interpretive synthesis of the literature

Literature Synthesis

• First Online: 31 August 2021

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• Ana Paula Cardoso Ermel   ORCID: orcid.org/0000-0002-3874-9792 5 ,
• D. P. Lacerda   ORCID: orcid.org/0000-0002-8011-3376 6 ,
• Maria Isabel W. M. Morandi   ORCID: orcid.org/0000-0003-1337-1487 7 &
• Leandro Gauss   ORCID: orcid.org/0000-0001-5708-5912 8  

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• The original version of this chapter was revised: Figure 5.1 was moved to section 5.2.9. The correction to this chapter can be found at https://doi.org/10.1007/978-3-030-75722-9_10

This chapter addresses the concept of Literature Synthesis and classifies it as Configurative and Aggregative based upon the research approach and objectives. For each type of synthesis, its main characteristics, techniques, and applications are pointed out.

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Cardoso Ermel, A.P., Lacerda, D.P., Morandi, M.I.W.M., Gauss, L. (2021). Literature Synthesis. In: Literature Reviews. Springer, Cham. https://doi.org/10.1007/978-3-030-75722-9_5

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"Critical interpretive synthesis involves an iterative approach to refining the research question and searching and selecting from the literature (using theoretical sampling) and defining and applying codes and categories. It also has a particular approach to appraising quality, using relevance – i.e. likely contribution to theory development – rather than methodological characteristics as a means of determining the 'quality' of individual papers" (Barnett-Page et al, 2009).

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Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

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BACKGROUND: Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.

RESULTS: Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.

DISCUSSION: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

Keywords / Materials (for Non-textual outputs)

• Great Britain
• Health Services Accessibility
• Health Services Research
• Meta-Analysis as Topic
• Patient Acceptance of Health Care
• Research Design
• Resource Allocation
• Sampling Studies
• Socioeconomic Factors
• State Medicine
• Vulnerable Populations

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• 10.1186/1471-2288-6-35

© 2006 Dixon-Woods et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• http://www.biomedcentral.com/1471-2288/6/35

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• Literature Social Sciences 100%
• Disadvantaged Group Social Sciences 100%
• Health Care Social Sciences 100%
• Groups Psychology 100%
• Healthcare Psychology 100%
• Synthesis Nursing and Health Professions 100%
• Systematic Review Nursing and Health Professions 80%
• Candidacy Social Sciences 60%

T1 - Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

AU - Dixon-Woods, Mary

AU - Cavers, Debbie

AU - Agarwal, Shona

AU - Annandale, Ellen

AU - Arthur, Antony

AU - Harvey, Janet

AU - Hsu, Ron

AU - Katbamna, Savita

AU - Olsen, Richard

AU - Smith, Lucy

AU - Riley, Richard

AU - Sutton, Alex J

PY - 2006/7/26

Y1 - 2006/7/26

N2 - BACKGROUND: Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.RESULTS: Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.DISCUSSION: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

AB - BACKGROUND: Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.RESULTS: Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.DISCUSSION: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

KW - Great Britain

KW - Health Services Accessibility

KW - Health Services Research

KW - Humans

KW - Meta-Analysis as Topic

KW - Patient Acceptance of Health Care

KW - Research Design

KW - Resource Allocation

KW - Sampling Studies

KW - Socioeconomic Factors

KW - State Medicine

KW - Vulnerable Populations

U2 - 10.1186/1471-2288-6-35

DO - 10.1186/1471-2288-6-35

M3 - Article

C2 - 16872487

SN - 1471-2288

JO - BMC Medical Research Methodology

JF - BMC Medical Research Methodology

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Music, Rhythm and Trauma: A Critical Interpretive Synthesis of Research Literature

Katrina skewes mcferran.

1 Creative Arts and Music Therapy Research Unit, Faculty of Fine Arts and Music, The University of Melbourne, Melbourne, VIC, Australia

Hsin I. Cindy Lai

Wei-han chang, daniela acquaro.

2 Melbourne School of Graduate Education, The University of Melbourne, Melbourne, VIC, Australia

Tan Chyuan Chin

Helen stokes, alexander hew dale crooke, associated data.

The datasets generated for this study are available on request to the corresponding author.

Recent theorizing about the connection between the brain and trauma (Perry, 2009 ; Porges, 2011 ; van der Kolk, 2015 ) has led to a burgeoning of interest in the provision of music-based programs with people who have had adverse experiences. Although there has been critique of the lack of scientific basis of these theories and their implications for practice (McLean, 2016 ), they remain popular with practitioners who are keen to introduce innovative and potentially beneficial approaches to the people with whom they work. Music therapists have a long tradition of working with traumatized clients, however, the brain-based rationales did not seem congruent with the less predictable and more idiosyncratic benefits reported, which seem to occur through more psychodynamic mechanisms of action. In order to unravel what seemed to be a body of literature plagued by the conflation of theories, we undertook a critical interpretive synthesis of literature in the past 10 years to cross-examine the ways that music and trauma have been connected. To do this we extracted data from 36 identified articles to distinguish what music methods were used, what claims were made about benefits, what theoretical justifications were provided and how much research basis there was for the claims being made. Having systematically disentangled the various dimensions, we then constructed a spectrum of approaches that offers a logical categorization of four different ways of using music with people who have had adverse life experiences. These included using music for stabilizing, entrainment, expressive and performative purposes. Specific music-based methods were proposed for those associated with brain-based rationales, and more responsive, multi-method approaches were congruent with recovery and social change models. Future research would benefit from a more clearly articulated connection between theoretical rationale, music-based methods, benefits and research approaches. The resultant spectrum may provide useful guidance for both practice and research design.

International interest in the relationship between rhythm and trauma has burgeoned in response to recent endorsement through popular trauma discourse that relies on neurological mechanisms of action. A number of popular theorists' ideas have been used to suggest that rhythm-based activities are beneficial for people who have had adverse experiences because it bypasses higher cognitive functioning and allows connections to form via more primitive, undamaged regions of the brain. One of these theories has been posed by psychiatrist Perry ( 2009 ), who uses brain studies to argue that since trauma has a visible impact on the primitive brain, interventions which also operate at a pre-conscious level should logically be more effective than cognitively mediated strategies. Porges ( 2011 ) has developed a more complex theoretical explanation, labeled Polyvagal theory, to propose that trauma symptoms are mediated by an amygdala that has become hyper-vigilant to threat-related cues, and therefore activities which regulate physiological arousal will be helpful in stimulating the vagally modulated social engagement system in positive ways. van der Kolk et al. ( 2007 ) adds that rhythmic activities can fulfill this function by reawakening feelings of pleasure and engagement dulled by prolonged trauma exposure, and that rhythm stimulates patterned, repetitive neural brainstem activity necessary for restoration of brain functioning. These three men have had an enormous influence on music practitioners in the field of trauma, with an anecdotal increase in rhythm-based programs being noticed through social media posts and requests for information from music therapists by the public and by students and practitioners in trauma related fields.

Some critique has emerged of these perspectives and the practice implications that have results from them, often categorized as “trauma-informed” practices. McLean ( 2016 ) summarizes the precarious assumptions underpinning this discourse as follows.

• “The way in which brain development in the context of early adversity and trauma is represented may be oversimplifying the science;
• Claims regarding the plasticity of the brain and what it might mean for therapeutic intervention are not justified by the available science; and
• Therapeutic interventions that are based on these assumptions (e.g., song, rhythmic drumming, spinning), although popular, have not yet been subject to the systematic evaluation that other trauma-specific therapies have.” (p. 3).

We agree that there is a great deal of optimism in these theories and note that our practice experiences as therapists and teachers with young people who have had adverse childhood experiences suggests that the role of rhythm is less reliably mechanical, and more complexly woven into a fabric of relationship, musical encounters, creativity and safety. Because of our shared interest in the practical application of music/rhythm with young people, the final point made by McLean is our focus in this systematic review of the literature. Meticulous and systematic evaluation of these popular ideas is needed in order to ensure that they are effective, and prior to that, some of the key theoretical constructs need to be disentangled and clarified. To begin this process, we undertook a careful search of the literature that connects music with trauma, abuse and foster care. Our aim was to cross-examine the ways that music and trauma are connected in the literature. To do this, we extracted data to answer four questions from which we could draw conclusions in relation to the aim.

• Which music methods are used by practitioners describing work with people who have experienced trauma, and to what degree is rhythm emphasized?
• What claims are made about the benefits of using music to work with people who have experienced trauma?
• What theoretical justifications are utilized for using music with people who have experienced trauma?
• How much research basis is there for the claims being made?

Critical Interpretive Synthesis

Systematic literature reviews have become an increasingly relevant method for scholars to interrogate a burgeoning literature that makes it difficult for readers to be fully cognizant of the breadth of theories and results that are constantly emerging. This notion was most popularly posed by Archie Cochrane, who recognized the divide between how clinicians were practicing in the field and the most recent findings being produced through medical research (Bero and Rennie, 1995 ). His intention was to increase awareness of findings in order to improve practice. The “Cochrane Reviews” then became a dominant and sometimes oppressive force within medical and educational practice (Aigen, 2015 ), accompanied by a demand for “evidence-based practice” which has been adopted by insurance companies and government agencies charged with distributing funds to service providers. The evidence-based movement is hierarchical, and privileges quantitative data over qualitative knowing because it supports the application of tenets of objectivism such as randomization and controlled conditions. The implications of this uneven emphasis have been critiqued, but this view continues to dominate in many cultures.

One alternative approach that has grown from the same desire to organize knowledge in ways that can inform readers about emerging ideas (Sackett et al., 1996 ), is the critical interpretive synthesis. Rather than summarizing knowledge, this critical approach recognizes that some knowledge is considered more credible than others, and that trends in the literature often emerge from a culture of privilege (Baines and Edwards, 2015 ). Therefore, rather than reinforce dominant ideas, a critical approach seeks to reveal the forces that have been previously rendered invisible, as articulated by Bourdieu (Navarro, 2006 ). There is an existing tradition of critical literature reviews such as these in the medical (Dixon-Woods et al., 2006 ) and ethnographic (Noblit and Hare, 1988 ) fields which provides a precedent for adopting a similar approach in the current investigation. By adopting a recursive but systematic approach it becomes possible to interrogate the literature, rather than to accept it, thereby challenging assumptions and recognizing forces at play that underpin knowledge generation (McFerran et al., 2017 ). This approach is well-suited to our aim of cross-examining the ways that music and trauma are connected in the literature.

Search Strategy

We undertook a number of searches to identify relevant literature, including a combination of words for “music” + “trauma.” The alternate search terms used for music included: music, drum, drumming, hip hop, rhythm, improvisation, rap, beat making, songwriting, sing, singing, song, GIM (Guided Imagery and Music), and audio. Two additional terms were used as alternatives to trauma: abuse and foster care. Excluded topics were more focused on the event rather than the response and included: surgical trauma, medical trauma, cultural or historical trauma, immigration, political trauma, traumatic injury, physical trauma, traumatic event (not specifying the result of trauma), musician's trauma and substance abuse.

Our search focused on articles published in the last 10 years, which was from 2009 to 2018. Ninety-one sources were identified through this search, including a range of manuscript types. We decided to focus on peer-reviewed literature including journal articles and dissertations, and excluded chapters and books from the analysis, we also removed repetition of research projects that were reported in multiple articles. This reduced the number to 36 sources which are summarized in Table 1 . Twenty-six of these were research studies and ten were case studies that did not ultimately qualify as research but which provided in-depth, detailed descriptions.

Included studies.

Data Extraction

Once the articles were identified, data was extracted from each against a set of questions as reported above. The intention was to generate a concise answer to the question, and not to rely on direct quotations which could require entire paragraphs. In some cases, interpretation was required if the information was not explicit. For example, not all authors distinguished between aims and outcomes, or gave details about the specific music method being used. The research assistant worked closely with the primary author to determine answers in these cases, using a combination of logical and reflexive questioning to determine if the information could be interpreted or if doing so was beyond our abilities to assume. For example, limited information about the setting of the program might be supplemented through online searching, or making assumptions based on the language used to describe the participants which may be more typical of medical or community contexts. We relied on the information published and did not make contact with authors if data was missing. The data were extracted in answer to the following prompts.

• How the participants are described—e.g., their behaviors and their presenting issues
• How the participants' trauma is described/diagnosed—e.g., complex, PTSD, etc.
• The reported cause of the trauma—e.g., events
• Race/ ethnicity
• Group or individual program
• Number of people
• Research or not? If so, chosen design
• Claims about program aims
• Claims about program findings/results
• Music methods used
• Music genres referenced
• Any specific references to rhythm
• Citations used as justification for using music with traumatized people.

Data Analysis

Simple descriptive analysis was used to analyze the data in regard to the four research questions as a beginning point. This process required some interpretation when answers were not readily available, but our intention was to remain close to what the authors were describing in their articles, defined by our extractions being “recognizable.” The over-arching question about how music and trauma are connected within the literature was then examined via meta-synthesis—exploring patterns that presented across the data, often examined through the intersections between multiple categories. This was undertaken with particular attention to critical questions about assumptions underpinning decisions, what was missing as well as what was dominant, who seems to benefit from the findings, and also attending to any emotional responses (frustration, sadness, surprise) to emerging patterns (McFerran et al., 2017 ).

