in some cases problematic. Finding appropriately skilled staff to cover services particularly in highly specialised areas and, or recruiting to short term, often part time, vacancies were challenges. In contrast some managers saw this as an opportunity to give other staff the chance to act up, for succession planning, or worked creatively to make release possible.” [ 16 ]
“Protected time for the APNs [Advanced Practice Nurses] (i.e., at least one day a week) to engage in research activities was crucial to the program and, at times, difficult to achieve.” [ 32 ]

The majority of the described clinical academic activity centred on short-term secondments, which elicited issues with the return to clinical practice from a research role . These included difficulties in maintaining evidence-based practice due to time constraints and a lack of opportunity to use the research skills that had been developed:

“On my return to work I was unable to continue to facilitate evidence-based practice as much as I would have liked due to time constraints. Within my working role there was no dedicated time to devote to evidence-based activity.” [ 37 ]

ii. Clinical academic workforce

Clinical academic infrastructure was described in terms of fellowship and career pathways. Steps were taken to ensure visibility of these opportunities to facilitate the development of research capacity. However, it was also noted that the absence of established clinical academic career structures resulted in a perceived lack of value of these skills and caused difficulties for clinical managers when trying to plan their service:

“Clinical and academic mentorship exposed the Chief Nurse Fellows to clinical academic career role models, which in turn raised the profile of this alternative career route.” [ 27 ]
“There’s a huge untapped workforce … with the right support and time we could be doing things more effectively and more efficiently, but that isn’t necessarily valued in organisations. We’ve got to see this many patients, (we’re) not using our skills of criticality, reflectivity; we’re not going to innovate and change practice.” [ 39 ]
"Imagine being able to continue my research and tie the results directly to clinical practice. I would like there to be an opportunity of this kind. However, there is a lack of services for nurses with higher academic qualifications who want to develop clinical practice.” [ 25 ]

Challenges encountered in balancing the clinical and research components of the role were widely reported. Clinical duties were given priority and some articles reported unclear expectations for the research roles, in contrast to established clinical job descriptions:

“A culture that prioritises practice in the current context means that the doing of nursing work only is seen as core business. This, together with the need for managers and clinicians to make quick decisions in order to achieve short term goals, operates as a disincentive to rigorous research activity at ward level. Within this context, the expectations for those with a research component in their role, is at times unclear.” [ 30 ]

In addition, some articles recounted strategies that aided the development of research skills and clinical academic roles:

“Also, I think the option of having 0.5FTE [full-time equivalent) backfill was good, as it allowed greater flexibility for staff who have roles that are difficult to backfill full-time, also I thought it was useful to have more thinking time, and time to access support, get feedback etc. Full-time research can be very intense especially when you are not conditioned for it.” [ 13 ]

Where clinical academics identified access to resources and support , this was identified as a positive asset. However, a number of articles recalled issues with a lack of manager awareness and support, and insufficient funding for research activities and computer software:

“I have a very supportive divisional head nurse and have been appointed into a trailblazer post; we haven’t got anything similar within the organisation. So there’s real potential to forge out innovative ways in which clinical academics can fulfil that remit of working in clinical practice and undertaking research, but also pave the way for others that want to come up.” [ 39 ]
“Biggest challenge: Getting managers on board, in particular releasing staff to take advantage of internship opportunities offered by HEE [Health Education England] Wessex, and recognising that research is essential to the core business of the Trust.” [ 17 ]
“It’s not the scheme, but greater staff access to relevant software (such as SPSS) would be useful.” [ 13 ]

Impacts to the research profile, culture and capacity

Research profile, culture and capacity were interlinked and several of the reported impacts spanned all aspects of this theme. However, winning research funding and other awards , publication of journal articles and clinical guidelines, and conference presentations were primarily considered as contributing to the organisation’s research profile:

“Since completing the programme - One Chief Nurse Fellow was the first UK nurse to be recognised by the Daisy Foundation and has received a Daisy Award for Extraordinary Nurses. Others have also received nominations and were shortlisted for national nursing awards. In addition, two of the projects are featured on The Academy of Fabulous NHS Stuff.” [ 27 ]
“As a result of the research activities, seven manuscripts were submitted and accepted for peer-reviewed publications.” [ 28 ]

The provision of research training and support , and organisational-wide research engagement and participation were commonly reported as beneficial impacts to the organisations’ research culture and capacity:

“Improved attitudes towards research were noted by a clinician, ‘ … research isn’t this incredibly difficult thing that only very special people can do. Actually, it’s attainable by many and it was quite inspiring actually … I don’t know that that would have been their view prior to this position developing that profile.” [ 41 ]
“It’s about allowing people to engage with research and become enthused by it. It’s also about having the right leaders who are able to take the step back and say: ‘This is a good use of your time’. You can find better ways of giving care if you have a culture that values research.” [ 36 ]

There were also aspects where the lack of research culture within an organisation was seen as a challenge for research involvement:

“There is the perception that doing research is an ‘imposition, on clinical nursing staff, that it is not ‘real nursing work’; rather, it is a ‘luxury’. When invited by nurse researchers to participate in research activities, clinical nurses often say ‘I don’t have time for this’ and the general attitude is ‘we’ll think about it’, ‘if I have time’, or ‘tell us about the result’. Indeed, in some instances there is a perception amongst discussion group members that projects are undermined through gate-keeping behaviour and lack of support by the ‘sceptics’.” [ 30 ]

Clinical academics were able to promote evidence-based practice among their peers, for example by sharing resources and setting up journal clubs or other special interest groups. This facilitated a shift towards research becoming embedded in practice :

“I now exhort other colleagues to question day-to-day practice and we have introduced a journal club.” [ 29 ]
“The group process allowed scholars to participate in joint problem solving and enhanced their ability to apply current research to questions arising from clinical practice. The scholars were expected to serve as clinical resources to others in the healthcare system.” [ 33 ]

Three additional elements were identified that encompassed both research profile and research culture/capacity. These were: building local and external collaborations , creating visible clinical academic opportunities and being seen as an attractive place to work :

“We have increasing numbers of staff involved in research activity, studying for MRes and PhDs, and their research is closely related to their professional practice and aims to improve care. We have five research themes with [the healthcare organisation’s] nurses/midwives leading these and staff linking into these themes for their masters or doctoral study and we are starting to build groups of staff at different points on a clinical academic career pathway. Many staff present their research nationally and internationally and publish widely and some are part of national expert groups, linked to their research.” [ 17 ]
“People can choose where they want to work. They’ll be looking for organisations that are aspirational. So actually offering innovative career pathways that can intellectually challenge, but also have that direct patient care element, is going to be attractive to a lot of people.” [ 39 ]

Economic impacts

The funding required to support the clinical academic activity was generally sourced from outside the clinical organisation. Reported benefits of receiving research funding included dedicated time for research training and activity and bringing in additional money to the clinical service:

“Increased grant income – the value of successful non-medic research grants in 2014–2015 (the last financial year the outcome of all grant applications is known) was £923,495. Appointments of clinical academic posts were achieved by securing external grant funding, use of research capability funding to pump prime, and commitment to 50:50 funding from academic partners.” [ 17 ]

However, there were also issues where funding for research was not available, or was repurposed from clinical budgets :

“Management are more than happy to support research initiatives in principle, however, [they are] usually unable to provide [this] support as they have extremely tight budgets and other clinical management demands.” [ 30 ]
“The initiative was resourced by the reallocation of nursing/ODP vacancy funding within each clinical division.” [ 27 ]

As discussed in theme 2 (provision of clinical service), it was proposed that clinical academic activity was associated with financial gains in terms of cost-savings and efficiencies , although the difficulty of capturing this data was recognised:

“The amount of money saved by using the scanner and avoiding catheterisation was estimated to be around £1.2m per year. This did not include the cost of bacteraemia attributed to urinary tract infections. Savings associated with using a scanner, such as fewer treatment delays and overnight stays in hospital, were recognised as additional savings. The set up and running costs of a scanner were estimated to be met within six months to two years, after which significant ongoing cost efficiencies would be realised over its eight to ten year lifespan.” [ 17 ]
“The work had led to a decrease in patients’ clinical stay following surgery from six to four days, resulting in savings that allowed additional needs and demands to be met. We were very open and transparent with the data, and clinical practice changed. We calculated that there was a total of 28,000 bed-days saved per year as a result of this work.” [ 36 ]

Financial implications for the clinical academics were also reported. These were largely negative and included reductions in salary and pension contributions, and the need to self-fund conference attendance:

“Well one of the big decisions I had to make about whether or not to accept the role (associated with a research training award) was the hours and the money because it’s moving to full time, which is fine... Therefore, by moving to full time but losing my enhancements I’ll be on around the same as I get on a good month when I have done lots of nights and weekends. But by working as I’m doing there won’t be any opportunity to do extra shifts, any overtime. So a lot of it was money.” [ 16 ]
“The presenters had to either self-fund their travel and conference registration, or apply for travel scholarships through internal or external opportunities.” [ 28 ]

Impacts on staff recruitment and retention

The lack of clinical academic career opportunities was noted as a challenge that individuals wishing to maintain a dual role needed to negotiate. This related to the sub-theme ‘balancing clinical and academic components of the role’ discussed in theme 2 (impacts for the clinical academic workforce), and was identified as a potential driver for individuals to return to full-time clinical work, or move into purely academic roles after completion of their clinical academic activity:

“The organisational system is perceived as unfamiliar with, and unsupportive of, non-physician clinician scientist positions, and, in consequence, active job crafting is necessary to obtain positions in which such individuals can exert both roles. Dual positions are often a personal combination of jobs instead of being offered from within one institution.” [ 31 ]
"Unfortunately, I wasn’t offered the chance to implement the results of my study in my organisation, due to the lack of development positions. So, as a result, I have applied for, and been given, a position as a teacher at the university college." [ 25 ]

A particular challenge for healthcare managers was the need to provide backfill or make other arrangements to enable the release of clinical staff for research activities. The need to recruit to backfill posts was discussed in theme 2 (impact to clinical service provision), specifically the sub-themes: release of clinical staff for research and return to clinical practice from a research role.

Several articles reported strategies to support clinical academics and increase awareness and access to clinical research opportunities. Where successful, it was suggested that these aided the retention and career progress of staff who were involved in clinical academic activity. Such strategies also contributed to job satisfaction and recruitment more generally and were closely linked with the impacts to the organisation’s research profile, research culture and capacity (theme 3):

“Since completing their year as a fellow, the entire pilot cohort still works within the organisation, with five of them having moved into junior leadership positions. Although we cannot assume that this would not have been their career trajectory had they not undertaken this fellowship, the skills developed and demonstrated through the initiative are essential for the job specifications of more senior posts.” [ 27 ]
“Interviewees reported that their department was seen as a more ‘attractive employer’ and was ‘attracting higher calibre staff’. Clinicians described staying in the health service to undertake research, ‘because these opportunities do exist, these really fabulous clinicians that we have just might stay’.” [ 41 ]

Impacts to knowledge exchange

Contributions to knowledge transfer were reported in all articles, and there was a large overlap with theme 3 (research profile, culture and capacity). Knowledge exchange activities included formal dissemination , such as conference presentations and posters, publications, being an invited speaker and winning prizes and awards that further highlighted the value of the work. It was recognised that there would be a delay between completion of the research activity and delivery of these research outputs:

“Interviewees provided numerous and diverse examples of presentations at grand rounds, poster presentations and oral presentations at both local and international conferences, including one interviewee who noted her team had presented their research project findings at three international and three local conferences. Another interviewee stated, ‘We have presented at a couple of conferences and we presented at a … convention or meeting and we actually got an award for our poster’.” [ 26 ]
“Individuals need time in the role as well to get some momentum, get the relationships in the department, get the research programs going and there's usually a delay until you start to see the pure research outputs.” [ 41 ]

Clinical academics also played a role in developing networks and collaborations aiding the transfer of knowledge among clinical and academic communities and patient populations. This included sharing their expertise with clinical colleagues and other practice improvement strategies aimed at the implementation of clinical guidelines and delivery of evidence-based practice. Again there was a large overlap with theme 2 (impacts to clinical service provision), specifically the sub-theme translation of research into practice and evidence implementation:

“What I notice clearly is that I’m very well informed about scientific evidence and sharing this information with my colleagues. [I ask them] did you read this? And [I] pass on knowledge in that way.” [ 31 ]
“After being able to demonstrate the success of the approach locally, David was asked to help with a national roll out, organising with colleagues an audit of all 22 orthopaedic units across Scotland over 12 weeks.” [ 36 ]

Impacts to the clinical academic

Many of the themes and sub-themes of impact discussed above had also had a direct influence on the individuals involved in clinical academic activities. Developing networks and collaborations, discussed in theme 6 (knowledge exchange), and building local and external collaborations, discussed in theme 3 (research profile, culture and capacity), were similarly interpreted as individual clinical academics developing their networks and influence :

“I think the impact of the role on me has been quite incredible. … how much you learn about the different disciplines and then develop those networks … it’s been a huge learning curve.” [ 41 ]

Furthermore, clinical academics reported a change in their attitude to clinical practice, with greater reflection and questioning of established practice, which was also reflected in theme 1 (impacts for patients), particularly in terms of improved clinical practice and access to evidence-based healthcare:

“They felt that they had developed from “doers” to “thinkers”, in that they felt more aware of and reflective in relation to their colleagues … The nurses perceived progress in acquiring new knowledge, in spite of language barriers, and recognised the value of scientific knowledge for clinical practice. They experienced healthcare in a ‘new light’ through their knowledge development.” [ 25 ]

The development of research and leadership skills was identified as a beneficial effect of being involved in clinical academic activity. In some articles, it was suggested that this unlocked new career opportunities for the individuals involved, however in many instances there were no existing roles within the organisation for the research-active clinicians to aspire to, as discussed in theme 5 (recruitment and retention):

“The majority agreed or strongly agreed that they felt more confident developing a research question (94%/49), searching (87%/45) and appraising (90%/47) literature, challenging practice using evidence (85%/44), assisting others to use critical appraisal skills (79%/41) and engage in the clinical academic training pathway (87%/45).” [ 16 ]
“Despite their achievements during the PhD, many participants expressed anxieties about their future careers, having been made to move aside clinically in order to progress their academic ambitions, rather than being able to develop their academic and clinical skills in tandem. For example a dietician said: Recently I’ve had to step out of my area of expertise … I’m just doing general, allergies, weight management, which is not my area, but I need to pay the mortgage.” [ 39 ]

Clinical academics appeared to find self-fulfilment with their roles, and described a passion for their contributions to clinical research:

“It is actually exciting to learn that the world does not work the way you thought it did”. 70 [ 38 ]. “I want to do this for me, but I also want to do it for my daughters to show that women can be in science and can lead in these fields and yes we might have to juggle family things and children, but you can do it.” [ 39 ]
“What accomplishments are you most proud of? Knowing that I am now a subject expert – I get phone calls asking, `How would you handle this?’.” [ 40 ]

The challenges and sacrifices of clinical academic roles were widely recounted, examples of which have been included in the previous themes. Financial implications were discussed in theme 4 (economic impacts, sub-theme financial implications for the clinical academic) and the challenge of combining clinical and academic work and identities were included in theme 2 (impacts for the clinical academic workforce, sub-theme balancing clinical and academic components of the role) and theme 5 (impacts on staff recruitment and retention, sub-theme maintaining a dual role). A lack of time for clinical academic activity was another widely reported issue:

“When you are really interested in something or passionate about it, you use whatever time you have, even if it means writing your proposal after your regular hours at home.” [ 38 ]
“The time taken to do research is often underestimated and considerable time and effort is often put into preparing a grant application which ultimately may not be successful. Focusing on meeting deadlines and the progress of a project means that less attention can be given to other aspects of work roles. Ultimately, doing research without adequate support or funding becomes a constant juggle.” [ 30 ]

Finally, a few articles reported reflections on what it takes to be a clinical academic . These included the qualities of determination, tenacity and resilience, and serendipity:

“The demanding expectations surrounding a clinical academic role were described by interviewees (participants and managers) and the characteristics and behaviours that were perceived as required for success. These included confidence, doggedness and resilience, reflective skills, criticality, and growing political know-how to better navigate organisations.” [ 16 ]
“Mentorship (from nursing, midwifery and medical colleagues), determination, tenacity, resilience and serendipity have been key factors in achieving success.” [ 17 ]

This systematic review identified 20 articles that discussed elements of the impact of clinical academic activity among healthcare professionals outside medicine. With the addition of a theme for the impacts to the clinical academic, all reported types of impact could be mapped to the VICTOR framework creating the following themes: impacts for patients; impacts for service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic. In order to develop and evaluate clinical academic roles for healthcare professionals outside medicine, the range of impacts of this clinical academic activity need to be understood and valued by healthcare leaders and managers. This review has systematically identified and mapped the nature of the impacts reported in the literature, and forms a valuable resource for healthcare services looking to develop and evaluate these roles at local and national levels.

Within the main headings of impact described above, we identified several similar sub-themes that cut across the different categories of impact. Sub-themes described the content of each of the categories of impact and included perceived enablers of creating the desired impact and associated detrimental features. Notably, the sub-themes that reflected the challenge of maintaining or balancing the clinical and academic components of the role contributed to four main themes. Within clinical service provision (theme 2i), this related to the need for clinical services to manage both the release of clinical staff for research, and their return to clinical practice after research secondments. For the clinical academic workforce (theme 2ii), this led to individuals and team members being required to adapt to the different pace and duties associated with research and clinical work. The process of showcasing a visible clinical academic pathway (that incorporated both research and clinical activities) was identified as key feature of building research profile, culture and capacity (theme 3), and being able to offer suitable clinical academic posts was important for staff recruitment and retention (theme 5). Finally, being able to work and develop in both clinical and academic roles offered self-fulfilment for the individual clinical academic (theme 7). Similarly, the creation and implementation of new evidence was also a component of several themes, as was the development of collaborations and networks.

The multifaceted nature of research impact identified in this review illustrates that different aspects of clinical academic activity may be perceived as having both positive and negative impacts. Furthermore, these conflicting impacts may apply to the same individual or across different stakeholders. Different aspects of research impact may be more or less important in different contexts and the relative value of these different impacts will need to be considered to enable meaningful evaluation [ 42 , 43 , 44 ].

This systematic review was deliberately broad in scope to allow the identification of the whole range of impacts associated with clinical academic activity. The lack of an agreed and consistently used definition of clinical academic proves problematic and has been discussed elsewhere [ 45 , 46 ]. Clinical academic activity (defined here as the involvement of practising clinicians in research) in the included articles incorporated a range of research fellowships and research training programmes, and/or in-practice mentorship and research support. The aims of the articles varied. Many described and evaluated specific interventions that were aimed at increasing research activity among healthcare professional group(s), while others provided summary case studies of individuals who had been successful in a clinical academic role.

The inclusion of grey literature increased the breadth of the review, particularly given the finding that the impacts of non-medical healthcare research are underrepresented in the academic literature [ 47 ]. However, it is acknowledged that the methodological quality of the included institutional reports was lower than the standards for peer-reviewed publication. Data obtained from the institutional reports were largely positive reflections of strategies that had been put into place to encourage and support research activity among healthcare professionals outside medicine. Expressions of the less positive aspects of these strategies may therefore have been excluded or not collected by the authors. Importantly, the distribution of the seven identified themes of impacts did not differ between organisational reports and peer review journals, illustrating that the types of impact that were considered important by study participants and organisations were similar.

