literature review using thematic approach

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

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

Table of Contents

What is a thematic literature review?

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

When to opt for thematic literature review?

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

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

Advantages of a Thematic Literature Review

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

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

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

How to write a thematic literature review

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

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

Thematic literature review example

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

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

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

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The Guide to Thematic Analysis

• What is Thematic Analysis?
• Advantages of Thematic Analysis
• Disadvantages of Thematic Analysis
• Thematic Analysis Examples
• How to Do Thematic Analysis
• Thematic Coding
• Collaborative Thematic Analysis
• Thematic Analysis Software
• Thematic Analysis in Mixed Methods Approach
• Abductive Thematic Analysis
• Deductive Thematic Analysis
• Inductive Thematic Analysis
• Reflexive Thematic Analysis
• Thematic Analysis in Observations
• Thematic Analysis in Surveys
• Thematic Analysis for Interviews
• Thematic Analysis for Focus Groups
• Thematic Analysis for Case Studies
• Thematic Analysis of Secondary Data
• Introduction

What is a thematic literature review?

Advantages of a thematic literature review, structuring and writing a thematic literature review.

• Thematic Analysis vs. Phenomenology
• Thematic vs. Content Analysis
• Thematic Analysis vs. Grounded Theory
• Thematic Analysis vs. Narrative Analysis
• Thematic Analysis vs. Discourse Analysis
• Thematic Analysis vs. Framework Analysis
• Thematic Analysis in Social Work
• Thematic Analysis in Psychology
• Thematic Analysis in Educational Research
• Thematic Analysis in UX Research
• How to Present Thematic Analysis Results
• Increasing Rigor in Thematic Analysis
• Peer Review in Thematic Analysis

Thematic Analysis Literature Review

A thematic literature review serves as a critical tool for synthesizing research findings within a specific subject area. By categorizing existing literature into themes, this method offers a structured approach to identify and analyze patterns and trends across studies. The primary goal is to provide a clear and concise overview that aids scholars and practitioners in understanding the key discussions and developments within a field. Unlike traditional literature reviews , which may adopt a chronological approach or focus on individual studies, a thematic literature review emphasizes the aggregation of findings through key themes and thematic connections. This introduction sets the stage for a detailed examination of what constitutes a thematic literature review, its benefits, and guidance on effectively structuring and writing one.

A thematic literature review methodically organizes and examines a body of literature by identifying, analyzing, and reporting themes found within texts such as journal articles, conference proceedings, dissertations, and other forms of academic writing. While a particular journal article may offer some specific insight, a synthesis of knowledge through a literature review can provide a comprehensive overview of theories across relevant sources in a particular field.

Unlike other review types that might organize literature chronologically or by methodology , a thematic review focuses on recurring themes or patterns across a collection of works. This approach enables researchers to draw together previous research to synthesize findings from different research contexts and methodologies, highlighting the overarching trends and insights within a field.

At its core, a thematic approach to a literature review research project involves several key steps. Initially, it requires the comprehensive collection of relevant literature that aligns with the review's research question or objectives. Following this, the process entails a meticulous analysis of the texts to identify common themes that emerge across the studies. These themes are not pre-defined but are discovered through a careful reading and synthesis of the literature.

The thematic analysis process is iterative, often involving the refinement of themes as the review progresses. It allows for the integration of a broad range of literature, facilitating a multidimensional understanding of the research topic. By organizing literature thematically, the review illuminates how various studies contribute to each theme, providing insights into the depth and breadth of research in the area.

A thematic literature review thus serves as a foundational element in research, offering a nuanced and comprehensive perspective on a topic. It not only aids in identifying gaps in the existing literature but also guides future research directions by underscoring areas that warrant further investigation. Ultimately, a thematic literature review empowers researchers to construct a coherent narrative that weaves together disparate studies into a unified analysis.

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Conducting a literature review thematically provides a comprehensive and nuanced synthesis of research findings, distinguishing it from other types of literature reviews. Its structured approach not only facilitates a deeper understanding of the subject area but also enhances the clarity and relevance of the review. Here are three significant advantages of employing a thematic analysis in literature reviews.

Enhanced understanding of the research field

Thematic literature reviews allow for a detailed exploration of the research landscape, presenting themes that capture the essence of the subject area. By identifying and analyzing these themes, reviewers can construct a narrative that reflects the complexity and multifaceted nature of the field.

This process aids in uncovering underlying patterns and relationships, offering a more profound and insightful examination of the literature. As a result, readers gain an enriched understanding of the key concepts, debates, and evolutionary trajectories within the research area.

Identification of research gaps and trends

One of the pivotal benefits of a thematic literature review is its ability to highlight gaps in the existing body of research. By systematically organizing the literature into themes, reviewers can pinpoint areas that are under-explored or warrant further investigation.

Additionally, this method can reveal emerging trends and shifts in research focus, guiding scholars toward promising areas for future study. The thematic structure thus serves as a roadmap, directing researchers toward uncharted territories and new research questions .

Facilitates comparative analysis and integration of findings

A thematic literature review excels in synthesizing findings from diverse studies, enabling a coherent and integrated overview. By concentrating on themes rather than individual studies, the review can draw comparisons and contrasts across different research contexts and methodologies . This comparative analysis enriches the review, offering a panoramic view of the field that acknowledges both consensus and divergence among researchers.