Music Methods

Music has a long history of application in the mental health field and practitioners have been using an array of music-based methods with people who have had adverse life experiences for many decades (e.g., Rogers, 1993 ). For example, the profession of music therapy was established in the 1950s in the U.S.A. in response to the high number of veterans who returned from fighting in the war with post-traumatic stress disorder, as well as in response to later wars (Slotoroff, 1994 ). Some of the authors are qualified music therapists, and therefore have a particular interest in, and knowledge of this discourse. This potentially influenced the balance of articles with just under half being music therapy articles ( n = 17), 9 being from psychology, and 10 coming from other disciplines including other creative arts and expressive arts therapies, guided imagery and music, education, occupational therapy, nursing and arts backgrounds. In categorizing the methods used however, we have not distinguished between music therapists uses of particular methods, such as song writing.

We began our investigation expecting to find an emphasis on rhythm in the literature given the prominence of reference to this musical element in the social discourse emerging from the neurological theories about trauma. In the initial search, the term “rhythm” did not result in any identified sources, nor did “beat making” or “audio.” We reviewed our conception of “rhythm” and chose to expand our searching to recognize that rhythm is inherent in music and that we were interested in the degree to which it was made prominent by different authors. As noted above, we then used 14 terms for music in our searches of the peer-reviewed literature of which rhythm was the primary focus of 5 of the 37 manuscripts identified, with group drumming being the sole method described in all but one of these. In addition to the four using group drumming exclusively, 9 of the 37 articles in total included drumming as one of their methods and it was the fourth most common method described along with those that described playing on other instruments. Songwriting was the most common method referenced and both music listening and the music therapy technique of improvisation was reported in 11 articles. There was also reference to performances, singing, and others represented in Figure 1 .

Frequency of reference to music-based methods (only method = light; one of multiple methods = dark).

In further interrogating the representation of different methods within the literature, it became clear that there was an even split between those focusing on the use of one method only and those using multiple methods, with 18 manuscripts describing between 2 and 6 methods (average 3.6). Of those focusing on a single method, half relied on receptive music experiences, including music listening for analysis of lyrics, imagery, relaxation, and other meaning making processes that relied on associations being explored.

Although we only focused on literature in the past 10 years, we were interested to examine how many different approaches were being described in contemporary discourse, and to consider what trends may have impacted these findings. Only one study made reference to Hip Hop, despite our combined experience suggesting that it is a popular method in current practice, particularly in the provision of services for youth. This suggests that the research is lagging behind practice in this space, as McLean ( 2016 ) has suggested. It would be a mistake to assume this means Hip Hop is not relevant and/or helpful, however. A strong theoretical rationale exists for the value of culturally relevant music practices (Stige, 2002 ), whether that is related to black American culture, or youth culture more generally. Similarly, the prominence of songwriting does not imply this method is most useful, but rather, that it is most published.

Theoretical Basis

One important part of the rationale for this investigation was the influx of interest in the connection between music, trauma and the brain. In our view, this has largely been at the instigation of three popular authorities in the field of trauma—Perry ( 2009 ), van der Kolk et al. ( 2007 ), and Porges ( 2011 ). In addition, music therapy theorist, Thaut ( 2005 ), has long posited that the benefits of music therapy are best explained by studying brain based reactions, and has been particularly interested in the role of rhythm in this context. Our first interrogation of the theoretical underpinnings of the 37 studies was therefore to determine the degree to which a brain-based rationale was provided for music-based interventions (see Figure 2 ). Ten of the articles made reference to either Porges or van der Kolk, with van der Kolk being the most referenced theorist (8 articles), while Porges was only noted in three and Thaut in one. The second most prominent theorist was Herman ( 2015 ), whose work on “Trauma and Recovery” transformed the discourse in the early 1990s and is probably still the most influential trauma text of our time. Herman does not directly address music, but rather it is her three-stage model of recovery that many practitioners use as a guide to their work. Perry was not referenced in any of the articles, perhaps because he is more well-known as a presenter than a published author.

Theoretical rationale provided in included manuscripts. CAT is abbreviated from Creative Arts Therapies.

Music therapy theory and theory from other Creative Arts Therapies (CAT), including the specific field of Guided Imagery and Music which requires advanced training, was also referenced frequently in the included manuscripts, once again reflecting the professional training of some of the authors. No single CAT authors were referenced in particular, and many music therapists also integrate theoretical approaches dominant in psychology and psychiatry. This was true of the rationales used across many articles, including psychoanalytic and psychodynamic theorists, cognitive behavioral therapy, attachment theory, gestalt theory, as well as some scholars from music psychology and creative arts therapies more broadly. Resilience was referenced by a significant number of authors, although no particular resilience theorists were dominant.

Ascribed Benefits

Two sets of data were included in this analysis. The primary data was the findings/results that were described for participants in the music-based programs. However, we also felt it was important to critically analyze the authors' aims, since assumptions are often embedded in the intentions for a project, and therefore interrogating them may be revealing. This was certainly the case in our investigation, with 22 of the authors describing aims that included demonstrating how music could serve as a useful medium for people who had adverse experiences. This focus reveals a high degree of investment in positive outcomes; however, minimal reflexivity was presented in the qualitative research, and only two of the quantitative studies included a control condition so that an objective comparison could be made. Either of these approaches to confirming how findings may have been influenced by the expectations of the researchers would have enhanced the quality of the literature. Whilst it is natural that practitioner-researchers should believe in their approach, and certainly, it would make no sense to investigate something considered to be unhelpful, scientific standards demand that some effort is therefore made to ensure findings are trustworthy. Further development is needed in this area.

Working in the field of trauma is complex and unlike some other fields of practice where music is used (for example, rehabilitation), specific improvements cannot always be readily targeted and measured. It can be difficult for people with lived experience, their carers, and their workers to know exactly what part of the complex psychological ramifications of adverse experiences should be focused upon—behavior, memories, meaning-making, and emotions are all intertwined and difficult to separate. Herman ( 2015 ) popular model recognizes this by focusing on different program aims for each stage rather than focusing on benefits or expected outcomes. She does not make generalizable predictions about universal benefits but focuses on recovery as a unique and ongoing journey. However, there is a strong (reductive) trend in the cognitive and psychological sciences more generally that brain-based explanations appear to solve because it provides elegant explanations that could explain the complexity. However, the reality of the complex terrain of living with trauma is reflected in the kinds of benefits reported by authors in the literature. A focus on intrusive trauma symptoms that could be paired with measurable outcomes appeared adequate only for those living with the most severe behavioral responses. For example, symptom reduction was a target in 11 manuscripts of which seven were describing trauma experienced in military contexts, and six of this sub-set used quantitative designs and two used mixed methods. Another behavioral outcome noted in the analysis was a focus was on sleep and/or relaxation , represented in five articles.

However, for those with adverse life experiences beyond the military it seemed more difficult for authors to nominate specific benefits and there was a great deal of variety in the ways that authors couched the outcomes they were reporting. For example, an emphasis on resilience and/or empowerment was present in five articles that were set in community-based contexts, including a kindergarten and youth center. Social benefits were posited in a different set of seven manuscripts, and all of these were related to programs provided in groups, rather than individual therapy where trust in the therapist might be more relevant, although not usually described as a benefit. Self-worth was another important benefit posited in a different set of eight manuscripts, with all of these being programs for marginalized young people in non-acute contexts. Some kind of emotional outcome was referenced by eight of the authors, but these were difficult to categorize as benefits, and were mostly described more generally as having opportunities for emotional expression and processing rather than improvements per se (i.e., emotional responsiveness, emotional balance, emotional expression, work through emotional aspects, understanding of emotion, expressing musical emotions, regulate and express emotions). The term affect was used by some quantitative researchers (i.e., affect and mood stabilization, fewer affective and cognitive disturbances), and feelings were also referenced by some authors (express repressed feelings, increased expression of non-traumatic feelings). Although the benefit of working with emotions was difficult to articulate, emotional challenges are central to many traumatized peoples' experience and the opportunity to participate seems justifiable as a benefit of therapeutic work with music.

There was a suite of 11 articles in this review from which it was more difficult to extrapolate specific well-being benefits to participants and that were more exploratory in nature. Many of these were focused on exploring whether music-based programs were useful in the diverse contexts where they had been introduced, from inpatient and outpatient mental health programs, private practice, and a range of community-based programs for survivors of torture, sexual exploitation, refugee detention and those in the foster care or family violence systems. Authors described aims such as:

• Exploring the ways in which music can speak directly to the trauma, and how music therapy offers a unique means to understand the traumatized patient
• Exploring whether and how rhythmic interactions within musical improvisations facilitate the repair of ruptures in such rhythms
• Describing women's experiences of song writing to support parenting
• Describing the evolution of an innovative program for incarcerated adolescent girls in which youth work collaboratively with theater professionals to create, develop, and perform musicals based on their experiences
• Understanding to what extent, and in what ways, the mental health condition of the research subjects changes during music psychotherapy treatment
• Exploring the ways in which music therapy programming can support and enhance care systems already in place for survivors of sex trafficking and their care staff
• Presenting a new way of combining songwriting and visual art to facilitate emotional expression
• Balancing the representation of children in this context by using music to explore their resources and what helps them to “do well” throughout their experiences of homelessness and family violence
• Presenting a framework for music therapy processes and practices with foster-care youth
• Describing how a performing arts troupe program supports vulnerable youth
• Helping to develop musical aspects of a local program that contributes to the welfare of children and to use the social power of music to raise awareness of their situation in a wider world.

Research Approaches

This critical interpretive synthesis does not aim to synthesize all the literature on the topic of rhythm and trauma, but rather, to interrogate the ways that music and trauma are connected in the peer reviewed literature. Our decision to focus on peer-reviewed literature was intentional and we aimed to avoid the inclusion of anecdotal report and to focus on what McLean ( 2016 ) calls science, but what we would call research-based reports. Despite this intention, of the 36 manuscripts included in our investigation, 10 were not research articles but were descriptive program reports without a clear research methodology. They did contain useful information in answer to the remaining questions however, and, were included in the analysis of other sections. Of the 26 manuscripts that had a clear methodology, the research approaches were dispersed across data types, with qualitative research being most common, and although the case studies are displayed separately, these all used qualitative approaches. Those studies that used quantitative data included two randomized controlled trials, while the rest of the studies did not have control conditions or randomization (see Figure 3 ).

Research approaches used in 26 manuscripts.

The studies relying on quantitative data came from a range of regions, including Israel (3) and the Middle East (2), U.K. and Denmark, as well as Australia and the U.S.A. The qualitative studies were more likely to come from Australia (4) or the U.S.A. (3), with one each from the U.K. and Denmark, and the case studies were similarly dominated by north American authors, with one set of three case studies from Finland. There are a number of possible explanations for the limited number of objectivist studies. It may suggest that the interface between trauma and music is considered to be challenging by many to quantify, or that ethics approval for conducting studies with people considered to be so vulnerable is difficult in western countries with stringent systems for monitoring and approving research projects. Pragmatically, it can be difficult to adequately power experimental research studies with this population due to limited sample sizes. Alternatively, it might be that authors' felt quantitative data was incongruent with the importance of narrative that is often emphasized in therapeutic works with people who have had adverse experiences.

Meta Synthesis

The notion of meta-analysis in quantitative systematic review refers to the use of statistical methods to combine the data from a large number of studies. In qualitative syntheses, the “meta” does not refer to aggregating, but rather to broadening understanding of a particular phenomenon (Grant and Booth, 2009 ), in this case through identifying more nuanced and qualitative distinctions between strands of data. After immersion in the results of the analysis above, we constructed a spectrum of approaches that could be used to distinguish four categories aligning with a set of proposed musical purposes relevant for working with people who have lived experience of trauma (see Table 2 ). The spectrum transpired after grappling with how theories that posit primitive neural activity as key mechanisms of action (such as Porges, 2011 ; van der Kolk, 2015 ) were related to specific types of music methods suggested and this led us to conceptualize the first two categories. What remained were approaches that required higher level brain activity such as emotion processing and social awareness and these were then connected to different music methods proposed. Benefits were also an important consideration in constructing the emerging spectrum, since we were endeavoring to untangle various strands of discourse in order to identify whether there could be cogent links between theorized mechanisms of action, music methods and expected benefits. We used abductive logic to explore this possibility in the meta-synthesis and as a result, speculate that there are four ways of understanding how music and rhythm can afford a range of benefits for those who have had adverse life experiences resulting in trauma.

Spectrum of approaches to music and trauma.

Stabilizing

The term stabilizing has been used to label this group of manuscripts because there was no suggestion of the music being used in a responsive way. Rather, listening to recorded music was the selected method for individuals with a PTSD diagnosis because it provided a safe structure affording a stable pulse lasting for the duration of each musical piece. This allows for predictability when used in a repeated way and emphasizes tempo rather than rhythm per se . Importantly, recorded music is reliable as a variable within quantitative research designs and music listening was found to be effective in influencing physiological regulation, resulting in improved sleep, increased relaxation and the reduction of negative PTSD symptoms.

The theoretical basis for this category relies on the premise that physiological processes can be modulated via brain-based processing that bypass areas of the brain damaged by trauma. For example, Perry's neurosequential model (Perry, 2006 , 2009 ) suggests that regular and repetitive rhythmic activities can regulate these primitive areas of the brain, even when early adversity has led to chronic hyper-arousal. Porges' theorizing also implicates rhythm as a way to calm an over-sensitive central nervous system by drawing on the autonomic nervous system (Porges, 2011 ). He introduced the term neuroception (Porges, 2004 ) to refer to the ways the autonomic nervous system evaluates risk in the environment, and suggests that prosodic acoustic stimulation signals safety. These theories are precisely the ones criticized by McLean ( 2016 ) because of the lack of scientific evidence. Whilst we believe her critique is well-founded, these studies do demonstrate that music listening can improve physiological markers of distress in people who have had adverse experiences. These are likely to be temporary, rather than leading to healing in the brain, as suggested by these popular theorists, however they may still be appreciated by those benefiting from greater amounts of sleep and relaxation.