Existing reviews on the impact of clinical academic activity have focused on individual clinical groups within the non-medical workforce [ 10 ] or at the level of the healthcare institution [ 1 ]. Boaz et al. found that healthcare organisations which deliberately integrated research into their practice and fostered research engagement reported improved healthcare performance including clinical outcomes and processes of care, and our review also identified similar improvements. However, Boaz et al.’s review included papers focused primarily on research led by clinical academic doctors, and the impacts of the research processes on the clinical teams and the individuals involved was not reported [ 1 ]. Wenke and Mickan identified four themes of impact associated with allied health research positions based in clinical settings: increased individual research skills and participation; increased research activity; improved research culture and attitudes; and increased team and organisational level skills [ 10 ]. These features were also described within the current review under the themes: impact for patients; impacts to the clinical academic; impacts to research profile, culture and capacity; and impacts for service provision and workforce. In addition, we also identified impacts on staff recruitment and retention, knowledge exchange and economic impacts.

The distribution of impacts reported in the current review did not differ in relation to the clinical groups involved in each of the included articles, indicating that similar methods of capturing the impact of clinical academic research activity could be applied across the professions outside medicine, rather than being discipline-specific. A similar systematic review search strategy could also be applied to assess the reported impact of clinical academic activity by alternative and complementary therapy practitioners.

The impacts reported in the included articles were largely qualitative reports. Some studies incorporated quantitative data capture tools, such as the Research Capacity and Culture tool [ 48 , 49 ] and the WReN (Wessex Research Network) spider [ 50 , 51 ], or counts of publications, presentations and awards. The quantitative measures appeared to explore a discrete component of research impact, whereas the qualitative data provided a broad picture of the impacts in different contexts and uncovered both intended and unintended consequences of the research activity. Reed et al. proposed five impact evaluation typologies (experimental and statistical methods, systems analysis methods, textual, oral and arts-based methods, indicator-based approaches, and evidence synthesis approaches); our findings illustrate the first and third of these categories [ 44 ]. Future work should explore standardised methods of capturing the research impact that address the full range of impacts identified in this systematic review and are specific to the context of clinical academics outside medicine. With the desire for at least 1% of the UK NMAHP workforce to be clinical academics by 2030 [ 8 ], policy makers will need to consider, promote or potentially mitigate the different types of impacts that this systematic review identified in connection with these roles.

The VICTOR framework [ 22 ] was used to guide data extraction in the current review, with a priori modifications to include the impacts to the individual clinical academic and to merge the category relating to the organisation’s influence and reputation with the category for research profile, culture and capacity. No further refinements were made during the analysis process as all reported impacts were able to be mapped. While other research impact frameworks exist [ 14 , 44 ], our findings suggest that the VICTOR tool may be a good starting point for capturing the nature of research impact that is important for clinical academic healthcare research outside the medical professions, and it is already endorsed for use in the UK [ 23 ]. The identification of sub-themes that crossed one or more of the main impact themes indicate that these may be key areas to explore, particularly for organisations looking to support and increase academic activity among these clinical groups.

Limitations

The systematic review team comprised research-active clinicians from professions outside medicine, and therefore the review took place through this lens. Steps were taken to facilitate objectivity, including: a clearly defined protocol [ 18 ]; two or more reviewers independently conducting each stage of the review; inclusion of reviewers with different levels of clinical and research experience; and the provision of oversight by senior (clinically-active) academics. We acknowledge that the thematic analysis and coding of the extracted data may have been interpreted differently by reviewers from different backgrounds. Furthermore, the definition of clinical academic activity used in our review differs from that used elsewhere [ 45 , 52 ]. However, the absence of an agreed definition has been recognised [ 45 ] and the overlap of our findings with the existing literature support our review processes and findings [ 1 , 10 ].

As with other reviews of research impact, there is a risk that relevant studies were excluded due to poor indexing in the medical databases [ 14 ]. We took the additional step of including grey literature searches in both established repositories and through a naïve web search engine in an attempt to maximise the identification of eligible articles, but accept that articles may still have been missed if they were not identified through these mechanisms. We did not formally screen the reference lists of the included articles, and accept that this may have yielded additional studies.

The MMAT tool used for methodological assessment of the included articles was designed for the appraisal of mixed methods studies [ 20 ], although our review included mixed methods, qualitative, and quantitative articles. The MMAT was chosen to allow the same criteria to be applied across all included articles using the relevant sub-sections as appropriate. Quality assessment scores were not used to determine how the extracted data was incorporated into the thematic synthesis. We acknowledge that the presented synthesis therefore includes the findings from studies and organisational reports across the spectrum of methodological quality. However, no theme or sub-theme solely comprised data from articles that were assessed to be of lower quality.

The application of alternative impact frameworks would have yielded different theme headings, as these were taken directly from the VICTOR terminology. However, the use of an established impact assessment tool aided transparency and consistency of data extraction and categorisation. The coding and resulting theme descriptions were created through an inductive process that explored the meaning of the extracted data, rather than looking to specifically fit it to the VICTOR headings. The descriptions of the content of each theme illustrate the available data.

Finally, the aim of our review was to capture the range of impacts associated with clinical academic activity outside medicine. We have highlighted the key themes of impact and described the characteristic content of these themes. While this work contributes to the existing discussion around research impact, it does not explore the utility of capturing and comparing the reported impacts using a standardised method in a clinical research setting.

Twenty articles were identified that reported the impact of clinical academic activity among the healthcare professions outside medicine. These impacts could be mapped using a modified VICTOR framework and were classified as: impacts for patients; impacts for service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic. With our addition of impacts to clinical academics, the VICTOR tool may be a useful starting point for individuals and organisations to record the impact of their research activity, although further work is needed to establish its utility. This review identified several sub-themes of impact that crossed one or more of the main themes: the challenges and benefits of balancing clinical and academic roles; the creation and implementation of new research evidence; and the development of collaborations and networks. These are likely to be key areas for organisations to explore when looking to support and increase academic activity among healthcare professionals outside medicine.

Availability of data and materials

The datasets generated and analysed during the current review are available in the Open Science Framework (OSF) repository ( https://osf.io/gj7se ). All other relevant data are included as supplementary files.

Abbreviations

allied health professional (includes: art therapists; drama therapists; music therapists; chiropodists/podiatrists; dietitians; occupational therapists; operating department practitioners; orthoptists; osteopaths; paramedics; physiotherapists; prosthetists and orthotists; radiographers; and speech and language therapists)

Association of UK University Hospitals

Department of Health and Social Care (UK)

Mixed Methods Appraisal Tool

nurses, midwives and allied health professionals

Nursing, Midwifery and Allied Health Professions Research Unit (Scotland)

preferred reporting items for systematic reviews and meta-analyses

making Visible the ImpaCT Of Research framework, a research impact capture tool

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Acknowledgements

Thank you to Clare Leon-Villapalos, Melanie Almonte, Jinju James and Gemma Clunie for their support with screening, data extraction and quality assessment; and to Lisa Gardner for her assistance in refining the search strategy.

This research was funded by the NIHR Imperial Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Lisa Newington, Mary Wells, Adine Adonis, Lee Bolton, Layla Bolton Saghdaoui, Margaret Coffey, Jennifer Crow, Olga Fadeeva Costa, Catherine Hughes, Matthew Savage, Lillie Shahabi & Caroline M. Alexander

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Contributions

LN, MW and CMA designed the review. LN, JC, OFC, LS and LB completed the title and abstract screening. LN, AA, MC, LS, OFC, MA and LBS completed the full text screening. LN, AA, LBS, CL, LS, MC, JJ, LB and JC completed quality assessment and data extraction. Disagreements during screening were resolved by MW and CMA. Differences in data extraction were reviewed by MS and CH. LN, AA, LB, LBS, MC, JC, MS and CH thematically analysed the extracted data, and LN, MW and CMA completed the thematic synthesis. LN drafted the manuscript with major contributions from MW and CMA. All authors reviewed and approved the final manuscript.

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Supplementary Information

Additional file 1..

Example search strategy for Medline. Search strategy terms.

Additional file 2.

Mixed Methods Appraisal Tool. Quality appraisal form and instruction for use.

Additional file 3.

Articles excluded during full text screen and reasons for exclusion. References of the excluded articles and reason for exclusion.

Additional file 4.

Coding framework for the types of impact identified and exemplar quotes. Full listing of the theme headings with descriptors and supplementary quotes.

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Newington, L., Wells, M., Adonis, A. et al. A qualitative systematic review and thematic synthesis exploring the impacts of clinical academic activity by healthcare professionals outside medicine. BMC Health Serv Res 21 , 400 (2021). https://doi.org/10.1186/s12913-021-06354-y

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thematic synthesis of the literature

Educational resources and simple solutions for your research journey

thematic synthesis of the literature

How to Write a Thematic Literature Review: A Beginner’s Guide

How to Write a Thematic Literature Review

Literature reviews provide a comprehensive understanding of existing knowledge in a particular field, offer insights into gaps and trends, and ultimately lay the foundation for innovative research. However, when tackling complex topics spanning multiple issues, the conventional approach of a standard literature review might not suffice. Many researchers present a literature review without giving any thought to its organization or structure, but this is where a thematic literature review comes into play. In this article, we will explore the significance of thematic reviews, delve into how and when to undertake them, and offer invaluable guidance on structuring and crafting a compelling thematic literature review.

Table of Contents

What is a thematic literature review?

A thematic literature review, also known as a thematic review, involves organizing and synthesizing the existing literature based on recurring themes or topics rather than a chronological or methodological sequence. Typically, when a student or researcher works intensively on their research there are many sub-domains or associated spheres of knowledge that one encounters. While these may not have a direct bearing on the main idea being explored, they provide a much-needed background or context to the discussion. This is where a thematic literature review is useful when dealing with complex research questions that involve multiple facets, as it allows for a more in-depth exploration of specific themes within the broader context.

thematic synthesis of the literature

When to opt for thematic literature review?

It is common practice for early career researchers and students to collate all the literature reviews they have undertaken under one single broad umbrella. However, when working on a literature review that involves multiple themes, lack of organization and structure can slow you down and create confusion. Deciding to embark on a thematic literature review is a strategic choice that should align with your research objectives. Here are some scenarios where opting for a thematic review is advantageous:

  • Broad Research Questions: When your research question spans across various dimensions and cannot be adequately addressed through a traditional literature review.
  • Interdisciplinary Research: In cases where your research draws from multiple disciplines, a thematic review helps in synthesizing diverse literature cohesively.
  • Emerging Research Areas: When exploring emerging fields or topics with limited existing literature, a thematic review can provide valuable insights by focusing on available themes.
  • Complex Issues: Thematic reviews are ideal for dissecting complex issues with multiple contributing factors or dimensions.

Advantages of a Thematic Literature Review

With better comprehension and broad insights, thematic literature reviews can help in identifying possible research gaps across themes. A thematic literature review has several advantages over a general or broad-based approach, especially for those working on multiple related themes.

  • It provides a comprehensive understanding of specific themes within a broader context, allowing for a deep exploration of relevant literature.
  • Thematic reviews offer a structured approach to organizing and synthesizing diverse sources, making it easier to identify trends, patterns, and gaps.
  • Researchers can focus on key themes, enabling a more detailed analysis of specific aspects of the research question.
  • Thematic reviews facilitate the integration of literature from various disciplines, offering a holistic view of the topic.
  • Researchers can provide targeted recommendations or insights related to specific themes, aiding in the formulation of research hypotheses.

Now that we know the benefits of a thematic literature review, what is the best way to arrange reviewed literature in a thematic format?

How to write a thematic literature review

To effectively structure and write a thematic literature review, follow these key steps:

  • Define Your Research Question: Clearly define the overarching research question or topic you aim to explore thematically. When writing a thematic literature review, go through different literature review sections of published research work and understand the subtle nuances associated with this approach.
  • Identify Themes: Analyze the literature to identify recurring themes or topics relevant to your research question. Categorize the bibliography by dividing them into relevant clusters or units, each dealing with a specific issue. For example, you can divide a topic based on a theoretical approach, methodology, discipline or by epistemology. A theoretical review of related literature for example, may also look to break down geography or issues pertaining to a single country into its different parts or along rural and urban divides.
  • Organize the Literature: Group the literature into thematic clusters based on the identified themes. Each cluster represents a different aspect of your research question. It is up to you to define the different narratives of thematic literature reviews depending on the project being undertaken; there is no one formal way of doing this. You can weigh how specific areas stack up against others in terms of existing literature or studies and how many more aspects may need to be added or further looked into.
  • Review and Synthesize: Within each thematic cluster, review and synthesize the relevant literature, highlighting key findings and insights. It is recommended to identify any theme-related strengths or weaknesses using an analytical lens.
  • Integrate Themes: Analyze how the themes interact with each other, draw linkages between earlier studies and see how they contribute to your own research. A thematic literature review presents readers with a comprehensive overview of the literature available on and around the research topic.
  • Provide a Framework: Develop a framework or conceptual model that illustrates the relationships between the themes. Present the most relevant part of the thematic review toward the end and study it in greater detail as it reflects the literature most relevant and directly related to the main research topic.
  • Conclusion: Conclude your thematic literature review by summarizing the key findings and their implications for your research question. Be sure to highlight any gaps or areas requiring further investigation in this section.
  • Cite and Reference: It is important to remember that a thematic review of literature for a PhD thesis or research paper lends greater credibility to the student or researcher. So ensure that you properly cite and reference all sources according to your chosen citation style.
  • Edit and Proofread: Take some time to review your work, ensure proper structure and flow and eliminate any language, grammar, or spelling errors that could deviate reader attention. This will help you deliver a well-structured and elegantly written thematic literature review.

Thematic literature review example

In essence, a thematic literature review allows researchers to dissect complex topics into smaller manageable themes, providing a more focused and structured approach to literature synthesis. This method empowers researchers to gain deeper insights, identify gaps, and generate new knowledge within the context of their research.

To illustrate the process mentioned above, let’s consider an example of a thematic literature review in the context of sustainable development. Imagine the overarching research question is: “What are the key factors influencing sustainable urban planning?” Potential themes could include environmental sustainability, social equity, economic viability, and governance. Each theme would have a dedicated section in the review, summarizing relevant literature and discussing how these factors intersect and impact sustainable urban planning. Close with a strong conclusion that highlights research gaps or areas of investigation. Finally, review and refine the thematic literature review, adding citations and references as required.

In conclusion, when tackling multifaceted research questions, a thematic literature review proves to be an indispensable tool for researchers and students alike. By adopting this approach, scholars can navigate the intricate web of existing literature, unearth meaningful patterns, and contribute to the advancement of knowledge in their respective fields. We hope the information in this article helps you create thematic reviews that illuminate your path to new discoveries and innovative insights.

R Discovery is a literature search and research reading app that uses your interests to instantly create personalized reading feeds. Researchers can stay updated on the latest, most relevant content from its continually expanding library of 115M+ research articles sourced from trusted aggregators like CrossRef, Unpaywall, PubMed, PubMed Central, Open Alex as well as prestigious publishing houses like Springer Nature, JAMA, IOP, Taylor & Francis, NEJM, BMJ, Karger, SAGE, Emerald Publishing and more. The top-rated app in its space, R Discovery’s carefully curated features give you the power to choose what, where, and how you read research.     

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Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

By: Derek Jansen (MBA) | Expert Reviewer: Eunice Rautenbach (DTech) | August 2023

One of the most common mistakes that students make when writing a literature review is that they err on the side of describing the existing literature rather than providing a critical synthesis of it. In this post, we’ll unpack what exactly synthesis means and show you how to craft a strong literature synthesis using practical examples.

This post is based on our popular online course, Literature Review Bootcamp . In the course, we walk you through the full process of developing a literature review, step by step. If it’s your first time writing a literature review, you definitely want to use this link to get 50% off the course (limited-time offer).

Overview: Literature Synthesis

  • What exactly does “synthesis” mean?
  • Aspect 1: Agreement
  • Aspect 2: Disagreement
  • Aspect 3: Key theories
  • Aspect 4: Contexts
  • Aspect 5: Methodologies
  • Bringing it all together

What does “synthesis” actually mean?

As a starting point, let’s quickly define what exactly we mean when we use the term “synthesis” within the context of a literature review.

Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study’s research aims and questions .

Put another way, a good synthesis tells the reader exactly where the current research is “at” in terms of the topic you’re interested in – specifically, what’s known , what’s not , and where there’s a need for more research .

So, how do you go about doing this?

Well, there’s no “one right way” when it comes to literature synthesis, but we’ve found that it’s particularly useful to ask yourself five key questions when you’re working on your literature review. Having done so,  you can then address them more articulately within your actual write up. So, let’s take a look at each of these questions.

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1. Points Of Agreement

The first question that you need to ask yourself is: “Overall, what things seem to be agreed upon by the vast majority of the literature?”

For example, if your research aim is to identify which factors contribute toward job satisfaction, you’ll need to identify which factors are broadly agreed upon and “settled” within the literature. Naturally, there may at times be some lone contrarian that has a radical viewpoint , but, provided that the vast majority of researchers are in agreement, you can put these random outliers to the side. That is, of course, unless your research aims to explore a contrarian viewpoint and there’s a clear justification for doing so. 

Identifying what’s broadly agreed upon is an essential starting point for synthesising the literature, because you generally don’t want (or need) to reinvent the wheel or run down a road investigating something that is already well established . So, addressing this question first lays a foundation of “settled” knowledge.

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thematic synthesis of the literature

2. Points Of Disagreement

Related to the previous point, but on the other end of the spectrum, is the equally important question: “Where do the disagreements lie?” .

In other words, which things are not well agreed upon by current researchers? It’s important to clarify here that by disagreement, we don’t mean that researchers are (necessarily) fighting over it – just that there are relatively mixed findings within the empirical research , with no firm consensus amongst researchers.

This is a really important question to address as these “disagreements” will often set the stage for the research gap(s). In other words, they provide clues regarding potential opportunities for further research, which your study can then (hopefully) contribute toward filling. If you’re not familiar with the concept of a research gap, be sure to check out our explainer video covering exactly that .

thematic synthesis of the literature

3. Key Theories

The next question you need to ask yourself is: “Which key theories seem to be coming up repeatedly?” .

Within most research spaces, you’ll find that you keep running into a handful of key theories that are referred to over and over again. Apart from identifying these theories, you’ll also need to think about how they’re connected to each other. Specifically, you need to ask yourself:

  • Are they all covering the same ground or do they have different focal points  or underlying assumptions ?
  • Do some of them feed into each other and if so, is there an opportunity to integrate them into a more cohesive theory?
  • Do some of them pull in different directions ? If so, why might this be?
  • Do all of the theories define the key concepts and variables in the same way, or is there some disconnect? If so, what’s the impact of this ?

Simply put, you’ll need to pay careful attention to the key theories in your research area, as they will need to feature within your theoretical framework , which will form a critical component within your final literature review. This will set the foundation for your entire study, so it’s essential that you be critical in this area of your literature synthesis.

If this sounds a bit fluffy, don’t worry. We deep dive into the theoretical framework (as well as the conceptual framework) and look at practical examples in Literature Review Bootcamp . If you’d like to learn more, take advantage of our limited-time offer to get 60% off the standard price.

thematic synthesis of the literature

4. Contexts

The next question that you need to address in your literature synthesis is an important one, and that is: “Which contexts have (and have not) been covered by the existing research?” .