Moreover, the thematic framework supports the integration of findings, presenting a unified and comprehensive portrayal of the research area. Such integration is invaluable for scholars seeking to navigate the extensive body of literature and extract pertinent insights relevant to their own research questions or objectives.

The process of structuring and writing a thematic literature review is pivotal in presenting research in a clear, coherent, and impactful manner. This review type necessitates a methodical approach to not only unearth and categorize key themes but also to articulate them in a manner that is both accessible and informative to the reader. The following sections outline essential stages in the thematic analysis process for literature reviews , offering a structured pathway from initial planning to the final presentation of findings.

Identifying and categorizing themes

The initial phase in a thematic literature review is the identification of themes within the collected body of literature. This involves a detailed examination of texts to discern patterns, concepts, and ideas that recur across the research landscape. Effective identification hinges on a thorough and nuanced reading of the literature, where the reviewer actively engages with the content to extract and note significant thematic elements. Once identified, these themes must be meticulously categorized, often requiring the reviewer to discern between overarching themes and more nuanced sub-themes, ensuring a logical and hierarchical organization of the review content.

Analyzing and synthesizing themes

After categorizing the themes, the next step involves a deeper analysis and synthesis of the identified themes. This stage is critical for understanding the relationships between themes and for interpreting the broader implications of the thematic findings. Analysis may reveal how themes evolve over time, differ across methodologies or contexts, or converge to highlight predominant trends in the research area. Synthesis involves integrating insights from various studies to construct a comprehensive narrative that encapsulates the thematic essence of the literature, offering new interpretations or revealing gaps in existing research.

Presenting and discussing findings

The final stage of the thematic literature review is the discussion of the thematic findings in a research paper or presentation. This entails not only a descriptive account of identified themes but also a critical examination of their significance within the research field. Each theme should be discussed in detail, elucidating its relevance, the extent of research support, and its implications for future studies. The review should culminate in a coherent and compelling narrative that not only summarizes the key thematic findings but also situates them within the broader research context, offering valuable insights and directions for future inquiry.

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How To Structure Your Literature Review

3 options to help structure your chapter.

By: Amy Rommelspacher (PhD) | Reviewer: Dr Eunice Rautenbach | November 2020 (Updated May 2023)

Writing the literature review chapter can seem pretty daunting when you’re piecing together your dissertation or thesis. As  we’ve discussed before , a good literature review needs to achieve a few very important objectives – it should:

• Demonstrate your knowledge of the research topic
• Identify the gaps in the literature and show how your research links to these
• Provide the foundation for your conceptual framework (if you have one)
• Inform your own  methodology and research design

To achieve this, your literature review needs a well-thought-out structure . Get the structure of your literature review chapter wrong and you’ll struggle to achieve these objectives. Don’t worry though – in this post, we’ll look at how to structure your literature review for maximum impact (and marks!).

But wait – is this the right time?

Deciding on the structure of your literature review should come towards the end of the literature review process – after you have collected and digested the literature, but before you start writing the chapter. 

In other words, you need to first develop a rich understanding of the literature before you even attempt to map out a structure. There’s no use trying to develop a structure before you’ve fully wrapped your head around the existing research.

Equally importantly, you need to have a structure in place before you start writing , or your literature review will most likely end up a rambling, disjointed mess. 

Importantly, don’t feel that once you’ve defined a structure you can’t iterate on it. It’s perfectly natural to adjust as you engage in the writing process. As we’ve discussed before , writing is a way of developing your thinking, so it’s quite common for your thinking to change – and therefore, for your chapter structure to change – as you write. 

Need a helping hand?

Like any other chapter in your thesis or dissertation, your literature review needs to have a clear, logical structure. At a minimum, it should have three essential components – an  introduction , a  body   and a  conclusion . 

Let’s take a closer look at each of these.

1: The Introduction Section

Just like any good introduction, the introduction section of your literature review should introduce the purpose and layout (organisation) of the chapter. In other words, your introduction needs to give the reader a taste of what’s to come, and how you’re going to lay that out. Essentially, you should provide the reader with a high-level roadmap of your chapter to give them a taste of the journey that lies ahead.

Here’s an example of the layout visualised in a literature review introduction:

Your introduction should also outline your topic (including any tricky terminology or jargon) and provide an explanation of the scope of your literature review – in other words, what you  will   and  won’t   be covering (the delimitations ). This helps ringfence your review and achieve a clear focus . The clearer and narrower your focus, the deeper you can dive into the topic (which is typically where the magic lies). 

Depending on the nature of your project, you could also present your stance or point of view at this stage. In other words, after grappling with the literature you’ll have an opinion about what the trends and concerns are in the field as well as what’s lacking. The introduction section can then present these ideas so that it is clear to examiners that you’re aware of how your research connects with existing knowledge .

2: The Body Section

The body of your literature review is the centre of your work. This is where you’ll present, analyse, evaluate and synthesise the existing research. In other words, this is where you’re going to earn (or lose) the most marks. Therefore, it’s important to carefully think about how you will organise your discussion to present it in a clear way. 

The body of your literature review should do just as the description of this chapter suggests. It should “review” the literature – in other words, identify, analyse, and synthesise it. So, when thinking about structuring your literature review, you need to think about which structural approach will provide the best “review” for your specific type of research and objectives (we’ll get to this shortly).