Entrainment

The term entrainment has a long history in musicological and music psychology discourse and is usually paired with the notion of synchronization. Some scholars distinguish entrainment as the purpose and as “a process that governs the alignment of the auditory and motor domain,” whilst synchronization is the action, being “a dynamic attraction point where the timing differences between music and person are stabilized” (Moumdjian et al., 2018 ). In the music psychology literature, it is often about pairing human behavior with an external auditory source, as described by Cameron and Grahn ( 2016 ): “The synchronization of internal rhythm processes (such as neuronal oscillations) or behavior (such as tapping or dancing) to external, periodic events (e.g., the beats in a rhythm)” (p. 363). However, in the ethnomusicology literature, the freedom to oscillate rather than be mechanically steady is emphasized (Clayton et al., 2005 ), which is critical to its use in this meta-synthesis since keeping perfectly in time is neither necessary nor likely when working with non-musicians.

The term entrainment has been chosen here because it is a logical extension of an approach that relies on primitive neural activity as a mechanism for bypassing more complex trauma related behaviors such as hyper- and hypo-arousal—bringing people into a more optimal “window of tolerance,” as described by Siegel ( 1999 ). This kind of sensorimotor approach has been advocated by much quoted practitioner-researcher, Pat Ogden (Ogden et al., 2006 ), who suggests connecting with people via basic functions such as rhythm when cognitive processing and self-regulation are considered to be unavailable. Hence music methods that rely on clearly guided musical experiences emphasizing basic pulses and synchronized activity are a good match for this theorizing.

Drumming is the most obvious music method that can be classified as a sensorimotor activity in music with basic research suggesting that this should result in improvements through co-regulation. Drumming groups often imply high levels of structure and rule-following, as distinct from the more emergent and responsive approaches described in the Expressive category. However, drumming appears to have been integrated into a range of approaches in the literature and used in both dynamics and more ordered ways. This distinction is critical for facilitators to consider, since the way drumming is used would logically lead to quite different outcomes. This point has been made in Michael Thaut's rhythm-based approach to music therapy (Thaut et al., 2015 ) which has been tested in rehabilitative contexts, but for which there is less evidence in mental health domains. Critical to this approach is focused and repetitive music activities that are reliably delivered with strict adherence to musical parameters, similar to a behavioral approach. This does involve live music making, so that the therapist can make adjustments to timing where necessary, however, it is very different from a psychodynamic approach that may use drumming experiences as the basis of interpretation and fostering insight. In the literature reviewed, it was not always possible to understand how rhythm-based methods were being offered.

This category takes expression in its title because it encompasses an array of personally expressive dimensions—including emotions and feelings as one component, but also the broader constructs of personal expression, identity work, and a range of other well-being benefits. Rather than bypassing damaged regions of the brain, as posed in the previous two categories, the expressive emphasis is about acknowledgment and integration of adverse experiences. This requires higher cognitive functioning and the ability to actively reflect and make meaning and is classically associated with psychotherapy, where uncovering repressed experiences is considered critical to recovery. However, following on from the seminal work of Herman ( 2015 ), contemporary trauma work emphasizes the importance of establishing safety and stability before progressing to reconstructing the trauma narrative. This may explain the mixture of methods used in this category, where song writing can be used for reconstructing the trauma narrative, and improvisation for exploring less conscious reactions, and movement through a range of other activities can provide opportunities for moving back into relationship building and re-establishing safety.

van der Kolk's ( 2015 ) work provides a good theoretical framework for this category, with an emphasis on finding ways to be fully alive and engaged. Self-exploration within a safe therapeutically contained relationship is critical to this grouping, which is all contributed by trained professional psychotherapists specializing in music—music therapists. Carefully managed, expressive arts-based activities can be useful in re-establishing ownership of body and mind (van der Kolk et al., 2007 ) through becoming more familiar with ways of expressing the self—one's history, aspirations, relational capacities and hopes and dreams. This incorporates the emotional work noted by Herman ( 2015 ) in the second stage of remembrance and mourning, and having multiple creative methods available means that the therapist can circle back into safety and self-soothing, or forward into reconnection as required.

Performative

The distinction between personal work and recognition that war and abuse occur in a social context that condones or tolerates these adverse experiences is critical to the distinction between this and the previous category. The word performative has been selected because it encompasses this critical positioning [influenced strongly by Butler ( 2010 )], where identity is bought to life through words and actions rather than being an expression of something that is already fixed. This upends the notion that people's lives have been determined by their adverse experiences, and focuses on how certain affordances invite agency (Withagen et al., 2017 ), in this case, how public, creative affordances offered through musical performances can invite reconstruction of identity and also, advocate for social change.

As a critical scholar, Herman's ( 2015 ) final stage of recovery is aligned with the integration of private and public self that is demanded by the performative category. Other renowned critical scholars from outside the trauma field also provide an important framework for understanding. Freire's ( 1993 ) pedagogical theories for education are often applied in community, and emphasizes the importance of political performative acts to bring about social change. Similarly, arts-based approaches have been theorized with social justice agendas, such as Community Music Therapy (Stige et al., 2010 ) and Community Music more broadly (Bartleet and Higgins, 2018 ). Although not specifically theorized for those who have had adverse life experiences, these discourses do have oppressed and marginalized persons at their center, with an emphasis on society's responsibilities for the conditions that allowed abuse, rather than centralizing the individual's experiences of it and certainly not the neural pathways in the brain.

This category is therefore not restricted to contributions by qualified therapists, but also includes community artists, public health researchers, and other allied health practitioners working in community contexts. Groups are privileged because of the opportunities they afford for internal as well as public-facing performances, and the benefits are linked to these social possibilities. Interestingly, they are reported most often by privileged practitioners in first world economies working with people from marginalized backgrounds, including people traumatized through experiences of war in other countries.

This critical interpretive synthesis grew from a shared frustration with a set of literature that seemed to conflate a range of theories about trauma and music-based practices. Ideas about how rhythm influences brain activity were used as a rationale for a wide range of music-based experiences that placed little emphasis on rhythm. The possibilities of bypassing damaged areas of the brain through musical engagement seemed to draw attention away from critical therapeutic processes built through safety and containment. Beliefs about what music could do to the brain seemed to override fundamental therapeutic tenets such as responsiveness, compassion and careful exploration of repressed material through music. This enthusiasm for a scientific rationale seemed to bear little relevance to our shared experiences of working with young people who had adverse childhood experiences as teachers, therapists and researchers.

By first asking specific questions of the literature and extracting data into discrete categories, we were able to identify where patterns existed and where no patterns could be discerned. For example, the theoretical rationales provided for most programs did not bear direct relevance to the specific type of music-based methods being used. We hope that this synthesis will encourage authors to articulate more clear lines of argument in the future. In addition, it became evident that there were high levels of bias in the research of all types, with little reflexivity, use of control groups, or any other strategies that might support a more scientific assertion of why music might be helpful for traumatized individuals and groups. Sometimes this was overt, such as when people's explicit intentions were to demonstrate how valuable their program had been, and other times it was covert but still missing. There was also little explanation for why specific music methods were used or how that decision related to the intended outcome. The inclusion of this information would benefit readers and scientists alike.

In order to make the discourse more amenable to scientific standards, a more coherent approach may be helpful that involves congruent connections between intentions, rationales, music methods, benefits and research methodologies. This is relatively straight forward when designing programs that target entrainment or stabilization—specific music methods should be linked to predictable outcomes if it is proposed that they will be activated through neural mechanisms, and these can be measured and compared to control conditions. Michael Thaut has modeled this approach in rehabilitation (2015), and appropriately advocates for strict application in order for this to be effective. By contrast, programs that have expressive or performative purposes do not rely on understanding music as a variable but instead draw more on sociological notions of music affording possibilities for constructing self-understandings and enacting social critique. In this context, multiple methods may lead to benefits at different times depending on what is needed by the individual of group in a given moment, with particular attention being paid to safety in the context of trauma. Subjective and emancipatory research is more congruent with these values and would benefit the field. One approach that might address the need for greater scientific basis would be to systematically compare different approaches to determine if there are differences in outcomes, which would confirm the necessary connections between inputs and outcomes. This would suit the first two categories of stabilization and entrainment, but might not capture the complexity of the second two, which would demand the inclusion of more subjective views collected through qualitative data, reflexively analyzed.

In concluding, it is important to recognize the complexity of the lived experience of trauma. For people to have presented to services for support that are then documented in the manuscripts analyzed, we can assume that adverse experiences have had a profound experience on their lives. There was clearly a need for helpful, and perhaps evidence-based support. However, given the statistics available at a population level on the high level of abuse that is perpetrated in most societies, we must also recognize that the response to adverse experiences is idiosyncratic, not universal. Some people survive without need for expert support, some people develop inspiring resilience and thrive in the same society that allowed abuse to occur. Therefore, it is logical that not all people benefit from the same supports, for a range of reasons including personal readiness, trust in therapist and services, suitability of services etc. A spectrum of approaches is therefore necessary, and it would be inappropriate to advocate for one over the other, but rather to attend to the individual in context and determine what music-based approach would meet their needs and desires at a given moment in time.

Data Availability Statement

Author contributions.

KM conceived the project, conducted the analysis, and drafted the article. W-HC undertook the initial data extraction, supported by HL. AC contributed to conceptualization and offered feedback. HS, DA, and TC contributed to analysis and editing.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. This research was funded by internal grants from the Melbourne Social Equity Institute and Melbourne Engagement Grants at The University of Melbourne, Australia.

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Cochrane Colloquium Abstracts

Critical interpretive synthesis: what it is and why it is needed.

Article type Oral Year 2006 Dublin Authors Dixon-Woods M Abstract Background: The weaknesses of informal reviews are seen to derive from failures in their procedural specification and the tendency of the (thus) undisciplined reviewer to construct idiosyncratic theories and marshall the evidence accordingly, or to be chaotic or negligent in identifying the evidence. However, critiques of conventional systematic review methodology have focused on both the nature of the truth claims it can make and its inappropriateness for some forms of review question. Objectives: To propose Critical Interpretive Synthesis (CIS) as a way of synthesising diverse forms of evidence and illustrate its application to a review on access to health care. Methods: CIS draws both on traditions of qualitative research inquiry and on systematic review methodology, and can be used to synthesise qualitative and quantitative forms of evidence. It is explicitly oriented towards theory building; proposes an iterative and dynamic approach to question formulation, searching, and selection of materials for inclusion in reviews; treats the literature as warranting critical scrutiny in its own right by questioning its underlying assumptions; and achieves synthesis through a dialectic process between evidence and theory. It is explicitly reflexive about the 'authorial voice' that produces the account of the evidence. Results: Using CIS allows an identification of the limitations of studies of utilisation as a guide to explaining inequities in access to health care. It also allows the generation of a conceptual model that emphasises 'candidacy' as the core organising construct, and recasts access as highly dynamic and contingent, and subject to constant negotiation. Conclusions: CIS offers a way of synthesising diverse forms of evidence. It does not claim to be an inherently reproducible process or product, but can be defended on other grounds and may provide an important complement to more conventional forms of systematic review. PDF 5374-5368.pdf

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Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

2006, BMC medical research methodology

Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people&#39;s eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property ...

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• DOI: 10.1080/13645579.2020.1799637
• Corpus ID: 212631267

The critical interpretive synthesis: an assessment of reporting practices

• Joke Depraetere , C. Vandeviver , +1 author T. Beken
• Published in International Journal of… 31 August 2020

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What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework

• Caroline French 1 ,
• Anna Dowrick 2 ,
• Nina Fudge 1 ,
• Hilary Pinnock 3 &
• Stephanie J. C. Taylor 1  

BMC Medical Research Methodology volume  22 , Article number:  302 ( 2022 ) Cite this article

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Process evaluations aim to understand how complex interventions bring about outcomes by examining intervention mechanisms, implementation, and context. While much attention has been paid to the methodology of process evaluations in health research, the value of process evaluations has received less critical attention. We aimed to unpack how value is conceptualised in process evaluations by identifying and critically analysing 1) how process evaluations may create value and 2) what kind of value they may create.

We systematically searched for and identified published literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues . We conducted a critical interpretive synthesis and developed a practical planning framework.

We identified and included 147 literature items. From these we determined three ways in which process evaluations may create value or negative consequences: 1) through the socio-technical processes of ‘doing’ the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge. We identified 15 value themes. We also found that value varies according to the characteristics of individual process evaluations, and is subjective and context dependent.

The concept of value in process evaluations is complex and multi-faceted. Stakeholders in different contexts may have very different expectations of process evaluations and the value that can and should be obtained from them. We propose a planning framework to support an open and transparent process to plan and create value from process evaluations and negotiate trade-offs. This will support the development of joint solutions and, ultimately, generate more value from process evaluations to all.

Peer Review reports

By examining intervention mechanisms, implementation, and context, process evaluations aim to understand how complex interventions bring about outcomes, shed light on unanticipated effects, and inform optimal integration into existing practice [ 1 ]. They are often conducted alongside outcome/effectiveness evaluations of complex interventions, including trials, pilot and feasibility studies, and implementation studies [ 1 ]. As recognition has grown that outcome/effectiveness evaluations often provided insufficient understanding of increasingly complex interventions and their effects in different contexts, process evaluations have become increasingly common [ 1 ].