For example, sticking with our earlier hypothetical topic (factors that impact job satisfaction), you may find that most of the research has focused on white-collar , management-level staff within a primarily Western context, but little has been done on blue-collar workers in an Eastern context. Given the significant socio-cultural differences between these two groups, this is an important observation, as it could present a contextual research gap .

In practical terms, this means that you’ll need to carefully assess the context of each piece of literature that you’re engaging with, especially the empirical research (i.e., studies that have collected and analysed real-world data). Ideally, you should keep notes regarding the context of each study in some sort of catalogue or sheet, so that you can easily make sense of this before you start the writing phase. If you’d like, our free literature catalogue worksheet is a great tool for this task.

5. Methodological Approaches

Last but certainly not least, you need to ask yourself the question: “What types of research methodologies have (and haven’t) been used?”

For example, you might find that most studies have approached the topic using qualitative methods such as interviews and thematic analysis. Alternatively, you might find that most studies have used quantitative methods such as online surveys and statistical analysis.

But why does this matter?

Well, it can run in one of two potential directions . If you find that the vast majority of studies use a specific methodological approach, this could provide you with a firm foundation on which to base your own study’s methodology . In other words, you can use the methodologies of similar studies to inform (and justify) your own study’s research design .

On the other hand, you might argue that the lack of diverse methodological approaches presents a research gap , and therefore your study could contribute toward filling that gap by taking a different approach. For example, taking a qualitative approach to a research area that is typically approached quantitatively. Of course, if you’re going to go against the methodological grain, you’ll need to provide a strong justification for why your proposed approach makes sense. Nevertheless, it is something worth at least considering.

Regardless of which route you opt for, you need to pay careful attention to the methodologies used in the relevant studies and provide at least some discussion about this in your write-up. Again, it’s useful to keep track of this on some sort of spreadsheet or catalogue as you digest each article, so consider grabbing a copy of our free literature catalogue if you don’t have anything in place.

Looking at the methodologies of existing, similar studies will help you develop a strong research methodology for your own study.

Bringing It All Together

Alright, so we’ve looked at five important questions that you need to ask (and answer) to help you develop a strong synthesis within your literature review.  To recap, these are:

  • Which things are broadly agreed upon within the current research?
  • Which things are the subject of disagreement (or at least, present mixed findings)?
  • Which theories seem to be central to your research topic and how do they relate or compare to each other?
  • Which contexts have (and haven’t) been covered?
  • Which methodological approaches are most common?

Importantly, you’re not just asking yourself these questions for the sake of asking them – they’re not just a reflection exercise. You need to weave your answers to them into your actual literature review when you write it up. How exactly you do this will vary from project to project depending on the structure you opt for, but you’ll still need to address them within your literature review, whichever route you go.

The best approach is to spend some time actually writing out your answers to these questions, as opposed to just thinking about them in your head. Putting your thoughts onto paper really helps you flesh out your thinking . As you do this, don’t just write down the answers – instead, think about what they mean in terms of the research gap you’ll present , as well as the methodological approach you’ll take . Your literature synthesis needs to lay the groundwork for these two things, so it’s essential that you link all of it together in your mind, and of course, on paper.

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  • Published: 18 April 2018

Protocol for a systematic review and thematic synthesis of patient experiences of central venous access devices in anti-cancer treatment

  • Caoimhe Ryan   ORCID: orcid.org/0000-0001-7279-563X 1 ,
  • Hannah Hesselgreaves 2 ,
  • Olivia Wu 1 ,
  • Jim Paul 3 ,
  • Judith Dixon-Hughes 3 &
  • Jonathan G. Moss 4  

Systematic Reviews volume  7 , Article number:  61 ( 2018 ) Cite this article

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Three types of central venous access devices (CVADs)—peripherally inserted central catheters (PICCs), skin-tunnelled central catheters (Hickman-type devices), and implantable chest wall Ports (Ports)—are routinely used in the intravenous administration of anti-cancer treatment. These devices avoid the need for peripheral cannulation and allow for home delivery of treatment. Assessments of these devices have tended to focus on medical and economic factors, but there is increased interest in the importance of patient experiences and perspectives in this area. The aim of this systematic review is to synthesise existing research regarding patient experiences of these CVADs to help clinicians guide, prepare, and support patients receiving CVADs for the administration of anti-cancer treatment.

A systematic search of MEDLINE, Embase, and CINAHL research databases will be carried out along with a supplementary reference list search. This review will include quantitative, qualitative, and mixed methods studies published in peer-review journals, reporting some aspect(s) of patient experiences or perspectives regarding the use of PICC, Hickman, or Port CVADs for the administration of anti-cancer drugs. The methodological quality and risk of bias of included papers will be assessed using the Mixed Methods Appraisal Tool (MMAT). Relevant outcome data will be extracted from included studies and analysed using a thematic synthesis approach.

The results section of the review will comprise thematic synthesis of quantitative studies, thematic synthesis of qualitative studies, and the aggregation of the two. Results will aim to offer an account of current understandings of patient experiences and perspective regarding PICC, Hickman-type, and Port devices in the context of anti-cancer treatment. Confidence in cumulative evidence will be assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach.

Systematic review registration

This systematic review protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42017065851 . This protocol was prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols checklist (PRISMA-P) (Shamseer et al., BMJ 349: 2015).

Peer Review reports

Three types of central venous access devices (CVADs) are routinely used in the intravenous administration of anti-cancer treatment: peripherally inserted central catheters (PICCs), skin-tunnelled central catheters (Hickman-type devices), and implantable chest wall Ports (Ports).

All three deliver the drug into the superior vena cava, which drains directly into the right atrium of the heart. PICC lines are inserted into a peripheral vein in the arm. The end of the line remains outside the body, emerging from a point usually above the elbow. Hickman-type devices are inserted into a central vein in the neck or upper chest. The end of the line is tunnelled under the skin to emerge from the chest, where it sits outside the body. Chest wall Ports constitute a closed-system that is fully implanted in the body with no external lines. Vascular access is via needle puncture.

The main benefit of the devices is that they avoid the need for peripheral cannulation which relies on peripheral arm veins that easily become occluded. Moreover, peripheral cannulation usually involves repeated needle insertions which patients tend to find unpleasant, even painful and distressing [ 1 ]. They also allow for home delivery of treatment via portable chemotherapy infusion pump.

Patient-centred approaches in the area of vascular access exist but are limited. Published reports on the use of vascular access devices in the context of anti-cancer treatment have tended to focus on medical and economic factors such as cost, maintenance, infection, and other complications [ 2 , 3 ], with much less attention given to patient experiences and perspectives. It is therefore difficult to gain a clear picture of how patients experience PICC, Hickman, and Port devices [ 4 ]. Developing a better understanding of these experiences would offer important insight into the roles these devices play in patients’ quality of life and in the burden of treatment. Moreover, a comparison of the effects and experiences of these different devices would be important in guiding device selection where more than one device is clinically suitable.

To our knowledge no systematic review has previously been carried out on this topic. The present review will draw together existing approaches to recording and assessing patient experiences of these CVADs in order to produce a coherent understanding of such experiences. This will help clinicians guide, prepare, and support patients receiving CVADs for the administration of anti-cancer treatment.

The aim of this review is to synthesise existing literature that investigates patient experiences with PICC, Hickman-type, and Port devices in the context of anti-cancer treatment.

This review will address the following questions: What are patients’ experiences and perspectives regarding the three different central venous access devices implanted for delivering long-term anti-cancer treatment: peripherally inserted central catheters (PICC), Hickman-type tunnelled catheters, and totally implanted chest wall Ports? What effect (if any) do these CVADs have on patients’ quality of life in the context of anti-cancer treatment, and what aspects of each device are important in this respect? To what extent is it possible to compare and contrast patient experiences of different CVADs? What are the limitations of the existing literature, and what additional research is needed?

Eligibility criteria

This review will include empirical studies published in peer-review journals meeting review-specific eligibility criteria. These criteria were developed in line with the existing search tools PICO (Population, Intervention, Comparison, Outcome) [ 5 ] and SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) [ 6 ]. PICO is typically used in systematic reviews of quantitative research, answering clinical questions. SPIDER was adapted from the former for use in systematic reviews of qualitative and mixed method research. As our review will comprise quantitative, qualitative, and mixed methods studies, our eligibility criteria include elements from both.

As the use of PICCs and chest wall Ports in cancer treatment was not well established until the 1990s and involved a learning curve of several years, this review will consider only studies published from the year 1997 onward.

Participant population

Studies will be eligible for inclusion where participants are adult or paediatric patients (or parents/guardians of paediatric patients) diagnosed with any type of cancer including solid malignancy and haematologic malignancy, who have received PICC, Hickman-type or chest wall Port CVADs for the primary purpose of the administration of anti-cancer drugs.

Intervention

Included studies will involve the implantation (via any technique) of any of the following venous access devices for the long-term administration of any anti-cancer treatment: (i) peripherally inserted central catheters (PICC), (ii) subcutaneously tunnelled central catheters (Hickman-type device), and (iii) implantable chest wall Ports (Port).

Comparator/control

Studies will not be included or excluded on the basis of comparator. Where relevant and appropriate, comparisons between devices or other forms of venous access in the administration of anti-cancer treatment will be considered in analysis.

The review will include empirical studies using quantitative and/or qualitative analytic methods. It will exclude non-empirical studies but will not limit inclusion based on study design. Studies that report outcomes regarding CVADs but do not report or discuss any patient experience will also be excluded, as will studies that do not provide sufficient detail for a thematic synthesis—i.e. studies that do not contribute to themes or where data cannot be themed.

This review will include studies conducted in oncology settings such as hospitals, and clinics, or related contexts including home-treatment, patient care facilities, or patient groups/organisations.

Evaluation/outcomes

Finally, to be eligible for inclusion study, participants must have completed a measure (e.g. questionnaire, survey) or provided an account (e.g. interview, focus group) of some aspect of their own experience with or perspectives on CVADs or in the case of paediatric patients, where parents/guardians similarly report on some aspect of their own and their children’s experiences and perspectives (please see ‘ Outcomes and Prioritisation ’ section, below, for explanations of these outcomes).

Information sources

A systematic search strategy will be used to search MEDLINE, Embase, and CINAHL research databases. A further important component of our search strategy, especially for the purposes of identifying relevant qualitative research, involves forward and backward citation tracking of publications meeting the inclusion criteria, via Web of Science and Google Scholar. In addition, experts including authors of key papers will be contacted to minimise the likelihood of overlooking key sources.

Search strategy

Search terms will target three key domains: (i) central venous access devices, (ii) patient population, and (iii) patient experiences. Search terms for Hickman and Port devices and for cancer and chemotherapy will be adapted from an existing systematic review comparing the clinical effectiveness of these devices [ 7 ]. The search strategy has been constructed with advice and guidance from an information scientist. An example of search terms and strategy is provided in Appendix .

Data management

Details of all searches will be recorded. Search results will be downloaded to EndNote desktop software. Studies sourced through supplemental hand searching will be recorded and imported into EndNote.

Selection process

Duplicate publications will be removed. The titles and abstracts of all remaining publications will be assessed against inclusion criteria. Those not meeting these criteria will be excluded. All titles and abstracts identified at this stage will also be screened independently by a second reviewer. Disparities will be resolved through discussion or in consultation with a third party. Full texts of the remaining publications will be obtained for further review. Reasons for further exclusions at this stage will be documented. The selection process, including search results and reasons for exclusion at each stage of screening, will be recorded and represented in a PRISMA flow diagram (Additional file  1 )[ 8 ].

Data collection process

Data extraction will be performed by one reviewer using a data extraction form developed by the researchers for the purposes of this review. This form will be refined by the reviewer until the data extraction is complete, to ensure the appropriateness and usefulness of all fields.

For all studies, descriptive data will be extracted regarding type(s) of vascular access device included in the study, patient population, sample size, stated research aims, study context, study design, methodology, reason for measurement of patient experience, and timing of measurement (in relation to device placement).

For quantitative studies, outcome data including descriptive and inferential statistics will be extracted for measures of patient experiences or perspectives regarding CVADs. Details of measurement instruments will also be recorded. The purpose of qualitative synthesis is to ‘go beyond’ primary studies. This means the data to be extracted from the qualitative studies comprises the analyses and interpretations of the study authors including all themes, categories, theories, models, and similar. Therefore, all material labelled as results or findings by the authors as well as subsequent discussions and conclusions relating to CVADs will be extracted in full [ 9 ].

Outcomes and prioritisation

The primary outcomes of interest will be any aspect of patients’ (or parent/guardians’) self-reported experiences or perspectives relating to PICC, Hickman, or Port devices. The data to be collected will include quantitative and qualitative materials, i.e. survey or questionnaire data, qualitative themes, and participant quotations.

For our present purposes, ‘patient perspectives’ will include opinions, attitudes, and evaluations (including acceptance and satisfaction). Patient experiences will include emotions, physical sensations (e.g. pain, discomfort), psychological factors (e.g. stress, mood), and pragmatic factors (e.g. routine activities).

Our analyses will prioritise any of the above as they relate to device acceptance or preference or to patient wellbeing or quality of life. Secondary prioritisation will be given to any of the above as they relate to device placement (insertion).

Risk of bias in individual studies

Critical appraisal of methodological quality and risk of bias of included papers will be undertaken independently by two reviewers according to the Mixed Methods Appraisal Tool (MMAT) developed by Pluye and colleagues [ 10 ] for the appraisal of qualitative, quantitative, and mixed methods research. Following these guidelines, the reviewers will assess for all included studies whether (i) there are clear research questions and (ii) the data collected address the research question. The following assessments will then be made, depending on study type:

Qualitative studies

The reviewers will assess the appropriateness of data sources and analytical processes, the study’s consideration of context/setting, and the study’s consideration of researchers’ influence.

Randomised controlled trials

The reviewers will assess the study’s descriptions of randomisation and allocation concealment, the completeness of outcome data, and the level of drop-out rates.

Nonrandomised quantitative studies

The reviewers will assess the study’s minimisation of selection bias, use of appropriate measurement instruments, use of comparable groups across study conditions, and the completeness of outcome data.

Descriptive cross-sectional quantitative studies

The reviewers will assess the appropriateness of the study’s sampling strategy and the representativeness of the sample, use of appropriate measurement instruments, and acceptability of response rate.

Data analysis and synthesis

Data will be analysed using a narrative approach, specifically thematic synthesis. Our analysis will comprise three phases. The first phase will be a thematic synthesis of the patient experience and perspective data extracted from the quantitative studies selected for inclusion in our review. We use inclusive definitions of patient experience and perspectives in this review. Our search strategy therefore includes a range of broad search terms relating to these phenomena. In addition, to our knowledge, there are no validated or standardised measures relating to patient experiences of CVADs in common usage. For instance, one such measure recently developed in France (specific to Port devices) [ 11 ] has to date been used in a single pilot study [ 12 ]. Consequently, we anticipate significant heterogeneity with regard to quantitative outcomes, and these data will not be quantitatively synthesised. The second phase of analysis will be a thematic synthesis of the qualitative studies selected for inclusion. The final third stage will be an aggregation of both sets of analysis. In the interests of transparency, detailed accounts of each stage of analysis will be recorded. The second phase of analysis will be a thematic synthesis of the patient experience and perspective data extracted from qualitative studies selected for inclusion. The final third stage will be an aggregation of both sets of analysis. In the interests of transparency, detailed accounts of each stage of analysis will be recorded.

Analytic method

Thematic synthesis is an adaptation for the purpose of secondary data synthesis of ‘thematic analysis’ and provides a set of established methods and techniques for the identification and development of analytic themes in primary research data [ 9 ]. Thematic synthesis was selected for the purposes of this review for a several reasons [ 13 ]. First, it is well suited to our present objective of aggregating existing evidence and identifying patterns within data. Second, whilst it is most commonly associated with the synthesis of qualitative research outcomes, thematic synthesis is also used for the synthesis of quantitative research outcomes, particularly where there is heterogeneity in outcome variables and measurements. Finally, the process of thematic synthesis offers good transparency and outcomes are accessible.

Thematic synthesis involves three stages of analysis (all three stages will be applied to all included quantitative studies and repeated for all included qualitative studies). First, the data—here, those pertaining to patient experiences and perspectives—are coded. A coding frame will be developed comprising codes derived from the data. Coding will be carried out by the first reviewer and checked by a second reviewer. Disparities or discrepancies in coding will be resolved through discussion or in consultation with a third party if necessary; the coding frame will be adjusted accordingly.

In the second stage of analysis, similarities between codes will be identified. Codes will be grouped into ‘descriptive themes’ that capture and describe patterns in the data across studies. Each theme will be entered as columns into a table, and coded data from each study will illustrate the themes in rows, to facilitate comparison within and between studies, as part of the constant comparison analytic process [ 14 , 15 ]. Memos will be used as part of the analysis process and may be included in the summary table where clarity may be required about the interpretation of a piece of evidence [ 16 ]. The aim of this table is to demonstrate themes with illustrative data and capture similarities and differences within the data where possible—that is, to show how themes are generated but also show divergence of findings in each theme, where it applies.

The third stage of thematic synthesis will involve the development of analytic themes. The purpose of this phase of analysis is to ‘go beyond’ the primary reported data by synthesising findings across studies and interpreting their meaning in relation to our review research questions. This will comprise the narrative component of our analysis, which will provide narrative descriptions of each theme.

Once thematic synthesis has been completed for quantitative studies and for qualitative studies, a final phase of analysis will compare both sets of results, and the three central venous access devices included in the review. This process will aggregate results, providing an overall account of current understandings of patient experiences and perspectives of CVADs in the context of anti-cancer treatment.

Confidence in cumulative evidence

Confidence in discrete review findings will be assessed using the recently developed Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach [ 17 ]. Assessment of confidence in a given review finding involves evaluating how likely it is that the finding represents a real phenomenon, i.e. genuine patient experiences of CVADs. This assessment will be based upon an evaluation of the following: (i) methodological limitations of the primary studies contributing to the finding, (ii) the relevance of the primary contributing studies with regard to the objectives of the systematic review, (iii) the coherence of the finding, and (iv) the adequacy of data supporting the finding.

For the purposes of this study, these evaluations will be conducted as follows:

Methodological limitations of contributing studies: With reference to our prior critical appraisal of methodological quality of these studies (see above), we will evaluate the extent to which the primary studies contributing to the finding are generally of good methodological quality.

Relevance of contributing studies: We will evaluate the extent to which the primary studies contributing to the finding are similar in context and aims/objectives to the present review. For instance, studies carried out with the primary aim of investigating some aspect of patients’ experiences of CVADs in the context of cancer treatment will be considered highly relevant. Those in which findings relating to patient experiences of CVADs are secondary or incidental to an alternative aim will be considered to be of low relevance.

Coherence of finding: We will assess the extent to which the finding offers a credible explanation for the patterns it describes (e.g. tendencies, relationships between relevant factors). This will involve assessing the consistency or inconsistency of the pattern across various research contexts represented by studies included in the review and the ability of the finding to account for notable variations across contexts. Findings will be judged to be of low coherence if they describe inconsistent or contradictory patterns and where inconsistencies are unexplained.