There are (broadly speaking)  three options  for organising your literature review.

Option 1: Chronological (according to date)

Organising the literature chronologically is one of the simplest ways to structure your literature review. You start with what was published first and work your way through the literature until you reach the work published most recently. Pretty straightforward.

The benefit of this option is that it makes it easy to discuss the developments and debates in the field as they emerged over time. Organising your literature chronologically also allows you to highlight how specific articles or pieces of work might have changed the course of the field – in other words, which research has had the most impact . Therefore, this approach is very useful when your research is aimed at understanding how the topic has unfolded over time and is often used by scholars in the field of history. That said, this approach can be utilised by anyone that wants to explore change over time .

For example , if a student of politics is investigating how the understanding of democracy has evolved over time, they could use the chronological approach to provide a narrative that demonstrates how this understanding has changed through the ages.

Here are some questions you can ask yourself to help you structure your literature review chronologically.

• What is the earliest literature published relating to this topic?
• How has the field changed over time? Why?
• What are the most recent discoveries/theories?

In some ways, chronology plays a part whichever way you decide to structure your literature review, because you will always, to a certain extent, be analysing how the literature has developed. However, with the chronological approach, the emphasis is very firmly on how the discussion has evolved over time , as opposed to how all the literature links together (which we’ll discuss next ).

Option 2: Thematic (grouped by theme)

The thematic approach to structuring a literature review means organising your literature by theme or category – for example, by independent variables (i.e. factors that have an impact on a specific outcome).

As you’ve been collecting and synthesising literature , you’ll likely have started seeing some themes or patterns emerging. You can then use these themes or patterns as a structure for your body discussion. The thematic approach is the most common approach and is useful for structuring literature reviews in most fields.

For example, if you were researching which factors contributed towards people trusting an organisation, you might find themes such as consumers’ perceptions of an organisation’s competence, benevolence and integrity. Structuring your literature review thematically would mean structuring your literature review’s body section to discuss each of these themes, one section at a time.

Here are some questions to ask yourself when structuring your literature review by themes:

• Are there any patterns that have come to light in the literature?
• What are the central themes and categories used by the researchers?
• Do I have enough evidence of these themes?

PS – you can see an example of a thematically structured literature review in our literature review sample walkthrough video here.

Option 3: Methodological

The methodological option is a way of structuring your literature review by the research methodologies used . In other words, organising your discussion based on the angle from which each piece of research was approached – for example, qualitative , quantitative or mixed  methodologies.

Structuring your literature review by methodology can be useful if you are drawing research from a variety of disciplines and are critiquing different methodologies. The point of this approach is to question  how  existing research has been conducted, as opposed to  what  the conclusions and/or findings the research were.

For example, a sociologist might centre their research around critiquing specific fieldwork practices. Their literature review will then be a summary of the fieldwork methodologies used by different studies.

Here are some questions you can ask yourself when structuring your literature review according to methodology:

• Which methodologies have been utilised in this field?
• Which methodology is the most popular (and why)?
• What are the strengths and weaknesses of the various methodologies?
• How can the existing methodologies inform my own methodology?

3: The Conclusion Section

Once you’ve completed the body section of your literature review using one of the structural approaches we discussed above, you’ll need to “wrap up” your literature review and pull all the pieces together to set the direction for the rest of your dissertation or thesis.

The conclusion is where you’ll present the key findings of your literature review. In this section, you should emphasise the research that is especially important to your research questions and highlight the gaps that exist in the literature. Based on this, you need to make it clear what you will add to the literature – in other words, justify your own research by showing how it will help fill one or more of the gaps you just identified.

Last but not least, if it’s your intention to develop a conceptual framework for your dissertation or thesis, the conclusion section is a good place to present this.

Example: Thematically Structured Review

In the video below, we unpack a literature review chapter so that you can see an example of a thematically structure review in practice.

Let’s Recap

In this article, we’ve  discussed how to structure your literature review for maximum impact. Here’s a quick recap of what  you need to keep in mind when deciding on your literature review structure:

• Just like other chapters, your literature review needs a clear introduction , body and conclusion .
• The introduction section should provide an overview of what you will discuss in your literature review.
• The body section of your literature review can be organised by chronology , theme or methodology . The right structural approach depends on what you’re trying to achieve with your research.
• The conclusion section should draw together the key findings of your literature review and link them to your research questions.

If you’re ready to get started, be sure to download our free literature review template to fast-track your chapter outline.

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

28 Comments

Great work. This is exactly what I was looking for and helps a lot together with your previous post on literature review. One last thing is missing: a link to a great literature chapter of an journal article (maybe with comments of the different sections in this review chapter). Do you know any great literature review chapters?

I agree with you Marin… A great piece

I agree with Marin. This would be quite helpful if you annotate a nicely structured literature from previously published research articles.

Awesome article for my research.

I thank you immensely for this wonderful guide

It is indeed thought and supportive work for the futurist researcher and students

Very educative and good time to get guide. Thank you

Great work, very insightful. Thank you.

Thanks for this wonderful presentation. My question is that do I put all the variables into a single conceptual framework or each hypothesis will have it own conceptual framework?

Thank you very much, very helpful

This is very educative and precise . Thank you very much for dropping this kind of write up .