Health research funding and commissioning bodies in the UK, including the Medical Research Council [ 1 ], National Institute for Health and Care Research [ 2 ], and Public Health England (now the UK Health Security Agency) [ 3 ], highlight benefits of including process evaluations with evaluations of complex interventions. Their importance is also recognised internationally [ 4 , 5 ], and in other fields such as education [ 6 ]. However, process evaluations have potential disadvantages, including Hawthorne effects [ 3 ] and participant burden [ 7 ]. There are also possible challenges to conducting process evaluations, including under-resourcing [ 1 ], and the complexity of interventions and contexts being evaluated [ 8 ].

Questions about how to do process evaluations have been substantially addressed in the literature [ 1 , 9 ], however to our knowledge the concept of the ‘value’ of process evaluations has not been systematically critically examined. In scoping for this review, we noted that authors often used value-laden but ambiguous adjectives, such as ‘high-quality’, ‘useful’ or ‘necessary’ to describe aspects of process evaluation and process evaluation knowledge, without defining these terms. Some aspects of value have been considered, including whether process evaluations can satisfactorily meet the aim of explaining outcomes [ 10 ], the value of pragmatic formative process evaluation [ 11 ], and the reported value of process evaluations in pragmatic randomised controlled trials (RCTs) [ 12 ]. O’Cathain et al. [ 13 ] investigated the value of combining RCTs and qualitative research but did not specifically examine process evaluations.

Recommendations and assertions about value are likely to reflect authors’ ontological and epistemological standpoints [ 8 ], and accordingly there are a variety of interpretations of ‘optimal’ process evaluation design and conduct in the literature. For example, the MRC process evaluation guidance [ 1 ] outlines ontological and epistemological debates about how aspects of process such as fidelity and intervention mechanisms may be conceptualised and studied. There are also paradigmatic differences in how complex interventions are conceptualised [ 14 ], which impact perspectives on what a process evaluation should be and do.

The concept of “value” in research is multifaceted, with diverse definitions such as ”why we do things, what is important, and to whom” [ 15 ]; “the established collective moral principles and accepted standards of persons or a social group; principles, standards or qualities considered worthwhile or desirable” [ 16 ]; and “ contribution, impact and success” [ 13 ]. Research value is also commonly described in terms of impact, and various typologies and frameworks for categorising and assessing research impact have been proposed [ 17 , 18 , 19 , 20 ]. Value is also often discussed in terms of financial value and reducing waste brought about through inefficient research processes [ 21 , 22 ].

In this paper we take a broad perspective on value, aiming to examine the different ways in which the ‘value’ of process evaluation is conceptualised and consider how and why perspectives may differ within the field. Essentially, we seek to establish what may be gained from process evaluation and for whom, potential negative consequences of process evaluations, and what is considered to make a ‘good’ or ‘useful’ process evaluation. In agreement with O’Cathain et al.’s [ 13 ] rationale for studying the value of qualitative research in RCTs, we believe taking stock of, and critically analysing the value of process evaluation in its broadest sense is important to advance the methodological knowledge base.

We also believe developing a planning framework of process evaluation value provides practical assistance to researchers designing process evaluations. By making explicit at the outset different expectations of value by different stakeholders, potential tensions may be addressed [ 16 ]. Given that process evaluation researchers likely need to prioritise which aspects of interventions to examine and may choose from a wide selection of methods and frameworks [ 1 ], we suggest it pertinent to address the question ‘what do we want to get out of this process evaluation?’ before addressing the question ‘how are we going to do this process evaluation?’.

Our aims were to identify and critically analyse 1) how process evaluations may create value and negative consequences, and 2) what kind of value process evaluations may create.

We conducted a critical interpretive synthesis, broadly following the approach outlined by Dixon-Woods et al. [ 23 ]. Accordingly, we aimed to synthesise a diverse body of literature to develop a conceptual framework of a concept (value) that has not been consistently defined and operationalised in this context (process evaluation). The critical interpretive synthesis approach is inductive and interpretive, with the body of literature itself used as an object of analysis as well as individual papers, for example by questioning the inherent assumptions behind what is said and not said [ 23 ]. Dixon-Woods et al. [ 23 ] describe critical interpretive synthesis as an approach to review and not exclusively a method of synthesis, and do not prescribe a step-by-step method of operationalising their approach. Accordingly, we adopted the basic principles of their approach and adapted it to suit this body of literature, the aims of this review, and our available resources.

Since there has been little previous research into the value of process evaluations, we based this review on literature including process evaluation guidance, opinions about process evaluations, and discussion of methodological and practical issues. Thus, we considered what authors were stating about process evaluations and their value in texts such introductions, discussions, opinion pieces, and editorials, as well as any research findings we did locate in the searches.

Search strategy

We searched for literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues.

We searched the following sources:

Reference lists of four major process evaluation frameworks [ 1 , 4 , 9 , 24 ]

Forward citation searches of the same four process evaluation frameworks using Web of Science and Google Scholar

Medline database search for articles with term “process evaluation*” in title; limited to English language

Scopus database search for articles with term “process evaluation*” in title; limited to English language; subjects limited to medicine, social sciences, nursing, psychology, health professions, pharmacology, dentistry

ETHOS database for PhD theses with term ‘process evaluation’ in the title (excluded in updated search)

Literature items not located by the searches but which we knew contained relevant information about process evaluation from our work in this field, such as broader guidance documents about evaluation methods containing sections on process evaluation.

CF originally conducted the search in September 2017 and updated it in January 2021. In the updated search we excluded the ETHOS database search due to time constraints.

Definition of process evaluation

We used the definition of process evaluation provided in the Medical Research Council’s process evaluation guidance [ 1 ] when selecting items for inclusion: ‘a study which aims to understand the functioning of an intervention, by examining implementation, mechanisms of impact, and contextual factors’. We chose this definition because the MRC’s process evaluation guidance is extensive and widely cited, and we considered its definition comprehensive.

Screening, inclusion, and exclusion criteria

We did not aim to include every item of relevant literature, rather to systematically search for and select literature most relevant to our aims. For example, literature on mixed-methods research and process evaluation concepts such as fidelity would have been relevant, however we only included those focusing on the overall concept of process evaluation. Although we only searched health-related sources, we did not limit inclusion to the field of health.

Inclusion criteria

We included published literature (including editorials, letters, commentaries, book chapters, research articles) that met all the following criteria:

Used the term ‘process evaluation’ in line with the above definition

Discussed process evaluation in any field, providing ‘process evaluation’ met the definition above

Discussed process evaluation accompanying any kind of outcome/effectiveness evaluation, intervention development work, or standalone process evaluation

Exclusion criteria

Items in which term ‘process evaluation’ is used to describe an evaluation not meeting the definition in our review

Items which only reported process evaluation protocols or findings – these were only included if they also discussed wider process evaluation issues (e.g. methodological, operational)

No full-text available online

Not in English language

Results screening

CF screened the titles and abstracts of all results, obtaining full texts where necessary to aid decisions.

Data analysis and synthesis

We did not conduct quality appraisal of the included literature as we selected diverse items such as editorials, and synthesised whole texts as qualitative data, rather than aggregated research findings.

This review was inductive and we did not start out with a priori concepts or categories about how process evaluations create value or the type of value they create. We kept in mind however the value system of ‘process’, ‘substantive’ and ‘normative’ values outlined by Gradinger et al. [ 16 ] to sensitise us to values possibly stemming from 1) the conduct of process evaluation; 2) the impact of process evaluation or 3) the perceived intrinsic worth of process evaluation, respectively. We considered ‘value’ in its broadest possible sense, and examined what authors stated, implied, and discussed about what may result from a process evaluation (both positive and negative), the purposes of process evaluation, and what makes a ‘good’ or ‘useful’ process evaluation.

Following the critical interpretive synthesis approach [ 23 ], we also aimed to be critical through questioning the nature of assumptions and proposed solutions relating to process evaluation issues discussed in the literature. This enabled us to examine how authors covering diverse fields and types of process evaluation variously perceived value in different contexts.

CF initially undertook this work as part of her PhD from the original search results in September 2017 with 109 included items (see Fig.  1 ). Following initial reading of all items to gain familiarity she began the detailed analysis of approximately one third of randomly selected papers ( n  = 40) by extracting sections of text relating to how process evaluations create value and types of value that may be created. She organised these into an initial coding framework, using NVivo to manage the data and noting impressions of the overall literature. She then used this framework to code the remaining items ( n  = 69), amending the framework as necessary. A further 38 literature items were identified following the updated search in January 2021 (see Fig.  1 ), which CF coded in the same way, further refining the framework.

PRISMA flow diagram

Dixon-Woods et al. [ 23 ] describe the benefits of a multidisciplinary team approach to the whole review and synthesis process. As this paper reports work initiated through individual doctoral work we decided to strengthen and deepen the analysis by independently double coding a total of 36 of the total 147 items (approximately 25%). We used purposive sampling to select the 36 papers for double coding, selecting papers with varied characteristics (year of publication, country of lead author, field of practice, and focus of paper). Four authors coded nine papers each using the coding framework developed by CF, also noting any new themes, interpretations, and areas of disagreement. We brought these to a team discussion to refine the themes and develop the final analysis. We developed this double coding approach as a pragmatic solution to incorporating multiple perspectives into the synthesis, based on our experience of conducting similar narrative reviews and team qualitative data analysis.

From the resulting themes, notes on interpretations, and team discussions we created a narrative and conceptual framework of our analysis, along with a practical planning framework for researchers designing process evaluations.

Search results

We included 147 literature items, and our search results are shown in Fig.  1 .

Table 1 shows characteristics of the included literature items, with a detailed summary table in additional file 1 .

Critical interpretive synthesis overview

Figure  2 provides an overview of the findings of this synthesis.

Overview of synthesis findings

As shown in Fig.  2 , we identified three ways in which process evaluations may create value: 1) through the socio-technical processes of ‘doing’ the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge.

From these three ways in which process evaluations may create value we identified 15 value themes. Many of these 15 themes included both positive and potentially negative consequences of process evaluations. Value and negative consequences may be created for many different stakeholders, including research participants, researchers, students, funders, research commissioners, intervention staff, organisations, practice settings, research sites, interventions, practice outcomes, and outcome evaluations.

However, as shown in the box describing process evaluation characteristics in Fig.  2 , process evaluations may vary widely in terms of 1) which processes are evaluated 2) how these processes are evaluated, 3) the practical conduct of the process evaluation, and 4) how process evaluation knowledge is disseminated. Value is therefore at least partially contingent on the characteristics of individual process evaluations.

Finally, process evaluations are designed, conducted, and their knowledge applied in many different contexts. We found different stakeholders in different contexts may have different perspectives on what is valuable, meaning the value created by process evaluations is subjective. We therefore noted potential tensions and payoffs between certain values.

Figure  3 provides an overview of the themes of value and shows how the themes relate to the three identified ways in which value may be created. We describe these findings in detail in Tables 2 , 3 , and 4 , including subthemes and examples from the synthesised literature. We then end this results section with a discussion of tensions between values.

Overview of the themes of value

Value created through the socio-technical processes of ‘doing’ the process evaluation

Many social and technical processes are involved in the design, conduct, and dissemination of process evaluation, and thus value and negative consequences may arise from the ‘doing’ of the process evaluation. Examples of socio-technical processes include collecting observational data at a research site, inviting a trial participant to participate in a process evaluation, and designing a questionnaire. These are all carried out by multiple human actors (for example researchers and research participants) using a variety of knowledge products (for example evaluation frameworks and research protocols). In Fig.  2 , these processes and actors are summarised under the heading ‘process evaluation characteristics’. Taking a stance that value is situated and formed out of context, the way in which these processes evolve have a direct impact on the value that can be derived from a process evaluation. We identified six themes of value stemming from socio-technical processes:

Relationships

Giving people a voice

Ethical issues

Impact on the outcome evaluation

Table 2 shows the themes, subthemes, and examples of how socio-technical processes may create value from process evaluations.

Value related to the features/qualities of process evaluation knowledge

The second way in which process evaluations may create value relates to the features and perceived qualities of the knowledge they produce. The process evaluation characteristics outlined in Fig.  2 clearly lead to different kinds of process evaluation knowledge being produced, for example qualitative or quantitative. We identified three themes of value which relate to the features and qualities of process evaluation knowledge:

Knowledge credibility

Knowledge accuracy

Knowledge completeness

Table 3 outlines how process evaluation variables may impact on the perceived value of the knowledge that is produced.

Inevitably, some of the ways in which process evaluation knowledge may be inaccurate or incomplete described in Table 3 may be unavoidable. For example, it is likely impossible for financial, practical, and ethical reasons for process evaluations to investigate every potentially important aspect of an intervention [ 1 , 41 ]. Issues such as gatekeeping, self-selection bias, and social desirability bias are research challenges not unique to process evaluations. However, the literature suggests that process evaluation reporting is often suboptimal, with detail on methods lacking, choices about methodology and areas of enquiry not justified [ 9 , 34 , 40 , 55 , 63 , 71 , 97 , 131 ], and limited discussion of quality, validity, and credibility [ 9 , 40 , 63 , 90 ]. This suggests inaccuracy and incompleteness of process evaluation knowledge may not always be acknowledged.

