critical analysis of qualitative research essay

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Appraisal of a Qualitative paper : Top tips

• Introduction

Critical appraisal of a qualitative paper

This guide aimed at health students, provides basic level support for appraising qualitative research papers. It's designed for students who have already attended lectures on critical appraisal. One framework  for appraising qualitative research (based on 4 aspects of trustworthiness) is  provided and there is an opportunity to practise the technique on a sample article.

Support Materials

• Framework for reading qualitative papers
• Critical appraisal of a qualitative paper PowerPoint

To practise following this framework for critically appraising a qualitative article, please look at the following article:

Schellekens, M.P.J.  et al  (2016) 'A qualitative study on mindfulness-based stress reduction for breast cancer patients: how women experience participating with fellow patients',  Support Care Cancer , 24(4), pp. 1813-1820.

Critical appraisal of a qualitative paper: practical example.

• Credibility
• Transferability
• Dependability
• Confirmability

How to use this practical example 

Using the framework, you can have a go at appraising a qualitative paper - we are going to look at the following article: 

Step 1.  take a quick look at the article, step 2.  click on the credibility tab above - there are questions to help you appraise the trustworthiness of the article, read the questions and look for the answers in the article. , step 3.   click on each question and our answers will appear., step 4.    repeat with the other aspects of trustworthiness: transferability, dependability and confirmability ., questioning the credibility:, who is the researcher what has been their experience how well do they know this research area, was the best method chosen what method did they use was there any justification was the method scrutinised by peers is it a recognisable method was there triangulation ( more than one method used), how was the data collected was data collected from the participants at more than one time point how long were the interviews were questions asked to the participants in different ways, is the research reporting what the participants actually said were the participants shown transcripts / notes of the interviews / observations to ‘check’ for accuracy are direct quotes used from a variety of participants, how would you rate the overall credibility, questioning the transferability, was a meaningful sample obtained how many people were included is the sample diverse how were they selected, are the demographics given, does the research cover diverse viewpoints do the results include negative cases was data saturation reached, what is the overall transferability can the research be transferred to other settings , questioning the dependability :, how transparent is the audit trail can you follow the research steps are the decisions made transparent is the whole process explained in enough detail did the researcher keep a field diary is there a clear limitations section, was there peer scrutiny of the researchwas the research plan shown to peers / colleagues for approval and/or feedback did two or more researchers independently judge data, how would you rate the overall dependability would the results be similar if the study was repeated how consistent are the data and findings, questioning the confirmability :, is the process of analysis described in detail is a method of analysis named or described is there sufficient detail, have any checks taken place was there cross-checking of themes was there a team of researchers, has the researcher reflected on possible bias is there a reflexive diary, giving a detailed log of thoughts, ideas and assumptions, how do you rate the overall confirmability has the researcher attempted to limit bias, questioning the overall trustworthiness :, overall how trustworthy is the research, further information.

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Critically appraising qualitative research

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• Ayelet Kuper , assistant professor 1 ,
• Lorelei Lingard , associate professor 2 ,
• Wendy Levinson , Sir John and Lady Eaton professor and chair 3
• 1 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
• 2 Department of Paediatrics and Wilson Centre for Research in Education, University of Toronto and SickKids Learning Institute; BMO Financial Group Professor in Health Professions Education Research, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto
• 3 Department of Medicine, Sunnybrook Health Sciences Centre
• Correspondence to: A Kuper ayelet94{at}post.harvard.edu

Six key questions will help readers to assess qualitative research

Summary points

Appraising qualitative research is different from appraising quantitative research

Qualitative research papers should show appropriate sampling, data collection, and data analysis

Transferability of qualitative research depends on context and may be enhanced by using theory

Ethics in qualitative research goes beyond review boards’ requirements to involve complex issues of confidentiality, reflexivity, and power

Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use.

In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system.

Box 1 Key questions to ask when reading qualitative research studies

Was the sample used in the study appropriate to its research question.

Were the data collected appropriately?

Were the data analysed appropriately?

Can I transfer the results of this study to my own setting?

Does the study adequately address potential ethical issues, including reflexivity?

Overall: is what the researchers did clear?

One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a …

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Qualitative Research Methods: A Critical Analysis

11 Pages Posted: 13 May 2021

Northern Caribbean University

Enid F. Newell-McLymont

Date Written: May 13, 2021

Creswell (2014) noted that qualitative research is an approach for exploring and understanding the meaning individuals or groups ascribe to a social or human problem. The article embodies a critical analysis of chapters one to twelve of Stake (2010). In chapter one, Qualitative research: How things work is seen as qualitative, is based on a comprehensive aim seeking to answer the questions why and how. It analyzes actions and interactions, taking into account the intentions of the actors. An analytic perspective on the interpretation of the Person as an instrument is the thrust of chapter two. Chapter three examines the experiential understanding: Most qualitative study is experiential, in this chapter stake (2010) discusses two common research approaches, qualitative and quantitative methods. Chapter four Stating the Problem: Questioning How This Thing Works. Chapter five deals with the Methods-Gatherings Data, while chapter six illuminates the Review of Literature: Zooming to See the Problem. In chapter seven, the author implores the evidence: Bolstering Judgment and Reconnoitering. Chapter eight propels Analysis and Synthesis: How Things Work. Chapter nine acts as a mirror that invites the researcher to examine their action research and Self-­Evaluation: Finding our Own How our Place Works. Finally, in chapters ten to twelve, the author compels Storytelling: Illustrating How Things Work, Writing the Final Report: An Iterative Convergence, and Advocacy and Ethics: Making Things Work Better. This work is expected to guide future researchers in developing their research in qualitative research.

Keywords: Qualitative Research, The Thing, Review of Literature, Evidence, Triangulation, Bias

Suggested Citation: Suggested Citation

Willy Lima (Contact Author)

Northern caribbean university ( email ), do you have a job opening that you would like to promote on ssrn, paper statistics, related ejournals, engineering education ejournal.

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The following video (4 min 5 sec.) considers the background knowledge needed to critically appraise a qualitative study. Includes what critical appraisal means, and the tools available to help carry out critical appraisal.

Appraisal of qualitative research using a CASP checklist

The following video (3 min. 5 sec.) summarizes what to look for in a piece of qualitative research, and an introduction to the CASP checklist for qualitative research. 

Critical appraisal of qualitative research (webinar)

The following is a recording of a webinar, based upon the critical appraisal of qualitative research, using a CASP checklist:

'Focus on' videos (qualitative research)

The following videos (all approx. 4-9 min.) focus on particular aspects of critical appraisal methodology for qualitative studies.

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• Volume 22, Issue 1
• How to appraise qualitative research
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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Methods for the synthesis of qualitative research: a critical review

Elaine barnett-page.

1 Evidence for Policy and Practice Information and Co-ordinating (EPPI-) Centre, Social Science Research Unit, 18 Woburn Square, London WC1H 0NS, UK

James Thomas

Associated data.

In recent years, a growing number of methods for synthesising qualitative research have emerged, particularly in relation to health-related research. There is a need for both researchers and commissioners to be able to distinguish between these methods and to select which method is the most appropriate to their situation.

A number of methodological and conceptual links between these methods were identified and explored, while contrasting epistemological positions explained differences in approaches to issues such as quality assessment and extent of iteration. Methods broadly fall into 'realist' or 'idealist' epistemologies, which partly accounts for these differences.

Methods for qualitative synthesis vary across a range of dimensions. Commissioners of qualitative syntheses might wish to consider the kind of product they want and select their method – or type of method – accordingly.

The range of different methods for synthesising qualitative research has been growing over recent years [ 1 , 2 ], alongside an increasing interest in qualitative synthesis to inform health-related policy and practice [ 3 ]. While the terms 'meta-analysis' (a statistical method to combine the results of primary studies), or sometimes 'narrative synthesis', are frequently used to describe how quantitative research is synthesised, far more terms are used to describe the synthesis of qualitative research. This profusion of terms can mask some of the basic similarities in approach that the different methods share, and also lead to some confusion regarding which method is most appropriate in a given situation. This paper does not argue that the various nomenclatures are unnecessary, but rather seeks to draw together and review the full range of methods of synthesis available to assist future reviewers in selecting a method that is fit for their purpose. It also represents an attempt to guide the reader through some of the varied terminology to spring up around qualitative synthesis. Other helpful reviews of synthesis methods have been undertaken in recent years with slightly different foci to this paper. Two recent studies have focused on describing and critiquing methods for the integration of qualitative research with quantitative [ 4 , 5 ] rather than exclusively examining the detail and rationale of methods for the synthesis of qualitative research. Two other significant pieces of work give practical advice for conducting the synthesis of qualitative research, but do not discuss the full range of methods available [ 6 , 7 ]. We begin our Discussion by outlining each method of synthesis in turn, before comparing and contrasting characteristics of these different methods across a range of dimensions. Readers who are more familiar with the synthesis methods described here may prefer to turn straight to the 'dimensions of difference' analysis in the second part of the Discussion.

Overview of synthesis methods

Meta-ethnography.

In their seminal work of 1988, Noblit and Hare proposed meta-ethnography as an alternative to meta-analysis [ 8 ]. They cited Strike and Posner's [ 9 ] definition of synthesis as an activity in which separate parts are brought together to form a 'whole'; this construction of the whole is essentially characterised by some degree of innovation, so that the result is greater than the sum of its parts. They also borrowed from Turner's theory of social explanation [ 10 ], a key tenet of which was building 'comparative understanding' [[ 8 ], p22] rather than aggregating data.

To Noblit and Hare, synthesis provided an answer to the question of 'how to "put together" written interpretive accounts' [[ 8 ], p7], where mere integration would not be appropriate. Noblit and Hare's early work synthesised research from the field of education.

Three different methods of synthesis are used in meta-ethnography. One involves the 'translation' of concepts from individual studies into one another, thereby evolving overarching concepts or metaphors. Noblit and Hare called this process reciprocal translational analysis (RTA). Refutational synthesis involves exploring and explaining contradictions between individual studies. Lines-of-argument (LOA) synthesis involves building up a picture of the whole (i.e. culture, organisation etc) from studies of its parts. The authors conceptualised this latter approach as a type of grounded theorising.

Britten et al [ 11 ] and Campbell et al [ 12 ] have both conducted evaluations of meta-ethnography and claim to have succeeded, by using this method, in producing theories with greater explanatory power than could be achieved in a narrative literature review. While both these evaluations used small numbers of studies, more recently Pound et al [ 13 ] conducted both an RTA and an LOA synthesis using a much larger number of studies (37) on resisting medicines. These studies demonstrate that meta-ethnography has evolved since Noblit and Hare first introduced it. Campbell et al claim to have applied the method successfully to non-ethnographical studies. Based on their reading of Schutz [ 14 ], Britten et al have developed both second and third order constructs in their synthesis (Noblit and Hare briefly allude to the possibility of a 'second level of synthesis' [[ 8 ], p28] but do not demonstrate or further develop the idea).

In a more recent development, Sandelowski & Barroso [ 15 ] write of adapting RTA by using it to ' integrate findings interpretively, as opposed to comparing them interpretively' (p204). The former would involve looking to see whether the same concept, theory etc exists in different studies; the latter would involve the construction of a bigger picture or theory (i.e. LOA synthesis). They also talk about comparing or integrating imported concepts (e.g. from other disciplines) as well as those evolved 'in vivo'.

Grounded theory

Kearney [ 16 ], Eaves [ 17 ] and Finfgeld [ 18 ] have all adapted grounded theory to formulate a method of synthesis. Key methods and assumptions of grounded theory, as originally formulated and subsequently refined by Glaser and Strauss [ 19 ] and Strauss and Corbin [ 20 , 21 ], include: simultaneous phases of data collection and analysis; an inductive approach to analysis, allowing the theory to emerge from the data; the use of the constant comparison method; the use of theoretical sampling to reach theoretical saturation; and the generation of new theory. Eaves cited grounded theorists Charmaz [ 22 ] and Chesler [ 23 ], as well as Strauss and Corbin [ 20 ], as informing her approach to synthesis.

Glaser and Strauss [ 19 ] foresaw a time when a substantive body of grounded research should be pushed towards a higher, more abstract level. As a piece of methodological work, Eaves undertook her own synthesis of the synthesis methods used by these authors to produce her own clear and explicit guide to synthesis in grounded formal theory. Kearney stated that 'grounded formal theory', as she termed this method of synthesis, 'is suited to study of phenomena involving processes of contextualized understanding and action' [[ 24 ], p180] and, as such, is particularly applicable to nurses' research interests.

As Kearney suggested, the examples examined here were largely dominated by research in nursing. Eaves synthesised studies on care-giving in rural African-American families for elderly stroke survivors; Finfgeld on courage among individuals with long-term health problems; Kearney on women's experiences of domestic violence.

Kearney explicitly chose 'grounded formal theory' because it matches 'like' with 'like': that is, it applies the same methods that have been used to generate the original grounded theories included in the synthesis – produced by constant comparison and theoretical sampling – to generate a higher-level grounded theory. The wish to match 'like' with 'like' is also implicit in Eaves' paper. This distinguishes grounded formal theory from more recent applications of meta-ethnography, which have sought to include qualitative research using diverse methodological approaches [ 12 ].

Thematic Synthesis

Thomas and Harden [ 25 ] have developed an approach to synthesis which they term 'thematic synthesis'. This combines and adapts approaches from both meta-ethnography and grounded theory. The method was developed out of a need to conduct reviews that addressed questions relating to intervention need, appropriateness and acceptability – as well as those relating to effectiveness – without compromising on key principles developed in systematic reviews. They applied thematic synthesis in a review of the barriers to, and facilitators of, healthy eating amongst children.