Adequacy of supporting data: We will assess the extent to which a given finding is supported by substantial evidence defined both in terms of number of studies contributing to a given study and the quantitative robustness or qualitative richness (i.e. fullness and depth) of the data provided by these studies.

The above evaluations will necessarily entail subjective judgements and will therefore be carried out by two reviewers working in collaboration. A summary table will list for each review finding—primary contributing studies, evaluations of the above four domains, an overall confidence rating (high, moderate, low, or very low), and an explanation of the rating judgement.

The results section of the review will summarise the findings of (i) the thematic synthesis of quantitative studies, (ii) the thematic synthesis of qualitative studies, and (iii) the aggregation (comparison and juxtaposition) of both sets of findings.

The results will offer an account of current understandings of patient experiences and perspective regarding PICC, Hickman-type, and Port devices in the context of anti-cancer treatment. They will explore the extent to which and/or the ways in which these devices affect patients’ quality of life. Comparisons between experiences of different devices, or between especially positive and negative experiences, will be explored as appropriate and similarities and differences discussed and tabulated, if the data lend themselves to this. Not all relevant comparisons can be identified in advance, so other comparisons may become important. Finally, the results of this review will consider the gaps in the existing literature and of ways in which existing data can be used to support patients.

Abbreviations

Confidence in the Evidence from Reviews of Qualitative research

Central venous access device

Mixed Methods Appraisal Tool for the appraisal of qualitative, quantitative, and mixed methods research

Peripherally inserted central catheter

Framework for the development of systematic literature searches. Acronym derived from key aspects of empirical studies: Population, Intervention, Comparison, Outcome

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Adaptation of PICO for the development of systematic searches of qualitative literature. Acronym derived from key aspects of empirical studies: Sample, Phenomenon of Interest, Design, Evaluation

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Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK

Caoimhe Ryan & Olivia Wu

School of Medical Education, Newcastle University, Newcastle upon Tyne, UK

Hannah Hesselgreaves

Institute of Cancer Sciences, University of Glasgow, Glasgow, UK

Jim Paul & Judith Dixon-Hughes

Gartnavel General Hospital, Glasgow, UK

Jonathan G. Moss

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Contributions

CR drafted this manuscript. HH contributed to the design of the protocol and provided input across all sections. OW provided guidance during the initial development of this protocol and offered comments on full drafts of the protocol. JDH was consulted during the development of the protocol and provided comments on full drafts. JP was consulted during the development of the protocol and provided comments on full drafts. JM offered expertise regarding limitations by year for the systematic review described as well as comments on full drafts of the protocol. All authors read and approved the final manuscript.

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Correspondence to Caoimhe Ryan .

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Additional file

Additional file 1:.

PRISMA-P checklist. (DOCX 35 kb)

Ovid MEDLINE(R) via Ovid 1946 to Week 2 2017

exp Vascular Access Devices/

Catheterization, Central Venous/

(central venous adj5 (catheter* or access)).tw.

percutaneous catheter*.tw.

(venous adj5 (catheter* or access)).tw.

vascular access.tw.

hickman*.tw.

((perhiperally adj5 catheter*) or PICC*).tw.

(implant* adj5 catheter*).tw.

(venous adj5 Port*).tw.

(Portacath* or Port-a-cath*).tw.

(implant* adj5 Port*).tw.

(implant* adj5 reservoir*).tw.

(subcutaneous* adj5 Port*).tw.

(tunnel* adj5 catheter*).tw.

exp Neoplasms/

chemotherapy.tw.

(tumor* or tumour*).tw.

cancer*.tw.

malignan*.tw.

oncolog*.tw.

exp Patient Satisfaction/

(patient* adj5 experience*).tw.

(patient* adj5 perspective*).tw.

(patient* adj5 view*).tw.

(patient* adj5 attitude*).tw.

(patient* adj5 opinion*).tw.

(patient* adj5 satisf*).tw.

(patient* adj5 accept*).tw.

(patient* adj5 evaluat*).tw.

(patient* adj5 assess*).tw.

(patient* adj5 choice*).tw.

(patient* adj5 decision*).tw.

(patient* adj5 prefer*).tw.

(patient* adj5 (questionnaire* or survey*)).tw.

16 and 23 and 38

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Ryan, C., Hesselgreaves, H., Wu, O. et al. Protocol for a systematic review and thematic synthesis of patient experiences of central venous access devices in anti-cancer treatment. Syst Rev 7 , 61 (2018). https://doi.org/10.1186/s13643-018-0721-x

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Synthesizing Sources | Examples & Synthesis Matrix

Published on July 4, 2022 by Eoghan Ryan . Revised on May 31, 2023.

Synthesizing sources involves combining the work of other scholars to provide new insights. It’s a way of integrating sources that helps situate your work in relation to existing research.

Synthesizing sources involves more than just summarizing . You must emphasize how each source contributes to current debates, highlighting points of (dis)agreement and putting the sources in conversation with each other.

You might synthesize sources in your literature review to give an overview of the field or throughout your research paper when you want to position your work in relation to existing research.

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Example of synthesizing sources, how to synthesize sources, synthesis matrix, other interesting articles, frequently asked questions about synthesizing sources.

Let’s take a look at an example where sources are not properly synthesized, and then see what can be done to improve it.

This paragraph provides no context for the information and does not explain the relationships between the sources described. It also doesn’t analyze the sources or consider gaps in existing research.

Research on the barriers to second language acquisition has primarily focused on age-related difficulties. Building on Lenneberg’s (1967) theory of a critical period of language acquisition, Johnson and Newport (1988) tested Lenneberg’s idea in the context of second language acquisition. Their research seemed to confirm that young learners acquire a second language more easily than older learners. Recent research has considered other potential barriers to language acquisition. Schepens, van Hout, and van der Slik (2022) have revealed that the difficulties of learning a second language at an older age are compounded by dissimilarity between a learner’s first language and the language they aim to acquire. Further research needs to be carried out to determine whether the difficulty faced by adult monoglot speakers is also faced by adults who acquired a second language during the “critical period.”

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thematic synthesis of the literature

To synthesize sources, group them around a specific theme or point of contention.

As you read sources, ask:

  • What questions or ideas recur? Do the sources focus on the same points, or do they look at the issue from different angles?
  • How does each source relate to others? Does it confirm or challenge the findings of past research?
  • Where do the sources agree or disagree?

Once you have a clear idea of how each source positions itself, put them in conversation with each other. Analyze and interpret their points of agreement and disagreement. This displays the relationships among sources and creates a sense of coherence.

Consider both implicit and explicit (dis)agreements. Whether one source specifically refutes another or just happens to come to different conclusions without specifically engaging with it, you can mention it in your synthesis either way.

Synthesize your sources using:

  • Topic sentences to introduce the relationship between the sources
  • Signal phrases to attribute ideas to their authors
  • Transition words and phrases to link together different ideas

To more easily determine the similarities and dissimilarities among your sources, you can create a visual representation of their main ideas with a synthesis matrix . This is a tool that you can use when researching and writing your paper, not a part of the final text.

In a synthesis matrix, each column represents one source, and each row represents a common theme or idea among the sources. In the relevant rows, fill in a short summary of how the source treats each theme or topic.

This helps you to clearly see the commonalities or points of divergence among your sources. You can then synthesize these sources in your work by explaining their relationship.

If you want to know more about ChatGPT, AI tools , citation , and plagiarism , make sure to check out some of our other articles with explanations and examples.

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Synthesizing sources means comparing and contrasting the work of other scholars to provide new insights.

It involves analyzing and interpreting the points of agreement and disagreement among sources.

You might synthesize sources in your literature review to give an overview of the field of research or throughout your paper when you want to contribute something new to existing research.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

Topic sentences help keep your writing focused and guide the reader through your argument.

In an essay or paper , each paragraph should focus on a single idea. By stating the main idea in the topic sentence, you clarify what the paragraph is about for both yourself and your reader.

At college level, you must properly cite your sources in all essays , research papers , and other academic texts (except exams and in-class exercises).

Add a citation whenever you quote , paraphrase , or summarize information or ideas from a source. You should also give full source details in a bibliography or reference list at the end of your text.

The exact format of your citations depends on which citation style you are instructed to use. The most common styles are APA , MLA , and Chicago .

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Older people's perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature

Affiliations.

  • 1 The George Institute for Global Health, The University of Sydney, Sydney, New South Wales, Australia.
  • 2 School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.
  • 3 Faculty of Health Science, The University of Sydney, Sydney, New South Wales, Australia.
  • 4 Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, New South Wales, Australia Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, UNESP-Univ Estadual Paulista, Presidente Prudente, São Paulo, Brazil.
  • PMID: 25586911
  • DOI: 10.1136/bjsports-2014-094015

Background: Physical inactivity accounts for 9% of all deaths worldwide and is among the top 10 risk factors for global disease burden. Nearly half of people aged over 60 years are inactive. Efforts to identify which factors influence physical activity behaviour are needed.

Objective: To identify and synthesise the range of barriers and facilitators to physical activity participation.

Methods: Systematic review of qualitative studies on the perspectives of physical activity among people aged 60 years and over. MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched. Independent raters assessed comprehensiveness of reporting of included studies. Thematic synthesis was used to analyse the data.

Results: From 132 studies involving 5987 participants, we identified six major themes: social influences (valuing interaction with peers, social awkwardness, encouragement from others, dependence on professional instruction); physical limitations (pain or discomfort, concerns about falling, comorbidities); competing priorities; access difficulties (environmental barriers, affordability); personal benefits of physical activity (strength, balance and flexibility, self-confidence, independence, improved health and mental well-being); and motivation and beliefs (apathy, irrelevance and inefficacy, maintaining habits).

Conclusions: Some older people still believe that physical activity is unnecessary or even potentially harmful. Others recognise the benefits of physical activity, but report a range of barriers to physical activity participation. Strategies to enhance physical activity participation among older people should include (1) raising awareness of the benefits and minimise the perceived risks of physical activity and (2) improving the environmental and financial access to physical activity opportunities.

Keywords: Aging; Elderly people; Exercise; Physical activity.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Publication types

  • Research Support, Non-U.S. Gov't
  • Systematic Review
  • Aged, 80 and over
  • Anxiety / psychology
  • Attitude to Health*
  • Costs and Cost Analysis
  • Environment Design
  • Exercise / psychology*
  • Interpersonal Relations
  • Leisure Activities / psychology
  • Middle Aged
  • Muscle Strength / physiology
  • Sedentary Behavior
  • Self Concept
  • Walking / psychology
  • Open access
  • Published: 07 July 2023

Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis

  • Helen Brooks   ORCID: orcid.org/0000-0002-2157-0200 1 ,
  • Angela Devereux-Fitzgerald 1 ,
  • Laura Richmond 1 , 2 ,
  • Neil Caton 3 ,
  • Mary Gemma Cherry 4 , 5 ,
  • Penny Bee 1 ,
  • Karina Lovell 1 , 6 ,
  • James Downs 7   na1 ,
  • Bethan Mair Edwards 8   na1 ,
  • Ivaylo Vassilev 9 ,
  • Laura Bush 10 &
  • Anne Rogers 9  

BMC Psychiatry volume  23 , Article number:  486 ( 2023 ) Cite this article

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People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people with mental health difficulties and identify barriers and facilitators to effective delivery. This was undertaken with a view to understanding how social network interventions might work best in the mental health field.

Systematic searches using combinations of synonyms for mental health difficulties and social network interventions were undertaken across 7 databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science) and 2 grey literature databases (EThoS and OpenGrey) from their inception to October 2021. We included studies reporting primary qualitative and quantitative data from all study types relating to the use of social network interventions for people with mental health difficulties. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data were extracted and synthesised narratively.

The review included 54 studies, reporting data from 6,249 participants. Social network interventions were generally beneficial for people with mental health difficulties but heterogeneity in intervention type, implementation and evaluation made it difficult to draw definitive conclusions. Interventions worked best when they (1) were personalised to individual needs, interests and health, (2) were delivered outside formal health services and (3) provided the opportunity to engage in authentic valued activities. Several barriers to access were identified which, without careful consideration could exacerbate existing health inequalities. Further research is required to fully understand condition-specific barriers which may limit access to, and efficacy of, interventions.

Conclusions

Strategies for improving social networks for people with mental health difficulties should focus on supporting engagement with personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should be carefully considered within implementation contexts and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation and in future research.

Peer Review reports

Mental health difficulties are increasingly globally and are one of the primary drivers of disability worldwide [ 1 , 2 ]. In the UK alone, 3.3 million adults in the United Kingdom (UK) were referred to mental health services between 2020 and 2021 [ 3 ]. More disability-adjusted life years are lost to mental health difficulties than to any other health condition in the UK, including cancer and heart disease, with considerable economic, societal and individual cost [ 4 ]. Adults with severe and/or enduring mental health difficulties, such as schizophrenia and bipolar disorder, face additional challenges; they are at greater risk of multiple physical health comorbidities, and have a 15-20-year shorter life expectancy than the general population [ 5 , 6 ]. Optimising the effectiveness and reach of mental health support for these people is essential to ensure high-quality care whilst minimising pressures on already-stretched NHS resources.

Community engagement and social connections can support people living with mental health difficulties in the community, sometimes preventing the need for the involvement of formal health service provision and providing support for recovery post-discharge [ 7 ]. Community engagement is often used as a proxy measure of community integration which is considered a fundamental aspect of recovery from mental health difficulties [ 8 ]. Evidence suggests that both close and distal social network support are associated with community integration [ 9 ]. However, recent research suggests both individual and wider barriers to community engagement [ 10 ]. This highlights the potential value of interventions designed specifically to mitigate both the individual level barriers such as physical and psychological capabilities and social barriers which reduce access to suitable community resources [ 10 ].

Social networks Footnote 1 , social connectivity and engagement in valued activities have multiple benefits for people with severe and/or enduring mental health difficulties and associated benefits for the services and people that support them. They enhance recovery and self-management, promote engagement with community-based support and extend the availability of heterogenous support for the secondary prevention of mental health difficulties, with potential to reduce direct healthcare costs [ 7 , 12 , 13 , 14 , 15 , 16 ]. It is theorised that formal and informal social support, interpersonal contact, and mobilisation of resources enhance individual coping strategies and functional support [ 17 , 18 ], thereby providing protection from stress and improving daily self-management of mental health difficulties [ 19 , 20 , 21 ]. In turn, social activity can increase the size and quality of an individual’s social network [ 22 ], further sustaining and enhancing social connectivity and well-being promotion [ 14 ].

The usefulness of social networks is contingent on the availability of requisite knowledge, understanding and willingness to provide help within networks. These are not always present, available or acceptable to individuals [ 23 ]. People with mental health difficulties tend to have smaller, less diverse networks of poorer quality and configuration, and tend to rely heavily on support from family members or health professionals [ 24 , 25 ]. Social network availability and configuration varies depending on the severity of mental health difficulties and availability of resource [ 26 ].

Interventions designed to improve people’s social networks by connecting them with meaningful and valued activities, people, and places, can extend access to support, thus aiding and sustaining recovery [ 25 ]. These interventions can be effective in optimising social connections for people with mental health difficulties [ 12 ]. It is important to note that social network interventions include those that strive to modify the composition or size of social networks by adding new members and those that seek to bring together existing network members to modify existing links to enhance the functional quality of a network. The former includes linking individuals to new activities or social situations where new network connections can be made [ 27 ] whilst the latter often take the form of network meetings which dependent on an individual’s personal situation bring together relevant network members (family, friends and other supporters) in order to optimise the consistency and connectedness of network support [ 28 ]. However, specific attention needs to be paid to implementation of these types of interventions because previous research in other fields suggest variability in uptake of network interventions, fluctuating capacity of organisations to deliver such interventions and organisational cultures which do not allow for sustainable implementation [ 29 , 30 ].

To fully translate social network interventions into mainstream mental health services and optimise their use, we must first ascertain how effective, acceptable and feasible existing interventions are, and understand their mechanisms of effect [ 12 ]. A recent systematic review examining the effectiveness, acceptability, feasibility and cost-effectiveness of existing interventions concluded that extant literature is in its infancy, but suggested that social network interventions which connect and support people to engage in social activities may be acceptable, economically viable and effective [ 12 ]. The aim of this review is to build on these findings by providing a critical overview of how social network interventions might work best for adults with mental health difficulties. We used systematic review methods to critically answer the following questions: for people with mental health difficulties, (i) what social network interventions work best and for whom; and (ii) what are the optimal conditions for implementing social network interventions?

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidance [ 31 ] informed the methods and reporting of this systematic review and narrative synthesis, and the protocol is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020206490 .

Eligibility

Published journal articles or dissertations reporting primary data on the use of interventions designed specifically to improve and/or measure social network quantity or quality for people with mental health difficulties were included in this review. Review articles were excluded but reference lists of identified reviews were checked for potentially relevant articles. Only studies with a sample mean age ≥ 18 years and a minimum of 75% of participants with primary diagnosis of mental health difficulties (self-report or physician defined) were included.

No restrictions were imposed in relation to language or date of publication. Non-English language articles were screened for eligibility by native speakers affiliated with the research team. Papers where the sample held a primary diagnosis of substance misuse, autism spectrum disorders, dementia, attention deficit hyperactivity disorder (ADHD), or cognitive impairment were excluded. Also excluded were dyadic interventions or individual-level interventions such as purely social skills/cognition programmes. Table  1 displays full inclusion and exclusion criteria.

Search strategy

The following seven databases were searched in August 2020 with searches updated in October 2021: Medline, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Published reviews and literature on social network interventions informed the search strategy which was agreed with the wider authorship team and was subject to a Peer Review of Electronic Search Strategies (PRESS) review by an expert librarian [ 32 ]. Search terms were organised using the first two components of the Population, Intervention, Comparator, Outcome (PICO) framework (Population: People with a diagnosis of mental health difficulties or self-reported emotional distress and Intervention: Social network) and were intentionally broad to maximise search returns (see Additional File 1 for an example search syntax).

To reduce publication bias, grey literature sites such as EThoS and OpenGrey were also searched. We also contacted authors of possibly eligible conference abstracts for full manuscripts where these were not readily available and examined identified review articles and book chapters for relevant literature.

Data extraction

The data management software Covidence ( http://www.covidence.org ) was used to aid the data selection and extraction process. After duplicates were removed, titles and abstracts of identified studies were screened independently by two reviewers, and conflicts were resolved by a third reviewer in line with the inclusion/exclusion criteria (See Table  1 ). Full text reviews of potential papers were undertaken by the team, with two reviewers independently screening each paper and conflicts resolved by consensus.

Standardised data extraction forms were created in Excel and used to extract data from all eligible papers by seven team members (HB, ADF, LR, NC, JD and BME), including both academic and patient and public involvement (PPI) researchers. Extracted data included social network measures (where applicable), factors of context, mechanisms and outcomes, acceptability and standard demographics. Interventions were categorised into broad groups for the purposes of analysis by one member of the research team (HB) and checked for accuracy by another (MGC). For qualitative data, both raw data quotations and author interpretations were extracted where applicable and identified as such. A second reviewer from those outlined above (HB and ADF) cross-checked 30% of extracted data from each member of the review team for accuracy.