Furthermore, some authors suggest that some process evaluation researchers do not recognise that their methods may be overly simplistic portrayals of reality, and therefore fail to consider important aspects of process [ 40 , 59 ]. Some papers conceptualised process evaluation components as highly complex, suggesting that methods such as ethnography [ 34 ], realist evaluation [ 46 ], and the use of theoretical frameworks such as normalisation process theory [ 132 ] were necessary to fully capture what was going on. At the opposite end of the spectrum some papers conceptualised process evaluation components simplistically, for example equating whether or not intervention recipients enjoyed intervention components with their effectiveness [ 91 ]. A potential negative consequence of process evaluations therefore may be if knowledge is uncritically presented as providing explanations when researchers did not account for all factors or the true level of complexity. For example, assessing single dimensions of implementation may lead to ‘type III errors’ through incorrectly attributing a lack of intervention effect to a single implementation factor, when the actual cause was not investigated [ 40 , 117 ].

Value created by using process evaluation knowledge

The third way in which value and negative consequences may be created is through using the knowledge produced by process evaluations. Process evaluation knowledge may be used and applied after the evaluation. It may also be used formatively to make changes to interventions, implementation, contexts, and evaluation processes during the evaluation. Some experimental outcome evaluation methods prevent formative use of knowledge to maintain internal and external validity. We identified six themes of value stemming from the use of process evaluation knowledge:

Supporting implementation of interventions into practice

Informing development of interventions

Improving practice and outcomes

Contribution to wider knowledge

Financial value of knowledge

These are described along with sub-themes and examples in Table 4 .

Tensions within and between values

As well as identifying how process evaluations may create value and themes of value, we found that the concept of value in process evaluations is subjective and context-dependent, and there are tensions within and between values.

The value of process evaluation is not pre-existing but enacted and created through ongoing negotiation between those with a stake in what is being evaluated. Through designing and conducting a process evaluation and disseminating and using its knowledge, process evaluation actors and knowledge products may directly or indirectly create value and negative consequences for many different stakeholders and bystanders in different contexts. These include people and organisations who participate in research, conduct research, use research findings, receive interventions, work in research and practice settings, fund research, regulate research, or are simply present where process evaluations are being conducted. These groups and organisations have different expectations, values, and needs; and there is also variability within groups and organisations. This creates the potential for tension between expectations, values, and needs of different stakeholders.

We identified two broad perspectives on value. In the first, process evaluations are primarily valued for supporting the scientific endeavour of outcome evaluations, particularly trials. Examples of this include process evaluations being conducted to minimally contaminate or threaten interventions and outcome evaluations, with the generated knowledge applied post-hoc and providing retrospective understanding [ 87 , 118 ]. Formative monitoring and correction of implementation aims to ensure internal validity [ 24 , 44 , 48 , 77 , 93 , 94 ]. Value is framed around meeting the needs of the outcome evaluation, such as through complementing trial findings [ 9 ], and the perceived utility of findings may be contingent on what happens in an outcome evaluation [ 133 ]. They are also framed around the needs of researchers and systematic reviewers. For example, calls for them to include set components to make them less daunting to conduct and enable easier cross-study comparison [ 1 , 5 , 24 , 57 , 58 ].

In the second perspective process evaluations are mostly valued for formatively contributing to intervention development, improving practice, and forging relationships with stakeholders. Evaluating implementation may allow for the adaptation and tailoring of interventions to local contexts [ 1 ], which may result in them being more patient-centred [ 126 ], with better fit and feasibility in local settings [ 55 ]. Process evaluations may be seen as opportunities to utilise methodologies with different ontological and epistemological assumptions to RCTs, with flexible designs that are tailored to the uniqueness of each intervention and setting [ 34 , 67 ]. These process evaluations are more likely to find multiple nuanced answers, reflecting assumptions that reality is unpredictable and complex, and that interventions are most effective when adapted to different contexts. These seem more concerned with giving participants voices and uncovering messy realities, developing effective sustainable interventions, and through these, improving outcomes [ 33 , 60 ].

Some authors give examples of process evaluation designs which may capitalise on both perspectives on value. In-depth realist formative process evaluations at the stage of piloting interventions incorporate the benefits of developing and theorising effective, sustainable, adaptable interventions that are tailored to local contexts, which can then be tested in a rigorous outcome evaluation [ 46 ]. Pragmatic formative process evaluations theorise interventions which are already in practice and optimise implementation in readiness for outcome evaluations [ 11 , 35 ].

The literature also contains examples of tensions between these two perspectives. For example, process evaluation methods that enhance engagement with participants may increase the effect of the intervention, which may be seen as desirable [ 32 ] or a problematic Hawthorne effect [ 1 ]. If data from summative process evaluations reveal problems with interventions or implementation during the evaluation, this can raise ethical and methodological dilemmas about whether to intervene [ 42 , 43 ]. Riley et al. suggested process data monitoring committees as forums for debating such contentious scenarios to address these issues [ 43 ]. Others highlighted the importance of stakeholders having clear expectations about the value that process evaluations may create and when, to avoid tensions stemming from unmet expectation. Examples include establishing clear mandates with intervention staff about when they will receive feedback on their delivery [ 31 ] and how their data will improve interventions [ 89 ].

Summary of findings

Process evaluations do not have value a priori. Their value is contingent on the features and qualities of the knowledge they produce, and the socio-technical processes used to produce that knowledge. There is also potential to create consequences that may be perceived negatively. However, there are not simple definitive answers to the questions ‘what kind of value do/should process evaluations create?’ or ‘how do/should process evaluations create value?’. This is because:

The label ‘process evaluation’ may be applied to many different types of studies producing diverse kinds of knowledge and using diverse socio-technical processes.

Process evaluations are undertaken in different research and practice contexts in which different kinds of knowledge and socio-technical processes may be perceived as more or less valuable or desirable.

Process evaluations are undertaken by researchers with differing ontological and epistemological standpoints and research traditions, who have different views on what constitutes high-quality, useful, and valuable knowledge.

Theoretical considerations

Our analysis shows that part of the challenge of interpreting the value of process evaluation is that researchers and other stakeholders are debating value from different ontological and epistemological starting points. These tensions resonate with the wider literature on qualitative research with quantitative outcome evaluation [ 13 , 45 , 134 , 135 ], and how complex interventions should be conceptualised and evaluated [ 136 , 137 , 138 ].

There are tensions between values, particularly payoffs between optimising value to outcome evaluations and triallists, and optimising value to intervention development and relationship-building. While the professed aims of both are to improve practice and outcomes for intervention recipients and to advance knowledge, the beliefs about how this is best achieved often differ. For example, process evaluation researchers with a more positivist stance likely believe a positive primary outcome result with high internal validity is most likely to ultimately improve practice and outcomes. They may therefore value process evaluations which minimally contaminate interventions and measure fidelity. Process evaluation researchers with a more interpretivist stance likely believe in-depth understanding of the experiences of intervention recipients is more likely to ultimately improve practice and outcomes. They could therefore value process evaluations which engage participants in more in-depth data collection methods.

While it is beyond the scope of this paper to debate the relative merits of these paradigmatic differences, ontological and epistemological perspectives appear to strongly influence perspectives on what kind of knowledge it is valuable for process evaluations to generate. This demonstrates the importance of making ontological and epistemological perspectives explicit when discussing how to design and conduct process evaluations, for example in process evaluation guidance and frameworks [ 8 ].

We also encourage researchers to take stock of these different perspectives on value and critically reflect on whether concentrating value on one perspective potentially misses the opportunities to create value offered by another. For example, through the aim of minimally contaminating interventions are opportunities missed to engage stakeholders who could assist with intervention improvement and post-evaluation implementation? Are there potential ways to combine both approaches to process evaluation? As highlighted in our analysis, in-depth formative process evaluations in the intervention development and feasibility testing stages offer this opportunity [ 46 ]. Furthermore, the newly updated Medical Research Council Framework for evaluating complex interventions [ 138 ] (published after we completed the searches for this review) states “A trade-off exists between precise unbiased answers to narrow questions and more uncertain answers to broader, more complex questions; researchers should answer the questions that are most useful to decision makers rather than those that can be answered with greater certainty” . This suggests pragmatic weighing-up of the overall value created by process evaluations will become increasingly significant.

Practical applications

Our findings have practical applications for researchers designing process evaluations to be intentional in creating value and avoiding negative consequences. We recommend that since process evaluations vary widely, before researchers ask: ‘how do we do this process evaluation? they ask: ‘what do we want to get out of this process evaluation?’. Process evaluations will create value, and potentially negative consequences regardless of whether it is planned, so we suggest purposefully and explicitly preparing to create value in conjunction with stakeholders.

Figure  4 shows a planning framework to be used in conjunction with Fig.  3 and the analysis in this paper to aid this process. As would be good practice in any research, we recommend these discussions include as many stakeholders as possible, including intended beneficiaries of research, also reflecting the possible diversity of research backgrounds and epistemological standpoints within research teams. This would help guide decisions around design, conduct, and dissemination by making expectations of value explicit from the outset, addressing potential tensions, and ensure contextual fit. While the nature of any accompanying outcome evaluation will influence expectations of value, it is useful for stakeholders to be aware of potential payoffs and ensure there is a shared vision for creating value. This will likely also aid researchers to narrow the focus of process evaluation to make it more feasible and best allocate resources, as well as highlighting its value to stakeholders without relevant knowledge and experience.

Process evaluation planning framework

Strengths and limitations

We included a large number of literature items relating to process evaluations in diverse contexts, which enabled us to synthesise a broad range of perspectives on value and highlight how value may be context dependent. This will enable readers to apply findings to their own contexts. Nonetheless our review does not include all literature that could have been informative, and therefore the values and issues identified are unlikely to be exhaustive. Furthermore, author texts we extracted as data for our review may have been influenced by expectations and limitations of publishing journals. Exploring the concept of value by reviewing the literature only captures perspectives which authors have decided to publish, and other aspects of value are likely to be uncovered through empirical study of process evaluation practice.

Although we have outlined our review methods as explicitly as possible, in line with critical interpretive synthesis the review was by nature interpretive and creative, therefore full transparency about step-by-step methods is not possible [ 23 ]. We present our interpretation of this body of literature and acknowledge that this will have been influenced by our pre-existing opinions about process evaluation. Nonetheless our team included researchers from different backgrounds, and through a double-coding process and reflective team discussion ensured we did not unduly focus on one aspect of value or prioritise certain perspectives.

Conclusions

Process evaluations vary widely and different stakeholders in different contexts may have different expectations and needs. This critical interpretive synthesis has identified potential sources of and themes of value and negative consequences from process evaluations, and critically analysed potential tensions between values. Accommodating all needs and expectations of different stakeholders within a single process evaluation may not be possible, but this paper offers a framework to support an open transparent process to plan and create value and negotiate trade-offs. This supports the developments of joint solutions and, ultimately, generate more value from process evaluations to all.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

randomised controlled trial

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CF was funded by a PhD studentship awarded by Queen Mary University of London. This report is independent research supported by the National Institute for Health and Care Research ARC North Thames. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care .

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French, C., Dowrick, A., Fudge, N. et al. What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework. BMC Med Res Methodol 22 , 302 (2022). https://doi.org/10.1186/s12874-022-01767-7

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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See an example

Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

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.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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Qualitative Synthesis Methods: Critical Interpretive Reviews, Narrative Reviews, Expert Opinions

To view in your browser and/or download the article, click on the PDF below. 

Synthesis as a research method is frequently defined as the integration of multiple sources of data to generate new findings, to increase the statistical power of an analysis, or to broaden the spatial or temporal inference of results. (Also see Carpenter et al. 2009, Hackett et al. 2016.) With individual datasets that are in the same format or those that can be harmonized, 1   researchers can combine them into a single database and subject them to a traditional statistical analysis. Socio-environmental research, however, brings together information from many disciplines and in many forms—including both quantitative and qualitative data. Thus, it is not always possible to use data-focused statistical methods. Further, it is not always desirable to do so because synthesis goals may be related to elaborating perspectives or generating theory rather than evaluating evidence to support a specific question. 

Qualitative and semi-qualitative syntheses help accomplish those goals. They may rely on published or unpublished work and usually are done by scholars with deep knowledge of the topic. However, they may also involve input from non-specialists, especially individuals who are in a position to use the synthesis results to inform policies, management, or practices. In the following sections of this explainer, brief overviews of three types of qualitative review approaches are provided. For more information on these see: Dixon-Woods et al. 2006; Popay et al. 2006; Edwards et al. 2016.

Critical Interpretive Reviews  

A critical interpretive review integrates the methods used in systematic reviews with a qualitative tradition of inquiry. It may clearly delineate how sources of information were selected, but it does not seek to draw conclusions based on all relevant sources or to say what “all the evidence” suggests. Rather, it seeks to generate a framework or theory by interpreting or critiquing a group of studies that are often qualitative in nature. And it uses an interactive and iterative process for collecting information to address a question that may actually evolve over time during the review process. Offering qualitative insights on a topic, critical interpretive reviews often appear in work that requires some subjective insights. McDougall (2015) discusses it well in her article on bioethics research. A socio-environmental example comes from work by Hirons (2021) who used critical interpretive review methods to synthesize selected research. He used synthesis to reflect on key issues and future prospects related to “natural climate solutions” and the extent to which those solutions deliver on their "promises” depends on governance.