Free codes of findings are organised into 'descriptive' themes, which are then further interpreted to yield 'analytical' themes. This approach shares characteristics with later adaptations of meta-ethnography, in that the analytical themes are comparable to 'third order interpretations' and that the development of descriptive and analytical themes using coding invoke reciprocal 'translation'. It also shares much with grounded theory, in that the approach is inductive and themes are developed using a 'constant comparison' method. A novel aspect of their approach is the use of computer software to code the results of included studies line-by-line, thus borrowing another technique from methods usually used to analyse primary research.

Textual Narrative Synthesis

Textual narrative synthesis is an approach which arranges studies into more homogenous groups. Lucas et al [ 26 ] comment that it has proved useful in synthesising evidence of different types (qualitative, quantitative, economic etc). Typically, study characteristics, context, quality and findings are reported on according to a standard format and similarities and differences are compared across studies. Structured summaries may also be developed, elaborating on and putting into context the extracted data [ 27 ].

Lucas et al [ 26 ] compared thematic synthesis with textual narrative synthesis. They found that 'thematic synthesis holds most potential for hypothesis generation' whereas textual narrative synthesis is more likely to make transparent heterogeneity between studies (as does meta-ethnography, with refutational synthesis) and issues of quality appraisal. This is possibly because textual narrative synthesis makes clearer the context and characteristics of each study, while the thematic approach organises data according to themes. However, Lucas et al found that textual narrative synthesis is 'less good at identifying commonality' (p2); the authors do not make explicit why this should be, although it may be that organising according to themes, as the thematic approach does, is comparatively more successful in revealing commonality.

Paterson et al [ 28 ] have evolved a multi-faceted approach to synthesis, which they call 'meta-study'. The sociologist Zhao [ 29 ], drawing on Ritzer's work [ 30 ], outlined three components of analysis, which they proposed should be undertaken prior to synthesis. These are meta-data-analysis (the analysis of findings), meta-method (the analysis of methods) and meta-theory (the analysis of theory). Collectively, these three elements of analysis, culminating in synthesis, make up the practice of 'meta-study'. Paterson et al pointed out that the different components of analysis may be conducted concurrently.

Paterson et al argued that primary research is a construction; secondary research is therefore a construction of a construction. There is need for an approach that recognises this, and that also recognises research to be a product of its social, historical and ideological context. Such an approach would be useful in accounting for differences in research findings. For Paterson et al, there is no such thing as 'absolute truth'.

Meta-study was developed to study the experiences of adults living with a chronic illness. Meta-data-analysis was conceived of by Paterson et al in similar terms to Noblit and Hare's meta-ethnography (see above), in that it is essentially interpretive and seeks to reveal similarities and discrepancies among accounts of a particular phenomenon. Meta-method involves the examination of the methodologies of the individual studies under review. Part of the process of meta-method is to consider different aspects of methodology such as sampling, data collection, research design etc, similar to procedures others have called 'critical appraisal' (CASP [ 31 ]). However, Paterson et al take their critique to a deeper level by establishing the underlying assumptions of the methodologies used and the relationship between research outcomes and methods used. Meta-theory involves scrutiny of the philosophical and theoretical assumptions of the included research papers; this includes looking at the wider context in which new theory is generated. Paterson et al described meta-synthesis as a process which creates a new interpretation which accounts for the results of all three elements of analysis. The process of synthesis is iterative and reflexive and the authors were unwilling to oversimplify the process by 'codifying' procedures for bringing all three components of analysis together.

Meta-narrative

Greenhalgh et al [ 32 ]'s meta-narrative approach to synthesis arose out of the need to synthesise evidence to inform complex policy-making questions and was assisted by the formation of a multi-disciplinary team. Their approach to review was informed by Thomas Kuhn's The Structure of Scientific Revolutions [ 33 ], in which he proposed that knowledge is produced within particular paradigms which have their own assumptions about theory, about what is a legitimate object of study, about what are legitimate research questions and about what constitutes a finding. Paradigms also tend to develop through time according to a particular set of stages, central to which is the stage of 'normal science', in which the particular standards of the paradigm are largely unchallenged and seen to be self-evident. As Greenhalgh et al pointed out, Kuhn saw paradigms as largely incommensurable: 'that is, an empirical discovery made using one set of concepts, theories, methods and instruments cannot be satisfactorily explained through a different paradigmatic lens' [[ 32 ], p419].

Greenhalgh et al synthesised research from a wide range of disciplines; their research question related to the diffusion of innovations in health service delivery and organisation. They thus identified a need to synthesise findings from research which contains many different theories arising from many different disciplines and study designs.

Based on Kuhn's work, Greenhalgh et al proposed that, across different paradigms, there were multiple – and potentially mutually contradictory – ways of understanding the concept at the heart of their review, namely the diffusion of innovation. Bearing this in mind, the reviewers deliberately chose to select key papers from a number of different research 'paradigms' or 'traditions', both within and beyond healthcare, guided by their multidisciplinary research team. They took as their unit of analysis the 'unfolding "storyline" of a research tradition over time' [[ 32 ], p417) and sought to understand diffusion of innovation as it was conceptualised in each of these traditions. Key features of each tradition were mapped: historical roots, scope, theoretical basis; research questions asked and methods/instruments used; main empirical findings; historical development of the body of knowledge (how have earlier findings led to later findings); and strengths and limitations of the tradition. The results of this exercise led to maps of 13 'meta-narratives' in total, from which seven key dimensions, or themes, were identified and distilled for the synthesis phase of the review.

Critical Interpretive Synthesis

Dixon-Woods et al [ 34 ] developed their own approach to synthesising multi-disciplinary and multi-method evidence, termed 'critical interpretive synthesis', while researching access to healthcare by vulnerable groups. Critical interpretive synthesis is an adaptation of meta-ethnography, as well as borrowing techniques from grounded theory. The authors stated that they needed to adapt traditional meta-ethnographic methods for synthesis, since these had never been applied to quantitative as well as qualitative data, nor had they been applied to a substantial body of data (in this case, 119 papers).

Dixon-Woods et al presented critical interpretive synthesis as an approach to the whole process of review, rather than to just the synthesis component. It 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 [ 35 ]. The authors also stress, as a defining characteristic, critical interpretive synthesis's critical approach to the literature in terms of deconstructing research traditions or theoretical assumptions as a means of contextualising findings.

Dixon-Woods et al rejected reciprocal translational analysis (RTA) as this produced 'only a summary in terms that have already been used in the literature' [[ 34 ], p5], which was seen as less helpful when dealing with a large and diverse body of literature. Instead, Dixon-Woods et al adopted a lines-of-argument (LOA) synthesis, in which – rejecting the difference between first, second and third order constructs – they instead developed 'synthetic constructs' which were then linked with constructs arising directly from the literature.

The influence of grounded theory can be seen in particular in critical interpretive synthesis's inductive approach to formulating the review question and to developing categories and concepts, rejecting a 'stage' approach to systematic reviewing, and in selecting papers using theoretical sampling. Dixon-Woods et al also claim that critical interpretive synthesis is distinct in its 'explicit orientation towards theory generation' [[ 34 ], p9].

Ecological Triangulation

Jim Banning is the author of 'ecological triangulation' or 'ecological sentence synthesis', applying this method to the evidence for what works for youth with disabilities. He borrows from Webb et al [ 36 ] and Denzin [ 37 ] the concept of triangulation, in which phenomena are studied from a variety of vantage points. His rationale is that building an 'evidence base' of effectiveness requires the synthesis of cumulative, multi-faceted evidence in order to find out 'what intervention works for what kind of outcomes for what kind of persons under what kind of conditions' [[ 38 ], p1].

Ecological triangulation unpicks the mutually interdependent relationships between behaviour, persons and environments. The method requires that, for data extraction and synthesis, 'ecological sentences' are formulated following the pattern: 'With this intervention, these outcomes occur with these population foci and within these grades (ages), with these genders ... and these ethnicities in these settings' [[ 39 ], p1].

Framework Synthesis

Brunton et al [ 40 ] and Oliver et al [ 41 ] have applied a 'framework synthesis' approach in their reviews. Framework synthesis is based on framework analysis, which was outlined by Pope, Ziebland and Mays [ 42 ], and draws upon the work of Ritchie and Spencer [ 43 ] and Miles and Huberman [ 44 ]. Its rationale is that qualitative research produces large amounts of textual data in the form of transcripts, observational fieldnotes etc. The sheer wealth of information poses a challenge for rigorous analysis. Framework synthesis offers a highly structured approach to organising and analysing data (e.g. indexing using numerical codes, rearranging data into charts etc).

Brunton et al applied the approach to a review of children's, young people's and parents' views of walking and cycling; Oliver et al to an analysis of public involvement in health services research. Framework synthesis is distinct from the other methods outlined here in that it utilises an a priori 'framework' – informed by background material and team discussions – to extract and synthesise findings. As such, it is largely a deductive approach although, in addition to topics identified by the framework, new topics may be developed and incorporated as they emerge from the data. The synthetic product can be expressed in the form of a chart for each key dimension identified, which may be used to map the nature and range of the concept under study and find associations between themes and exceptions to these [ 40 ].

'Fledgling' approaches

There are three other approaches to synthesis which have not yet been widely used. One is an approach using content analysis [ 45 , 46 ] in which text is condensed into fewer content-related categories. Another is 'meta-interpretation' [ 47 ], featuring the following: an ideographic rather than pre-determined approach to the development of exclusion criteria; a focus on meaning in context; interpretations as raw data for synthesis (although this feature doesn't distinguish it from other synthesis methods); an iterative approach to the theoretical sampling of studies for synthesis; and a transparent audit trail demonstrating the trustworthiness of the synthesis.

In addition to the synthesis methods discussed above, Sandelowski and Barroso propose a method they call 'qualitative metasummary' [ 15 ]. It is mentioned here as a new and original approach to handling a collection of qualitative studies but is qualitatively different to the other methods described here since it is aggregative; that is, findings are accumulated and summarised rather than 'transformed'. Metasummary is a way of producing a 'map' of the contents of qualitative studies and – according to Sandelowski and Barroso – 'reflect [s] a quantitative logic' [[ 15 ], p151]. The frequency of each finding is determined and the higher the frequency of a particular finding, the greater its validity. The authors even discuss the calculation of 'effect sizes' for qualitative findings. Qualitative metasummaries can be undertaken as an end in themselves or may serve as a basis for a further synthesis.

Dimensions of difference

Having outlined the range of methods identified, we now turn to an examination of how they compare with one another. It is clear that they have come from many different contexts and have different approaches to understanding knowledge, but what do these differences mean in practice? Our framework for this analysis is shown in Additional file 1 : dimensions of difference [ 48 ]. We have examined the epistemology of each of the methods and found that, to some extent, this explains the need for different methods and their various approaches to synthesis.

Epistemology

The first dimension that we will consider is that of the researchers' epistemological assumptions. Spencer et al [ 49 ] outline a range of epistemological positions, which might be organised into a spectrum as follows:

Subjective idealism : there is no shared reality independent of multiple alternative human constructions

Objective idealism : there is a world of collectively shared understandings

Critical realism : knowledge of reality is mediated by our perceptions and beliefs

Scientific realism : it is possible for knowledge to approximate closely an external reality

Naïve realism : reality exists independently of human constructions and can be known directly [ 49 , 45 , 46 ].

Thus, at one end of the spectrum we have a highly constructivist view of knowledge and, at the other, an unproblematized 'direct window onto the world' view.

Nearly all of positions along this spectrum are represented in the range of methodological approaches to synthesis covered in this paper. The originators of meta-narrative synthesis, critical interpretive synthesis and meta-study all articulate what might be termed a 'subjective idealist' approach to knowledge. Paterson et al [ 28 ] state that meta-study shies away from creating 'grand theories' within the health or social sciences and assume that no single objective reality will be found. Primary studies, they argue, are themselves constructions; meta-synthesis, then, 'deals with constructions of constructions' (p7). Greenhalgh et al [ 32 ] also view knowledge as a product of its disciplinary paradigm and use this to explain conflicting findings: again, the authors neither seek, nor expect to find, one final, non-contestable answer to their research question. Critical interpretive synthesis is similar in seeking to place literature within its context, to question its assumptions and to produce a theoretical model of a phenomenon which – because highly interpretive – may not be reproducible by different research teams at alternative points in time [[ 34 ], p11].

Methods used to synthesise grounded theory studies in order to produce a higher level of grounded theory [ 24 ] appear to be informed by 'objective idealism', as does meta-ethnography. Kearney argues for the near-universal applicability of a 'ready-to-wear' theory across contexts and populations. This approach is clearly distinct from one which recognises multiple realities. The emphasis is on examining commonalities amongst, rather than discrepancies between, accounts. This emphasis is similarly apparent in most meta-ethnographies, which are conducted either according to Noblit and Hare's 'reciprocal translational analysis' technique or to their 'lines-of-argument' technique and which seek to provide a 'whole' which has a greater explanatory power. Although Noblit and Hare also propose 'refutational synthesis', in which contradictory findings might be explored, there are few examples of this having been undertaken in practice, and the aim of the method appears to be to explain and explore differences due to context, rather than multiple realities.