Quality appraisal

The Mixed Methods Appraisal Tool (MMAT) [ 33 ] was used to assess the quality of the included papers, applicable to the broad range of research arising in this review [ 34 ]. Each full-text paper was quality assessed by one reviewer in parallel with data extraction with 10% of quality appraisals cross-checked for accuracy. Disagreements were resolved through consensus.

Data synthesis

Meta-analysis of the quantitative data was not possible due to the heterogeneity of included studies. Consequently, a narrative synthesis was undertaken following the stages outlined in the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 35 ]. Data were collated and textual summaries of study characteristics were produced via data extraction spreadsheets (including intervention content, study design, participants, recruitment and delivery). Qualitative data from qualitative and mixed methods studies were explored inductively using aspects of thematic synthesis: a thematic framework was developed consisting of themes which were refined, merged, split or created, as necessary, with analysis of each study [ 36 ]. Constant comparison was used to translate concepts between studies [ 37 , 38 ]. Verification of findings were provided by a second researcher and verified by the wider team. The thematic framework was also applied to the quantitative data from quantitative studies and mixed-methods studies, which aided with the visual grouping of patterns across the whole data set. Quality appraisals were used to assess the robustness of the thematic analysis by removing papers of the lowest quality from each theme to consider their impact on overall presentation. No themes needed to be revised following this process so references were added back into the synthesis [ 35 ]. Data from all included studies were also grouped on aspects of context such as delivery setting and approach, diagnosis and significance of results [ 35 ]. Analytical themes were inferred from the material inherent in the descriptive findings and, together with the patterns apparent across the whole data set formed the narrative synthesis. This synthesis allowed interpretation of the concepts arising in this review beyond the primary findings of individual papers.

As shown in Fig.  1 , searches identified 22,367 potentially relevant studies, resulting in 19,575 unique citations after de-duplication. The full texts of 841 studies were reviewed for relevance, resulting in the inclusion of 54 unique papers. Of these, 17 were randomised controlled trials (RCTs), 12 were quantitative studies of other designs (‘other quantitative studies’), 13 studies were qualitative, and 12 used mixed methods. Studies were conducted in the following countries: UK (n = 25), United States of America (n = 8), Australia (n = 5), China, India, Ireland, Italy, Netherlands, Sweden and Canada (all n = 2), Denmark and Hungary (n = 1). For more information on included studies, see Additional File 2 and Additional File 3 for a completed PRISMA checklist.

figure 1

PRISMA 2020 flow diagram

There was a total of 6,249 participants recruited across the included studies with an average age of 47.42 years and broadly equivalent numbers of males and females. Most (21/54) studies recruited participants with mixed forms of mental health difficulties and emotional distress. The remaining studies included only participants with the following diagnoses or self-reported difficulties Footnote 2 :

Psychosis and/or schizophrenia (n = 12).

Serious and/or long-term mental health difficulties (n = 10).

Depression (n = 4).

Mild to moderate mental health difficulties (n = 2).

DSM AXIS 1 disorders (e.g. anxiety disorders, such as panic disorder, social anxiety disorder, and post-traumatic stress disorder) (n = 2).

Psychotic and affective disorders (n = 1).

Eating disorder (n = 1).

PTSD and depression (n = 1).

For more information on participants in included studies, see Additional File 2 .

The 54 included studies reported on 51 unique interventions which were broadly categorised into five types. The most commonly reported interventions were those that supported community or social activities (25/51). These included 13 interventions that supported access to existing community resources and activities, 3 football interventions, 5 horticulture or nature-based interventions, 3 arts-based intervention and one which involved closed group social activities. The second most included type of intervention (13/51) was intensive or enhanced community treatment. These were mostly assertive community treatment (n = 3), case management approaches (n = 3) and specialised community treatment teams (n = 2). There was also one reported example of each of the following: day centre, community club, social recreation team, occupational therapy and rehabilitation specialised services. There were 7 peer support group interventions within included studies and 3 one-to-one interventions (behavioural activation, cognitive behavioural therapy and peer-led recovery). Three interventions were classified as other and these included 2 action research approaches and an enhanced sheltered accommodation project. Please see Table S1 in the additional files for additional detail on included interventions.

23/54 intervention activities were additional to statutory provision and delivered externally to statutory services, 9 were additional but were delivered within health services, 1 was a combination of both internally and externally delivered activities and 21 were designed to enhance existing provision.

There was minimal description of formal patient and public involvement (PPI) in the included studies, with notable few exceptions (n = 10; [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]). PPI activities included participatory approaches such as Photovoice [ 39 ], co-production activities [ 47 ], peer researchers/facilitators [ 40 , 41 , 42 , 44 ] and inclusion of advisory groups or public advisors [ 43 , 45 , 46 , 48 ].

Quality assessment

Details of the quality assessment of included studies is found in Additional File 2 which includes assessments for each type of study. Quality assessments and main methodological weaknesses for each type of study are summarised in Table  2 .

Review question 1: what type of social network interventions work best and for whom?

Of the 17 RCTs, 12 other quantitative and 12 mixed-methods studies included, 9 RCTs [ 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ], 3 other quantitative studies [ 58 , 59 , 60 ] and 1 mixed-methods study [ 61 ] used included a formal quantitative measure of social network size or quality. Of these, 7 provided evidence of statistically significant improvements to social networks post intervention [ 49 , 51 , 53 , 55 , 56 , 58 , 59 ] and others demonstrated improvements which favoured the intervention group but did not reach statistical significance [ 52 , 54 , 62 ]. Just over half (5/9) of the RCTs examined the effectiveness of interventions using aspects of supported socialisation [ 53 , 54 , 56 , 59 , 62 ], highlighting the potential value of these types of interventions for people with mental health difficulties. The follow up periods for RCTs ranged from 3 months to 24 months and effect sizes were generally small to moderate when compared to usual care – ranging from 0.39 to 0.65 [ 12 ].

A range of statistically significant improvements in other outcomes following intervention were reported across the included studies. These included mental health symptomatology [ 44 , 51 , 55 , 63 , 64 , 65 , 66 , 67 ], general health [ 68 ], social anxiety [ 69 ], social support, social capital and satisfaction with aspects social relationships [ 43 , 49 , 50 , 70 ], distress [ 50 ], general and social functioning/engagement [ 43 , 44 , 54 , 63 , 64 , 65 , 71 , 72 , 73 , 74 ], occupational functioning [ 75 ], structured activity levels [ 76 ], loneliness [ 43 , 54 , 64 , 69 ], relatedness and social inclusion [ 42 , 44 ], sense of belonging [ 69 ], self-esteem [ 43 ], quality of life [ 43 , 72 ], wellbeing [ 42 , 64 , 77 ], treatment adherence [ 72 ], service use [ 44 , 52 ] and satisfaction with care [ 52 , 72 ]. Of these 24 studies, 20 provided information on follow-up periods which were on average 9 months ranging from 2 to 18 months. See Additional File 2 .

It was not possible from included studies to draw definitive conclusions about the groups of people for whom these interventions work best due to the heterogeneity of participants in included studies. However, 8 of the 28 studies that demonstrated significant improvements in outcomes evaluated the effectiveness of interventions for people with schizophrenia and/or psychosis. Significant improvements at follow-up across studies were also associated with:

Being female [ 57 , 58 , 63 ].

Being married [ 43 , 58 ].

Living with a spouse or partner [ 43 ].

Completing A-levels [ 57 ].

Fewer negative symptoms [ 57 ].

Larger network at baseline [ 57 ].

Better baseline functioning [ 63 ].

Greater distress from positive symptoms [ 51 ].

Longer duration of illness [ 51 ].

People who demonstrated improvement in other outcomes [ 56 ].

Undertaking more social activities [ 51 , 65 ].

Having a better clinical prognosis [ 56 ].

What are the optimal conditions for the implementation of social network interventions?

Synthesis of data from qualitative and mixed-methods studies identified a range of barriers and facilitators to implementing social network interventions which are presented in Table  3 (Individual level barriers and facilitators) and Table  4 (Provider/agender level barriers and facilitators). Overarching themes identified during the narrative synthesis relating to optimal conditions for implementation and how interventions are thought to bring about changes in outcomes are presented below with supporting quotes presented in Table  5 .

Bridging the gap – the fundamental role of facilitation

Facilitators played a central role in the successful implementation of social network interventions for all types of mental health difficulties. A facilitator could support the initiation of social activity through personalised discussions about activity options and going along to activities with an individual until they had developed sufficient skills, knowledge and confidence to undertake activities on their own [ 39 , 40 , 42 , 46 , 48 , 62 , 67 , 78 , 79 , 80 , 81 , 82 ]. To do this well, facilitators needed to have sufficient local knowledge, empathy and engagement skills [ 83 , 84 ]. The development of interpersonal trust and provision of suitable options for an individual to consider were considered key to successful facilitation [ 41 , 84 ]. Other requirements included being non-judgemental, approachable, friendly, and having a basic understanding of mental health difficulties [ 41 , 42 , 48 , 62 , 66 , 67 , 74 , 82 , 85 ]. A mutual understanding and respect of roles and boundaries was also crucial to successful facilitation [ 79 ].

Participants described how facilitators needed to maintain a delicate balance between providing support to engage with new social activities and promoting independence to ensure future sustainability [ 39 , 46 , 83 ]. Facilitators could support the uptake of social activities by providing structured programmes with sufficient flexibility to overcome individual barriers to accessing local activities [ 40 ]. Studies also highlighted the need for adequate training and supervision for facilitators in advance of programmes starting and for consideration to be given to the end of interventions when contact with the facilitator ended. Sufficient facilitator relationships coming to an end and for consideration of how benefits would be sustained once the programme ended [ 67 , 79 , 81 ].

Whilst there wasequivalence in the quantitative effectiveness data in relation to peer versus non-peer facilitators [ 12 ], qualitative data identified particular strengths of peer facilitators in relation to having shared experiences and having opportunities to model behaviours. Peer facilitators were seen to provide hope for the future as an example of someone who had recovered from a mental health difficulty, and also to reduce the imbalance of power between facilitator and service user, which improved their relationship [ 41 , 79 ].

Social network interventions could benefit facilitators and host organisations by increasing knowledge about, and access to community infrastructure which provided s ongoing support to service users. Additionally, professionals were able to develop more in-depth understanding of individual service users during such interventions, which could improve understanding about individual triggers of distress and relapse [ 67 , 79 ].

My voice, my choice, my pace – the need for flexibility and valuing individual differences

Social network interventions worked best when service users felt they could choose activities within interventions which mirrored their own interests [ 46 , 48 , 67 ]. This improved uptake and engagement with social activities particularly when users felt that their voices were being heard and their choices considered [ 39 , 40 , 83 , 84 ].

Acknowledgement of individual differences and allowing people to be who they are whilst providing gentle encouragement appeared to increase engagement with valued activities [ 46 , 62 , 79 , 86 ]. Participants, particularly those with serious and/or enduring mental health difficulties, experienced increased motivation for, and enjoyment of, self-selected activities [ 79 , 82 , 86 ]. Participants described such activities as evoking a sense of fun and spontaneity which helped them to be playful and self-expressive [ 77 , 79 , 87 ] as well as to laugh and be adventurous [ 41 ]. Engagement with valued activities was seen as empowering and participants expressed an increased desire for future engagement, feeling as though they were seen as a person rather than an ‘illness’ [ 42 , 62 , 88 ]. Participation was optimised if space was provided to allow people to try different activities and ascertain what was most enjoyable for them. This allowed people to become familiar with, and embedded into, intervention locations [ 48 , 66 , 74 ].

Participants described the impact that their mental health and other external circumstances could have on their ability or readiness to engage with social network interventions. Studies recommended flexibility in implementation to mitigate against this [ 67 , 77 , 78 , 80 , 82 ]. Interventions worked best when participants felt that they could be honest in relation to their own boundaries/capabilities [ 80 ] and when they could be left alone when they needed to be [ 46 ]. This flexibility and acceptance of individual situations meant people felt their own needs, choices and health were being adequately considered, which allowed them to push themselves further than they might have thought possible [ 46 , 80 ]. It also appeared to contribute to a sense of agency and control over their own participation which was deemed important for successful engagement with social network interventions [ 46 , 82 ]. Not having individual needs met through a lack of flexibility could result in withdrawal from intervention activities [ 81 ].

Another key feature of successful social network interventions was allowing participants to progress at their own pace, one that was manageable given their individual circumstances [ 62 , 79 , 82 , 85 , 89 ]. Any pressure to move faster than this or at another’s pace was viewed as a potential barrier to these types of interventions. One study with people with serious mental health difficulties found that those who engaged with social activities independently were more consistent and committed in their engagement, and this was attributed to the ability to go at their own pace [ 78 ].

Similarly, social network interventions should not be seen as a quick fix or panacea for people with mental health difficulties. What is experienced as valuable and beneficial for one person is likely to be different for another and individual preferences may change over time. These types of interventions need to be personalised to individuals to ensure they meet people’s needs and that expectations for engagement are realistic for the individual [ 46 , 67 , 79 ]. It was recognised, within included studies, that not everyone would be able to engage with social network interventions, and this should be factored in from the outset and a flexible approach undertaken [ 79 , 80 ]. Flexibility in delivery also incorporated the ability to include the wider family, friends and other supporters in intervention activities where appropriate and desired [ 46 ].

Social building blocks – rebuilding or acquiring social resources and skills and making connections with others

Social network interventions were considered to work best when they enabled individuals to build on existing or develop new skills whilst also being supported to make connections with others [ 45 , 83 , 86 ]. This applied at an individual level (self-esteem, self-efficacy, resilience, social skills, self-management) and social network level (quantity and quality of new and existing social networks) [ 39 , 41 , 42 , 45 , 46 , 48 , 77 , 78 , 81 , 82 , 83 , 87 , 88 , 89 ]. Individual-level improvements were considered necessary in order to realise benefits from social network interventions [ 84 ]. Such benefits could be conferred formally through didactic sessions or naturally through group interactions [ 46 , 48 ].

Benefits could impact on other wider aspects of everyday life including health and employment [ 40 , 41 , 62 , 84 , 87 ] as well as having ripple effects on friends and family through the sharing of knowledge about social and cultural activities in local areas [ 78 ].

A range of potential mechanisms through which interventions were thought to bring about benefits were identified. Social network interventions provided the opportunities for distraction, allowing attendees to clear their minds which promoted self-reflection and the ability to process negative thoughts through engagement with valued activities [ 42 , 62 , 82 , 86 ]. This led to calmer states which enabled cognitive and social skills to develop or be re-established [ 62 , 86 ].

Social acceptance through connectedness with the local community helped individuals to see themselves in a more positive light, reminding them of their own strengths whilst challenging previously-held beliefs about what they could and could not do [ 48 , 77 , 80 , 82 ]. One study found that that the use of humour around previously shame-inducing situations could support people to disidentify with negative identities and increase their sense of belonging [ 80 ]. This, combined with undertaking new or re-engaging with lost skills and pursuits, could engender a sense of pride and hope for the future [ 41 , 45 , 46 , 77 , 79 , 89 ]. Studies also highlighted how connections made during intervention activities were considered to reduce the intensity of interactions within existing networks thereby improving social interactions more generally [ 45 ].

Participants described a virtuous cycle whereby participating in social network interventions developed skills and capabilities to support social connectedness, which in turn stimulated a sense of purpose, renewed interest in the world and desire for further social engagement and participation [ 39 , 41 , 46 , 62 , 77 , 78 , 81 , 83 , 86 ].

However, such benefits were not seen in all those who accessed social network interventions [ 40 ]. Involvement in interventions which were considered too challenging or encouraged downward social comparison had little impact on individual or social network outcomes [ 40 ].

The importance of a positive and safe space to support community integration

Participants expressed a strong desire to reduce social isolation and valued interventions that promoted community integration [ 42 , 77 , 87 ]. A key factor in the success of social network interventions was the context in which the intervention was delivered. Social network interventions were considered more likely to be successful if delivered in community venues external to formal health services. Those delivered in group settings were experienced as less intimidating as there was less pressure to make one-to-one connections [ 80 ].

Successful participation in real world activities was highly valued and indeed necessary for participants to benefit from social network interventions [ 39 , 83 ]. Participants felt that interventions should be integrated into local communities and provide an access point to resources rather than further segregating people with mental health difficulties [ 80 , 86 ]. However, such interactions could be challenging due to concerns about stigmatisation and previous negative experiences; facilitation or support to mitigate this was identified as imperative across studies [ 39 , 48 , 77 , 78 , 80 ]. This was particularly important at the early stages of involvement before trust and belonging had developed [ 80 ]. Engagement in shared activities that were not overburdensome (e.g. sport, games, shopping) helped to develop community relationships and overcome initial doubts and concerns [ 39 ].

Community engagement in non-judgemental settings had a range of benefits including increased community integration and improved connection to society more generally. These appeared particularly salient for those with serious mental health difficulties [ 78 , 86 , 89 ]. They also fostered the development of transferable skills that were easily integrated into everyday life and provided connections to wider society beyond the health care system [ 66 , 78 , 79 , 82 , 83 , 84 ]. It was considered important to foster connections with people in the community who understood but did not necessarily have direct experience of mental health difficulties so that the focus of interactions was on shared interests or hobbies rather than ‘illnesses’ [ 40 , 42 , 48 , 62 , 84 ]. Self-selected, reciprocal and naturally occurring social connections were highly valued and considered more likely to occur outside of formal mental health settings [ 41 , 42 , 46 , 81 , 85 , 86 ]. Participants also valued opportunities to help others and give back to the community [ 40 ].

Participants’ feeling safe, relaxed and accepted during intervention activities was considered instrumental to successful implementation of social network interventions. This was supported, where necessary, by home visits, particularly prior to community engagement [ 39 , 40 , 41 , 46 , 48 , 79 , 80 ]. These were more easily arranged for interventions in non-statutory settings, and particularly for nature or arts-based activities [ 42 , 48 , 62 , 74 , 77 , 78 ]. Outdoor interventions were generally considered to be naturally restorative, calm, peaceful and safe which facilitated social interactions [ 48 , 74 , 86 ].

The need for available, accessible and sustainable activities

The availability of appropriate community resources for supported socialisation interventions and those interventions led by the third sector was raised as a challenge to the implementation of social network interventions in included studies [ 39 , 83 ]. Funding for third sector activities was often precarious which meant that activities stopped with little notice. This was hard for intervention facilitators to keep abreast of and could be demotivating for participants [ 39 ]. Adequate staff training in relation to awareness of such activities locally and optimal ways to connect people to them was raised as a key facilitator to success.

Lack of accessibility to intervention activities was also highlighted as a barrier to intervention success. Issues included lack of funding for transport and access [ 39 , 46 , 67 , 84 ], gender inaccessibility within activities [ 40 , 41 , 77 ], inflexibility which reduced accessibility for those with work or caring responsibilities [ 67 , 78 , 79 , 89 ], stigma [ 41 ], lack of support for social anxiety and amotivation [ 42 , 66 , 67 , 77 , 79 , 80 , 82 ], social barriers, such as social norms and stereotypes [ 41 ], language barriers and low literacy [ 67 , 77 ], rurality [ 67 ], and safety concerns created by location or timing of activities (e.g. at night) [ 78 ]. These barriers were particularly pertinent for participants who lacked family support to attend groups [ 41 ].