Narrative Reviews

In the context of synthesis, a narrative review is interpretative in nature and aimed at developing or advancing concepts, theories, or “plausible truths” (as understood or defined by   Greenhalgh et al. 2018). It can read very much like a standard scientific paper, or it can use a story-like narrative summary to explain findings, views, and perspectives based on the author’s knowledge. It usually starts as a broad question or topic and evolves over the course of the synthesis process. Policy makers or other stakeholders may be involved in the process when the purpose of the review is to inform decisions. Often, however, the review is by a scholar with broad knowledge of the field and some perspective on work that has been done on the topic. The review process may involve using tools to analyze textual documents and extract themes, but it can also involve tabulating information, categorizing it as a group, and counting votes. A socio-environmental example comes from work by Froeling et al. (2021) who provided a narrative review to “promote” (their words) the understanding and application of citizen science in environmental epidemiology. They cite literature extensively to bolster their explanations and arguments but do not describe any type of systematic evaluation of the literature. 

Expert Opinions

Expert opinions play a significant role in evaluating or developing policies or procedures in a variety of fields but particularly in the health sciences and natural resource management. There is now wide recognition that policies are more equitable when a broad range of people contribute to their development, and they are also more likely to have traction. How opinions are collected range from highly structured, scientific approaches (e.g., see expert elicitation methods in the SESYNC Explainer: Quantitative Synthesis Methods: Literature Reviews, Expert Elicitation ) to very informal methods based on conversations. Many socio-environmental studies rely only on the research team and its discussions or critical evaluations of material as the expert sources. For example, Weiskopf et al. (2022) developed recommendations for improving decision makers' uptake of socio-ecological models based on discussions among the authors who had e xtensive experience in modeling . Increasingly, researchers are extending their definition of “experts” much more broadly to bring in more diverse types of knowledge, which may lead to more sustainable decisions  e.g., Albuquerque et al. 2021.

1  Data harmonization is the process of building a composite dataset after ensuring data are in a consistent, standardized format. Often, this process involves converting data to common units, but sometimes, data on the same topic has been collected using different methods or at different scales, and thus researchers must use modeling or other tools to make them comparable. References: Albuquerque, U.P., Ludwig, D., Feitosa, I.S. et al. (2021). Integrating traditional ecological knowledge into academic research at local and global scales.  Regional Environmental Change,  21(2) : 1-11. https://doi.org/10.1007/s10113-021-01774-2

Carpenter, S.R. et al. (2009). Accelerate synthesis in ecology and environmental sciences. BioScience, 59 : 699–701. https://doi.org/10.1525/bio.2009.59.8.11

Dixon-Woods, M., Cavers, D., Agarwal, S. et al. (2006) Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Medical Research Methodology,  6(35) . https://doi.org/10.1186/1471-2288-6-35

Edwards, J., & Kaimal, G. (2016). Using meta-synthesis to support application of qualitative methods findings in practice: A discussion of meta-ethnography, narrative synthesis, and critical interpretive synthesis.  The Arts in Psychotherapy,   51 : 30-35. https://doi.org/10.1016/j.aip.2016.07.003

Froeling, F., Gignac, F., Hoek, G., Vermeulen, R. et al. (2021). Narrative review of citizen science in environmental epidemiology: Setting the stage for co-created research projects in environmental epidemiology. Environment International, 152 : 106470. https://doi.org/10.1016/j.envint.2021.106470

Greenhalgh, T., Thorne, S., & Malterud, K. (2018). Time to challenge the spurious hierarchy of systematic over narrative reviews?  European Journal of Clinical Investigation   48(6) : e12931. https://doi.org/10.1111/eci.12931

Hackett, E.J., & Parker, J.N. (2016). From Salomon's house to synthesis centers. In: Heinze, T., Muench, R. (Eds.), Innovation in Science and Organizational Renewal: Historical and Sociological Perspectives . (pp. 53–88). Palgrave Macmillan New York.

Hirons, M. (2021). Governing natural climate solutions: prospects and pitfalls.  COSUST 52 : 36-44. https://doi.org/10.1016/j.cosust.2021.06.012

McDougall, R. (2015). Reviewing literature in bioethics research: increasing rigor in non-systematic reviews. Bioethics 29 : 523-528. https://dx.doi.org/10.1111/bioe.12149

Popay, J., Roberts, H., Sowden, A. et al. (2006). Guidance on the Conduct of Narrative Synthesis in Systematic Reviews: A Product from the ESRC Methods Programme,  Version, 1(1), b92.

Weiskopf, S.R., Harmáčková, Z.V., Johnson, C.G., Londoño-Murcia, M.C., Miller, B.W., Myers, B.J., Pereira, L, Arce-Plata, M.I., Blanchard, J.L., Ferrier, S., & Fulton, E.A. (2022). Increasing the uptake of ecological model results in policy decisions to improve biodiversity outcomes. Environmental Modelling & Software,   149 : 105318.  https://doi.org/10.1016/j.envsoft.2022.105318

Margaret A. Palmer, SESYNC

Related Content

Approaches and methods to integrate diverse socio-environmental data, combining diverse data to address a problem: climate and education outcomes example, introduction to qualitative methods for sustainability lesson: narrative and identity in climate beliefs, qualitative data for sustainability problems: an example integrating textual data, anthropological research methods, quantitative synthesis methods: literature reviews (systematic and meta-analyses), expert elicitation.

• Open access
• Published: 02 January 2022

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

• Faith Boutcher 1 ,
• Whitney Berta 2 ,
• Robin Urquhart 3 &
• Anna R. Gagliardi 4  

BMC Health Services Research volume  22 , Article number:  11 ( 2022 ) Cite this article

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Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Peer Review reports

Contributions to the literature

MMs may play an important KB role in healthcare organizations.

Additional support for the MM KB role may help enhance quality of care in healthcare settings.

An improved understanding of MM KBs will contribute to this nascent area of inquiry in health care.

Health systems are under increasing pressure to improve performance including productivity, quality of care, and efficiency in service delivery. To promote optimal performance, health systems hold healthcare organizations such as hospitals accountable for the quality of care they provide through accountability agreements tied to performance targets [ 1 , 2 ]. Despite such incentives, healthcare organizations face considerable challenges in providing high-quality care and research continues to show that the quality of hospital-based care is less than ideal [ 3 , 4 , 5 ]. Some researchers contend that this is attributed, in part, to the challenges that healthcare organizations face when integrating new knowledge into practice. Some challenges include dedicating sufficient resources to adopt or implement evidence-informed innovations that enhance service delivery and optimize patient health and outcomes [ 6 ].

Healthcare organizations use knowledge translation (KT) approaches to promote the use of evidence-based practices intended to optimize quality of care. The use of knowledge brokers (KBs) is one such approach. KBs are defined as the human component of KT who work collaboratively with stakeholders to facilitate the transfer and exchange of knowledge in diverse settings, [ 7 , 8 , 9 ]. KBs that facilitate the use of knowledge between people or groups have been referred to as opinion leaders, facilitators, champions, linking agents and change agents whose roles can be formal or informal [ 10 , 11 ]. These “influencer” roles are based on the premise that interpersonal contact improves the likelihood of behavioral change associated with use or adoption of new knowledge [ 12 ]. Research shows that KBs have had a positive effect on increasing knowledge and evidence-based practices among clinicians in hospitals, and on advocating for change on behalf of clinicians to executives [ 13 , 14 , 15 ]. However, greater insight is needed on how to equip and support KBs, so they effectively promote and enable clinicians to use evidence-based practices that improve quality of care [ 13 , 16 , 17 ].

Middle managers (MMs) play a pivotal role in facilitating high quality care and may play a brokerage role in the sharing and use of knowledge in healthcare organizations [ 18 , 19 ]. MMs are managers at the mid-level of an organization supervised by senior managers, and who, in turn, supervise frontline clinicians [ 20 ]. MMs facilitate the integration of new knowledge in healthcare organizations by helping clinicians appreciate the rationale for organizational changes and translating adoption decisions into on-the-ground implementation strategies [ 18 , 19 ]. Current research suggests that MMs may play an essential role as internal KBs because of their mid-level positions in healthcare organizations. Some researchers have called for a deeper understanding of the MM role in knowledge brokering, including how MMs enact internal KB roles [ 16 , 17 , 18 , 19 , 21 ].

To this end, further research is needed on who assumes the KB role and what they do. Prior research suggests that KBs may function across five key roles: knowledge manager, linking agent, capacity builder, facilitator, and evaluator, but it is not clear whether these roles are realized in all healthcare settings [ 7 , 21 , 22 ]. KBs are often distinguished as external or internal to the practice community that they seek to influence, and most studies have focused on external KBs with comparatively little research focused on the role of internal KBs [ 7 , 9 , 17 , 23 , 24 ]. To address this gap, we will focus on internal KBs (MMs) who hold a pivotal position because their credibility and detailed knowledge of local context allows them to overcome the barriers common to external KBs. One such barrier is resistance to advice from external sources unfamiliar with the local context [ 25 ].

With respect to what KBs do, two studies explored KB roles and activities, and generated frameworks that describe KB functions, processes, and outcomes in health care [ 7 , 22 ]. However, these frameworks are not specific to MMs and are limited in detail about KB roles and functions. This knowledge is required by healthcare organizations to develop KB capacity among MMs, who can then enhance quality of care. Therefore, the focus of this study was to synthesize published research on factors that influence the KB roles, activities, and impact of MMs in healthcare settings. In doing so, we will identify key concepts, themes, and the relationships among them to generate an organizing framework that categorizes how MMs function as KBs in health care to guide future policy, practice, and research.

We used a critical interpretive synthesis (CIS) to systematically review the complex body of literature on MM KBs. This included qualitative, quantitative, and theoretical papers. CIS offers an iterative, dynamic, recursive, and reflexive approach to qualitative synthesis. CIS was well-suited to review the MM KB literature than traditional systematic review methods because it integrates findings from diverse studies into a single, coherent framework based on new theoretical insights and interpretations [ 26 , 27 ]. A key feature that distinguishes CIS from other approaches to interpretive synthesis is the critical nature of the analysis that questions the way studies conceptualize and construct the topic under study and uses this as the basis for developing synthesizing arguments [ 26 ]. We ensured rigor by complying with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) criteria (Additional file  1 ) and other criteria of trustworthiness [ 28 , 29 ]. We did not register a protocol for this review.

With a medical librarian, we developed a search strategy (Additional file  2 ) that complied with the evidence-based checklist for peer review of electronic search strategies [ 30 ]. We included Medical Subject Headings and keywords that captured the concepts of MMs (e.g., nurse administrator, manager), explicit or non-explicit KB roles (e.g., diffusion of innovation, dissemination, broker, and facilitator), evidence-based practice (e.g., knowledge, evidence) and setting (e.g., hospital, healthcare, or health care). We searched MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC, and the Cochrane Library from January 1, 2001, to August 14, 2020. We searched from 2001 onward because the field of KT did not substantially investigate KBs until 2001 [ 7 , 21 ]. We reviewed the reference lists of eligible articles for additional relevant studies not identified by searches. As is typical of CIS, this was an iterative process allowing search terms to be expanded to optimize search results [ 26 , 31 ].

Eligibility

We generated eligibility criteria based on the PICO framework (population, intervention, comparisons, and outcomes) (Additional file  3 ). Populations refer to MMs functioning as KBs in hospitals or other healthcare settings but did not necessarily use those labels. Because the MM literature is emergent, we included settings other than hospitals (e.g., public health department, Veteran Affairs Medical Centres). We included studies involving clinical and non-clinical administrators, managers, directors, or operational leaders if those studies met all other inclusion criteria. The intervention of interest was how MM KBs operated in practice for the creation, use and sharing of knowledge, implementation of evidence-based practice(s), or innovation implementation. Study comparisons may have evaluated one or more MM KB roles, approaches and associated barriers, enablers and impacts alone or in comparison with other types of approaches for the sharing or implementation of knowledge, evidence, evidence-based practices, or innovations. Outcomes included but were not limited to MM KB effectiveness (change in knowledge, skills, policies and/or practices, care delivery, satisfaction in role), behaviors, and outcomes. Searches were limited to English language quantitative, randomized, or pragmatic controlled trials, case studies, surveys, quasi-experimental, qualitative, or mixed methods studies and conceptual papers. Systematic reviews were not eligible, but we screened references for additional eligible primary studies. Publications in the form of editorials, abstracts, protocols, unpublished theses, conference proceedings were not eligible.

FB and ARG independently screened 50 titles and abstracts according to the eligibility criteria and compared and discussed results. Based on discrepancies, they modified the eligibility criteria and discussed how to apply them. Thereafter, FB screened all remaining titles, and discussed all uncertainties with ARG and the research team. FB retrieved all potentially eligible articles. FB and ARG independently screened a sample of 25 full-text articles, and again discussed selection discrepancies to further standardize how eligibility criteria were applied. Thereafter, FB screened all remaining full-text items.

Quality appraisal

We employed quality appraisal tools relevant to different research designs: Standards for Reporting Qualitative Research (SRQR) [ 32 ], the Good Reporting of a Mixed Methods Study (GRAMMS) tool [ 33 ], Critical Appraisal of a Questionnaire Study [ 34 ], Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) tool [ 35 ], and the Critical Appraisal Checklist for Quasi-Experimental Studies [ 36 ]. FB and ARG independently assessed and compared the quality of a sample of seven studies each. Thereafter, FB assessed the quality of the remaining 24 studies.

Data extraction

We developed a data extraction form to extract information on study characteristics (date of publication, country, purpose, research design) and MM KB characteristics, roles, activities, enablers, barriers, and impacts. To pilot test data extraction, FB and ARG independently extracted data from the same 25 articles, then compared results and discussed how to refine data extraction. Thereafter, FB extracted data from remaining articles, which was independently checked by ARG, and then reviewed by the research team.