Despite an assumption of a reality which is perhaps less contestable than those of meta-narrative synthesis, critical interpretive synthesis and meta-study, both grounded formal theory and meta-ethnography place a great deal of emphasis on the interpretive nature of their methods. This still supposes a degree of constructivism. Although less explicit about how their methods are informed, it seems that both thematic synthesis and framework synthesis – while also involving some interpretation of data – share an even less problematized view of reality and a greater assumption that their synthetic products are reproducible and correspond to a shared reality. This is also implicit in the fact that such products are designed directly to inform policy and practice, a characteristic shared by ecological triangulation. Notably, ecological triangulation, according to Banning, can be either realist or idealist. Banning argues that the interpretation of triangulation can either be one in which multiple viewpoints converge on a point to produce confirming evidence (i.e. one definitive answer to the research question) or an idealist one, in which the complexity of multiple viewpoints is represented. Thus, although ecological triangulation views reality as complex, the approach assumes that it can be approximately knowable (at least when the realist view of ecological triangulation is adopted) and that interventions can and should be modelled according to the products of its syntheses.

While pigeonholing different methods into specific epistemological positions is a problematic process, we do suggest that the contrasting epistemologies of different researchers is one way of explaining why we have – and need – different methods for synthesis.

Variation in terms of the extent of iteration during the review process is another key dimension. All synthesis methods include some iteration but the degree varies. Meta-ethnography, grounded theory and thematic synthesis all include iteration at the synthesis stage; both framework synthesis and critical interpretive synthesis involve iterative literature searching – in the case of critical interpretive synthesis, it is not clear whether iteration occurs during the rest of the review process. Meta-narrative also involves iteration at every stage. Banning does not mention iteration in outlining ecological triangulation and neither do Lucas or Thomas and Harden for thematic narrative synthesis.

It seems that the more idealist the approach, the greater the extent of iteration. This might be because a large degree of iteration does not sit well with a more 'positivist' ideal of procedural objectivity; in particular, the notion that the robustness of the synthetic product depends in part on the reviewers stating up front in a protocol their searching strategies, inclusion/exclusion criteria etc, and being seen not to alter these at a later stage.

Quality assessment

Another dimension along which we can look at different synthesis methods is that of quality assessment. When the approaches to the assessment of the quality of studies retrieved for review are examined, there is again a wide methodological variation. It might be expected that the further towards the 'realism' end of the epistemological spectrum a method of synthesis falls, the greater the emphasis on quality assessment. In fact, this is only partially the case.

Framework synthesis, thematic narrative synthesis and thematic synthesis – methods which might be classified as sharing a 'critical realist' approach – all have highly specified approaches to quality assessment. The review in which framework synthesis was developed applied ten quality criteria: two on quality and reporting of sampling methods, four to the quality of the description of the sample in the study, two to the reliability and validity of the tools used to collect data and one on whether studies used appropriate methods for helping people to express their views. Studies which did not meet a certain number of quality criteria were excluded from contributing to findings. Similarly, in the example review for thematic synthesis, 12 criteria were applied: five related to reporting aims, context, rationale, methods and findings; four relating to reliability and validity; and three relating to the appropriateness of methods for ensuring that findings were rooted in participants' own perspectives. Studies which were deemed to have significant flaws were excluded and sensitivity analyses were used to assess the possible impact of study quality on the review's findings. Thomas and Harden's use of thematic narrative synthesis similarly applied quality criteria and developed criteria additional to those they found in the literature on quality assessment, relating to the extent to which people's views and perspectives had been privileged by researchers. It is worth noting not only that these methods apply quality criteria but that they are explicit about what they are: assessing quality is a key component in the review process for both of these methods. Likewise, Banning – the originator of ecological triangulation – sees quality assessment as important and adapts the Design and Implementation Assessment Device (DIAD) Version 0.3 (a quality assessment tool for quantitative research) for use when appraising qualitative studies [ 50 ]. Again, Banning writes of excluding studies deemed to be of poor quality.

Greenhalgh et al's meta-narrative review [ 32 ] modified a range of existing quality assessment tools to evaluate studies according to validity and robustness of methods; sample size and power; and validity of conclusions. The authors imply, but are not explicit, that this process formed the basis for the exclusion of some studies. Although not quite so clear about quality assessment methods as framework and thematic synthesis, it might be argued that meta-narrative synthesis shows a greater commitment to the concept that research can and should be assessed for quality than either meta-ethnography or grounded formal theory. The originators of meta-ethnography, Noblit and Hare [ 8 ], originally discussed quality in terms of quality of metaphor, while more recent use of this method has used amended versions of CASP (the Critical Appraisal Skills Programme tool, [ 31 ]), yet has only referred to studies being excluded on the basis of lack of relevance or because they weren't 'qualitative' studies [ 8 ]. In grounded theory, quality assessment is only discussed in terms of a 'personal note' being made on the context, quality and usefulness of each study. However, contrary to expectation, meta-narrative synthesis lies at the extreme end of the idealism/realism spectrum – as a subjective idealist approach – while meta-ethnography and grounded theory are classified as objective idealist approaches.

Finally, meta-study and critical interpretive synthesis – two more subjective idealist approaches – look to the content and utility of findings rather than methodology in order to establish quality. While earlier forms of meta-study included only studies which demonstrated 'epistemological soundness', in its most recent form [ 51 ] this method has sought to include all relevant studies, excluding only those deemed not to be 'qualitative' research. Critical interpretive synthesis also conforms to what we might expect of its approach to quality assessment: quality of research is judged as the extent to which it informs theory. The threshold of inclusion is informed by expertise and instinct rather than being articulated a priori.

In terms of quality assessment, it might be important to consider the academic context in which these various methods of synthesis developed. The reason why thematic synthesis, framework synthesis and ecological triangulation have such highly specified approaches to quality assessment may be that each of these was developed for a particular task, i.e. to conduct a multi-method review in which randomised controlled trials (RCTs) were included. The concept of quality assessment in relation to RCTs is much less contested and there is general agreement on criteria against which quality should be judged.

Problematizing the literature

Critical interpretive synthesis, the meta-narrative approach and the meta-theory element of meta-study all share some common ground in that their review and synthesis processes include examining all aspects of the context in which knowledge is produced. In conducting a review on access to healthcare by vulnerable groups, critical interpretive synthesis sought to question 'the ways in which the literature had constructed the problematics of access, the nature of the assumptions on which it drew, and what has influenced its choice of proposed solutions' [[ 34 ], p6]. Although not claiming to have been directly influenced by Greenhalgh et al's meta-narrative approach, Dixon-Woods et al do cite it as sharing similar characteristics in the sense that it critiques the literature it reviews.

Meta-study uses meta-theory to describe and deconstruct the theories that shape a body of research and to assess its quality. One aspect of this process is to examine the historical evolution of each theory and to put it in its socio-political context, which invites direct comparison with meta-narrative synthesis. Greenhalgh et al put a similar emphasis on placing research findings within their social and historical context, often as a means of seeking to explain heterogeneity of findings. In addition, meta-narrative shares with critical interpretive synthesis an iterative approach to searching and selecting from the literature.

Framework synthesis, thematic synthesis, textual narrative synthesis, meta-ethnography and grounded theory do not share the same approach to problematizing the literature as critical interpretive synthesis, meta-study and meta-narrative. In part, this may be explained by the extent to which studies included in the synthesis represented a broad range of approaches or methodologies. This, in turn, may reflect the broadness of the review question and the extent to which the concepts contained within the question are pre-defined within the literature. In the case of both the critical interpretive synthesis and meta-narrative reviews, terminology was elastic and/or the question formed iteratively. Similarly, both reviews placed great emphasis on employing multi-disciplinary research teams. Approaches which do not critique the literature in the same way tend to have more narrowly-focused questions. They also tend to include a more limited range of studies: grounded theory synthesis includes grounded theory studies, meta-ethnography (in its original form, as applied by Noblit and Hare) ethnographies. The thematic synthesis incorporated studies based on only a narrow range of qualitative methodologies (interviews and focus groups) which were informed by a similarly narrow range of epistemological assumptions. It may be that the authors of such syntheses saw no need for including such a critique in their review process.

Similarities and differences between primary studies

Most methods of synthesis are applicable to heterogeneous data (i.e. studies which use contrasting methodologies) apart from early meta-ethnography and synthesis informed by grounded theory. All methods of synthesis state that, at some level, studies are compared; many are not so explicit about how this is done, though some are. Meta-ethnography is one of the most explicit: it describes the act of 'translation' where terms and concepts which have resonance with one another are subsumed into 'higher order constructs'. Grounded theory, as represented by Eaves [ 17 ], is undertaken according to a long list of steps and sub-steps, includes the production of generalizations about concepts/categories, which comes from classifying these categories. In meta-narrative synthesis, comparable studies are grouped together at the appraisal phase of review.

Perhaps more interesting are the ways in which differences between studies are explored. Those methods with a greater emphasis on critical appraisal may tend (although this is not always made explicit) to use differences in method to explain differences in finding. Meta-ethnography proposes 'refutational synthesis' to explain differences, although there are few examples of this in the literature. Some synthesis methods – for example, thematic synthesis – look at other characteristics of the studies under review, whether types of participants and their context vary, and whether this can explain differences in perspective.

All of these methods, then, look within the studies to explain differences. Other methods look beyond the study itself to the context in which it was produced. Critical interpretive synthesis and meta-study look at differences in theory or in socio-economic context. Critical interpretive synthesis, like meta-narrative, also explores epistemological orientation. Meta-narrative is unique in concerning itself with disciplinary paradigm (i.e. the story of the discipline as it progresses). It is also distinctive in that it treats conflicting findings as 'higher order data' [[ 32 ], p420], so that the main emphasis of the synthesis appears to be on examining and explaining contradictions in the literature.

Going 'beyond' the primary studies

Synthesis is sometimes defined as a process resulting in a product, a 'whole', which is more than the sum of its parts. However, the methods reviewed here vary in the extent to which they attempt to 'go beyond' the primary studies and transform the data. Some methods – textual narrative synthesis, ecological triangulation and framework synthesis – focus on describing and summarising their primary data (often in a highly structured and detailed way) and translating the studies into one another. Others – meta-ethnography, grounded theory, thematic synthesis, meta-study, meta-narrative and critical interpretive synthesis – seek to push beyond the original data to a fresh interpretation of the phenomena under review. A key feature of thematic synthesis is its clear differentiation between these two stages.

Different methods have different mechanisms for going beyond the primary studies, although some are more explicit than others about what these entail. Meta-ethnography proposes a 'Line of Argument' (LOA) synthesis in which an interpretation is constructed to both link and explain a set of parts. Critical interpretive synthesis based its synthesis methods on those of meta-ethnography, developing an LOA using what the authors term 'synthetic constructs' (akin to 'third order constructs' in meta-ethnography) to create a 'synthesising argument'. Dixon-Woods et al claim that this is an advance on Britten et al's methods, in that they reject the difference between first, second and third order constructs.

Meta-narrative, as outlined above, focuses on conflicting findings and constructs theories to explain these in terms of differing paradigms. Meta study derives questions from each of its three components to which it subjects the dataset and inductively generates a number of theoretical claims in relation to it. According to Eaves' model of grounded theory [ 17 ], mini-theories are integrated to produce an explanatory framework. In ecological triangulation, the 'axial' codes – or second level codes evolved from the initial deductive open codes – are used to produce Banning's 'ecological sentence' [ 39 ].

The synthetic product

In overviewing and comparing different qualitative synthesis methods, the ultimate question relates to the utility of the synthetic product: what is it for? It is clear that some methods of synthesis – namely, thematic synthesis, textual narrative synthesis, framework synthesis and ecological triangulation – view themselves as producing an output that is directly applicable to policy makers and designers of interventions. The example of framework synthesis examined here (on children's, young people's and parents' views of walking and cycling) involved policy makers and practitioners in directing the focus of the synthesis and used the themes derived from the synthesis to infer what kind of interventions might be most effective in encouraging walking and cycling. Likewise, the products of the thematic synthesis took the form of practical recommendations for interventions (e.g. 'do not promote fruit and vegetables in the same way in the same intervention'). The extent to which policy makers and practitioners are involved in informing either synthesis or recommendation is less clear from the documents published on ecological triangulation, but the aim certainly is to directly inform practice.

The outputs of synthesis methods which have a more constructivist orientation – meta-study, meta-narrative, meta-ethnography, grounded theory, critical interpretive synthesis – tend to look rather different. They are generally more complex and conceptual, sometimes operating on the symbolic or metaphorical level, and requiring a further process of interpretation by policy makers and practitioners in order for them to inform practice. This is not to say, however, that they are not useful for practice, more that they are doing different work. However, it may be that, in the absence of further interpretation, they are more useful for informing other researchers and theoreticians.

Looking across dimensions

After examining the dimensions of difference of our included methods, what picture ultimately emerges? It seems clear that, while similar in some respects, there are genuine differences in approach to the synthesis of what is essentially textual data. To some extent, these differences can be explained by the epistemological assumptions that underpin each method. Our methods split into two broad camps: the idealist and the realist (see Table ​ Table1 1 for a summary). Idealist approaches generally tend to have a more iterative approach to searching (and the review process), have less a priori quality assessment procedures and are more inclined to problematize the literature. Realist approaches are characterised by a more linear approach to searching and review, have clearer and more well-developed approaches to quality assessment, and do not problematize the literature.

Summary table

N.B.: In terms of the above dimensions, it is generally a question of degree rather than of absolute distinctions.

Mapping the relationships between methods

What is interesting is the relationship between these methods of synthesis, the conceptual links between them, and the extent to which the originators cite – or, in some cases, don't cite – one another. Some methods directly build on others – framework synthesis builds on framework analysis, for example, while grounded theory and constant comparative analysis build on grounded theory. Others further develop existing methods – meta-study, critical interpretive synthesis and meta-narrative all adapt aspects of meta-ethnography, while also importing concepts from other theorists (critical interpretive synthesis also adapts grounded theory techniques).