Insufficient consideration of accessibility issues could exacerbate health inequalities and meant that participants felt unable to realise their own potential for social connectedness [ 39 , 84 ]. An example of particularly accessible environments was public allotments, which were considered widely available, inexpensive and inclusive settings, and as a result involvement was easier to maintain post intervention [ 86 ]. The provision of stipends was found to be a useful way to mitigate financial barriers [ 78 ].

Concerns were raised about the sustainability of certain activities and the potential impact of this on intervention participants [ 83 ]. Several studies highlighted harms caused by ending interventions without adequate consideration of how activities would be sustained [ 79 , 87 ]. Most documented sustainability was attributed to participants’ planning for maintenance both within and outside their own networks [ 42 , 78 , 82 ]. This was considered particularly useful when facilitated as part of the intervention itself [ 46 , 79 ], or where ongoing post-intervention engagement with activities or individuals was supported [ 62 , 82 , 87 ].

This systematic review and narrative synthesis aimed to identify and synthesise current evidence pertaining to the use of social network interventions for people with mental health difficulties, with a view to understanding their effectiveness, and the conditions in which these interventions might work best. Collectively, data from the 54 included studies demonstrated the utility of these types of interventions for people with mental health difficulties in terms of improving social networks and other health and social outcomes. Studies included a breadth of data and range of implementation and evaluation methods that lacked an explicit focus on context and outcome relationships. This made it difficult to draw definitive conclusion about what types of interventions work best for whom. However, we were able to identify conditions in which interventions can be optimally implemented.

In line with previous research, data supported the potential utility of interventions which focussed on supporting socialisation for people with mental health difficulties [ 12 , 90 , 91 ]. Most (21/54) studies included people with a range of mental health diagnoses. The remainder included participants with diagnoses of schizophrenia and/or psychosis (n = 12) or serious and/or enduring mental health difficulties (n = 10) with lesser attention given to other diagnoses. As a result, it was not possible to ascertain whom social network interventions worked best for. Encouragingly, participants demonstrated a strong desire for interventions which reduced social isolation and promoted community integration, suggesting high levels of acceptability across mental health conditions. Despite this, it is unlikely that social network interventions are a panacea, with the qualitative studies demonstrating the need to consider individual readiness for intervention participation and to ensure that interventions are sufficiently personalised to individual needs, preferences, heath, and access requirements [ 39 , 83 ].

Factors that affected the implementation of social network interventions mirrored and extended those identified in the physical health field [ 23 , 92 ]. In the current review, greater salience was given to the value of freedom, choice and personalisation within intervention activities, the need for individuals to be heard and progress at their own pace, and safe and non-judgemental spaces for intervention activities. Participants were more likely to raise concerns about stigma relating to mental health or past negative experiences with community organisations, which may relate to differences in the experience of mental health difficulties when compared to physical health difficulties [ 93 ]. Specific requirements relating to mental health and appropriate facilitation in this regard suggests a need for mental health specific training for intervention facilitators. Factors affecting the implementation of social network interventions appeared broadly applicable across mental health conditions and nuances in identified barriers and facilitators for people with specific diagnoses or severity were not discernible. Future research is required to ascertain whether there are condition-specific challenges to accessing social network interventions so that strategies to mitigate these can be developed.

This manuscript adds to existing literature by demonstrating the complexity of implementing social network interventions in the mental health field and identifying a range of access- related barriers which can hinder engagement. Failure to adequately consider the context in which an intervention will be delivered can exacerbate existing health inequalities by reducing access to potentially effective interventions [ 6 ]. This was evidenced across included studies; participants who were female, white, educated, married and had stronger baseline social networks and functioning were the most likely to access and benefit from these types of interventions [ 43 , 57 , 63 ]. This highlights the need for pre-implementation preparation to fully understand local delivery contexts and the needs of all those who might benefit from such interventions [ 94 ]. It is notable that only 2/54 included studies involved transgender participants and no included studies recorded the sexual orientation of study participants or considered neurodiversity. There were also limited numbers of identified facilitators in the included studies which related to issues of diversity and inclusion (Tables  3 and 4 ). This supports wider calls for prioritisation of equality, diversity and inclusion in the design, delivery and evaluation of social network interventions in future research in order to maximise intervention benefits [ 95 ]. This could be facilitated through co-production activities with those from diverse backgrounds and who represent or have insight into these communities.

This review identified a range of facilitators and barriers to implementing social network interventions in the mental health field potentially identifying a fundamental set of requirements as well as more bespoke requirements specific to type of need (Tables  3 and 4 ). Concomitantly, it highlighted the need to consider both downstream and upstream factors relating to implementation (i.e., individual motivation, capabilities, and opportunities and social and organisation level capacity). There was a particular tension between the sustainability of intervention activities and meaningful outcomes for participants. Consideration should therefore be given to how interventions are delivered (e.g. length of engagement time and potential enhanced role of facilitators) and the need to prioritise valued resources/activities that are sustainable [ 23 ].

In terms of implications for health services, findings illustrated the importance of targeting people with lower levels of baseline social functioning and people with smaller social networks or networks of poorer quality at baseline [ 57 , 63 ]. Given the need for a safe and accessible venue for intervention delivery and the importance of the facilitator role, provision for someone to accompany people to activities, especially during early interactions should be included in intervention design [ 80 ]. The findings also lend support to recent calls to reorient mental health service provision and reduce the focus on individual psychopathology and one-to-one interactions with health professionals [ 96 , 97 ]. An alternative focus oncare provision through outreach work and engagement with community resources, to harness the collective value of social networks would potentially be of more value [ 98 ]. This review also highlights the need to prioritise third sector funding to provide suitable resources for people to access [ 29 ].

Strengths and limitations

This review benefits from comprehensive search strategies which incorporated both published and grey literature, the inclusion of papers published in languages other than English, and the rigour of screening and extraction processes. Hand-searching of relevant journals and included papers identified a further two papers to be included. Another strength was the inclusion of seven members of the review team who had lived experience of mental health difficulties and two members who had clinical experience of delivering mental health care. This enhanced the review in several ways: ensuring that search terms were inclusive and comprehensive; clarifying understanding of social network interventions; and enhancing contextualisation of implementation barriers and facilitators. The qualitative studies provided most learning in relation to the use of social network interventions for people with mental health difficulties. There is a need to further this research by testing these factors against outcomes through powered mechanistic trials.

Several limitations should also be considered. First, incorporation of two grey literature databases is unlikely to have fully addressed potential publication bias. Second, whilst attempts were made to integrate study quality into the narrative synthesis, the overall quality of included studies may have impacted on the synthesis presented. Finally, the review only included the views of participants in social network interventions in relation to perceived barriers and facilitators to implementation, and it may be that these participants were not fully aware of all the potential factors that impacted implementation. The review also did not include those who had a primary diagnosis of substance misuse, autism spectrum disorders, dementia, attention deficit hyperactivity disorder (ADHD), or cognitive impairment. These limitations should be carefully weighed against the feasibility of managing and synthesising manuscripts from a review strategy that was more inclusive.

Strategies for improving the social networks of people with mental health difficulties should focus on ensuring access to personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should also be carefully considered within implementation contexts, and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation, as well as in future research in this area.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Personally-meaningful communities, connections and ties which link people to relationships, resources and activities that may help to manage and optimise their mental health [ 11 ].

Terms are used that were included in the original paper.

Abbreviations

Attention deficit hyperactivity disorder

Mixed Methods Appraisal Tool

Population, intervention, comparatory, outcome

  • Patient and public involvement

Peer Review of Electronic Search Strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

randomised control tried

United Kingdom

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Acknowledgements

The authors would like to thank Alice Newton-Braithwaite for her helpful comments on the final version of the manuscript.

Funding for this project is through the Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0418-20011) via the National Institute for Health Research (NIHR). Views expressed within this article are those of the author(s) and not necessarily those of the Department of Health and Social Care or the NIHR.

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Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK

Helen Brooks, Angela Devereux-Fitzgerald, Laura Richmond, Penny Bee & Karina Lovell

Department of Clinical, Education & Health Psychology, University College London, London, UK

Laura Richmond

Patient and Public Involvement Contributor, University of Manchester, Manchester, UK

Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK

Mary Gemma Cherry

Linda McCartney Centre, Liverpool University Hospitals NHS Trust, Prescot St, Liverpool, UK

Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK

Karina Lovell

Patient and Public Involvement Contributor, Cambridge, UK

James Downs

School of Health Sciences, University of Manchester, Manchester, UK

Bethan Mair Edwards

NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK

Ivaylo Vassilev & Anne Rogers

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HB, MGC, PB, KL, II and AR obtaining funding for the study, formulated the review questions and designed the review. HB, PB, ADF KL, LR, NC, JD, BME, LB undertook title and abstract and full-text screening, data extraction and quality appraisal. HB, ADF and MGC undertook the narrative analysis. HB led the writing of the manuscript with input from AR and MGC. All authors provided input into draft manuscripts and approved the final version for submission.

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Brooks, H., Devereux-Fitzgerald, A., Richmond, L. et al. Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis. BMC Psychiatry 23 , 486 (2023). https://doi.org/10.1186/s12888-023-04881-y

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A qualitative systematic review and thematic synthesis exploring the impacts of clinical academic activity by healthcare professionals outside medicine

Lisa newington.

1 Imperial College Healthcare NHS Trust, Education Centre, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK

2 Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK

Adine Adonis

Layla bolton saghdaoui, margaret coffey, jennifer crow, olga fadeeva costa, catherine hughes, matthew savage, lillie shahabi.

3 Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK

Caroline M. Alexander

Associated data.

The datasets generated and analysed during the current review are available in the Open Science Framework (OSF) repository ( https://osf.io/gj7se ). All other relevant data are included as supplementary files.

There are increasing opportunities for healthcare professionals outside medicine to be involved in and lead clinical research. However, there are few roles within these professions that include time for research. In order to develop such roles, and evaluate effective use of this time, the range of impacts of this clinical academic activity need to be valued and understood by healthcare leaders and managers. To date, these impacts have not been comprehensively explored, but are suggested to extend beyond traditional quantitative impact metrics, such as publications, citations and funding awards.

Ten databases, four grey literature repositories and a naïve web search engine were systematically searched for articles reporting impacts of clinical academic activity by healthcare professionals outside medicine. Specifically, this did not include the direct impacts of the research findings, rather the impacts of the research activity. All stages of the review were performed by a minimum of two reviewers and reported impacts were categorised qualitatively according to a modified VICTOR (making Visible the ImpaCT Of Research) framework.

Of the initial 2704 identified articles, 20 were eligible for inclusion. Identified impacts were mapped to seven themes: impacts for patients; impacts for the service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic.

Conclusions

Several overlapping sub-themes were identified across the main themes. These included the challenges and benefits of balancing clinical and academic roles, the creation and implementation of new evidence, and the development of collaborations and networks. These may be key areas for organisations to explore when looking to support and increase academic activity among healthcare professionals outside medicine. The modified VICTOR tool is a useful starting point for individuals and organisations to record the impact of their research activity. Further work is needed to explore standardised methods of capturing research impact that address the full range of impacts identified in this systematic review and are specific to the context of clinical academics outside medicine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06354-y.

There is compelling evidence that research active healthcare organisations have improved care performance compared to their non-research active counterparts [ 1 ]. Examples include patients feeling better informed about their condition and medication, having greater confidence in their healthcare staff [ 2 ], greater staff adherence to treatment guidelines [ 3 ] and lower mortality rates [ 3 , 4 ]. In the UK, this has resulted in correlation between research activity and the national healthcare inspection rating [ 4 ].

Traditionally, healthcare research has been associated with medical professionals (doctors), with approximately 5% of UK medical consultants working in clinical academic roles [ 5 , 6 ]. Clinical academics engage in clinical practice and also conduct and lead programmes of applied health and/or social care research, often directly aimed at improving patient care and care pathways [ 7 ].

Healthcare professionals outside medicine are increasingly developing the expertise to lead clinically relevant research, with the aim of 1% of this workforce being employed in clinical academic roles by 2030 [ 8 ]. Healthcare professions outside medicine include: nursing, midwifery, the allied health professions (art therapists, dietitians, drama therapists, music therapists, occupational therapists, orthoptists, operating department practitioners, osteopaths, podiatrists, prosthetists/orthotists, paramedics, physiotherapists, radiographers, and speech and language therapists), clinical psychologists, healthcare scientists and pharmacists. Within the UK, the drive to increase the clinical academic workforce is supported by a targeted Health Education England/National Institute for Health Research funding stream specifically for these professions [ 9 ], and through fellowship funding from a number of national health charities. Similar schemes exist elsewhere [ 10 – 13 ].

As clinical academic activity increases, there is a need to evaluate its impact at both individual and organisational levels, and across the short to longer term. Several frameworks have been designed to guide impact assessments for healthcare research and these have recently been systematically reviewed to create a summary framework [ 14 ]. However, the focus is on evaluating individual programmes of research, rather than the impact of collective research activity within an organisation. This is also the case with other research impact assessment tools [ 15 ].

Outside the medical professions, the impacts of dedicated allied health professional (AHP) research roles have been systematically reviewed to explore their outcomes in terms of building research capacity and culture. Wenke and Mickan described varied roles, but most often these centred on the development of researchers’ own research projects and their dissemination [ 10 ]. Additional responsibilities included supervising others and developing strategies to promote research activity. These roles were found to have positive impacts on individual research skills, research outputs and research culture, however other areas of impact were not assessed, such as patient outcomes, changes to clinical training or practice guidelines, or increased investment. Importantly, only one study described practising clinicians with dual clinical and research roles, and other non-medical professionals, such as nurses and midwives, were excluded from the review.

Existing reviews have only included published research studies, thus overlooking impact reports that have been compiled by individual healthcare organisations or collaborations [ 16 , 17 ]. Such documents contain valuable insights and reflections on clinical academic programmes, often in the form of case studies, and are useful for other healthcare providers supporting or developing their own clinical academic strategies.

The current systematic review was developed in order to understand the full range of impacts of non-medical clinical academic roles. A cross-disciplinary approach was taken to include clinical academic activity among nurses, midwives, AHPs and other non-medical healthcare professionals.

The review protocol was pre-registered with the Open Science Foundation [ 18 ] and followed the PRISMA protocol reporting guidelines [ 19 ]. The primary review question was: what are the reported impacts of clinical academic activity among practising healthcare professionals outside medicine?

Selection criteria

Impact was not pre-defined for the purposes of this review, and eligible articles were those reporting any form of impact that was attributed to clinical academic activity carried out by non-medical healthcare professionals. This did not include the reported outcomes of clinical research studies, rather the impact of these individuals being involved in research activity. Clinical academic activity was defined as the review intervention, and was the involvement of practising clinicians in research. This included specific research roles, such as research fellowships or combined clinical academic positions, in addition to other protected research time or opportunities to be involved in research. The review population was defined as healthcare professionals outside medicine. Full eligibility criteria, including the list of eligible healthcare professions, are provided in Table  1 .

Review inclusion and exclusion criteria

Search strategy

Ten healthcare databases and four grey literature repositories were individually searched by the lead author between December 2019 and January 2020. Search locations are shown in Fig.  1 . The example search strategy for Medline is provided in Additional File  1 , which included i) terms for the different non-medical clinical disciplines, and ii) terms for clinical academic activity, combined with iii) terms for impact. The search strategy was developed and piloted by LN, CMA and MW, with additional assistance from a healthcare librarian (LG). There were no restrictions for country of publication, but due to time and resource limitations, articles were restricted to those available in the English language. An additional Google search for ‘impact of clinical academic nursing, midwifery and allied health’ was conducted in a naïve browser and the first 50 hits recorded.

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PRISMA flowchart

Eligibility assessment

Identified references were exported into Covidence ( Covidence.org ) and duplicates removed. Title and abstract screening were performed in two stages. Firstly, the lead author and two members of the review team (JC and OFC) independently screened out those articles which clearly met the exclusion criteria. Any disagreements were resolved by discussion. Secondly, the lead author and two members of the review team (LS and LB) independently screened the remaining articles against both the inclusion and exclusion criteria. Again, any disagreements were resolved by discussion. Full text screening was independently performed by LN and one of five members of the review team (AA, MC, LS, OFC and LBS); disagreements were resolved by MW and CMA.

Quality assessment

The mixed methods appraisal tool (MMAT) was used to evaluate the quality of the included studies [ 20 ]. The assessment form was piloted prior to use and modified to include key components of the qualitative checklist proposed by Walsh et al. [ 21 ]. The quality assessment form template is provided in Additional File  2 . Quality assessment was conducted independently by LN and one of eight members of the review team (AA, LBS, CL, LS, MC, JJ, LB and JC). Disagreements were resolved by discussion. All relevant studies were included regardless of their MMAT score.

Data extraction

Data extraction was completed independently by LN and one of the eight members of the review team, listed above, and was conducted in parallel to the quality assessment. Data items were extracted using a pre-piloted electronic form under the headings listed in Table  2 . The two independent data extraction forms for each article were compared and harmonised by MS and CH, who referred back to the original articles where disagreement occurred. The impacts of the clinic academic activity were broadly characterised using the section headings from the VICTOR (making Visible the ImpaCT Of Research) framework [ 22 ]. The VICTOR framework was developed for individual research teams to record the impact of their study and is endorsed by the UK National Institute for Health Research [ 23 ]. It comprises a series of open ended questions categorised under seven sections: health benefits, safety and quality improvements for research participants and carers during the study; service and workforce impacts; research profile of the organisation and research capacity; economic impacts; organisation’s influence and reputation; knowledge generation and exchange. Following piloting for this systematic review, the headings were modified to include a section for impacts to the individual, and research profile and research capacity and the organisation’s influence and reputation were merged.

Data extraction items

Categories of impact were based on the VICTOR tool [ 22 ]

Data synthesis

Extracted data for each of the pre-identified categories of impact (Table ​ (Table2) 2 ) were independently analysed by two members of the review team (LN and one of CH, AA, MS, JC, LSB, MC and LB) to create a thematic synthesis. This involved independently coding the data to identify recurring, unique and contradictory content and using the codes to independently summarise the content of the theme in a series of sub-themes [ 24 ]. The findings were discussed and agreed together by the two independent reviewers for each category of impact. The final analysis for all categories of impact was discussed and refined by CMA, MW and LN.

Study characteristics

A total of 2704 articles were identified after removal of duplicates, of which 20 met the review eligibility criteria (Fig. ​ (Fig.1) 1 ) [ 13 , 16 , 17 , 25 – 41 ]. The most common reasons for exclusion were that the study population did not involve clinical academics, that is clinicians who were also involved in research activity; or the study assessed the amount of research interest/activity, rather than the impacts of this activity (Additional File  3 ). Of the included articles, nine reported qualitative data [ 17 , 25 , 29 – 31 , 33 , 36 , 38 , 41 ], three reported quantitative data [ 28 , 35 , 37 ] and eight reported a mixture of both [ 13 , 16 , 26 , 27 , 32 , 34 , 39 , 40 ]. Sixteen were peer reviewed journal articles and four were organisational reports. Publication dates ranged from 2003 to 2019 and the geographical distribution was: Europe (including the UK) 10; North America 5; Australasia 4; Middle East 1 (Table  3 ).