Pheeww, so damn helpful, thank you for this informative piece.

I’m doing a research project topic ; stool analysis for parasitic worm (enteric) worm, how do I structure it, thanks.

comprehensive explanation. Help us by pasting the URL of some good “literature review” for better understanding.

great piece. thanks for the awesome explanation. it is really worth sharing. I have a little question, if anyone can help me out, which of the options in the body of literature can be best fit if you are writing an architectural thesis that deals with design?

I am doing a research on nanofluids how can l structure it?

Beautifully clear.nThank you!

Lucid! Thankyou!

Brilliant work, well understood, many thanks

I like how this was so clear with simple language 😊😊 thank you so much 😊 for these information 😊

Insightful. I was struggling to come up with a sensible literature review but this has been really helpful. Thank you!

You have given thought-provoking information about the review of the literature.

Thank you. It has made my own research better and to impart your work to students I teach

I learnt a lot from this teaching. It’s a great piece.

I am doing research on EFL teacher motivation for his/her job. How Can I structure it? Is there any detailed template, additional to this?

You are so cool! I do not think I’ve read through something like this before. So nice to find somebody with some genuine thoughts on this issue. Seriously.. thank you for starting this up. This site is one thing that is required on the internet, someone with a little originality!

I’m asked to do conceptual, theoretical and empirical literature, and i just don’t know how to structure it

Asking questions are actually fastidious thing if you are not understanding anything fully, but this article presents good understanding yet.

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Organizing Your Social Sciences Research Paper

• 5. The Literature Review
• Purpose of Guide
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• Independent and Dependent Variables
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• Reading Research Effectively
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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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Thematic Literature Review: A Beginner’s Guide

A thematic literature review is a powerful tool for synthesizing and analyzing existing research within a specific thematic framework. It enables researchers to explore key themes, patterns, and trends across a body of literature, providing valuable insights and understanding in a particular field or topic. In this beginner’s guide, we’ll delve into the essential steps and strategies for crafting a compelling thematic literature review.

Understanding Thematic Literature Reviews:

A thematic literature review focuses on identifying, analyzing, and synthesizing common themes, concepts, or patterns within a body of literature related to a specific research topic or question. Unlike traditional narrative reviews, which provide a chronological overview of literature, thematic reviews organize and categorize information based on thematic connections and relationships.

Steps to Write a Thematic Literature Review:

Define Your Research Question and Objectives:

• Clearly define your research question or topic of interest that will guide the thematic review.
• Determine the specific objectives or goals of the review, such as identifying themes, exploring relationships, or evaluating gaps in knowledge.

Conduct a Comprehensive Literature Search:

• Use academic databases, journals, books, and other sources to gather relevant literature related to your research topic.
• Employ keyword searches, Boolean operators, and advanced search techniques to identify key studies and resources.

Select and Evaluate Relevant Literature:

• Evaluate the quality, relevance, and credibility of each source based on criteria such as authorship, methodology, research design, and publication date.
• Select literature that directly contributes to addressing your research question and thematic focus.

Organize Literature Based on Themes:

• Identify common themes, concepts, or patterns emerging from the selected literature.
• Create a thematic framework or coding scheme to categorize and organize literature based on thematic connections and relationships.

Synthesize and Analyze Themes:

• Analyze each theme or category in-depth, summarizing key findings, arguments, and perspectives from the literature.
• Identify similarities, differences, contradictions, and gaps within and across themes to develop a comprehensive understanding of the research landscape.

Write the Thematic Literature Review:

• Structure the review based on thematic categories or sections, clearly labelling and defining each theme.
• Provide a synthesis of findings, discussing the implications, significance, and contributions of each theme to the research topic.

Include Critical Reflection and Discussion:

• Critically reflect on the strengths, limitations, and methodological considerations of the reviewed literature.
• Engage in a thoughtful discussion of the implications, theoretical frameworks, and future research directions based on the thematic analysis.

Use Clear and Concise Writing Style:

• Write in a clear, concise, and organized manner, presenting information logically and cohesively.
• Use transitions, signposts, and citations to guide readers through the thematic review and connect ideas seamlessly.

Tips for Writing a Compelling Thematic Literature Review:

• Stay Focused: Maintain focus on the thematic analysis and avoid unnecessary tangents or deviations from the main themes.
• Engage Critically: Critically evaluate and analyze literature, offering insights, interpretations, and evaluations within each theme.
• Provide Evidence: Support your analysis and arguments with evidence, citations, and references from the reviewed literature.
• Be Objective: Maintain objectivity and impartiality in presenting and interpreting findings, avoiding bias or personal opinions.
• Revise and Edit: Revise and edit your thematic review for clarity, coherence, and accuracy, ensuring that it meets scholarly standards and expectations.

Conclusion:

Crafting a thematic literature review requires careful planning, thorough research, critical analysis, and effective synthesis of findings. By following the steps outlined in this beginner’s guide and incorporating tips for writing a compelling thematic review, researchers can create a valuable scholarly contribution that enhances understanding, identifies trends, and informs future research in their field of study. Remember to approach the thematic review process with curiosity, rigour, and attention to detail, striving to uncover meaningful insights and contribute to the advancement of knowledge within your research area.