Some methods share a clear conceptual link, without directly citing one another: for example, the analytical themes developed during thematic synthesis are comparable to the third order interpretations of meta-ethnography. The meta-theory aspect of meta-study is echoed in both meta-narrative synthesis and critical interpretive synthesis (see 'Problematizing the literature, above); however, the originators of critical interpretive synthesis only refer to the originators of meta-study in relation to their use of sampling techniques.

While methods for qualitative synthesis have many similarities, there are clear differences in approach between them, many of which can be explained by taking account of a given method's epistemology.

However, within the two broad idealist/realist categories, any differences between methods in terms of outputs appear to be small.

Since many systematic reviews are designed to inform policy and practice, it is important to select a method – or type of method – that will produce the kind of conclusions needed. However, it is acknowledged that this is not always simple or even possible to achieve in practice.

The approaches that result in more easily translatable messages for policy-makers and practitioners may appear to be more attractive than the others; but we do need to take account lessons from the more idealist end of the spectrum, that some perspectives are not universal.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

Both authors made substantial contributions, with EBP taking a lead on writing and JT on the analytical framework. Both authors read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/9/59/prepub

Supplementary Material

Dimensions of difference . Ranging from subjective idealism through objective idealism and critical realism to scientific realism to naïve realism

Acknowledgements

The authors would like to acknowledge the helpful contributions of the following in commenting on earlier drafts of this paper: David Gough, Sandy Oliver, Angela Harden, Mary Dixon-Woods, Trisha Greenhalgh and Barbara L. Paterson. We would also like to thank the peer reviewers: Helen J Smith, Rosaline Barbour and Mark Rodgers for their helpful reviews. The methodological development was supported by the Department of Health (England) and the ESRC through the Methods for Research Synthesis Node of the National Centre for Research Methods (NCRM). An earlier draft of this paper currently appears as a working paper on the National Centre for Research Methods' website http://www.ncrm.ac.uk/ .

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A critical analysis of respondent quotes used as titles of qualitative research papers that are published in peer-reviewed journals

Affiliation.

• 1 National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK.
• PMID: 33685305
• DOI: 10.1080/08989621.2021.1901224

The use of respondent quotes to headline qualitative research papers is a popular literary device found in many academic journals. This practice has increased over the last four decades and now appears normalised within qualitative research writing. This article provides a critical analysis of this trend in academic writing and concomitant publishing. Content and framework analyses of 40 papers employing this literary device to summarise the respective studies identified (i) a lack of methodological rigor, (ii) incomplete analysis, (iii) an overall mis-representation of the wider qualitative dataset, and (iv) possible investigator bias associated with using respondent quotes as titles of qualitative research papers. This article questions the credibility of purposely selecting a single experience that reduces the wider collective experience into one deterministic statement. This article contends that such practice is antithetical to the principles of qualitative research. Recommendations are provided to better monitor this practice throughout the academy.

Keywords: Qualitative research; methodology and methods; research titles; respondent quotes.

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A Critical analysis of a qualitative research study Essay (Critical Writing)

• To find inspiration for your paper and overcome writer’s block
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Host nations of large and prestigious events make sure that they portray an impressive image to the world. Dolles and Söderman (2010) note that cities hosting famous global events like FIFA world cup football tournament and the Olympics are normally set to stage a show for the whole world.

Indeed, these cities normally use this spectacular chance to demonstrate their might to the rest of the world. One of the major issues which spring up upon hosting such games is the socio-economic impact they come with. Studies have revealed that the real inhabitants of a city are usually highly responsive in case of any changes (Kennelly & Watt, 2011).

The open national qualitative study was therefore carried out to analyze the experiences of the young and homeless group of persons living in London and Vancouver.

This sub population happened to be the distinct dwellers of the streets of the two Olympic cities of 2010 and 2012. The research is aimed at offering a critical analysis of qualitative research study of the article authored by Kennelly and Watt on the effect of Olympics on poor neighborhoods.

It was critical for the research to be done using qualitative methods of study. Qualitative research ensures the use of everyday experiences of life to develop desirable ideas that are deduced from the real life of the research subjects (Golriz & Walker, 2012).

This being a qualitative research, it was done through the observation of the daily patterns of the lives of the young and homeless in London and Vancouver. The inquiries were conducted by an interpretation of phenomenal aspects of their lives. The sensitive social life was keenly scrutinized. Audio recordings, photographs and observational field notes were taken for assessment.

The general displacement of people due to preparations in readiness for Olympics, the recount of general experiences of people who were affected by these early preparations and the feelings of the hosts needed more assessment work in order to give the finest result of the study.

One of the most remarkable impacts which arise from the restructuring of a city prior to an international event is the achievement of global status (Dolles & Söderman, 2010). This is definitely one of the expectations of governments hosting such remarkable events.

The cities of London and Vancouver have realized a proportionate growth due to the Olympic Games. This has happened despite the fact that the homeless minorities have been spatially impoverished. This group of people has been forced to move away into the outskirts of the cities.

This has compelled them to settle for lower low-waged jobs which are characterized by insecurity. In order to give room to the middle class and first class Olympic hype followers, the humble street dwellers have been retrieved from the now economically stabilized cities. This is a basic social injustice and a gross form of economic neo colonialism (Golriz & Walker, 2012).

A quality and standard study research is supposed to ensure an all around analysis of the issue at hand (Golriz & Walker, 2012). Dolles and Söderman (2010) propose that the net gain of hosting the Olympics should not be given a chance to block the fight against moral ills which are associated with famous events.

Youth related crimes like tourist robbery, drug trafficking and prostitution should be adequately buffered during the Olympic season. The low income people should be incorporated in the general agenda of achieving international cohesion through international games.

The study was geared towards giving the phenomenal improvement of the two cities in terms of urban space utilization and configuration. It brought out the disproportional event hosting policy which marginalize the poor homeless youths.

Governments should start being keen to conduct balanced expansion of cities. This is achieved by a strategic planning which caters for the welfare of all members of the society (Dolles & Söderman, 2010).

Dolles, H. & Söderman, S. (2010). Addressing ecology and sustainability in mega- sporting events: The 2006 football World Cup in Germany. Journal of Management and Organization, 16(4), 587-600.

Golriz, S. & Walker, B. (2012). Backpacks. Several factors likely to influence design and usage: A systematic literature review. Work , 42(4), 1-150.

Kennelly, J & Watt, P. (2011). Sanitizing Public Space in Olympic Host Cities: The Spatial Experiences of Marginalized Youth in 2010, Vancouver and 2012 London. Sociology 45(5) 765–781

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A Qualitative Research Essay

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1 Important points to consider when critically evaluating published research papers

Simple review articles (also referred to as ‘narrative’ or ‘selective’ reviews), systematic reviews and meta-analyses provide rapid overviews and ‘snapshots’ of progress made within a field, summarising a given topic or research area. They can serve as useful guides, or as current and comprehensive ‘sources’ of information, and can act as a point of reference to relevant primary research studies within a given scientific area. Narrative or systematic reviews are often used as a first step towards a more detailed investigation of a topic or a specific enquiry (a hypothesis or research question), or to establish critical awareness of a rapidly-moving field (you will be required to demonstrate this as part of an assignment, an essay or a dissertation at postgraduate level).

The majority of primary ‘empirical’ research papers essentially follow the same structure (abbreviated here as IMRAD). There is a section on Introduction, followed by the Methods, then the Results, which includes figures and tables showing data described in the paper, and a Discussion. The paper typically ends with a Conclusion, and References and Acknowledgements sections.

The Title of the paper provides a concise first impression. The Abstract follows the basic structure of the extended article. It provides an ‘accessible’ and concise summary of the aims, methods, results and conclusions. The Introduction provides useful background information and context, and typically outlines the aims and objectives of the study. The Abstract can serve as a useful summary of the paper, presenting the purpose, scope and major findings. However, simply reading the abstract alone is not a substitute for critically reading the whole article. To really get a good understanding and to be able to critically evaluate a research study, it is necessary to read on.

While most research papers follow the above format, variations do exist. For example, the results and discussion sections may be combined. In some journals the materials and methods may follow the discussion, and in two of the most widely read journals, Science and Nature, the format does vary from the above due to restrictions on the length of articles. In addition, there may be supporting documents that accompany a paper, including supplementary materials such as supporting data, tables, figures, videos and so on. There may also be commentaries or editorials associated with a topical research paper, which provide an overview or critique of the study being presented.

Box 1 Key questions to ask when appraising a research paper

• Is the study’s research question relevant?
• Does the study add anything new to current knowledge and understanding?
• Does the study test a stated hypothesis?
• Is the design of the study appropriate to the research question?
• Do the study methods address key potential sources of bias?
• Were suitable ‘controls’ included in the study?
• Were the statistical analyses appropriate and applied correctly?
• Is there a clear statement of findings?
• Does the data support the authors’ conclusions?
• Are there any conflicts of interest or ethical concerns?

There are various strategies used in reading a scientific research paper, and one of these is to start with the title and the abstract, then look at the figures and tables, and move on to the introduction, before turning to the results and discussion, and finally, interrogating the methods.

Another strategy (outlined below) is to begin with the abstract and then the discussion, take a look at the methods, and then the results section (including any relevant tables and figures), before moving on to look more closely at the discussion and, finally, the conclusion. You should choose a strategy that works best for you. However, asking the ‘right’ questions is a central feature of critical appraisal, as with any enquiry, so where should you begin? Here are some critical questions to consider when evaluating a research paper.

Look at the Abstract and then the Discussion : Are these accessible and of general relevance or are they detailed, with far-reaching conclusions? Is it clear why the study was undertaken? Why are the conclusions important? Does the study add anything new to current knowledge and understanding? The reasons why a particular study design or statistical method were chosen should also be clear from reading a research paper. What is the research question being asked? Does the study test a stated hypothesis? Is the design of the study appropriate to the research question? Have the authors considered the limitations of their study and have they discussed these in context?

Take a look at the Methods : Were there any practical difficulties that could have compromised the study or its implementation? Were these considered in the protocol? Were there any missing values and, if so, was the number of missing values too large to permit meaningful analysis? Was the number of samples (cases or participants) too small to establish meaningful significance? Do the study methods address key potential sources of bias? Were suitable ‘controls’ included in the study? If controls are missing or not appropriate to the study design, we cannot be confident that the results really show what is happening in an experiment. Were the statistical analyses appropriate and applied correctly? Do the authors point out the limitations of methods or tests used? Were the methods referenced and described in sufficient detail for others to repeat or extend the study?

Take a look at the Results section and relevant tables and figures : Is there a clear statement of findings? Were the results expected? Do they make sense? What data supports them? Do the tables and figures clearly describe the data (highlighting trends etc.)? Try to distinguish between what the data show and what the authors say they show (i.e. their interpretation).

Moving on to look in greater depth at the Discussion and Conclusion : Are the results discussed in relation to similar (previous) studies? Do the authors indulge in excessive speculation? Are limitations of the study adequately addressed? Were the objectives of the study met and the hypothesis supported or refuted (and is a clear explanation provided)? Does the data support the authors’ conclusions? Maybe there is only one experiment to support a point. More often, several different experiments or approaches combine to support a particular conclusion. A rule of thumb here is that if multiple approaches and multiple lines of evidence from different directions are presented, and all point to the same conclusion, then the conclusions are more credible. But do question all assumptions. Identify any implicit or hidden assumptions that the authors may have used when interpreting their data. Be wary of data that is mixed up with interpretation and speculation! Remember, just because it is published, does not mean that it is right.

O ther points you should consider when evaluating a research paper : Are there any financial, ethical or other conflicts of interest associated with the study, its authors and sponsors? Are there ethical concerns with the study itself? Looking at the references, consider if the authors have preferentially cited their own previous publications (i.e. needlessly), and whether the list of references are recent (ensuring that the analysis is up-to-date). Finally, from a practical perspective, you should move beyond the text of a research paper, talk to your peers about it, consult available commentaries, online links to references and other external sources to help clarify any aspects you don’t understand.

The above can be taken as a general guide to help you begin to critically evaluate a scientific research paper, but only in the broadest sense. Do bear in mind that the way that research evidence is critiqued will also differ slightly according to the type of study being appraised, whether observational or experimental, and each study will have additional aspects that would need to be evaluated separately. For criteria recommended for the evaluation of qualitative research papers, see the article by Mildred Blaxter (1996), available online. Details are in the References.

Activity 1 Critical appraisal of a scientific research paper

A critical appraisal checklist, which you can download via the link below, can act as a useful tool to help you to interrogate research papers. The checklist is divided into four sections, broadly covering:

• some general aspects
• research design and methodology
• the results
• discussion, conclusion and references.

Science perspective – critical appraisal checklist [ Tip: hold Ctrl and click a link to open it in a new tab. ( Hide tip ) ]

• Identify and obtain a research article based on a topic of your own choosing, using a search engine such as Google Scholar or PubMed (for example).
• The selection criteria for your target paper are as follows: the article must be an open access primary research paper (not a review) containing empirical data, published in the last 2–3 years, and preferably no more than 5–6 pages in length.
• Critically evaluate the research paper using the checklist provided, making notes on the key points and your overall impression.

Critical appraisal checklists are useful tools to help assess the quality of a study. Assessment of various factors, including the importance of the research question, the design and methodology of a study, the validity of the results and their usefulness (application or relevance), the legitimacy of the conclusions, and any potential conflicts of interest, are an important part of the critical appraisal process. Limitations and further improvements can then be considered.