Data analysis

FB and ARG conducted an initial reading and coding of a sample of articles independently. Codes were assigned to significant elements of data within the results and conclusions sections of the eligible articles and grouped into relevant categories with shared characteristics and organized into preliminary themes. This was an iterative process that involved ongoing consultation with the research team, who provided feedback on the codes and themes.

We created a matrix of MM KB roles and activities from extant MM and KB theory [ 7 , 18 , 22 , 37 ] and deductively mapped themes from included studies with the matrix to help inform the analysis and interpretation of our findings. As per CIS methodology, we developed an integrative grid (matrix table) where themes pertaining to MM KB roles and activities formed columns, and themes mapped to those roles/activities from individual studies formed rows [ 31 ]. The grid helped us integrate the evidence across studies and explore relationships between concepts and themes to inductively develop synthetic constructs [ 31 , 38 ]. Using a constant comparative approach, we critiqued the synthetic constructs with the full sample of papers to identify conceptual gaps in the available evidence in relation to our aims, and to ensure that the constructs were grounded in the data [ 31 , 38 ]. Our interpretive reflections on MM KB roles, activities, factors, and impacts led us to develop “synthetic arguments” and we used the arguments to structure our findings (attributes, roles, activities, impacts, enablers, barriers) in an organizing framework to capture our interpretation of how MMs function as KBs in healthcare organizations. We used NVivo 12 software to assist with data analysis.

Search results

The initial search yielded 9936 articles. Following removal of duplicates, 9760 titles were not eligible, and 176 items were retrieved as potentially relevant. Of those, 135 were excluded because the study design was ineligible (25), they did not examine MMs (27) or MM KBs (34), were not focused on the evaluation of an MM KB role (39), were editorials (4), or the publication was a duplicate (6). We included 41 articles for review (Fig.  1 PRISMA flow diagram). Additional file  4 includes all data extracted from included studies.

PRISMA flow diagram

Study characteristics

Eligible articles were published between 2003 and 2019. Three (7.3%) were conceptual and 38 (92.7%) were empirical studies. Conceptual articles discussed MM and KB theoretical constructs. Table  1 summarizes study characteristics. Studies examined the impacts of change efforts (47.3%), barriers to practice change (34.2%), and evaluation of KB interventions (18.4%). Most were qualitative (52.6%) and conducted in the United States (36.8%). Of study participants (34.2%) were MMs. In most studies, participants were nurses (63.1%) or allied health (13.2%) and based in hospitals (68.4%). Otherwise, (31.6%) were based in public health or occupational health departments, primary health care centers, Veterans Affairs Medical Centres, community care, and a senior’s care facility.

Quality assessment findings

A critical analysis of the included studies revealed issues related to research design, varying from data collected from heterogeneous healthcare settings and diverse types of MMs to the type of analyses completed (e.g., qualitative, mixed methods), to the strength of conclusions drawn from a few studies’ results (e.g., correlational, or causal). Fifteen (39.5%) studies met the criteria for quality. Twenty-three (60.5%) studies had minor methodological limitations (e.g., no research paradigm identified in qualitative studies, and mixed methods studies did not describe the integration of the two methods) (Additional file  5 ). These methodological flaws did not warrant exclusion of any studies as they provided relevant insights regarding the emerging framework.

MM KB attributes

Seven (18.4%) studies described MM KB attributes (Table  2 ). Of those, 4 (10.5%) identified MM attributes, 2 (5.2%) identified KB attributes, and 1 (2.6%) identified nurse knowledge broker attributes. MM KBs were described as confident, enthusiastic, and experienced with strong research skills [ 41 , 45 ]. They were also responsive and approachable, with an understanding of the complexity of an innovation and the organizational context [ 42 , 43 , 44 ].

MM KB roles and activities

Table  3 summarizes themes pertaining to roles and activities. A total of 63 activities were grouped in the following 12 MM KB roles: (1) gather data, (2) coordinate projects, (3) monitor and evaluate the progress of a project, (4) adjust implementation to organizational context, (5) disseminate information, (6) facilitate networks, (7) bridge the evidence-to-practice gap, (8) engage stakeholders, (9) convince others of the need for, and benefit of a project, (10) coach staff, (11) provide tools and resources and (12) function as a strategic influencer. Roles did not differ among MM KBs in hospital and non-hospital settings.

Table  4 summarizes the frequency of each of the 12 MM KB roles across included studies. The two most common MM KB roles were to monitor and evaluate the progress of a project (14, 36.8%) [ 40 , 41 , 47 , 48 , 49 , 50 , 51 , 54 , 57 , 60 , 63 , 64 , 65 , 66 ] and to convince others of the need for, and benefit of a project (12, 31.6%) [ 46 , 47 , 48 , 50 , 51 , 55 , 58 , 61 , 64 , 65 , 66 , 67 ]. For example, MM KBs played an important role in monitoring the progress of projects to evaluate and reinforce practice change [ 41 , 50 ]. To convince others of the need for, and benefit of a project and to promote staff buy-in, they held ongoing conversations with staff to help them understand the rationale for change, reinforce the message, and encourage staff to consistently maintain the innovations on their units [ 46 , 48 , 66 ]. The least common MM KB role was project coordination (4, 10.5%) [ 39 , 47 , 48 , 56 ].

Several of the identified MM KB roles aligned with five KB roles in prior published frameworks [ 7 , 22 ] and MM role theory [ 18 , 37 ] (Table  5 ). For example, 31 (81.6%) studies described MM KB roles of gather data, project coordination, disseminate information , and adjust implementation to organizational context , which aligned with the roles and activities of a KB knowledge manager. Twenty-nine (76.3%) studies described the MM KB roles of provide tools and resources, convince others of the need for and benefit of a project, and coach staff , which aligned with the roles and activities of a KB capacity builder. We found overlap between the MM KB roles and the four hypothesized roles in MM role theory: (1) disseminate and obtain information, (2) adapt information and the innovations, (3) mediate between strategy and day to day activities, and (4) selling innovation implementation) [ 18 , 37 ]. For example, we found that as capacity builders, MM KBs also mediated between strategy and day-to-day activities such as coaching staff and providing resources, and in the role of knowledge manager, MM KBs obtained, diffused, and synthesized information [ 18 , 37 ].

While MM KB roles identified in included studies aligned with the five previously identified KB roles, the CIS approach we employed identified 12 distinct roles that were further characterized based on corresponding activities associated with each of the 12 roles. Therefore, while this research agrees with prior work on MM KB roles, it represents a robust framework of MM KB roles and activities by elaborating the complexity of MM KB roles and activities.

We fully described two roles compared with prior frameworks: to convince others of the need for and benefit of a project, and function as a strategic influencer. To convince others of the need for and benefit of a project (e.g., a quality improvement, best practice guideline implementation, or innovation), MM KBs used tactics such as role modelling their commitment, providing the rationale for the change, being enthusiastic about its adoption, offering positive reinforcement, and providing emotional support [ 47 , 50 , 58 ]. The role of strategic influencer featured in 7 (18.4%) studies [ 39 , 48 , 52 , 56 , 62 , 65 , 68 ]. For example, MM KBs were influential at the executive level of the hospital, advocating for innovations among less involved team members and administrators, including the hospital board, were members of organizational decision-making groups for strategic planning, and served as an authoritative contact for initiatives.

Factors that influence MMs knowledge brokering

Table  6 summarizes the enablers and barriers of MM KB roles and activities, organized as individual or organizational factors. We identified four enablers at the organizational level: senior management support, availability of resources, engaged staff, and alignment to strategy. The most common was senior management support, featured in 12 (32.0%) studies. We found that senior management support enhanced the commitment of MM KBs to innovation implementation [ 16 , 17 , 19 , 44 , 45 , 52 , 61 , 63 , 66 , 67 , 68 , 69 , 70 ]. For example, senior managers empowered and supported MM KBs to make decisions by ensuring that the necessary structures and resources were in place, and by conveying that the implementation was an organizational priority [ 66 , 68 ]. We identified three individual-level facilitators: training and mentorship, personal attributes, and experience in the MM role. The most common facilitator was training and mentorship, featured in 8 (21.1%) studies. We found that training and mentorship with more experienced managers was important to the success of MM KBs and their projects, especially if they were new to their role [ 16 , 17 , 19 , 41 , 42 , 48 , 54 , 68 ].

Studies reported more barriers ( n  = 8) than enablers ( n  = 7). We found four organizational barriers: a lack of resources, lack of senior management support, staff resistance, and a lack of time. The most common barriers were lack of resources in 12 (32.0%) studies and lack of time in 12 (32.0%) studies. A lack of resources (budget constraints, limited staff) made it challenging for MM KBs to move their projects forward [ 39 , 42 , 44 , 47 , 52 , 55 , 57 , 64 , 68 , 69 , 70 , 71 ]. For example, inadequate funds interfered with obtaining appropriate resources and undermined the feasibility of implementing projects [ 47 , 55 ]. In addition, staffing issues created difficulty in engaging staff in project work and low staffing levels limited capacity to provide desired standards of care [ 42 , 64 ]. Additionally, a lack of protected time for data collection or other project work was identified as a significant barrier to implementing projects [ 17 , 19 , 39 , 42 , 44 , 47 , 52 , 55 , 57 , 64 , 68 , 71 ]. MM KBs also lacked the time to nurture, support and adequately coach staff [ 39 , 55 ].

We identified four individual-level barriers: lack of formal training, dissatisfaction with work life balance, being caught in the middle, and professional boundaries. The most common barriers were lack of formal training (8, 21.1%) and dissatisfaction with work life balance (8, 21.1%). For example, a lack of formal training resulted in MM KBs being unprepared for managerial roles and without the knowledge and skills to promote effective knowledge brokering and knowledge transfer with end users [ 17 , 39 , 41 , 42 , 55 , 57 , 69 , 71 ]. We also found that heavy workloads and conflicting priorities left MM KBs often dissatisfied with their work life balance and hindered their ability to successfully complete projects [ 42 , 44 , 51 , 52 , 57 , 61 , 64 , 71 ]. For example, because of multiple responsibilities and conflicting priorities, MM KBs were often pulled away to address problems or were so absorbed by administrative tasks that they had no time to complete project responsibilities [ 44 , 64 ].

Impact on service delivery and outcomes

Eight (21.1%) studies showed that MM KBs had some impact on organizational and provider outcomes [ 16 , 40 , 43 , 44 , 47 , 56 , 62 , 67 ]. One (2.6%) study reported that practice changes were greater when associated with higher MM leadership scores (OR 1.92 to 6.78) and when MMs worked to help create and sustain practice changes [ 40 ]. One (2.6%) study reported the impact of senior managers’ implementation of an evidence-based Hospital Elder Life Program on administrative outcomes (e.g., reduced length of stay and cost per patient), clinical outcomes (e.g., decreased episodes of delirium and reduced falls), and provider outcomes (e.g., increased knowledge and satisfaction) [ 67 ].

Two (5.3%) studies reported the impact of a Clinical Nurse Leader role on care processes at the service level in American hospitals. Benefits were evident in administrative outcomes such as RN hours per patient day (increased from 3.76 to 4.07) and in reduced surgical cancellation rates from 30 to 14%. There were also significantly improved patient outcomes in dementia care, pressure ulcer prevention, as well as ventilator-assisted pneumonia [ 56 , 62 ]. One (2.6%) study reported financial savings [ 56 ].

Four (10.5%) studies reported the effect of a KB strategy on health professionals’ knowledge, skills, and practices [ 16 , 43 , 44 , 47 ]. For example, Traynor et al. [ 44 ] found that participants who worked closely with a KB showed a statistically significant increase in knowledge and skill (average increase of 2.8 points out of a possible 36 (95% CI 2.0 to 3.6, p  < 0.001) from baseline.

Organizing framework of MM KBs in healthcare organizations

We sought to capture the roles, activities, enablers, barriers and impacts of MM KBs across diverse healthcare settings in an organizing framework (Fig.  2 Organizing framework of MMs who function as knowledge brokers in healthcare organizations). From our interpretation of the published evidence, the findings across studies were categorized into 12 roles and 63 associated activities to represent specific ways in which MM KBs described their roles and activities during project implementation. Influencing factors were categorized into individual and organizational enablers and barriers that influence the efforts of MM KBs in healthcare organizations. While attributes were categorized as enablers, their level of importance as enablers emerged from our synthesis in how they operated in practice. The types of outcomes that we examined also varied between changes in care practice, processes, and competencies which we constructed into provider and organizational outcomes. Our emergent insights were used to construct four synthesizing arguments from the available literature: (1) MM KBs have attributes that equip and motivate them to implement practice change and innovations in healthcare organizations, (2) MMs enact KB roles and activities in healthcare organizations, (3) enablers and barriers influence the knowledge brokering efforts of MMs in healthcare settings; and (4) MM KB efforts impact healthcare service delivery. These synthesizing arguments were used to structure the organizing framework presented in Fig. 2 , which depicts how MM function as KBs in healthcare organizations and their impact on service delivery.

Organizing framework of MMs who function as knowledge brokers in healthcare organizations

We conducted a CIS to synthesize published research on factors that influence the roles, activities, and impacts of MM KBs in healthcare organizations. As per CIS, our output was an organizing framework (Fig. 2 ) that promotes expansive thinking about and extends knowledge of MM KBs in healthcare settings. We identified 63 activities organized within 12 distinct MM KB roles, which is far more comprehensive than any other study [ 7 , 22 ]. We build on prior frameworks and characterize further the roles of strategic influencer and convincing others of the need for, and benefit of an innovation or evidence-based practice. We identified organizational and individual enablers and barriers that may influence the efforts and impact of MM KBs in health care. Of note, a key enabler was senior leadership support while a key barrier for MM KBs was a lack of formal training in project implementation. Such factors should be closely considered when looking at how to strengthen the MM KB role in practice. Furthermore, we found that the MM KB role was associated with enhanced provider knowledge and skills, as well as improved clinical and organizational outcomes.