Details of the included studies

Participants

A variety of healthcare professions outside medicine were included. Eight articles involved mixed professional groups, most commonly nursing, midwifery and one or more of the allied health professions. Nine articles were specific to nursing, two to allied health professions and one to pharmacy. The nature of the clinical academic activity was not consistent. All articles discussed clinicians conducting research in clinical practice, however some also incorporated formal educational components at masters or doctoral level and others involved short programmes of research training and/or mentorship (Table ​ (Table3 3 ).

Methodological assessment

Outcomes of the MMAT assessment [ 20 ] are shown in Fig.  2 and are available in full via the Open Science Framework [ 18 ]. No articles met all quality assessment criteria, although three qualitative studies were rated as having a single area of concern [ 31 , 38 , 41 ]. Common issues with study quality and risk of bias for qualitative and mixed methods studies were a lack of clarity in how the findings were derived from the data and a lack of coherence between data, analysis and interpretation. Common issues with quantitative and mixed methods studies were a lack of information about the measurement tools/methods and a lack of consideration of response bias. Common issues across all study types were inadequate sampling methods and a lack of reporting of ethics/other approvals.

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Object name is 12913_2021_6354_Fig2_HTML.jpg

Quality assessment scores for included articles using the Mixed Methods Assessment Tool

Reported impacts of clinical academic activity

Reported impacts were categorised into seven main themes based on the modified section headings for the VICTOR framework (Table ​ (Table2). 2 ). The distribution of the reported impact themes across the articles included in this review are presented in Table  4 . Extracted and coded data for each theme was used to generate the sub-themes, which are described below and presented with illustrative excerpts from the included articles. The full framework of themes, sub-themes and additional quotes is provided in Additional File  4 . Most of the extracted impacts were positive in nature, reflecting the aims of the included papers (Table ​ (Table3), 3 ), however challenges for the individual clinical academics and their healthcare teams were also described.

Themes of impact reported in the included papers

Abbreviations : AUKUH Association of UK University Hospitals, DHSC UK Department of Health and Social Care, NMAHP-RU Nursing, Midwifery and Allied Health Professions Research Unit (Scotland)

Impacts for patients

The reported impacts for patients focused on beneficial changes to service provision that arose as a result of local clinical academic activity, and wider access to evidence-based healthcare as a result of the promotion of evidence-based practice across research-active teams and departments:

“This project demonstrated significant improvements in the neutropenic patient pathway, enhancing experience and outcomes for patients and a reduction in unnecessary admissions.” [ 27 ]
“Behaviours learned during the programmes provided benefits for improving the quality of care delivered within services … Respondents reported they discussed evidence with colleagues, searched the literature for evidence updates, questioned and used evidence to inform their practice following completion of the programme.” [ 16 ]
“My research has demonstrated the benefits of these kinds of approaches both to patients’ quality of life, and patients, carers, friends and families’ experience of palliative care services.” [ 36 ]
"[It is a] synergistic relationship, as research knowledge improves the care I provide, but the close patient contact allows me to identify areas that require further research." [ 29 ]
“Participants expressed how their involvement in the innovation increased their observation of their own clinical practice, brought the research back to practice, enhanced practice development and the clinical role overall while contributing to improved patient care.” [ 34 ]

Impacts on service provision and workforce

I. clinical service provision.

In addition to the identified impacts to patients (theme 1), changes in practice as a result of the clinical academic activity were also regarded as beneficial to the clinical service through improved care delivery and pathways . This included the introduction of new equipment, better integration of clinical teams, efficiencies, cost-savings and securing new clinical funding:

“Research positions supported projects that led to changes in service delivery models, with [one] manager commenting, ‘ … it’s amazed me that through the research grant that she got for that project, she has now generated for the Health Service recurrent money for the full time [implementation of the] … rural allied health model’.” [ 41 ]
“One participant’s intervention removes the need for GPs’ referral for physiotherapy, potentially saving ‘multimillion pounds’ across the NHS [National Health Service], and has subsequently been recognised in the NHS long-term plan.” [ 39 ]
“As a clinical academic midwife my aim is to bring more evidence into practice and assist other midwives in doing the same.” [ 29 ]
“Most of this reported activity focused on reviewing published evidence in relation to clinical practice but participants also reported involvement in facilitating/enhancing research skills in other clinicians.” [ 37 ]
“Release from the workplace, despite the employer grant, was in some cases problematic. Finding appropriately skilled staff to cover services particularly in highly specialised areas and, or recruiting to short term, often part time, vacancies were challenges. In contrast some managers saw this as an opportunity to give other staff the chance to act up, for succession planning, or worked creatively to make release possible.” [ 16 ]
“Protected time for the APNs [Advanced Practice Nurses] (i.e., at least one day a week) to engage in research activities was crucial to the program and, at times, difficult to achieve.” [ 32 ]
“On my return to work I was unable to continue to facilitate evidence-based practice as much as I would have liked due to time constraints. Within my working role there was no dedicated time to devote to evidence-based activity.” [ 37 ]

ii. Clinical academic workforce

Clinical academic infrastructure was described in terms of fellowship and career pathways. Steps were taken to ensure visibility of these opportunities to facilitate the development of research capacity. However, it was also noted that the absence of established clinical academic career structures resulted in a perceived lack of value of these skills and caused difficulties for clinical managers when trying to plan their service:

“Clinical and academic mentorship exposed the Chief Nurse Fellows to clinical academic career role models, which in turn raised the profile of this alternative career route.” [ 27 ]
“There’s a huge untapped workforce … with the right support and time we could be doing things more effectively and more efficiently, but that isn’t necessarily valued in organisations. We’ve got to see this many patients, (we’re) not using our skills of criticality, reflectivity; we’re not going to innovate and change practice.” [ 39 ]
"Imagine being able to continue my research and tie the results directly to clinical practice. I would like there to be an opportunity of this kind. However, there is a lack of services for nurses with higher academic qualifications who want to develop clinical practice.” [ 25 ]
“A culture that prioritises practice in the current context means that the doing of nursing work only is seen as core business. This, together with the need for managers and clinicians to make quick decisions in order to achieve short term goals, operates as a disincentive to rigorous research activity at ward level. Within this context, the expectations for those with a research component in their role, is at times unclear.” [ 30 ]
“Also, I think the option of having 0.5FTE [full-time equivalent) backfill was good, as it allowed greater flexibility for staff who have roles that are difficult to backfill full-time, also I thought it was useful to have more thinking time, and time to access support, get feedback etc. Full-time research can be very intense especially when you are not conditioned for it.” [ 13 ]
“I have a very supportive divisional head nurse and have been appointed into a trailblazer post; we haven’t got anything similar within the organisation. So there’s real potential to forge out innovative ways in which clinical academics can fulfil that remit of working in clinical practice and undertaking research, but also pave the way for others that want to come up.” [ 39 ]
“Biggest challenge: Getting managers on board, in particular releasing staff to take advantage of internship opportunities offered by HEE [Health Education England] Wessex, and recognising that research is essential to the core business of the Trust.” [ 17 ]
“It’s not the scheme, but greater staff access to relevant software (such as SPSS) would be useful.” [ 13 ]

Impacts to the research profile, culture and capacity

Research profile, culture and capacity were interlinked and several of the reported impacts spanned all aspects of this theme. However, winning research funding and other awards , publication of journal articles and clinical guidelines, and conference presentations were primarily considered as contributing to the organisation’s research profile:

“Since completing the programme - One Chief Nurse Fellow was the first UK nurse to be recognised by the Daisy Foundation and has received a Daisy Award for Extraordinary Nurses. Others have also received nominations and were shortlisted for national nursing awards. In addition, two of the projects are featured on The Academy of Fabulous NHS Stuff.” [ 27 ]
“As a result of the research activities, seven manuscripts were submitted and accepted for peer-reviewed publications.” [ 28 ]
“Improved attitudes towards research were noted by a clinician, ‘ … research isn’t this incredibly difficult thing that only very special people can do. Actually, it’s attainable by many and it was quite inspiring actually … I don’t know that that would have been their view prior to this position developing that profile.” [ 41 ]
“It’s about allowing people to engage with research and become enthused by it. It’s also about having the right leaders who are able to take the step back and say: ‘This is a good use of your time’. You can find better ways of giving care if you have a culture that values research.” [ 36 ]
“There is the perception that doing research is an ‘imposition, on clinical nursing staff, that it is not ‘real nursing work’; rather, it is a ‘luxury’. When invited by nurse researchers to participate in research activities, clinical nurses often say ‘I don’t have time for this’ and the general attitude is ‘we’ll think about it’, ‘if I have time’, or ‘tell us about the result’. Indeed, in some instances there is a perception amongst discussion group members that projects are undermined through gate-keeping behaviour and lack of support by the ‘sceptics’.” [ 30 ]

Clinical academics were able to promote evidence-based practice among their peers, for example by sharing resources and setting up journal clubs or other special interest groups. This facilitated a shift towards research becoming embedded in practice :

“I now exhort other colleagues to question day-to-day practice and we have introduced a journal club.” [ 29 ]
“The group process allowed scholars to participate in joint problem solving and enhanced their ability to apply current research to questions arising from clinical practice. The scholars were expected to serve as clinical resources to others in the healthcare system.” [ 33 ]
“We have increasing numbers of staff involved in research activity, studying for MRes and PhDs, and their research is closely related to their professional practice and aims to improve care. We have five research themes with [the healthcare organisation’s] nurses/midwives leading these and staff linking into these themes for their masters or doctoral study and we are starting to build groups of staff at different points on a clinical academic career pathway. Many staff present their research nationally and internationally and publish widely and some are part of national expert groups, linked to their research.” [ 17 ]
“People can choose where they want to work. They’ll be looking for organisations that are aspirational. So actually offering innovative career pathways that can intellectually challenge, but also have that direct patient care element, is going to be attractive to a lot of people.” [ 39 ]

Economic impacts

The funding required to support the clinical academic activity was generally sourced from outside the clinical organisation. Reported benefits of receiving research funding included dedicated time for research training and activity and bringing in additional money to the clinical service:

“Increased grant income – the value of successful non-medic research grants in 2014–2015 (the last financial year the outcome of all grant applications is known) was £923,495. Appointments of clinical academic posts were achieved by securing external grant funding, use of research capability funding to pump prime, and commitment to 50:50 funding from academic partners.” [ 17 ]

However, there were also issues where funding for research was not available, or was repurposed from clinical budgets :

“Management are more than happy to support research initiatives in principle, however, [they are] usually unable to provide [this] support as they have extremely tight budgets and other clinical management demands.” [ 30 ]
“The initiative was resourced by the reallocation of nursing/ODP vacancy funding within each clinical division.” [ 27 ]
“The amount of money saved by using the scanner and avoiding catheterisation was estimated to be around £1.2m per year. This did not include the cost of bacteraemia attributed to urinary tract infections. Savings associated with using a scanner, such as fewer treatment delays and overnight stays in hospital, were recognised as additional savings. The set up and running costs of a scanner were estimated to be met within six months to two years, after which significant ongoing cost efficiencies would be realised over its eight to ten year lifespan.” [ 17 ]
“The work had led to a decrease in patients’ clinical stay following surgery from six to four days, resulting in savings that allowed additional needs and demands to be met. We were very open and transparent with the data, and clinical practice changed. We calculated that there was a total of 28,000 bed-days saved per year as a result of this work.” [ 36 ]
“Well one of the big decisions I had to make about whether or not to accept the role (associated with a research training award) was the hours and the money because it’s moving to full time, which is fine... Therefore, by moving to full time but losing my enhancements I’ll be on around the same as I get on a good month when I have done lots of nights and weekends. But by working as I’m doing there won’t be any opportunity to do extra shifts, any overtime. So a lot of it was money.” [ 16 ]
“The presenters had to either self-fund their travel and conference registration, or apply for travel scholarships through internal or external opportunities.” [ 28 ]

Impacts on staff recruitment and retention

The lack of clinical academic career opportunities was noted as a challenge that individuals wishing to maintain a dual role needed to negotiate. This related to the sub-theme ‘balancing clinical and academic components of the role’ discussed in theme 2 (impacts for the clinical academic workforce), and was identified as a potential driver for individuals to return to full-time clinical work, or move into purely academic roles after completion of their clinical academic activity:

“The organisational system is perceived as unfamiliar with, and unsupportive of, non-physician clinician scientist positions, and, in consequence, active job crafting is necessary to obtain positions in which such individuals can exert both roles. Dual positions are often a personal combination of jobs instead of being offered from within one institution.” [ 31 ]
"Unfortunately, I wasn’t offered the chance to implement the results of my study in my organisation, due to the lack of development positions. So, as a result, I have applied for, and been given, a position as a teacher at the university college." [ 25 ]

A particular challenge for healthcare managers was the need to provide backfill or make other arrangements to enable the release of clinical staff for research activities. The need to recruit to backfill posts was discussed in theme 2 (impact to clinical service provision), specifically the sub-themes: release of clinical staff for research and return to clinical practice from a research role.

Several articles reported strategies to support clinical academics and increase awareness and access to clinical research opportunities. Where successful, it was suggested that these aided the retention and career progress of staff who were involved in clinical academic activity. Such strategies also contributed to job satisfaction and recruitment more generally and were closely linked with the impacts to the organisation’s research profile, research culture and capacity (theme 3):

“Since completing their year as a fellow, the entire pilot cohort still works within the organisation, with five of them having moved into junior leadership positions. Although we cannot assume that this would not have been their career trajectory had they not undertaken this fellowship, the skills developed and demonstrated through the initiative are essential for the job specifications of more senior posts.” [ 27 ]
“Interviewees reported that their department was seen as a more ‘attractive employer’ and was ‘attracting higher calibre staff’. Clinicians described staying in the health service to undertake research, ‘because these opportunities do exist, these really fabulous clinicians that we have just might stay’.” [ 41 ]

Impacts to knowledge exchange

Contributions to knowledge transfer were reported in all articles, and there was a large overlap with theme 3 (research profile, culture and capacity). Knowledge exchange activities included formal dissemination , such as conference presentations and posters, publications, being an invited speaker and winning prizes and awards that further highlighted the value of the work. It was recognised that there would be a delay between completion of the research activity and delivery of these research outputs:

“Interviewees provided numerous and diverse examples of presentations at grand rounds, poster presentations and oral presentations at both local and international conferences, including one interviewee who noted her team had presented their research project findings at three international and three local conferences. Another interviewee stated, ‘We have presented at a couple of conferences and we presented at a … convention or meeting and we actually got an award for our poster’.” [ 26 ]
“Individuals need time in the role as well to get some momentum, get the relationships in the department, get the research programs going and there's usually a delay until you start to see the pure research outputs.” [ 41 ]
“What I notice clearly is that I’m very well informed about scientific evidence and sharing this information with my colleagues. [I ask them] did you read this? And [I] pass on knowledge in that way.” [ 31 ]
“After being able to demonstrate the success of the approach locally, David was asked to help with a national roll out, organising with colleagues an audit of all 22 orthopaedic units across Scotland over 12 weeks.” [ 36 ]

Impacts to the clinical academic

Many of the themes and sub-themes of impact discussed above had also had a direct influence on the individuals involved in clinical academic activities. Developing networks and collaborations, discussed in theme 6 (knowledge exchange), and building local and external collaborations, discussed in theme 3 (research profile, culture and capacity), were similarly interpreted as individual clinical academics developing their networks and influence :

“I think the impact of the role on me has been quite incredible. … how much you learn about the different disciplines and then develop those networks … it’s been a huge learning curve.” [ 41 ]

Furthermore, clinical academics reported a change in their attitude to clinical practice, with greater reflection and questioning of established practice, which was also reflected in theme 1 (impacts for patients), particularly in terms of improved clinical practice and access to evidence-based healthcare:

“They felt that they had developed from “doers” to “thinkers”, in that they felt more aware of and reflective in relation to their colleagues … The nurses perceived progress in acquiring new knowledge, in spite of language barriers, and recognised the value of scientific knowledge for clinical practice. They experienced healthcare in a ‘new light’ through their knowledge development.” [ 25 ]

The development of research and leadership skills was identified as a beneficial effect of being involved in clinical academic activity. In some articles, it was suggested that this unlocked new career opportunities for the individuals involved, however in many instances there were no existing roles within the organisation for the research-active clinicians to aspire to, as discussed in theme 5 (recruitment and retention):

“The majority agreed or strongly agreed that they felt more confident developing a research question (94%/49), searching (87%/45) and appraising (90%/47) literature, challenging practice using evidence (85%/44), assisting others to use critical appraisal skills (79%/41) and engage in the clinical academic training pathway (87%/45).” [ 16 ]
“Despite their achievements during the PhD, many participants expressed anxieties about their future careers, having been made to move aside clinically in order to progress their academic ambitions, rather than being able to develop their academic and clinical skills in tandem. For example a dietician said: Recently I’ve had to step out of my area of expertise … I’m just doing general, allergies, weight management, which is not my area, but I need to pay the mortgage.” [ 39 ]
“It is actually exciting to learn that the world does not work the way you thought it did”. 70 [ 38 ]. “I want to do this for me, but I also want to do it for my daughters to show that women can be in science and can lead in these fields and yes we might have to juggle family things and children, but you can do it.” [ 39 ]
“What accomplishments are you most proud of? Knowing that I am now a subject expert – I get phone calls asking, `How would you handle this?’.” [ 40 ]
“When you are really interested in something or passionate about it, you use whatever time you have, even if it means writing your proposal after your regular hours at home.” [ 38 ]
“The time taken to do research is often underestimated and considerable time and effort is often put into preparing a grant application which ultimately may not be successful. Focusing on meeting deadlines and the progress of a project means that less attention can be given to other aspects of work roles. Ultimately, doing research without adequate support or funding becomes a constant juggle.” [ 30 ]
“The demanding expectations surrounding a clinical academic role were described by interviewees (participants and managers) and the characteristics and behaviours that were perceived as required for success. These included confidence, doggedness and resilience, reflective skills, criticality, and growing political know-how to better navigate organisations.” [ 16 ]
“Mentorship (from nursing, midwifery and medical colleagues), determination, tenacity, resilience and serendipity have been key factors in achieving success.” [ 17 ]

This systematic review identified 20 articles that discussed elements of the impact of clinical academic activity among healthcare professionals outside medicine. With the addition of a theme for the impacts to the clinical academic, all reported types of impact could be mapped to the VICTOR framework creating the following themes: impacts for patients; impacts for service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic. In order to develop and evaluate clinical academic roles for healthcare professionals outside medicine, the range of impacts of this clinical academic activity need to be understood and valued by healthcare leaders and managers. This review has systematically identified and mapped the nature of the impacts reported in the literature, and forms a valuable resource for healthcare services looking to develop and evaluate these roles at local and national levels.

Within the main headings of impact described above, we identified several similar sub-themes that cut across the different categories of impact. Sub-themes described the content of each of the categories of impact and included perceived enablers of creating the desired impact and associated detrimental features. Notably, the sub-themes that reflected the challenge of maintaining or balancing the clinical and academic components of the role contributed to four main themes. Within clinical service provision (theme 2i), this related to the need for clinical services to manage both the release of clinical staff for research, and their return to clinical practice after research secondments. For the clinical academic workforce (theme 2ii), this led to individuals and team members being required to adapt to the different pace and duties associated with research and clinical work. The process of showcasing a visible clinical academic pathway (that incorporated both research and clinical activities) was identified as key feature of building research profile, culture and capacity (theme 3), and being able to offer suitable clinical academic posts was important for staff recruitment and retention (theme 5). Finally, being able to work and develop in both clinical and academic roles offered self-fulfilment for the individual clinical academic (theme 7). Similarly, the creation and implementation of new evidence was also a component of several themes, as was the development of collaborations and networks.