• Open access
• Published: 30 August 2024

Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review

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• Walid Theib Mohammad 6 ,
• Samira Mohajer   ORCID: orcid.org/0000-0001-7118-1783 1 , 4 &
• Mohammad Namazinia   ORCID: orcid.org/0000-0003-2198-7556 5  

BMC Palliative Care volume  23 , Article number:  217 ( 2024 ) Cite this article

Metrics details

Despite increasing interest in quality end-of-life care (EOLC), critically ill patients often receive suboptimal care. Critical care nurses play a crucial role in EOLC, but face numerous barriers that hinder their ability to provide compassionate and effective care.

An integrative literature review was conducted to investigate barriers impacting the quality of end-of-life care. This review process involved searching database like MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, and ScienceDirect up to November 2023. Search strategies focused on keywords related to barriers in end-of-life care and critical care nurses from October 30th to November 10th, 2023. The inclusion criteria specified full-text English articles published between 2010 and 2023 that addressed barriers perceived by critical care nurses. This integrative review employs an integrated thematic analysis approach, which combines elements of deductive and inductive analysis, to explore the identified barriers, with coding and theme development overseen by the primary and secondary authors.

Out of 103 articles published, 11 articles were included in the review. There were eight cross-sectional descriptive studies and three qualitative studies, which demonstrated barriers affecting end-of-life care quality. Quality appraisal using the Mixed Method Appraisal Tool was completed by two authors confirmed the high credibility of the selected studies, indicating the presence of high-quality evidence across the reviewed articles. Thematic analysis led to the three main themes (1) barriers related to patients and their families, (2) barriers related to nurses and their demographic characteristics, and (3) barriers related to health care environment and institutions.

This review highlights barriers influencing the quality of end of life care perceived by critical care nurses and the gaps that need attention to improve the quality of care provided for patients in their final stages and their fsmilies within the context of critical care. This review also notes the need for additional research to investigate the uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review examines how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome.

Peer Review reports

Introduction

It was estimated that 56.8 million people, including 25.7 million at the end of life, need palliative care; however, only about 14% of people who need palliative care currently receive it [ 1 ]. The need for acute care settings increased in response to life-threatening emergencies and the acute exacerbation of diseases [ 2 , 3 ]. These settings were developed to meet the need for providing optimal health care, saving patient lives and decreasing the rate of mortality using advanced technology [ 2 , 4 ]. Caring in intensive care units sometimes involves withholding or withdrawing treatments that have lasted a lifetime, and in these cases, the role of ICU nurses goes from providing life-saving measures to end-of-life care [ 5 ]. Care at the end of a life is a special kind of health care for individuals and families who are living with a life-limiting illness [ 6 ]. End-of-life care (EOLC) includes a crucial component of intensive care nurses’ work; nurses are in a unique position to cooperate with families to provide care for patients at the end of their lives [ 7 , 8 , 9 , 10 43 ].

Advanced technology in critical care units has led to improved nursing care in many areas, such as End-Of-Life-Care (EOLC) [ 11 ]. This type of care has moved towards enhancing comfort and reducing patients’ suffering [ 12 ]. As EOLC involves enhancing the physical, emotional, and spiritual quality of life for critically ill patients, traditional measures are now challenged as advanced technology has revolutionized nursing care through innovations such as adjustable beds and pressure-relieving mattresses, which help optimize patient comfort, and advanced communication technologies, for example, video conferencing facilitating communication between patients, families, and healthcare providers, allowing for ongoing support, counseling, and decision-making discussions throughout the end-of-life journey. Therefore, quality EOLC has become a significant concern for healthcare decision-makers, healthcare providers, researchers, patients, and families [ 13 ]. Despite the increased interest and demand in providing good EOLC, this care is still limited In the critical care and does not meet the recommended standards [ 14 ]. Critical Care Nurses spend more time with patients compared to other members of the multidisciplinary team. They serve as implementers, educators, and coordinators in end-of-life care. Their role in delivering EOLC is essential as they are presumably prepared to provide this care and meet patients and their family’s needs, including pain control, management of physical, emotional, spiritual, and social needs, and communication with patients and their families [ 15 ]. Therefore, it is important to look into the factors that impede the provision of quality end-of-life care from their perspectives. Many barriers affecting the provision of EOLC in critical care areas have been reported in the literature [ 13 , 16 , 17 ].

End-of-life care (EOLC) involves caring for and managing terminally ill patients and families. The quality of EOLC in critical care units has been evaluated based on factors such as patient/family involvement in decision-making, professional communication between health professionals and patients/families, care quality, support types, illness and symptom management, spirituality, and organizational support for critical care nurses [ 18 ]. Furthermore, working in a critical care unit environment is stressful and emotionally taxing for health professionals such as nurses. Carers of terminally ill patients may experience distressing emotions such as helplessness, loss of power, sadness, and hopelessness [ 18 ]. These feelings make it difficult to provide optimal end-of-life care. Additionally, nurses focus on managing symptoms, disease prognosis, treatment options, and physical aspects, but in fact, caring in critical care units follows a universal and holistic model. Previous research has shown that patients and families are not receiving adequate care at the end of life.

Researchers categorized factors that affect EOLC into barriers and challenges [ 13 ]. Barriers have been classified into three categories: patient and family-related, nurses and other health care workers’ related, and health care institutions’ related [ 16 , 17 ].

Barriers related to communication between health care providers and patients and families and characteristics of critical care nurses, including nurses’ age, gender, educational level, and end-of-life care training, significantly affect providing good EOLC [ 19 , 20 , 21 , 22 , 23 ]. this integrative review aims to go beyond merely identifying and categorizing barriers. By synthesizing results from a wide range of studies, the review seeks to uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review will examine how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome Despite the fact that EOLC is decisive to patient care, appropriate provision of this service is still lacking in several aspects. In the ICUs, EOLC must be considered an essential factor. However, owing to the existing practices of nurses, the adequate delivery of EOLC tends to bear various inefficiencies.

Nurses and other healthcare staff seem to come across multiple barriers that hinder their ability to offer effective care to critically ill patients. Considering the given dearth of research in this context, we intend to present a comprehensive insight into the issue. In this review, we focused on EOLC provided by critical care nurses, who were defined as nurses dealing with patients suffering from acute health problems due to injury, surgery, or exacerbated chronic diseases and need close monitoring in units such as intensive care units (surgical, medical, and pediatric) and cardiac care units. Due to the importance of exploring these barriers in determining the quality of EOLC, this integrative review paper was conducted to examine and highlight evidence from the literature on these barriers that affect the provision of quality EOLC. This paper explores and identifies current published peer-reviewed studies addressing barriers that affect the quality of EOLC as perceived by critical care nurses. This integrative review seeks to answer the following question: What barriers affect the quality of end-of-life care perceived by nurses working in critical care units?

An integrative review design was the most suitable method to explore and produce a new understanding from various types of literature (experimental, non-experimental, and theoretical) to enhance understanding of the phenomenon under investigation (i.e., EOLC). This method also facilitated nursing science by informing further research, care provision, and policy-making. It also highlights strengths, weaknesses, limitations, and gaps in knowledge, and supports what is already known about theories relevant to our topic [ 24 ]. Therefore, this design helps meet this review’s purposes.

Search strategies

The search process involved four phases which were developed by the first author (YR) and validated by two expert authors (MCC and KLA) as follows: (1) identifying the problems related to the research question, (2) conducting a systematic literature search, (3) screening the articles to develop themes, and (4) performing critical analysis to develop the themes.

From October 30, 2023, to November 10, 2023, electronic literature searches were conducted using major databases such as MEDLINE, Cochrane, CINAHL, EBSCO, and ScienceDirect.

Search methods were defined using the MeSH (Medical Subject Headings) descriptors of the keywords “end-of-life care,” “barriers,” and “critical care nurses.” Additionally, the reference lists of all identified articles were manually searched for additional studies. The operators used in this search included “AND” and “OR,” as well as the truncation tools of each database. A refined search was performed with terms such as “critical care nurses’ perceptions” OR “opinions” AND “quality end-of-life care” OR “quality of death and dying.” Subsequently, terms like “barriers” OR “obstacles” OR “challenges” AND “quality end-of-life care” OR “quality of death and dying” were employed. Finally, the descriptors “critical care nurses’ perceptions,” “barriers,” and “quality end-of-life care” were used (Fig.  1 ).

PRISMA search flow diagram

Inclusion and exclusion criteria

The inclusion criteria for this search to select relevant articles were as follows: (1) Full-text articles, (2) Papers published in the English language from 2010 to 2023, and (3) Articles that specifically describe the barriers perceived by critical care nurses that affect the quality of end-of-life care.

Intervention studies and studies that describe barriers to providing quality end-of-life care from other perspectives, such as physicians and patients’ families were excluded. For the studies who included nurses and other health care workers within the context of critical care, the researchers included the results that relevant to nurses and excluded the others.

Data extraction

The data extraction and analysis were carried out to collect and consolidate the data from the selected studies into a standard format relevant to the research field. The extracted data included specific descriptions of the settings, populations, study methods, and outcome measures (Table  31 ). Two authors (YSR and KLA) independently extracted the data and reached an agreement after discussion with the third author (MCC).

Included and excluded studies

Following the review process, the authors made the final decision on studies that met the study criteria. Out of a total of 103 articles, 9 duplicates were removed. The abstracts of the remaining 94 articles were initially found to be somewhat relevant to the research topic. However, after examining the articles in terms of research methodology and results, 36 articles that matched the selection criteria for this study were ultimately chosen. The full text of the 36 articles was reexamined based on the title first for suitability. Subsequently, the abstracts of the studies were reviewed, leading to the exclusion of 23 articles for various reasons, leaving 13 studies for further consideration in this study. However, two articles were disqualified as they did not contain a specific research methodology or reviewed literature papers; they relied solely on theoretical information. This step resulted in the inclusion of 11 research articles in this integrative review of the literature (Table  1 ).

Quality appraisal

To ensure the methodology’s quality and avoid bias in the design, highly credible and respected search engines were adopted to select peer-reviewed studies according to the inclusion criteria in this review. The articles chosen in this review were categorized into two sections based on study design and research methodology: quantitative and qualitative studies. These were evaluated manually and independently for each study, with any disagreements resolved by two experts (KLA, Professor, and MCC, Associate Professor) who have experience in research methodology, using the Mixed Methods Appraisal Tool (MMAT) version 2018 [ 25 ]. This tool includes specific criteria for evaluating the quality of quantitative, qualitative, and mixed-method studies. The MMAT consists of a checklist of five research components for each type of study with a rating scale including “Yes,” “No,” and “Can’t tell.” The overall results suggest that the evidence quality across the ten studies was high (Table  2 ).

Data synthesis

Thematic analysis in this review involves a systematic process of coding and theme development, using both inductive and deductive approaches. This method ensures a comprehensive synthesis of diverse data sources, providing valuable insights into the research topic [ 24 , 26 ]. Thematic analysis was employed for all studies to investigate the subject of interest. The coding for the themes in this review followed the six recommended phases: Familiarizing with the data; making initial codes; searching for themes; reviewing themes and making a thematic plan; defining and naming themes; generating the final picture of the report [ 24 ]. The coding was conducted by the primary author (YSR) and confirmed by the three secondary authors (LH, SM, and LY). Any discrepancies were discussed and resolved through consensus.

Search outcomes

The search process yielded a total of 103 articles. All articles resulting from the search process were independently reviewed by all authors in this study for the research process, purpose, methodology, tools, main findings, recommendations, and limitations.

Characteristics of included studies

Eight cross-sectional descriptive studies and three qualitative studies were selected, which were conducted in the following countries: two from the USA [ 27 , 28 ] and a single study from each of the following countries: Saudi Arabia [ 22 ], Jordan [ 29 ], Egypt [ 12 ], Malaysia [ 13 ], Scotland [ 30 ], Poland [ 31 ], Hong Kong [ 32 ], South Africa [ 33 ], and China [ 34 ].

In this comprehensive analysis of 11 studies, a diverse range of methodologies and findings were examined across different countries and healthcare settings. The studies included a mix of quantitative and qualitative approaches, with sample sizes varying from small convenience samples to larger cohorts. Key barriers to providing End of Life Care (EOLC) were identified, such as challenges in communication with families, lack of support from managers, and insufficient training in EOLC. The studies highlighted the importance of addressing these barriers to improve the quality of care provided by nurses in critical care settings. Notably, demographic characteristics and their impact on EOLC provision were not consistently addressed across the studies, indicating a potential area for further research and exploration in this field (Table  31 ).

The thematic analysis of included studies revealed several key themes and sub-themes related to barriers in End of Life Care (EOLC). These themes encompassed various aspects, including challenges related to patients and their families, healthcare institutions and the environment, as well as barriers specific to nurses. Communication and collaboration between patients, nurses, and families included issues such as seeking updates about patient status, misunderstandings about life-saving measures, misunderstanding poor prognosis, troubled family dynamics, and conflicts within families regarding life support decisions [ 22 , 34 ]. Additionally, barriers related to Institution Policy and procedures highlighted concerns such as insufficient standard procedures, communication challenges in decision-making, inadequate ICU design, inappropriate staffing policies, and deficiencies in rooms, supplies, and noise control. Furthermore, barriers associated with nurses encompassed their emotional experiences and socio-demographic characteristics [ 12 ] (Table  4 ).

Among the results of the selected articles on nurses’ perceptions of barriers affecting quality EOLC, three main themes were identified: (1) Communication and collaboration between patients, nurses, and families (2) Institution Policy and procedural barriers, and (3) barriers related to nurses and their demographics. An overlap in some of these areas, such as the themes addressing barriers related to patients and their families, was identified [ 11 , 22 , 35 ]. This overlap indicates a high level of consensus between the authors in identifying the barriers affecting the quality of end-of-life care.