We offer a novel conceptualization of MM KBs in healthcare organizations that has, thus far, not been considered in the literature. Our theoretical insights (summarized in Fig. 2 ) are an important first step in understanding how individual and organizational factors may influence how MMs enact KB roles, and the impact they have on service delivery and associated outcomes. We found that the many MM KB roles and activities corresponded to the characterization of KB roles in the literature and substantiated MM role theory. Our findings corroborate previous studies and systematic reviews by confirming that MMs function as KBs and build on the MM and KB theoretical constructs previously identified in the literature [ 7 , 18 , 21 , 22 , 37 , 46 , 48 ]. Building on Birken and colleagues’ theory [ 37 ], we found significant overlap between MM and KB roles and activities. Figure  2 helps to define and analyze the intersection of these roles while distinguishing MM KB roles and activities more clearly from other administrative roles.

We contend that Fig. 2 has applicability across a range of healthcare settings and may be used by hospital administrators, policymakers, service providers, and researchers to plan projects and programs. It may be used as a resource in strategic planning, to re-structure clinical programs, build staff capacity, and optimize HR practices. For example, Fig. 2 could be used as a foundation to establish goals, objectives, or key performance indicators for a new or existing clinical program; refine job postings for MM roles to encompass optimal characteristics of candidates to enable KB activities; or identify new evaluation criteria for staff performance and training gaps in existing HR practices. It could also help decision makers take on pilot projects to formalize the KB role in healthcare.

Figure 2 is intended to foster further discussion of the role that MMs play in brokering knowledge in healthcare settings. It can be modified for specific applications, although we encourage retaining the basic structure (reflecting the synthesizing arguments). For example, the factors may change depending on specific localized healthcare contexts (i.e., acute care versus long-term care, or rehabilitation). Although the use of our framework in practice has yet to be evaluated, it may be strengthened with the results of additional mixed methods studies examining MM KBs as well as quasi-experimental studies applying adapted HR practices based upon our framework. As more studies are reported in the literature, the roles, activities, factors, and outcomes can be further refined, organized, and contextualized. Figure 2 can also be used as a guide for future studies examining how MMs enact the KB role across healthcare settings and systems, disciplines, and geographic locations.

Our synthesis provides new insights into the roles of MM KBs in healthcare settings. For example, we further elucidate two MM KB roles: 1) functioning as a strategic influencer; and 2) convincing others of the need for, and benefit of an innovation or evidence-based practice. These are important roles that MM KBs enact when preparing staff for implementation and corroborate Birken et al.’s hypothesized MM role of selling innovation implementation [ 18 , 37 ]. Our findings validate the organizational change literature that emphasizes the important information broker role MMs play in communicating with senior management and helping frontline staff achieve desired changes by bridging information gaps that might otherwise impede innovation implementation [ 37 ]. Our new conceptualization of how MM KBs navigate and enact their roles, and the impact they may have on service delivery and associated outcomes extends the findings of recent studies. These studies found that the role of MMs in organizational change is evolving and elements such as characteristics and context may influence their ability to facilitate organizational adaptation and lead the translation of new ideas [ 53 , 72 , 73 ]. However, further research is required to test and further explicate these relationships in the broader context of practice change.

Our synthesis both confirms and extends previous research by revealing organizational and individual factors that both enabled and hindered MM KBs efforts in healthcare organizations. An important organizational factor in our study was having senior management support. We found that MM KBs who had healthy supportive working relationships with their senior leaders led to project success. This support was critical because without it they experienced significant stress at being “caught in the middle” trying to address the needs of staff while also meeting the demands of senior management. Recent studies confirm our finding that senior management engagement is essential to MM KBs’ ability to implement innovations and underscores the need for senior leaders to be aware of, and acknowledge, the impact that excessive workload, competing demands, and role stress can play in their effectiveness [ 19 , 74 ].

The personal attributes of MM KBs as well as their level of experience were both important factors in how they operated in practice. We identified that key attributes of MM KBs contributed to their ability to drive implementation of initiatives and enhanced staff acceptance and motivation to implement practice change [ 75 , 76 ]. Our findings corroborate recent studies that highlight how the key attributes of effective champions (those that are intrinsic and cannot be taught) [ 77 , 78 , 79 ] may contribute to their ability to lead teams to successful implementation outcomes in healthcare organizations [ 80 , 81 , 82 ]. We also found that experienced MM KBs were well trained, knowledgeable, and better prepared to understand the practice context than novice MM KBs, but a lack of formal training in project implementation was an impediment for both. This emphasizes the importance of providing opportunities for professional development and training to prepare both novice and experienced MM KBs to successfully implement practice change. Our findings contribute to the growing knowledge base regarding what makes an effective MM KB. However, future research should focus on generating evidence, not only on the attributes of MM KBs, but also on how those attributes contribute to their organizational KB roles as well as the relationships among specific “attributes” and specific KB roles. More research is also needed to better understand how and what skills can be taught to boost the professional growth of MM KBs in health care.

Organizational theory and research may provide further insight into our findings and guidance for future research on the role of MM KBs in healthcare organizations. For example, the literature suggests that by increasing MMs’ appreciation of evidence-based practice, context, and implementation strategies may enhance their role in implementing evidence-based practices in healthcare organizations [ 18 , 83 , 84 ]. We found that MM KBs’ commitment to the implementation of an evidence-based project was influenced by the availability of resources, alignment with organizational priorities, a supportive staff and senior leadership. Extending from organizational theory and research, further investigation is needed to explore the nature of the relationship between these factors and the commitment of MM KBs to evidence-based practice implementation and subsequent outcomes.

When assessing the impact of MM KBs in hospitals, we found some evidence of changes in organizational and provider outcomes, suggesting MM KB impact on service delivery. Given that the available outcome data were limited, associational in nature, or poorly evaluated, it was challenging to identify strong thematic areas. Like our study, several systematic reviews also reported the lack of available outcome data [ 7 , 18 , 21 ]. This highlights an important area for research. Future research must include evaluation of the effectiveness of MM KBs and establish rigorous evidence of their impact on service delivery.

Our findings have important implications for policy and practice. MMs are an untapped KB resource who understand the challenges of implementing evidence-based practices in healthcare organizations. Both policy makers and administrators need to consider the preparation and training of MM KBs. As with other studies, our study found that providing MM KBs with opportunities for training and development may yield a substantial return on investment in terms of narrowing evidence-to-practice gaps in health care [ 48 ]. Thus, an argument can be made for recruiting and training MM KBs in health care. However, the lack of guidance on how to identify, determine and develop a curriculum to prepare MM KBs requires more research.

Our synthesis revealed numerous activities associated with 12 MM KB roles providing further insight into the MM role in healthcare settings. Our list of 63 activities (Table 2 ) has implications for practice. We found that MMs enact numerous KB roles and activities, in addition to their day-to day operational responsibilities, highlighting the complexity of the MM KB role. Senior leaders and administrators must acknowledge this complexity. A greater understanding of these KB roles and activities may lead to MM implementation effectiveness, to sustainable MM staffing models, and to organizational structures to support the KB efforts that many MMs are already doing informally. For example, senior leaders and administrators need to take the MM KB role seriously and explicitly include KB activities as a core function of existing MM job descriptions. To date, the KB role and associated activities are not typically or explicitly written into the formal job descriptions for MMs in healthcare settings, as their focus is primarily on operational responsibilities. A formal job description for MM KBs would improve the KB capacity of MMs by giving them the permission and recognition to implement KB-related functions. Our findings inform future research by more clearly articulating the MM KB roles and activities that may be essential to the implementation of evidence-based practice and highlights a much-needed area for future work.

Our study features both strengths and weaknesses. One strength in using CIS methodology was the ability to cast a wide net representing a range of research designs of included studies. This included studies in which MMs were required to be KBs by senior leaders or functioned explicitly as KBs. This enabled us to identify and include diverse studies that made valuable theoretical contributions to the development of an emerging framework, which goes beyond the extant theories summarized in the literature to date [ 18 ]. In contrast to prior systematic reviews of MM roles in implementing innovations [ 18 ], the CIS approach is both systematic and iterative with an interpretive approach to analysis and synthesis that allowed us to capture and critically analyze an in-depth depiction of how MMs may enact the KB role in healthcare organizations. Our synthesis also revealed numerous activities associated with the 12 identified MM KB roles. The resulting theoretical insights were merged into a new organizing framework (Fig. 2 ). These insights are an important first step in understanding how individual and organizational factors may influence how MMs enact KB roles, and the impact they have on service delivery.

Although CIS is an innovative method of synthesizing the literature and continues to evolve, it does have limitations. CIS has yet to be rigorously evaluated [ 85 , 86 ]. While there is some precedent guiding the steps to conduct a CIS, one weakness is that CIS is difficult to operationalize. Another weakness is that the steps to conduct CIS reviews are still being refined and can lack transparency. Therefore, we used standardized, evidence-based checklists and reporting tools to assess transparency and methodological quality, and an established methodology for coding and synthesis. We provided an audit trail of the interpretive process in line with the ENTREQ guidance. Still, there was a risk of methodological bias [ 28 , 85 , 86 ]. Another weakness of qualitative synthesis is its inability to access first order constructs that is the full set of participants’ accounts in each study. As reviewers, we can only work with the data provided in the papers and, therefore, the findings of any review cannot assess primary datasets [ 31 ]. Study retrieval was limited to journals that are indexed in the databases that were searched. We did not search the grey literature, assuming that most empirical research on MM KBs would be found in the indexed databases. Finally, we may have synthesized too small a sample of papers to draw definitive conclusions regarding different aspects of MMs as KBs.

Our study is a first step in advancing the theoretical and conceptual conversation regarding MM KBs by articulating the attributes, roles, activities, and factors influencing their efforts and impact. Through the generation of a novel organizing framework, we identify a potential combination of roles for those in MM positions who may also function as KBs in healthcare organizations. Our study is a timely contribution to the literature and offers an initial understanding of extant evidence of the KB role MMs play in health care. Our framework has utility for policymakers, administrators, and researchers to strengthen the MM role and, ultimately, improve quality of care.

Availability of data and materials

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

Abbreviations

Middle Manager

Knowledge Broker

Middle managers who function as Knowledge brokers

Knowledge Translation

Critical Interpretive Synthesis

Quality Improvement

Enhancing Transparency in Reporting the Synthesis of Qualitative Research

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University Health Network, 13EN-228, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada

Anna R. Gagliardi

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FB, ARG, WB, and RU conceptualized and planned the study, and developed the search strategy and data collection instruments. FB and ARG screened and reviewed articles. FB, ARG, WB and RU analyzed the data. All authors read and gave approval of the final version of the manuscript.

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Correspondence to Faith Boutcher .

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ENTREQ checklist

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Data extraction form for eligible studies

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Quality appraisal tools and findings

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Boutcher, F., Berta, W., Urquhart, R. et al. The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis. BMC Health Serv Res 22 , 11 (2022). https://doi.org/10.1186/s12913-021-07387-z

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DOI : https://doi.org/10.1186/s12913-021-07387-z

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Culturally sensitive palliative care in humanitarian action: Lessons from a critical interpretive synthesis of culture in palliative care literature

Affiliations.

• 1 Department of Geography and Planning, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
• 2 University of Western Ontario, London, Ontario, Canada.
• 3 McMaster University, Hamilton, Ontario, Canada.
• 4 McGill University, Montreal, Quebec, Canada.
• PMID: 34183091
• DOI: 10.1017/S1478951521000894

Objective: There is growing recognition of the importance of increasing preparedness for and the provision of palliative care in humanitarian crises. The primary objective of this review is to interpret the existing literature on culture and palliative care to query the recommendation that humanitarian healthcare providers, teams, and organizations integrate palliative care into their practice in ways that are attentive to and respectful of cultural differences.

Methods: A critical interpretive synthesis was applied to a systematic literature review guided by the PRISMA framework. Analysis was based on directed data extraction and was team based, to ensure rigor and consistency.

Results: In total, 112 articles covering 51 countries and 9 major worldviews met inclusion criteria. This literature describes culture as it influences perspectives on death and dying, expectations of palliative care, and challenges to providing culturally sensitive care. A key pattern highlighted in articles with respect to the culture and palliative care literature is that culture is invoked in this literature as a sort of catch-all for non-white, non-Christian, indigenous practices, and preferences for palliative care. It is important that humanitarian healthcare providers and organizations aiming to enact their commitment of respect for all persons through attention to potential culturally specific approaches to pain management, suffering, and dying in specific crisis settings do so without reproducing Othering and reductionistic understandings of what culturally sensitive care in humanitarian crises settings involves.

Significance of results: This paper clarifies and unpacks the diverse influences of culture in palliative care with the goal of supporting the preparedness and capacity of humanitarian healthcare providers to provide palliative care. In doing so, it aids in thinking through what constitutes culturally sensitive practice when it comes to palliative care needs in humanitarian crises. Providing such care is particularly challenging but also tremendously important given that healthcare providers from diverse cultures are brought together under high stress conditions.

Keywords: Culturally sensitive care; Humanitarian health care; Palliative care; Relief work; Systematic review.

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