The multifaceted nature of research impact identified in this review illustrates that different aspects of clinical academic activity may be perceived as having both positive and negative impacts. Furthermore, these conflicting impacts may apply to the same individual or across different stakeholders. Different aspects of research impact may be more or less important in different contexts and the relative value of these different impacts will need to be considered to enable meaningful evaluation [ 42 – 44 ].

This systematic review was deliberately broad in scope to allow the identification of the whole range of impacts associated with clinical academic activity. The lack of an agreed and consistently used definition of clinical academic proves problematic and has been discussed elsewhere [ 45 , 46 ]. Clinical academic activity (defined here as the involvement of practising clinicians in research) in the included articles incorporated a range of research fellowships and research training programmes, and/or in-practice mentorship and research support. The aims of the articles varied. Many described and evaluated specific interventions that were aimed at increasing research activity among healthcare professional group(s), while others provided summary case studies of individuals who had been successful in a clinical academic role.

The inclusion of grey literature increased the breadth of the review, particularly given the finding that the impacts of non-medical healthcare research are underrepresented in the academic literature [ 47 ]. However, it is acknowledged that the methodological quality of the included institutional reports was lower than the standards for peer-reviewed publication. Data obtained from the institutional reports were largely positive reflections of strategies that had been put into place to encourage and support research activity among healthcare professionals outside medicine. Expressions of the less positive aspects of these strategies may therefore have been excluded or not collected by the authors. Importantly, the distribution of the seven identified themes of impacts did not differ between organisational reports and peer review journals, illustrating that the types of impact that were considered important by study participants and organisations were similar.

Existing reviews on the impact of clinical academic activity have focused on individual clinical groups within the non-medical workforce [ 10 ] or at the level of the healthcare institution [ 1 ]. Boaz et al. found that healthcare organisations which deliberately integrated research into their practice and fostered research engagement reported improved healthcare performance including clinical outcomes and processes of care, and our review also identified similar improvements. However, Boaz et al.’s review included papers focused primarily on research led by clinical academic doctors, and the impacts of the research processes on the clinical teams and the individuals involved was not reported [ 1 ]. Wenke and Mickan identified four themes of impact associated with allied health research positions based in clinical settings: increased individual research skills and participation; increased research activity; improved research culture and attitudes; and increased team and organisational level skills [ 10 ]. These features were also described within the current review under the themes: impact for patients; impacts to the clinical academic; impacts to research profile, culture and capacity; and impacts for service provision and workforce. In addition, we also identified impacts on staff recruitment and retention, knowledge exchange and economic impacts.

The distribution of impacts reported in the current review did not differ in relation to the clinical groups involved in each of the included articles, indicating that similar methods of capturing the impact of clinical academic research activity could be applied across the professions outside medicine, rather than being discipline-specific. A similar systematic review search strategy could also be applied to assess the reported impact of clinical academic activity by alternative and complementary therapy practitioners.

The impacts reported in the included articles were largely qualitative reports. Some studies incorporated quantitative data capture tools, such as the Research Capacity and Culture tool [ 48 , 49 ] and the WReN (Wessex Research Network) spider [ 50 , 51 ], or counts of publications, presentations and awards. The quantitative measures appeared to explore a discrete component of research impact, whereas the qualitative data provided a broad picture of the impacts in different contexts and uncovered both intended and unintended consequences of the research activity. Reed et al. proposed five impact evaluation typologies (experimental and statistical methods, systems analysis methods, textual, oral and arts-based methods, indicator-based approaches, and evidence synthesis approaches); our findings illustrate the first and third of these categories [ 44 ]. Future work should explore standardised methods of capturing the research impact that address the full range of impacts identified in this systematic review and are specific to the context of clinical academics outside medicine. With the desire for at least 1% of the UK NMAHP workforce to be clinical academics by 2030 [ 8 ], policy makers will need to consider, promote or potentially mitigate the different types of impacts that this systematic review identified in connection with these roles.

The VICTOR framework [ 22 ] was used to guide data extraction in the current review, with a priori modifications to include the impacts to the individual clinical academic and to merge the category relating to the organisation’s influence and reputation with the category for research profile, culture and capacity. No further refinements were made during the analysis process as all reported impacts were able to be mapped. While other research impact frameworks exist [ 14 , 44 ], our findings suggest that the VICTOR tool may be a good starting point for capturing the nature of research impact that is important for clinical academic healthcare research outside the medical professions, and it is already endorsed for use in the UK [ 23 ]. The identification of sub-themes that crossed one or more of the main impact themes indicate that these may be key areas to explore, particularly for organisations looking to support and increase academic activity among these clinical groups.

Limitations

The systematic review team comprised research-active clinicians from professions outside medicine, and therefore the review took place through this lens. Steps were taken to facilitate objectivity, including: a clearly defined protocol [ 18 ]; two or more reviewers independently conducting each stage of the review; inclusion of reviewers with different levels of clinical and research experience; and the provision of oversight by senior (clinically-active) academics. We acknowledge that the thematic analysis and coding of the extracted data may have been interpreted differently by reviewers from different backgrounds. Furthermore, the definition of clinical academic activity used in our review differs from that used elsewhere [ 45 , 52 ]. However, the absence of an agreed definition has been recognised [ 45 ] and the overlap of our findings with the existing literature support our review processes and findings [ 1 , 10 ].

As with other reviews of research impact, there is a risk that relevant studies were excluded due to poor indexing in the medical databases [ 14 ]. We took the additional step of including grey literature searches in both established repositories and through a naïve web search engine in an attempt to maximise the identification of eligible articles, but accept that articles may still have been missed if they were not identified through these mechanisms. We did not formally screen the reference lists of the included articles, and accept that this may have yielded additional studies.

The MMAT tool used for methodological assessment of the included articles was designed for the appraisal of mixed methods studies [ 20 ], although our review included mixed methods, qualitative, and quantitative articles. The MMAT was chosen to allow the same criteria to be applied across all included articles using the relevant sub-sections as appropriate. Quality assessment scores were not used to determine how the extracted data was incorporated into the thematic synthesis. We acknowledge that the presented synthesis therefore includes the findings from studies and organisational reports across the spectrum of methodological quality. However, no theme or sub-theme solely comprised data from articles that were assessed to be of lower quality.

The application of alternative impact frameworks would have yielded different theme headings, as these were taken directly from the VICTOR terminology. However, the use of an established impact assessment tool aided transparency and consistency of data extraction and categorisation. The coding and resulting theme descriptions were created through an inductive process that explored the meaning of the extracted data, rather than looking to specifically fit it to the VICTOR headings. The descriptions of the content of each theme illustrate the available data.

Finally, the aim of our review was to capture the range of impacts associated with clinical academic activity outside medicine. We have highlighted the key themes of impact and described the characteristic content of these themes. While this work contributes to the existing discussion around research impact, it does not explore the utility of capturing and comparing the reported impacts using a standardised method in a clinical research setting.

Twenty articles were identified that reported the impact of clinical academic activity among the healthcare professions outside medicine. These impacts could be mapped using a modified VICTOR framework and were classified as: impacts for patients; impacts for service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic. With our addition of impacts to clinical academics, the VICTOR tool may be a useful starting point for individuals and organisations to record the impact of their research activity, although further work is needed to establish its utility. This review identified several sub-themes of impact that crossed one or more of the main themes: the challenges and benefits of balancing clinical and academic roles; the creation and implementation of new research evidence; and the development of collaborations and networks. These are likely to be key areas for organisations to explore when looking to support and increase academic activity among healthcare professionals outside medicine.

Acknowledgements

Thank you to Clare Leon-Villapalos, Melanie Almonte, Jinju James and Gemma Clunie for their support with screening, data extraction and quality assessment; and to Lisa Gardner for her assistance in refining the search strategy.

Abbreviations

Authors’ contributions.

LN, MW and CMA designed the review. LN, JC, OFC, LS and LB completed the title and abstract screening. LN, AA, MC, LS, OFC, MA and LBS completed the full text screening. LN, AA, LBS, CL, LS, MC, JJ, LB and JC completed quality assessment and data extraction. Disagreements during screening were resolved by MW and CMA. Differences in data extraction were reviewed by MS and CH. LN, AA, LB, LBS, MC, JC, MS and CH thematically analysed the extracted data, and LN, MW and CMA completed the thematic synthesis. LN drafted the manuscript with major contributions from MW and CMA. All authors reviewed and approved the final manuscript.

This research was funded by the NIHR Imperial Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Availability of data and materials

Declarations.

Ethics approval was not required for this systematic review.

Not applicable.

The authors declare no competing interests.

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  • Perspective
  • Published: 07 March 2024

Analysis of metal–organic framework-based photosynthetic CO 2 reduction

  • P. M. Stanley   ORCID: orcid.org/0000-0002-1951-4074 1 ,
  • V. Ramm 1 ,
  • R. A. Fischer   ORCID: orcid.org/0000-0002-7532-5286 1 &
  • J. Warnan   ORCID: orcid.org/0000-0003-2729-8997 1  

Nature Synthesis volume  3 ,  pages 307–318 ( 2024 ) Cite this article

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  • Artificial photosynthesis
  • Metal–organic frameworks
  • Photocatalysis

Solar-driven synthetic fuel production couples solar energy conversion and storage in the form of chemical bonds and therefore has potential as a clean technology. The past decade has witnessed the continuous development of metal–organic framework (MOF) materials with considerable interest towards combining light harvesting with catalytic CO 2 conversion in one system. Built on a literature survey and data macroanalysis, this Perspective examines the development of this field by showcasing synthetic design approaches and highlighting attained milestones, while critically assessing pitfalls and opportunities. Five MOF-based material classifications for visible light-driven CO 2 reduction are determined and discussed through key photocatalysis figures of merits and metrics. Analysis reveals MOFs as a favourable platform to achieve high product-selectivity CO 2 photocatalysis. Non-standardized testing and reporting is found throughout this field and non-comparable product evolution rates, unverified carbon and electron source(s), and incomplete reporting checklists are identified as the main roadblocks towards accurate cross-laboratory benchmarking and breakthroughs. This Perspective additionally provides a balanced discussion and best practice recommendations to guide researchers investigating MOF-based materials for photocatalytic CO 2 reduction.

thematic synthesis of the literature

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Data availability

Source data of literature reports and contained performance metrics (DOI, publication year, main evolved product, selectivity, main product evolution rate, C x product, irradiation wavelength, lamp power, irradiation power, main solvent, sacrificial electron donor, operation hours, 13 C labelling, AQY, TONs and oxidation product) are available as Supplementary information.

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Acknowledgements

P.M.S. and V.R. thank the Chemical Industry Fonds (FCI) for a PhD fellowship. This work was supported by the German Research Foundation (DFG) Priority Program 1928 ‘Coordination Networks: Building Blocks for Functional Systems’, the research project MOFMOX (grant number FI 502/43-1) and by the Excellence Cluster 2089 ‘e-conversion’ (Fundamentals of Energy Conversion Processes).

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P.M.S. and J.W. conceived the idea and outline for this work. P.M.S. performed the literature overview and metrics analysis. P.M.S. and J.W. wrote the paper with contributions from V.R. and R.A.F. All authors have approved the final version of this paper.

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Stanley, P.M., Ramm, V., Fischer, R.A. et al. Analysis of metal–organic framework-based photosynthetic CO 2 reduction. Nat. Synth 3 , 307–318 (2024). https://doi.org/10.1038/s44160-024-00490-z

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IMAGES

  1. Synthesis of the literature review process and main conclusion

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  2. systematic review and thematic synthesis of qualitative literature

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  3. Concept map derived through thematic synthesis of the literature

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  4. Part 1: Thematic synthesis: an overview of its use and features

    thematic synthesis of the literature

  5. Concept map derived through thematic synthesis of the literature

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  6. Literature Synthesis Framework

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  1. Lecture 1(theory) Understanding Literary Theory and Literary Criticism #ugcnet #freeclasses

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  3. Ovid Synthesis Literature Search Overview

  4. Review of Related Literature

  5. 20th-Century Developments in Literary Criticism- Part 1|Literary Criticism and Theory|MEG-05

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COMMENTS

  1. Methods for the synthesis of qualitative research: a critical review

    Thematic Synthesis. Thomas and Harden ... although there are few examples of this in the literature. Some synthesis methods - for example, thematic synthesis - look at other characteristics of the studies under review, whether types of participants and their context vary, and whether this can explain differences in perspective. ...

  2. Methods for the thematic synthesis of qualitative research in

    We describe thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion research. Thematic synthesis has three stages: the coding of text 'line-by-line'; the development of 'descriptive themes'; and the generation of 'analytical themes'.

  3. Methods for the thematic synthesis of qualitative research in

    Detailed methods for thematic synthesis. The synthesis took the form of three stages which overlapped to some degree: the free line-by-line coding of the findings of primary studies; the organisation of these 'free codes' into related areas to construct 'descriptive' themes; and the development of 'analytical' themes.

  4. Thematic Synthesis

    Thematic synthesis offers a flexible, systematic and transparent method to move from the findings of multiple qualitative studies to synthesis. The webinar began by outlining the key features of thematic synthesis and how it relates to other synthesis methods. It then illustrated the steps involved using worked examples.

  5. A Step-by-Step Process of Thematic Analysis to Develop a Conceptual

    Thematic analysis is a research method used to identify and interpret patterns or themes in a data set; it often leads to new insights and understanding (Boyatzis, 1998; Elliott, 2018; Thomas, 2006).However, it is critical that researchers avoid letting their own preconceptions interfere with the identification of key themes (Morse & Mitcham, 2002; Patton, 2015).

  6. Qualitative Evidence Synthesis: Where Are We at?

    Thematic Synthesis (Thomas & Harden, 2008) Pros: Most accessible form of synthesis. Clear approach, can be used with data that are quite "thin" to produce descriptive themes and where data are "thicker" to develop descriptive themes in to more in-depth analytic themes. ... Using mixed methods research synthesis for literature reviews ...

  7. PDF A walk through Thematic Synthesis: A worked example of qualitative

    Qualitative evidence synthesis is a process of scientific enquiry aimed at reviewing and rigorously integrating the findings of qualitative research (Thorne et al. 2004, Sandelowski and Barroso 2007). A means of presenting the complexities of human experiences in a way that is recognisable to the evidence-based community (Thorne 2008).

  8. Protocol for a thematic synthesis to identify key themes and messages

    Thematic synthesis will be implemented at the analysis stages to allow for the generation of the key messages and themes. The following five steps will be carried out (1) setting the research question, (2) searching the literature; (3) sampling; (4) determination of quality; (5) data extraction; and (6) thematic synthesis.

  9. PDF Methods for the thematic synthesis of qualitative research in ...

    describe the activity of thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion and public health research. We compare thematic synthesis to other methods for the synthesis of qualitative research and discuss issues of context and rigour. 2

  10. Thematic Synthesis

    A typology of literature reviews. "Similar to analysis of primary qualitative datasets, thematic synthesis involves the systematic coding of data and generating of descriptive and analytical themes" (Nicholson et al, 2016).

  11. A qualitative systematic review and thematic synthesis exploring the

    Sub-themes described the content of each of the categories of impact and included perceived enablers of creating the desired impact and associated detrimental features. Notably, the sub-themes that reflected the challenge of maintaining or balancing the clinical and academic components of the role contributed to four main themes.

  12. How to Write a Thematic Literature Review: A Beginner's Guide

    Thematic literature review example. In essence, a thematic literature review allows researchers to dissect complex topics into smaller manageable themes, providing a more focused and structured approach to literature synthesis. This method empowers researchers to gain deeper insights, identify gaps, and generate new knowledge within the context ...

  13. Methods for the thematic synthesis of qualitative research in ...

    Thematic analysis is a method that is often used to analyse data in primary qualitative research. This paper reports on the use of this type of analysis in systematic reviews to bring together and integrate the findings of multiple qualitative studies. Methods: We describe thematic synthesis, outline several steps for its conduct and illustrate ...

  14. Literature Synthesis 101: How To Guide + Examples

    Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study's research aims and questions.

  15. Guidance on Conducting a Systematic Literature Review

    Thematic synthesis is very similar to meta-ethnography. The data extraction and synthesis process for thematic synthesis utilizes thematic analysis; themes are extracted from the literature, clustered, and eventually synthesized into analytical themes (Thomas and Harden 2008). These analytical themes, similar in their construction to third ...

  16. Full article: Austerity and the lives of people with learning

    A thematic synthesis of current literature. Melina Aikaterini Malli Tizard Centre, University of Kent ... The overall aim of this thematic synthesis was to build a holistic and international picture of the impact that austerity related policy has had on the lives of people with learning disabilities and the collateral effects on the people who ...

  17. Experiences of loneliness: a study protocol for a systematic review and

    Thematic synthesis will be used to synthesise this literature, and study quality will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The planned review will be reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.

  18. Protocol for a systematic review and thematic synthesis of patient

    The results section of the review will comprise thematic synthesis of quantitative studies, thematic synthesis of qualitative studies, and the aggregation of the two. ... The aim of this review is to synthesise existing literature that investigates patient experiences with PICC, Hickman-type, and Port devices in the context of anti-cancer ...

  19. What Synthesis Methodology Should I Use? A Review and Analysis of

    Types of Research Synthesis: Key Characteristics: Purpose: Methods: Product: CONVENTIONAL Integrative Review: What is it? "The integrative literature review is a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated" [, p.356]. ...

  20. Synthesizing Sources

    In a synthesis matrix, each column represents one source, and each row represents a common theme or idea among the sources. In the relevant rows, fill in a short summary of how the source treats each theme or topic. This helps you to clearly see the commonalities or points of divergence among your sources.

  21. Older people's perspectives on participation in physical ...

    Older people's perspectives on participation in physical activity: a systematic review and thematic synthesis of qualitative literature Br J Sports Med . 2015 Oct;49(19):1268-76. doi: 10.1136/bjsports-2014-094015.

  22. Exploring the use of social network interventions for adults with

    People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people ...

  23. A qualitative systematic review and thematic synthesis exploring the

    A qualitative systematic review and thematic synthesis exploring the impacts of clinical academic activity by healthcare professionals outside medicine. ... four grey literature repositories and a naïve web search engine were systematically searched for articles reporting impacts of clinical academic activity by healthcare professionals ...

  24. What Helps, What Hinders? Undergraduate Nursing Students' Perceptions

    The thematic synthesis was guided by quality criteria described in the ENTREQ statement by Tong et al., (2012) for enhancing the transparency of reporting in studies that synthesize qualitative research. The statement comprises 21 items grouped into five domains: introduction, methods and methodology, literature search and selection, appraisal ...

  25. Analysis of metal-organic framework-based photosynthetic CO

    We identified these five categories as recurring conceptual themes and synthetic focuses within the ~300 analysed literature reports, and a brief description of each is provided below.

  26. Graduate Course Offerings, Summer 2024

    ENGL 5355, Studies in Comparative Literature: Global Vietnam War Literature and Culture Dr. Yuan Shu Wednesdays, 6:00 - 8:50 PM Online (CRN: 72149) This course investigates the representation of the American War in Vietnam through diverse theoretical, cultural, and historical perspectives.