Communication and collaboration between patients, nurses, and families

After reviewing the existing body of literature in this domain, it was observed that some familial factors had been largely perceived as prominent barriers to providing EOLC by the nurses. Although some authors concluded family issues as the highest-ranking concern for nurses in providing quality EOLC, there were variations in the type of barriers they encountered [ 11 , 28 , 35 ]. For example, continuous requests for updates on patients’ status from their families were identified as the top-rated barrier affecting the quality of EOLC from the perspective of critical care nurses. In addition, family misunderstandings about life-saving measures, as well as doubts and uncertainties regarding prognosis, resulted in a lack of time for nurses to provide quality EOLC, as they spent significant time explaining these matters [ 29 ]. Similarly, continuous phone calls from family members seeking updates on patients’ conditions were ranked highest (M = 4.23) among barriers affecting EOLC [ 28 ]. Additionally, dealing with distressed family members also received the highest total mean score (M = 3.3) [ 13 ]. On the contrary, another study found that out of 70 nurses, the practice of calling nurses for updates on patients’ conditions had the lowest impact on EOLC practice (62.2%), while misunderstanding about life-saving measures (65.7%) played a crucial role in determining the quality of EOLC [ 36 ]. The study concluded that the primary barrier related to patients and their families was the lack of understanding among family members about what life-saving measures entailed. Similarly, another source also reported consistent findings indicating that families often did not accept poor prognoses for patients and struggled to grasp the significance of life-saving measures [ 22 ].

Furthermore, previous studies have indicated that barriers affecting EOLC and thereby the quality of care include the presence of family members with patients, inadequate communication with patients’ families, lack of involvement in discussions about patient care decisions, conflicts among family members regarding decisions to cease or continue life support treatment, and unrealistic expectations regarding prognosis [ 22 , 30 , 37 ].

Communication and collaboration among doctors and nurses are vital in designing an effective healthcare plan for patients. However, inadequate and inappropriate collaboration and support, such as conflicting opinions, disagreements, and insufficient cooperation between them, can lead to various difficulties that may result in poor patient care [ 22 ]. Research scholars who have conducted studies in this area have acknowledged that agreement between nurses and physicians regarding care directions for patients at the end of life is one of the most critical barriers to enhancing the quality of EOLC [ 29 ].

Similarly, another study found that poor communication between nurses and physicians resulted in inappropriate decision-making and disagreement about care plans, which subsequently impacted the quality of care [ 13 ]. Additionally, inadequate and poor communication between nurses and other healthcare teams diverted attention from the goal of care [ 28 ].

Failures in communication between nurses and other healthcare providers can lead to misunderstandings of care messages, which can affect EOLC practices [ 30 ]. It also highlighted the lack of communication and cooperation between doctors and other healthcare team members; nurses emphasized the need for a communication training course [ 11 ].

Good communication between nurses and physicians and consideration of nurses’ opinions were found to enhance the quality of EOLC [ 12 ]. Furthermore, educating critical care nurses about communication and collaboration skills was reported as crucial for improving the quality of EOLC [ 13 ].

Barriers related to nurses

The given three sub-themes were identified regarding the impact of nurses-related barriers and the influence of some of their demographic factors on the quality of EOLC:

Lack of opportunities for training and education.

Emotional and psychological issue.

Nurses’ socio -demographic factors.

Lack of opportunities for training and education

It was reported that critical care nurses were not adequately prepared to provide EOLC; nurses needed to increase their knowledge about cultural aspects, ethical issues, skills, communication, and training regarding the continuity of care and the management of physical and psychosocial symptoms [ 11 , 13 , 28 ]. Furthermore, nurses who did not participate in any EOLC training course perceived more barriers to delivering quality EOLC than those who had participated in introductory training courses [ 13 , 28 ]. Attia et al. [ 12 ]. reported that 60% of critical care nurses perceived that they had received poor education and training concerning family grieving, symptom management, and quality EOLC. Furthermore, Holms et al. [ 30 ]. found that all participants acknowledged that they had received very little formal education and training on EOLC, particularly those who worked in intensive care. In a study by Jordan et al. [ 37 ], nurses emphasized that EOLC education is essential during the orientation period before starting their ICU jobs.

Emotional and psychological issue

Five articles in this review have studied the effect of nurses’ feelings and emotions as barriers to providing quality EOLC [ 11 , 13 , 28 , 30 , 37 ]. Nurses stated that they feel sad when they cannot help the patients to die peacefully, and they lack emotional support, considering this one of the main barriers to providing EOLC [ 11 ]. Staff morale distress was reported repeatedly during interviews with ICU nurses about their experience of EOLC. This feeling of despair is accompanied by many causes, such as lack of staff experience, poor communication, inadequate training about EOLC, lack of a suitable environment, and lack of support from senior staff [ 30 ]. Nurses acknowledged that they felt like they were participating in decisions to withdraw or withhold life-sustaining treatment, resulting in conflicting emotions and feeling helpless in advocating for the patients with mixed feelings of sadness, grief, anger, and frustration [ 37 ]. Lastly, Crump et al. [ 28 ] and Omar Daw Hussin et al. [ 13 ] observed that critical care nurses received inadequate emotional support from managers and experts within healthcare institutions, which affects the quality of EOLC they provide.

Nurses’ socio -demographic factors

It has been identified that some socio-demographic characteristics of nurses also play a significant role in shaping their opinions regarding perceived barriers. For example, age, education, experience in the field, and other similar factors profoundly impact their perceptions of the barriers to providing EOLC. A study by Omar Daw Hussin et al. [ 13 ] revealed that nurses ( n  = 553) aged 21–30 years old had the highest mean total score for barrier factors to provide quality EOLC compared to other age groups. This was also higher in diploma holders than in nurses with certificates and bachelor’s degrees. Regarding years of experience as critical care nurses, they found that nurses with minimal years of experience (1–10 years) had the highest mean total score for difficulties. Similarly, Chan et al. [ 38 ] found that nurses’ age, qualifications, and experience in caring for patients at EOL were significantly associated with their perceived barriers. Nurses’ distress in intensive care units was linked to various factors, one of which is the lack of experience in providing EOLC, as reported by Holms et al. [ 30 ].

Institution Policy and procedural barriers

Healthcare facilities and the surrounding environment where patients stay have a significant influence on their quick recovery, mental and physical health, as well as health progress [ 11 ]. Therefore, healthcare institutions ought to establish a healthy environment for patients’ well-being. However, in the current review, it was understood that nurses identified a group of barriers related to hospital settings, such as the insufficiency of standard procedures pertaining to EOLC in place at the institution, inappropriate staffing policies in the ICU, lack of rooms prepared for EOLC, insufficient supplies to assist families in EOLC, and a noisy environment with bright lights in patients’ rooms [ 11 ]. Likewise, researchers concluded that intensive care unit nurses face time constraints due to heavy workloads; they also reported that intensive care units have poor designs that interrupt patients’ privacy and affect the provision of quality EOLC [ 12 , 28 ]. Previous studies identified a lack of EOLC rules and guidelines governing the provision of quality EOLC in critical care units, such as limited visiting hours, guiding preferred care pathways, and excessive paperwork burdens [ 12 , 13 , 30 ].

In this section, we discuss the results of this review on the barriers to providing quality end-of-life care derived from the literature and compare them with the results of previous studies.

The themes emerging from the data helped us understand that some familial factors play a decisive role in hindering timely and effective EOLC provision to patients. Our findings are consistent with Beckstrand et al. [ 36 ] and Friedenberg et al. [ 39 ], who also found that families’ lack of understanding or insufficient understanding of the life-saving measures performed for patients often contributes to delayed EOLC provision, due to their ambiguous opinions and uncertainty about the treatment given. Additionally, before taking any action, barriers related to other factors such as cultural aspects, not covered in this paper, should not be disregarded as they may have a significant influence on the outcomes.

There was agreement among all the authors in this review that communication and collaboration issues were at the forefront of factors that affect the quality of EOLC.in critical care setings, poor communication and collaboration between nurses and physicians makes nurses perceive their roles as secondary in the decision-making process. Additionally, critical care nurses also noted that interrupted communication leads to misunderstandings and conflicts in decision-making, diverting them from the goal of EOLC. It was also agreed that communication breakdown and conflicts in decision-making among healthcare teams impact the quality of care for patients with chronic end-stage diseases [ 40 ].

Reviewing the selected studies made us aware that nurses perceived inadequate training and education about EOLC significantly impacts their practice in delivering quality EOLC. The nurses also acknowledged the importance of receiving training and education regarding EOLC, such as symptom management, dealing with grieving families, and communication skills during the orientation period before starting their work in critical care units. Therefore, critical care nurses need to enhance their knowledge about cultural aspects, ethical issues, communication skills, and training related to the continuity of care and the management of physical and psychosocial symptoms [ 36 ].

Apart from training issues, we found that the feeling of not being able to provide proper care to some patients, consistent distress due to increased workload, or managing patients with critical conditions such as prolonging unavoidable death could be attributed to their deteriorating mental health, which they perceive as a barrier to offering EOLC. These results were also supported by Calvin et al. [ 41 ], who found that novice cardiac care unit nurses expressed more fear and discomfort while caring for dying patients and communicating with their families.

This review further shows that healthcare organizations lack policies and guidelines that govern EOLC, such as staffing policies and scheduling visiting hours, leading to a shortage of nurses, increased workload, and decreased presence of family members with their patients. This lack of policies was also indicated in their study [ 36 ]. Critical care units in this review have a poor design that challenges nurses when providing EOLC and interrupts patient privacy. This is consistent with Sheward et al. [ 42 ], who found that the poor design of critical care units may compromise patients’ confidentiality and affect the provision of quality EOLC.

In summary, our findings revealed that some familial factors play a decisive role in hindering timely and effective EOLC provision to patients. Moreover, nurses perceived that inadequate training and education about EOLC significantly impact their practice in providing good EOLC. Therefore, these aspects of our results are confirmed by broader literature, as evidenced before. The ceuurent review highlights the importance of enhancing family communication throught the needs for conducting education and training programs among health care profesionals in crirical care settings about communication skills. Additionally, healthcare organizations lack policies and guidelines that lead to a shortage of nurses, increased workload, and decreased family members’ presence with their patients, governing EOLC. Thus, this integrative review addresses the question of what barriers affect the quality of end-of-life care as perceived by nurses working in critical care units. Combining diverse methodologies can lead to inadequate rigor, imprecision, bias, flawed analysis, synthesis, and deductions. Therefore, there is a need for future studies to further refine the key indicators.

Strengths and limitations

The selected studies were conducted in several countries, which may enhance the generalizability of the study findings. The limitations of this review study are that it focused mainly on descriptive and non-experimental studies. Additionally, the assessment of quality appraisal for selected studies was subjective to the authors according to MMAT, which could affect the studies’ appraisal. The selection of only English articles may introduce bias regarding barriers beyond EOLC in countries where English is not commonly spoken.

The review indicated that healthcare organizations must provide critical care nurses with evidence-based pathways and guidelines to guide them in providing EOLC, increase emotional support from nursing managers and supervisors, and improve critical care settings design. Further studies need to be conducted on the barriers that affect the quality of EOLC and suggestions to overcome these barriers at the level of patients and families, nurses, physicians, other healthcare providers, and healthcare organizations to enhance teamwork and collaboration and improve the quality of EOLC.

This review also calls for additional research to be conducted to explore the barriers that affect the quality of end-of-life care. These studies should investigate barriers at multiple levels, including those affecting patients and families, nurses, physicians, other healthcare providers, and healthcare organizations. By identifying and understanding these barriers, recommendations can be made to overcome them, ultimately enhancing teamwork, collaboration, and the overall quality of end-of-life care.

International implications for practice

Many tools can be easily used to assess barriers to end-of-life care in critical care settings. We recommend monitoring and evaluating them regularly among nurses because they are significantly linked to the quality of end-of-life care. Furthermore, we advise to assess the quality of end-of-life care from patients and their families perspectives and provide them with greif and emotional support if they are unable to contribute in providing feedback that help in assissing the quality of end-of- life care. Refreshing training and education courses about end-of-life care aspects are significantly associated with the quality of care. We advise nursing management to conduct such courses for critical care nurses periodically. In general, there is an opportunity for improvement in terms of the quality of end-of-life care in critical care settings. As the critical care unit is part of a larger institution, it is worthwhile for the hospital’s management to adjust their policies regarding staffing, ICU design, visiting hours, and provide evidence-based guidelines so they can enhance the quality of end-of-life care.

Data availability

The data used to support the findings of this study are included within the article.

Abbreviations

End-Of-Life-Care

Mixed Method Appraisal Tool

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The past and present of thought experiments’ research at Glancy: bibliometric review and analysis

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• Hartono Bancong 1  

In the development of physical theories, thought experiments play a crucial role. Research on this topic began in 1976 and has continued to the present. This study aims to provide a more complete picture of the progress of thought experiments over the past two decades. To achieve this, this study employs bibliometric mapping methods. A total of 679 published papers were analyzed, including articles (504), conference papers (92), and book chapters (83). This data was retrieved from the Scopus database. The study's findings reveal that research and publications on thought experiments are highly valued and have received significant attention over the past eight years. According to the findings, 90% of the top 20 source titles contributing to thought experiments are from journals in the first and second quartiles (Q1 and Q2). This quartile ranking shows the quality and significant influence of a journal. The geographical distribution indicates that the United States contributes the most to thought experiments research, with 213 documents, 2592 citations, and 47 links. We also identified several prospective keywords that could be the focus of future research, including artificial intelligence, physics education, fiction, God, theology, productive imagination, technology, speculative design, and critical design. Therefore, this study provides a thorough picture of thought experiment research trends and future directions of potential topics that can be the focus of future researchers.