Recommended reading

Greetham, B. (2020). How to write your literature review. Macmillan (Click to view on Amazon #Ad)

This engaging guide by bestselling author Bryan Greetham takes students step-by-step through the process of writing a literature review, and equips them with practical strategies to help them navigate each stage. Each bite-sized chapter focuses on a specific aspect of the process, from generating ideas and pinning down the research problem through to searching for sources, citing references and planning, writing and editing the review.

Posted by Glenn Stevens

Glenn is an academic writing and research specialist with 15 years experience as a writing coach and PhD supervisor. Also a qualified English teacher, he previously had an extensive career in publishing. He is currently the editor of this website. Glenn lives in the UK. Contact Glenn Useful article? Why not buy Glenn a coffee!

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PY2106: Human Development Across the Lifespan Guide: Writing a Thematic Analysis

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What is a thematic analysis?

A thematic analysis is used in qualitative research to focus on examining themes within a topic by identifying, analysing and reporting patterns (themes) within the research topic. It is similar to a literature review, which is a critical survey and assessment of the existing research on your particular topic.

The following links provide more information about the thematic analysis process.

• About Thematic Analysis
• Using thematic analysis in psychology

Thematic Analysis Process

Writing a literature review

You may also find these resources on writing literature reviews useful to help you write your analysis.

• Writing a Literature Review
• Literature Reviews - Synthesise

Writing a literature review (part 1)

Literature review books

Doing a literature review in health and social care: A practical guide

The Literature Review

The Literature Review is a concise step-by-step guide to conducting a literature search and writing up the literature review chapter in graduate dissertations and in professional doctorate theses. 

Succeeding with Your Literature Review

This step-by-step handbook provides comprehensive and practical guidance on the process of researching a range of relevant literature on a subject, as well as planning and writing a literature review.

An interactive approach to writing essays and research reports in psychology

This writing guide offers students an engaging, accessible introduction to the conventions of writing in the psychology discipline.

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• How to Do Thematic Analysis | Step-by-Step Guide & Examples

How to Do Thematic Analysis | Step-by-Step Guide & Examples

Published on September 6, 2019 by Jack Caulfield . Revised on June 22, 2023.

Thematic analysis is a method of analyzing qualitative data . It is usually applied to a set of texts, such as an interview or transcripts . The researcher closely examines the data to identify common themes – topics, ideas and patterns of meaning that come up repeatedly.

There are various approaches to conducting thematic analysis, but the most common form follows a six-step process: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up. Following this process can also help you avoid confirmation bias when formulating your analysis.

This process was originally developed for psychology research by Virginia Braun and Victoria Clarke . However, thematic analysis is a flexible method that can be adapted to many different kinds of research.

Table of contents

When to use thematic analysis, different approaches to thematic analysis, step 1: familiarization, step 2: coding, step 3: generating themes, step 4: reviewing themes, step 5: defining and naming themes, step 6: writing up, other interesting articles.

Thematic analysis is a good approach to research where you’re trying to find out something about people’s views, opinions, knowledge, experiences or values from a set of qualitative data – for example, interview transcripts , social media profiles, or survey responses .

Some types of research questions you might use thematic analysis to answer:

• How do patients perceive doctors in a hospital setting?
• What are young women’s experiences on dating sites?
• What are non-experts’ ideas and opinions about climate change?
• How is gender constructed in high school history teaching?

To answer any of these questions, you would collect data from a group of relevant participants and then analyze it. Thematic analysis allows you a lot of flexibility in interpreting the data, and allows you to approach large data sets more easily by sorting them into broad themes.

However, it also involves the risk of missing nuances in the data. Thematic analysis is often quite subjective and relies on the researcher’s judgement, so you have to reflect carefully on your own choices and interpretations.

Pay close attention to the data to ensure that you’re not picking up on things that are not there – or obscuring things that are.

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Once you’ve decided to use thematic analysis, there are different approaches to consider.

There’s the distinction between inductive and deductive approaches:

• An inductive approach involves allowing the data to determine your themes.
• A deductive approach involves coming to the data with some preconceived themes you expect to find reflected there, based on theory or existing knowledge.

Ask yourself: Does my theoretical framework give me a strong idea of what kind of themes I expect to find in the data (deductive), or am I planning to develop my own framework based on what I find (inductive)?

There’s also the distinction between a semantic and a latent approach:

• A semantic approach involves analyzing the explicit content of the data.
• A latent approach involves reading into the subtext and assumptions underlying the data.

Ask yourself: Am I interested in people’s stated opinions (semantic) or in what their statements reveal about their assumptions and social context (latent)?

After you’ve decided thematic analysis is the right method for analyzing your data, and you’ve thought about the approach you’re going to take, you can follow the six steps developed by Braun and Clarke .

The first step is to get to know our data. It’s important to get a thorough overview of all the data we collected before we start analyzing individual items.

This might involve transcribing audio , reading through the text and taking initial notes, and generally looking through the data to get familiar with it.

Next up, we need to code the data. Coding means highlighting sections of our text – usually phrases or sentences – and coming up with shorthand labels or “codes” to describe their content.

Let’s take a short example text. Say we’re researching perceptions of climate change among conservative voters aged 50 and up, and we have collected data through a series of interviews. An extract from one interview looks like this:

In this extract, we’ve highlighted various phrases in different colors corresponding to different codes. Each code describes the idea or feeling expressed in that part of the text.