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1 Introduction

Thought experiments (TEs) have a long history in science. Since Ernst Mach, the term TEs, a direct translation of the phrase Gedankenexperimente , has been widely discussed in the philosophy of science [ 18 ]. Thought and experiments are two components of TEs [ 4 , 18 , 29 ]. The thought element involves visualizing an imaginary world based on theory and experience, whereas the experimental aspect entails practical tasks in a physical laboratory, such as manipulating items and related variables. While some authors consider TEs to be mere arguments [ 24 ], others believe TEs are a form of fiction since their function is comparable to literary fiction in that both have a narrative framework by creating scenarios of occurrences from beginning to end [ 13 , 22 ]. However, unlike fiction, which frequently provides contradictory discourses, we believe that TEs should be logically and conceptually cohesive. TEs are structured imaginative actions based on the theory and experience of thought experimenters to achieve certain goals.

The contributions of TEs to the growth of scientific theories, particularly in physics, are essential. Physicists have employed TEs several times throughout history to either come up with new hypotheses or disprove previous ones. As the most representative examples, Newton used the TEs of cannonballs to support his hypothesis that the force of gravity is universal and the principal force of planetary motion, or Galileo used the TEs of free-falling bodies to disprove Aristotle's theory of gravity, which stated that the speed of falling objects is proportional to their weight. Galileo’s falling body, Newton's bucket and cannon, Maxwell's demon, and Schrodinger’s cat are just a few of the well-known TEs in physics [ 4 ]. These are only a few examples of the significant role TEs played in the development of scientific theories.

In the past 10 years, several works have studied TEs from the perspectives of history and philosophy of science [ 7 , 8 , 10 , 30 , 33 ]. Because most existing historical work on TEs focuses on individual TEs or individual accounts of TEs, reassessing the history of the philosophical debate on TEs becomes essential [ 33 ]. In the philosophy of science, historical debates regarding interactions between various philosophers or philosophical explanations across time in developed TEs are sometimes disregarded. Several studies have also used TEs as an imaginative tool in the classroom to teach science subjects. Velentzas and Halkia [ 37 ], for example, used TEs from Newton's Cannon to teach satellite physics. They then assert that TEs, as a teaching tool, can assist students in strengthening their syllogistic abilities and help them conceive scenarios beyond their everyday experience [ 37 ]. El Skaf and Palacios [ 12 ] have also systematically analyzed the epistemic role of TEs from Wheeler's demon and Geroch's engine, which gave rise to black hole thermodynamics. Recently, Bancong et al. [ 2 ] reported that physics teachers in Indonesia have a high awareness of the importance of TEs in learning physics, especially atomic theory and relativity, even though they lack skills in the pedagogic aspects of TEs. Therefore, Indonesian physics teachers also suggest using technology such as virtual reality to help visualize an imaginary world when performing TEs.

Although a number of studies on TEs from various perspectives have been conducted, no study has yet completely examined this field to look at the trend of this topic in recent years. Therefore, it becomes essential to conduct a bibliometric study of TEs over time based on authoritative databases like Scopus. Because of Scopus's comprehensive coverage of scholarly articles in the field of education [ 23 , 27 , 34 ], it was chosen as the database for this study. Scopus is also a popular resource for bibliometric research [ 23 , 28 ]. For this reason, we use data sources from the Scopus database to carry out the bibliometric method. Our study covers journal articles, conference papers, and book chapters from the last 20 years to provide a more complete view.

To highlight the significance of TEs research, we compare its growth to other scientific topics. While many scientific fields have seen growth over the past two decades, TEs research has also shown a unique and sustained increase in interest and publications. This trend contrasts sharply with the decline in research focus on traditional physics experiments [ 41 ]. Similarly, other topics in physics education, such as methodological issues, textbook analysis, and pre-service physics teachers, are also experiencing reduced research interest [ 25 ]. Additionally, the integration of TEs with emerging technologies, such as artificial intelligence, underscores their evolving relevance and potential for future research [ 21 ].

Therefore, this study aims to provide an up-to-date overview of trends in TEs research. The research questions in this study are as follows:

How is the growth of research output on the topic of TEs over the last 20 years?

Which source titles have contributed the most to the publication of papers on TEs in the last 20 years?

Who are the most prominent authors on the topic of TEs in the last 20 years?

Which countries have published the most articles on TEs over the past 20 years?

What are the most relevant keywords that can be found in the studies of TEs over the last 20 years?

2.1 Research design

This study aims to analyze the trends in TEs research over the past 20 years by using a bibliometric mapping method. To ensure a thorough analysis of recent trends and developments, this study focused on studies published between 2003 and 2022. This period was chosen because of significant advancements in research methodologies and bibliometric analysis tools in the early 2000s, as well as the consistent growth and comprehensive coverage of the Scopus database since that time. Bibliometric analysis is a well-known statistical method for examining and analyzing a large amount of scientific data on a certain topic [ 26 , 39 ]. Metrics studied in bibliometric research include annual publications, source titles, authors, institutions, nations, and keywords, covering data from primary, secondary, and tertiary journals over a specific time period. It should be noted that no ethical approval was required for this study as it did not involve humans or animals.

2.2 Data collection

In this study, data were gathered from the Scopus database ( https://www.scopus.com ). Scopus was chosen because it covers a wider range of documents than any other scientific database [ 23 , 28 , 35 ]. Scopus is the world's largest abstracting and indexing database, with 84 million records containing over 18.0 million open access items, including gold, hybrid gold, green, and bronze, as well as 10.9 million conference papers, 25.8 thousand active peer-reviewed journals, and over 7000 publishers [ 14 ]. In addition, Scopus covers a wider range of educational disciplines than other databases, such as the Web of Science (WoS) [ 23 , 27 , 34 ]. As a result, using the Scopus database enables researchers to shed light on areas that may not be covered in WoS.

Electronic data search and retrieval were conducted on February 25, 2023. Keyword search was set to include title, abstract, and keywords. The keyword search was set to include the title, abstract, and keywords. The combination of search strings, operators, and filters used in this study was TITLE-ABS-KEY ("Thought-experiments" AND "Science" OR "Physics"). Quotation marks were used to focus on documents containing this exact phrase, thus ensuring high relevance to the study's scope. The Scopus database retrieved 898 documents related to these keywords with full bibliographical information, including articles (67.04%), paper proceedings (10.13%), book chapters (10.02%), and other types of documents (12.81%). By using the Scopus filter, other types of publications (12.81%), including review articles, were excluded from the list of documents. The exclusion of review articles was intentional to focus on original research contributions that advance the field of TEs directly. Including reviews could confound the analysis as they often summarize existing research rather than introduce new findings. Therefore, concentrating on the three most prevalent types of documents—articles, conference papers, and book chapters—allowed for a clearer interpretation of trends and patterns in original research outputs over the specified period. Additionally, we limited the year of publication to studies published within the last 20 years (2003–2022) to ensure the relevance and currency of our analysis. After using a filtering process to eliminate papers that did not meet the inclusion and exclusion criteria, a total of 679 articles were identified for bibliometric analysis. These articles included 504 articles, 92 book chapters, and 83 conference papers.

2.3 Data analysis

The data analysis process began with acquiring the necessary raw data by downloading it from the Scopus database in either comma-separated value (CSV) or research information system (RIS) format. For data analysis and visualization, we used VOSviewer and Microsoft Excel. VOSviewer, a sophisticated mapping tool, was employed to create collaborative networks for various variables and keywords, while Microsoft Excel was used for descriptive analysis, such as determining the number of articles published each year and identifying the most prolific source titles.

The network graphs in this study were generated using VOSviewer, based on co-authorship, co-occurrence, and citation data from Scopus. The analysis type focused on the co-occurrence of keywords and co-authorship, with a full counting method. Keywords with a minimum of four occurrences were included. The visualization settings in VOSviewer were mainly default, with the attraction parameter set to 2 and the repulsion parameter set to 0. These settings ensured that the most relevant and frequently occurring terms were highlighted, providing a clear overview of research trends and collaborations in the field of TEs over the past 20 years.

In this study, we explored the most productive publishers, the most referenced articles, the most productive authors, the most productive nations, and author keyword occurrences across time. An analysis of co-authorship and co-occurrence was performed at this stage. The analysis of co-authorship provides insights into the interactions between authors. This methodology was also used for metrics related to countries. For country attribution, we included all the countries of all authors involved in each publication, not just the corresponding author. This method ensures that all co-authors' contributions are acknowledged and provides a comprehensive representation of the global distribution of research. Co-occurrence analysis was employed as a means of investigating current keywords and their interrelationships with other phrases associated with TEs. Within this particular framework, the term “node size” refers to the frequency at which a certain keyword appears in comparison to other words. Additionally, interconnected nodes are visually represented by lines known as connections. The link establishes a connection between two nodes, while the width of the link signifies the intensity or potency of the connection between the aforementioned nodes [ 36 , 39 ].

In the context of network map visualization, nodes that exhibit a high degree of association are categorized into clusters. The clustering of items was performed using the Louvain algorithm, a popular method for community detection in large networks due to its efficiency and accuracy in handling large datasets [ 36 , 39 ]. This algorithm was chosen for its ability to uncover modular structures within large networks, which is particularly useful for identifying distinct research themes and collaboration groups in bibliometric data. Subsequently, a distinct color code was assigned to each cluster, wherein nodes within the same cluster exhibit a high degree of homogeneity. Therefore, this bibliometric mapping approach enabled researchers to discern patterns and emerging areas of interest throughout the timeframe spanning from 2003 to 2022. Figure 1 shows the stages in the process of collecting and analyzing data in this study.

The steps in collecting and analyzing the data

3.1 Statistics analysis

In this analysis, we use statistical data to observe differences in the number of articles published each year. The goal is to determine whether the quantity of publications on the topic of TEs has increased or decreased annually. Figure 2 illustrates the number of papers published over the last 20 years (2003–2022). As we can see, there has been an increase in the interest and attention of researchers, scholars, and experts in researching TEs. The growth started in 2004 and continued until 2006. The number of papers published then fluctuated between 2006 and 2015. The increase started again in 2015 and continued until 2021. The number of publications increased significantly in 2021, with 69 articles published. This growth demonstrates that research and publications on TEs are in high demand and have garnered significant attention globally in the last eight years despite a reduction in 2022. Although studies in this area are still ongoing, these findings indicate an annual growth in the writing and publication of TEs on Scopus.

Number of articles published each year

Statistical data are also used to see the number of source titles that have made the greatest contributions to TEs during the last 20 years. A total of 679 papers have been published from various sources with different types of documents in the form of articles (504), conference papers (92), and book chapters (83). According to statistical data in the Scopus database, publication in journals is very significant in publishing research on the topic of TEs, while publication in proceedings and book chapters with the main scope of TEs is not very significant. Therefore, researchers, academics, and experts are advised to submit their articles focused on TEs to journals rather than proceedings and chapter books. Table 1 lists the top 20 sources of scientific research publications covering the topic of TEs from 2003 to 2022.

As seen in Table 1 , 90% of the source titles contributing to the TEs topic are journals, with only one publishing conference proceedings. Philosophical studies ranks first, with 17 documents published in the last 20 years. This is followed by the AIP Conference Proceedings with 15 documents. The American Journal of Physics, Science and Education, and Studies in History and Philosophy of Science Part A have published 11 documents each. Other source titles, such as Synthese (10), Foundations of Science (9), Physics Teacher (9), Journal for General Philosophy of Science (8), and Philosophy of Science (8), also contributed to publishing TEs topics. Minds and Machines and Physics Education each published seven documents. Erkenntnis, European Journal of Physics, Physics Essays, and Religions each published six documents, Acta Analytica published five documents, while Axiomathes, Boston Studies in the Philosophy of and History of Science, and European Journal for Philosophy of Science each published four documents.

3.2 Bibliometric analysis

3.2.1 contributions of authors.

Table 2 shows the 10 most prolific authors based on the total number of published articles from 2003 to 2022. As shown in this list, Stuart is the most significant author with 7 papers (51 citations), followed by Bancong from Universitas Muhammadiyah Makassar, Indonesia, with 5 papers (15 citations). Following Bancong, Fehige from the University of Toronto, Canada, has also published 5 articles. The majority of Fehige’s research focuses on TEs in the context of religion. In contrast to Fehige, Brown, also from the University of Toronto in Canada, has studied TEs through the lens of history and philosophy of science in several of his works (4 documents, 52 citations). Similarly, Buzzoni (3 documents, 15 citations) and El Skaf (3 documents, 29 citations) from Italy, discuss TEs from historical and philosophical perspectives of science. Meanwhile, Halkia and Velentzas from the University of Athens, Greece, have analyzed TEs thoroughly from an educational standpoint, with the number of documents being 4 and 86 citations.

3.2.2 Contributions of country

In the context of the leading countries, authors from 64 different countries/territories published a total of 679 documents. Table 3 lists the top 20 countries in terms of TE contributions based on the number of papers published. As shown, the United States contributes the most to TEs research, with 213 documents, 2592 citations, and 47 links. The number of papers is about three times that of the United Kingdom, which comes second (75 documents, 1016 citations, and 31 links). European countries continue to hold third to sixth place, with Germany publishing 50 documents with 634 citations, followed by Canada (43 documents, 410 citations, and 17 links), Italy (33 documents, 96 citations, 6 links), and the Netherlands (28 documents, 342 citations, and 12 links). This suggests that countries in America and Europe contribute the most to TEs. The Asian country that has contributed the most to TEs is China, with 18 documents, 286 citations, and 11 links, followed by India (14 documents), Japan (12 documents), and South Korea (12 documents), with 97, 111, and 27 citations, respectively. The three countries below these are European countries, with Austria having issued 10 documents related to TEs with a total of 135 citations, followed by Finland (9 documents, 31 citations) and Spain (9 documents, 47 citations).