At this stage, we want to be thorough: we go through the transcript of every interview and highlight everything that jumps out as relevant or potentially interesting. As well as highlighting all the phrases and sentences that match these codes, we can keep adding new codes as we go through the text.

After we’ve been through the text, we collate together all the data into groups identified by code. These codes allow us to gain a a condensed overview of the main points and common meanings that recur throughout the data.

Next, we look over the codes we’ve created, identify patterns among them, and start coming up with themes.

Themes are generally broader than codes. Most of the time, you’ll combine several codes into a single theme. In our example, we might start combining codes into themes like this:

At this stage, we might decide that some of our codes are too vague or not relevant enough (for example, because they don’t appear very often in the data), so they can be discarded.

Other codes might become themes in their own right. In our example, we decided that the code “uncertainty” made sense as a theme, with some other codes incorporated into it.

Again, what we decide will vary according to what we’re trying to find out. We want to create potential themes that tell us something helpful about the data for our purposes.

Now we have to make sure that our themes are useful and accurate representations of the data. Here, we return to the data set and compare our themes against it. Are we missing anything? Are these themes really present in the data? What can we change to make our themes work better?

If we encounter problems with our themes, we might split them up, combine them, discard them or create new ones: whatever makes them more useful and accurate.

For example, we might decide upon looking through the data that “changing terminology” fits better under the “uncertainty” theme than under “distrust of experts,” since the data labelled with this code involves confusion, not necessarily distrust.

Now that you have a final list of themes, it’s time to name and define each of them.

Defining themes involves formulating exactly what we mean by each theme and figuring out how it helps us understand the data.

Naming themes involves coming up with a succinct and easily understandable name for each theme.

For example, we might look at “distrust of experts” and determine exactly who we mean by “experts” in this theme. We might decide that a better name for the theme is “distrust of authority” or “conspiracy thinking”.

Finally, we’ll write up our analysis of the data. Like all academic texts, writing up a thematic analysis requires an introduction to establish our research question, aims and approach.

We should also include a methodology section, describing how we collected the data (e.g. through semi-structured interviews or open-ended survey questions ) and explaining how we conducted the thematic analysis itself.

The results or findings section usually addresses each theme in turn. We describe how often the themes come up and what they mean, including examples from the data as evidence. Finally, our conclusion explains the main takeaways and shows how the analysis has answered our research question.

In our example, we might argue that conspiracy thinking about climate change is widespread among older conservative voters, point out the uncertainty with which many voters view the issue, and discuss the role of misinformation in respondents’ perceptions.

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

• Normal distribution
• Measures of central tendency
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Discourse analysis
• Cohort study
• Peer review
• Ethnography

Research bias

• Implicit bias
• Cognitive bias
• Conformity bias
• Hawthorne effect
• Availability heuristic
• Attrition bias
• Social desirability bias

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Explore different methods on how to structure your literature review.

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There is no single, conventional way to structure a literature review. However, there are a range of standard approaches that you can choose from to give your literature review an overall shape. The structure you select will depend on the aims and purpose of your literature review as well as the literature that exists.

The function of your literature review

Every literature review needs to show how the research problem you’re investigating arose, and give a critical overview of how it, or aspects of it, have been addressed by other researchers to date. However, within that overall purpose, the particular function of your literature review may vary, depending on your own research aim, the current state of knowledge in the field, and the amount and breadth of literature that currently exists. For example:

• If there is a large, longstanding body of research already in your field, the function of your might be to give an overview of how it evolved, to show how you build on it and sit within it.
• If there is very little research on your topic or it’s cutting edge, the function of your literature review might be to look at why it’s been overlooked til now, and piece together a useful basis out of comparable work in related fields.
• If your research is interdisciplinary, drawing on and bringing together different strands of the literature in new ways, the function of your literature review might be to identify and connect these previously unrelated strands.
• If your own research takes a clear stance on a contested topic, the function of your literature review might be to outline why the issue is problematic and the different sides of a debate
• If there are various ways you might approach your research or your approach is new, then an overview of the different ways other people have addressed similar research problems might help justify your method.

General approaches

There are four general approaches to structuring a literature review, depending on the main relationship you are creating between the texts you are reviewing, and how they serve your research aims.

This approach is useful if your central aim is to:

• Chart the developments in your chosen field in a way that highlights causality and consequence (for instance, how one piece of research informed or gave rise to another and so on)
• Use a chronological sequence to demonstrate how an issue or research area has evolved over time

Sometimes, your literature review might aim to bring together previously unrelated areas of research, and there is no linear structure to that relationship – you simply identify the different themes under which you want to organise it, depending on which texts you want to talk about as a group. You might choose to arrange your review into different themes, contexts, schools of thought, subject disciplines, or by methods, theories and approaches.

The funnel structure moves from the broad to the detailed, the general to the specific, or from the abstract to the concrete. So you start with the broader aspects of your topic (the contextual background, for instance) and then gradually narrow your focus until you reach the specific aspect of the topic that you will be addressing. You might equally be looking at the more abstract, theoretical work on your subject before moving to more concrete case studies in which those approaches have been applied, or more general treatments to more detailed and smaller scale studies. That way, you are guiding your reader and helping them build their understanding of your topic: providing them with the background information and context they need in order to grasp your main ideas.

Often, your literature review has more than one function and there is more than one key point you want to convey. For instance, you may need to define your theoretical framework, evaluate how other researchers have approached your topic more generally, then outline your specific area of focus and how it relates to the existing literature. Your finished literature review will then comprise different sub-sections that each achieve a particular aim.

Deciding on a structure

When deciding on a structure, you might find it useful to consider the following questions:

• What is the function of my literature review?
• What do I want my literature review to demonstrate to the reader? What do I want them to take away from it?
• What structure would best allow me to achieve my purpose and get my key points across, talking about the texts I want to bring together without circling around in my writing?

Whichever of these structural principles you decide on as a way to organise the whole literature review, you may well be using others of them as a way to structure subsections or even paragraphs. For example, you might be using a thematic approach overall, but each section could be structured chronologically.

Checking in

Each structural approach or option has its own strengths and weaknesses. It’s important to check in with yourself and review your literature review drafts periodically to see if your structure is working for you. Is it helping you convey your main ideas, bring together the texts you want to talk about together, or is it leading you to be descriptive, repetitive or lose sight of the literature’s relevance to your own research? If not, is there another option that might work better for you? Sometimes, our main ideas and key points don’t become clear to us until we start writing. So it may be that you are better placed to make a more informed idea about your structure once you have begun trying it out.

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• Practical thematic...

Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis

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• on behalf of the Coproduction Laboratory
• 1 Dartmouth Health, Lebanon, NH, USA
• 2 Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
• 3 Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
• 4 Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
• 5 Highland Park, NJ, USA
• 6 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
• Correspondence to: C H Saunders catherine.hylas.saunders{at}dartmouth.edu
• Accepted 26 April 2023

Qualitative research methods explore and provide deep contextual understanding of real world issues, including people’s beliefs, perspectives, and experiences. Whether through analysis of interviews, focus groups, structured observation, or multimedia data, qualitative methods offer unique insights in applied health services research that other approaches cannot deliver. However, many clinicians and researchers hesitate to use these methods, or might not use them effectively, which can leave relevant areas of inquiry inadequately explored. Thematic analysis is one of the most common and flexible methods to examine qualitative data collected in health services research. This article offers practical thematic analysis as a step-by-step approach to qualitative analysis for health services researchers, with a focus on accessibility for patients, care partners, clinicians, and others new to thematic analysis. Along with detailed instructions covering three steps of reading, coding, and theming, the article includes additional novel and practical guidance on how to draft effective codes, conduct a thematic analysis session, and develop meaningful themes. This approach aims to improve consistency and rigor in thematic analysis, while also making this method more accessible for multidisciplinary research teams.

Through qualitative methods, researchers can provide deep contextual understanding of real world issues, and generate new knowledge to inform hypotheses, theories, research, and clinical care. Approaches to data collection are varied, including interviews, focus groups, structured observation, and analysis of multimedia data, with qualitative research questions aimed at understanding the how and why of human experience. 1 2 Qualitative methods produce unique insights in applied health services research that other approaches cannot deliver. In particular, researchers acknowledge that thematic analysis is a flexible and powerful method of systematically generating robust qualitative research findings by identifying, analysing, and reporting patterns (themes) within data. 3 4 5 6 Although qualitative methods are increasingly valued for answering clinical research questions, many researchers are unsure how to apply them or consider them too time consuming to be useful in responding to practical challenges 7 or pressing situations such as public health emergencies. 8 Consequently, researchers might hesitate to use them, or use them improperly. 9 10 11

Although much has been written about how to perform thematic analysis, practical guidance for non-specialists is sparse. 3 5 6 12 13 In the multidisciplinary field of health services research, qualitative data analysis can confound experienced researchers and novices alike, which can stoke concerns about rigor, particularly for those more familiar with quantitative approaches. 14 Since qualitative methods are an area of specialisation, support from experts is beneficial. However, because non-specialist perspectives can enhance data interpretation and enrich findings, there is a case for making thematic analysis easier, more rapid, and more efficient, 8 particularly for patients, care partners, clinicians, and other stakeholders. A practical guide to thematic analysis might encourage those on the ground to use these methods in their work, unearthing insights that would otherwise remain undiscovered.

Given the need for more accessible qualitative analysis approaches, we present a simple, rigorous, and efficient three step guide for practical thematic analysis. We include new guidance on the mechanics of thematic analysis, including developing codes, constructing meaningful themes, and hosting a thematic analysis session. We also discuss common pitfalls in thematic analysis and how to avoid them.

Summary points

Qualitative methods are increasingly valued in applied health services research, but multidisciplinary research teams often lack accessible step-by-step guidance and might struggle to use these approaches

A newly developed approach, practical thematic analysis, uses three simple steps: reading, coding, and theming

Based on Braun and Clarke’s reflexive thematic analysis, our streamlined yet rigorous approach is designed for multidisciplinary health services research teams, including patients, care partners, and clinicians

This article also provides companion materials including a slide presentation for teaching practical thematic analysis to research teams, a sample thematic analysis session agenda, a theme coproduction template for use during the session, and guidance on using standardised reporting criteria for qualitative research

In their seminal work, Braun and Clarke developed a six phase approach to reflexive thematic analysis. 4 12 We built on their method to develop practical thematic analysis ( box 1 , fig 1 ), which is a simplified and instructive approach that retains the substantive elements of their six phases. Braun and Clarke’s phase 1 (familiarising yourself with the dataset) is represented in our first step of reading. Phase 2 (coding) remains as our second step of coding. Phases 3 (generating initial themes), 4 (developing and reviewing themes), and 5 (refining, defining, and naming themes) are represented in our third step of theming. Phase 6 (writing up) also occurs during this third step of theming, but after a thematic analysis session. 4 12

Key features and applications of practical thematic analysis

Step 1: reading.