3.2.3 Keywords

The results of a keyword analysis can be used in further investigation of the topic at hand. This study employs a minimum threshold of two occurrences of keywords in all research articles that were examined using VOSviewer. Figure 3 displays the 253 authors' keywords detected from 1990, which may be categorized into six distinct clusters. Cluster 1 is characterized by a red color, Cluster 2 by a green color, while Cluster 3 is distinguished by a blue color. In addition, Cluster 4 is characterized by a yellow color, Cluster 5 has a purple hue, and Cluster 6 is distinguished by a light blue shade. Each cluster is comprised of interconnected keywords that are visually represented by the same colors. It is important to note that the size and shape of the node are indicative of the frequency of its occurrences [ 36 , 39 ]. In other words, there is a positive correlation between the size of the node and the frequency of occurrences of these terms. Clustering is employed as a means to gain insights or a comprehensive understanding of bibliometric groupings, whereas image mapping serves the purpose of obtaining a holistic depiction of a bibliometric network.

Network visualization of TEs

Figure 3 shows Cluster 1 (red) with 68 items such as thought experiments, intuition, Science, Kant, Aristotle, Galileo, Platonism, personal identity, theology, fiction narrative, moral motivation, and neuroscience. Cluster 2 (green) consists of 57 categories, such as science fiction, philosophy of science, philosophy of physics, philosophical thought, epistemology, knowledge, scientific reasoning, experiments, models, and realism. Cluster 3 (blue) contains 41 items, such as consciousness, Maxwell's demon, Schrodinger's cat, quantum theory, entropy, uncertainty principle, quantum entanglement, quantum information, quantum physics, and Newton's bucket. Furthermore, cluster 4 (yellow) consists of 30 items: physics education, science education, visualization, special theory of relativity, history of physics, problem-solving, exploration, Einstein, relativity, and falsification. Cluster 5 (purple) consists of 29 items: imagination, ontology, physics, truth time, algorithm of discovery, artificial intelligence, ethics, nanotechnology, fiction, philosophy, and technology. Finally, cluster 6 (light blue) contains 16 categories, including popular science, fictionality, narrative, construction, sensation, a priori, story, Mach, memory, productive imagination, and schema.

Keywords in clusters 1 and 2 have a high number of occurrences and a high total link strength. The term thought experiment ranks first with 85 occurrences and a total link strength of 91. This is followed by the term thought experiment with 60 occurrences, a total link strength of 98, and several other keywords. The high number of occurrences and high total link strength indicate that scientific research publications on the topic of TEs in the 2003–2022 range indexed by Scopus have a strong and direct relationship with these keywords. Table 4 displays the ten keywords with the highest occurrence and overall link strength in the last 20 years on the topic of TEs.

VOSviewer, on the other hand, is also used to visualize the progress of keywords over a certain period. Figure 4 illustrates the overlay visualization of the TEs topic in the time range 2003 to 2022.

Overlay visualization of TEs

Figure 4 depicts the annual distribution of the number of articles containing keywords. The various colors represent the publication dates of the related papers where these keywords appear together. The data in Fig. 4 indicate that the most frequently used topics related to TEs from 2010 to 2014 were quantum theory, ethical naturalism, ethical naturalism, quantum mechanics, scientific discovery, and mental models. Then, from 2014 to 2018, keywords such as scientific reasoning, intuition, science education, computer simulation, history of science, and science fiction began to appear in the TEs topic. The hottest topics in TEs research are shown in yellow color, including fiction, artificial intelligence, God, theology, speculative design, critical design, and methods of case. These findings indicate that these keywords have gained popularity in recent years. It can be concluded that scholars have increasingly turned to research on the mentioned topics in recent years.

4 Discussion

The goal of this study is to use the bibliometric mapping method to examine the trend of studies on TEs during the last 20 years (2003–2022). According to the findings of the study, there has been an increase in the interest and attention of researchers, scholars, and professionals in studying TEs. Although research in this area is ongoing, these findings indicate an annual growth in the writing and publication of TEs on Scopus. This growth demonstrates that research and publications on TEs are in high demand and receive significant global attention.

Interestingly, 90% of the top 20 source titles contributing to TEs research are journals in the first quartile (Q1) and second quartile (Q2). Among these, 10 journals are in the highest quartile, Q1, and 8 journals are in Q2. The quartile level indicates that these journals have the highest quality and the greatest influence [ 39 , 40 ]. Furthermore, 7 source titles (Philosophical Studies, Synthese, Foundations of Science, Minds and Machines, Erkenntnis, Acta Analytica, and Axiomathes) that publish TEs topics focus on the field of philosophy. When studying TEs from a philosophical standpoint, researchers, scholars, and professionals have the option of submitting their articles to these journals. Alternatively, if TEs are studied from a historical perspective, journals such as Science and Education, Studies in History and Philosophy of Science Part A, Journal for General Philosophy of Science, Philosophy of Science, Boston Studies in the Philosophy and History of Science, and European Journal for Philosophy of Science are appropriate. Meanwhile, if TEs are studied from an educational perspective, Physics Teacher, Science and Education, Physics Education, American Journal of Physics, and European Journal of Physics are ideal choices for publishing articles. These journals regularly publish articles in physics education studies.

If we look at the authors who have made the greatest contributions to the topic of TEs in the previous 20 years (2003–2022), Stuart is the most significant author with 7 articles (51 citations). Stuart’s work focuses on the history and philosophy of TEs [ 31 , 32 , 33 ], with the first publication in 2014 in the journal Perspectives of Science. In contrast to Stuart, Bancong's work, which ranks second, investigates various TEs from an educational standpoint. His first work, published in 2018, examined TEs in high school physics textbooks [ 3 ], followed by an investigation of how students construct TEs collaboratively [ 4 ], and an identification of factors influencing TEs during problem-solving activities [ 5 ]. Following Bancong, Fehige from the University of Toronto, Canada, has also published 5 articles. Most of his work examines TEs in religious contexts, such as thought experiments, Christianity and science in novalis [ 15 ], thought experiments and theology [ 16 ], and the book of job as a thought experiment: on science, religion, and literature [ 17 ] which was published in the journal Religions in 2019. Brown examines TEs in several of his works in light of the history and philosophy of science [ 6 , 7 ], as do Buzzoni and El Skaf from Italy, who mostly discuss TEs in light of the history and philosophy of science [ 8 , 12 ]. Meanwhile, Halkia and Velentzas from the University of Athens, Greece, have discussed TEs from an educational perspective, such as using TEs from Newton's Cannon for teaching satellite physics [ 37 ] and using TEs from the theory of relativity for teaching relativity theories [ 38 ].

Over the past two decades, authors have examined TEs from diverse perspectives, including history, philosophy, education, and religion. This variety highlights a significant shift in the disciplinary landscape of TE research, which is historically rooted in the philosophy of science [ 18 , 24 ]. The true strength of TEs lies in their adaptability across disciplines, rather than in resolving philosophical disputes. Although TEs were traditionally centered on history and philosophy of science (HPS), recent trends show a growing application in education and technology, particularly in artificial intelligence and speculative design. This shift indicates that TEs have not lost their significance but have instead found new areas of relevance. In HPS, the focus has moved toward understanding the methodological and epistemological implications of TEs, confirming their essential role in scientific reasoning [ 7 , 30 ]. Additionally, in fields such as physics education, TEs are increasingly utilized to explore complex theoretical concepts and enhance educational methodologies [ 2 , 12 ].

Based on the most commonly used keywords in the last 20 years, research on TEs has mostly focused on understanding TEs from a philosophical perspective in the first five years (2003–2007). Thought experiments rethought and reperceived [ 19 ], on thought experiments: is there more to the argument? [ 24 ] and thought experiments [ 9 ] are a few examples. Then, over the next five years (2008–2012), many studies looked at how TEs contributed to physical theories, including the special theory of relativity and quantum theory. The keywords that emerged frequently during this period were quantum theory, scientific discovery, methodology, quantum mechanics, twin earths, falling bodies, and others. In the last ten years, TEs have been studied from various perspectives. For example, in 2013, Velentzas and Halkia [ 38 ] also used TEs as a didactic tool in teaching physics to upper-secondary students. Fehige, on the other hand, began to connect TEs to theology, with a specific focus on the interaction between Christianity and science [ 15 , 16 ]. There are also researchers who continue to study the existence of TEs from a philosophical point of view and claim that TEs are science fiction [ 1 , 20 ]. In recent years, TEs have become increasingly popular in education and have been linked to artificial intelligence. Artificial intelligence, physics education, productive imagination, technology, and speculative design are some of the keywords that appear frequently. This is not surprising because TEs, as experimental activities using mental models, are not easy for students to perform on their own [ 4 , 5 ]. Therefore, technology that can assist students in creating an imaginative world for constructing TEs is required.

Since no studies have charted the trends in TEs research so far, it is difficult to compare the research results obtained with those of others. Nevertheless, several studies that examine trends in physics education reveal that although research on experiments is declining in physics education, TEs are still important to physics teaching and learning [ 41 ]. Hallswoth et al. [ 21 ] have also used artificial intelligence technologies to support TEs in the field of wet biology research, which is dominated by experiments on microbial growth and survival. The use of artificial intelligence in learning is based on the growing interest in artificial intelligence methods in science, technology, and education [ 11 ]. Overall, our study contributes to a more comprehensive understanding of TEs research trends during the last 20 years. In addition, this research also contributes to providing an overview of several potential topics that can be the focus of future researchers, such as the use of artificial intelligence in TEs. By situating our findings within the broader context of previous studies, we provide a clearer picture of how TE research has evolved and where it is heading.

5 Conclusions

This study aims to present a more comprehensive understanding of the trend of studies on TEs during the last 20 years (2003–2022). Research on this topic began in 1976, and its progress has continued to the present. A total of 679 published papers from various sources, including articles (504), conference papers (92), and book chapters (83), were analyzed. The results of the study show that research and publications on TEs are of interest and have received a lot of attention during the last eight years. A significant increase occurred in 2021, with 69 published articles. According to the findings, 95% of the top 20 source titles contributing to TEs are from journals in the first and second quartiles (Q1 and Q2). This quartile ranking shows the quality and significant influence of a journal. The geographical distribution reveals that the United States contributes the most to TEs research, with 213 documents, 2592 citations, and 47 links. We also identified several prospective keywords that could be the focus of future research, including artificial intelligence, physics education, fiction, God, theology, productive imagination, technology, speculative design, and critical design. Therefore, this study contributes to providing a thorough picture of thought experiment research trends and future directions of potential topics that can be the focus of future researchers.

This research has several limitations. The exclusive source of publication data utilized in this study is the Scopus database, which is recognized as one of the most extensive databases in the field. However, it is worth noting that future research endeavors may consider including publication data from other prominent sources such as WoS and Google Scholar. Furthermore, the utilization of the search function in the TITLE-ABS-KEY field, specifically employing the terms "Thought-experiments" AND "Science" OR "Physics," was used for the purpose of data retrieval. However, it is important to acknowledge that this approach is not infallible, as there is a potential for some papers to be overlooked, making the process less than completely accurate. Despite its limitations, this research is often regarded as a pioneering contribution to the field of bibliometric studies on the subject of TEs during the past two decades.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Bancong, H. The past and present of thought experiments’ research at Glancy: bibliometric review and analysis. Discov Educ 3 , 142 (2024). https://doi.org/10.1007/s44217-024-00246-z

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Critical factors driving construction project performance in integrated 5d building information modeling.

1. Introduction

2. materials and methods, 2.1. procedure for the systematic literature review, 2.2. search strategy, 2.3. tools and software, 2.4. data resources, 2.5. prisma flow for systematic review, 2.6. network analysis, 3.1. development trends for 5d bim in the construction industry, 3.1.1. publications per year, 3.1.2. major countries or regions undertaking research, 3.1.3. key productive authors, 3.1.4. keyword co-occurrence and cluster identification, 3.2. factors significantly affecting the adoption of 5d bim, 3.3. key project performance factors affected by the implementation of 5d bim, 4. discussion, 4.1. evolution of 5d bim in the construction industry, 4.1.1. citation bursts and trend evaluation, 4.1.2. cluster analysis, 4.2. critical factors influencing the implementation of 5d bim, 4.2.1. technology factors, 4.2.2. organizational factors, 4.2.3. environmental factors, 4.2.4. operator factors, 4.2.5. project factors, 4.2.6. government policy, 4.3. key performance indicators affected by the implementation of 5d bim, 4.3.1. project cost performance, 4.3.2. project time performance, 4.3.3. project quality performance, 5. limitations and future research directions, 6. conclusions, author contributions, data availability statement, conflicts of interest.

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Sun, H.; Khoo, T.J.; Esa, M.; Mahdiyar, A.; Li, J. Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling. Buildings 2024 , 14 , 2807. https://doi.org/10.3390/buildings14092807

Sun H, Khoo TJ, Esa M, Mahdiyar A, Li J. Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling. Buildings . 2024; 14(9):2807. https://doi.org/10.3390/buildings14092807

Sun, Hui, Terh Jing Khoo, Muneera Esa, Amir Mahdiyar, and Jiguang Li. 2024. "Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling" Buildings 14, no. 9: 2807. https://doi.org/10.3390/buildings14092807

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