All manuscript authors read the data

All manuscript authors write summary memos

Step 2: Coding

Coders perform both data management and early data analysis

Codes are complete thoughts or sentences, not categories

Step 3: Theming

Researchers host a thematic analysis session and share different perspectives

Themes are complete thoughts or sentences, not categories

Applications

For use by practicing clinicians, patients and care partners, students, interdisciplinary teams, and those new to qualitative research

When important insights from healthcare professionals are inaccessible because they do not have qualitative methods training

When time and resources are limited

Steps in practical thematic analysis

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We present linear steps, but as qualitative research is usually iterative, so too is thematic analysis. 15 Qualitative researchers circle back to earlier work to check whether their interpretations still make sense in the light of additional insights, adapting as necessary. While we focus here on the practical application of thematic analysis in health services research, we recognise our approach exists in the context of the broader literature on thematic analysis and the theoretical underpinnings of qualitative methods as a whole. For a more detailed discussion of these theoretical points, as well as other methods widely used in health services research, we recommend reviewing the sources outlined in supplemental material 1. A strong and nuanced understanding of the context and underlying principles of thematic analysis will allow for higher quality research. 16

Practical thematic analysis is a highly flexible approach that can draw out valuable findings and generate new hypotheses, including in cases with a lack of previous research to build on. The approach can also be used with a variety of data, such as transcripts from interviews or focus groups, patient encounter transcripts, professional publications, observational field notes, and online activity logs. Importantly, successful practical thematic analysis is predicated on having high quality data collected with rigorous methods. We do not describe qualitative research design or data collection here. 11 17

In supplemental material 1, we summarise the foundational methods, concepts, and terminology in qualitative research. Along with our guide below, we include a companion slide presentation for teaching practical thematic analysis to research teams in supplemental material 2. We provide a theme coproduction template for teams to use during thematic analysis sessions in supplemental material 3. Our method aligns with the major qualitative reporting frameworks, including the Consolidated Criteria for Reporting Qualitative Research (COREQ). 18 We indicate the corresponding step in practical thematic analysis for each COREQ item in supplemental material 4.

Familiarisation and memoing

We encourage all manuscript authors to review the full dataset (eg, interview transcripts) to familiarise themselves with it. This task is most critical for those who will later be engaged in the coding and theming steps. Although time consuming, it is the best way to involve team members in the intellectual work of data interpretation, so that they can contribute to the analysis and contextualise the results. If this task is not feasible given time limitations or large quantities of data, the data can be divided across team members. In this case, each piece of data should be read by at least two individuals who ideally represent different professional roles or perspectives.

We recommend that researchers reflect on the data and independently write memos, defined as brief notes on thoughts and questions that arise during reading, and a summary of their impressions of the dataset. 2 19 Memoing is an opportunity to gain insights from varying perspectives, particularly from patients, care partners, clinicians, and others. It also gives researchers the opportunity to begin to scope which elements of and concepts in the dataset are relevant to the research question.

Data saturation

The concept of data saturation ( box 2 ) is a foundation of qualitative research. It is defined as the point in analysis at which new data tend to be redundant of data already collected. 21 Qualitative researchers are expected to report their approach to data saturation. 18 Because thematic analysis is iterative, the team should discuss saturation throughout the entire process, beginning with data collection and continuing through all steps of the analysis. 22 During step 1 (reading), team members might discuss data saturation in the context of summary memos. Conversations about saturation continue during step 2 (coding), with confirmation that saturation has been achieved during step 3 (theming). As a rule of thumb, researchers can often achieve saturation in 9-17 interviews or 4-8 focus groups, but this will vary depending on the specific characteristics of the study. 23

Data saturation in context

Braun and Clarke discourage the use of data saturation to determine sample size (eg, number of interviews), because it assumes that there is an objective truth to be captured in the data (sometimes known as a positivist perspective). 20 Qualitative researchers often try to avoid positivist approaches, arguing that there is no one true way of seeing the world, and will instead aim to gather multiple perspectives. 5 Although this theoretical debate with qualitative methods is important, we recognise that a priori estimates of saturation are often needed, particularly for investigators newer to qualitative research who might want a more pragmatic and applied approach. In addition, saturation based, sample size estimation can be particularly helpful in grant proposals. However, researchers should still follow a priori sample size estimation with a discussion to confirm saturation has been achieved.

Definition of coding

We describe codes as labels for concepts in the data that are directly relevant to the study objective. Historically, the purpose of coding was to distil the large amount of data collected into conceptually similar buckets so that researchers could review it in aggregate and identify key themes. 5 24 We advocate for a more analytical approach than is typical with thematic analysis. With our method, coding is both the foundation for and the beginning of thematic analysis—that is, early data analysis, management, and reduction occur simultaneously rather than as different steps. This approach moves the team more efficiently towards being able to describe themes.

Building the coding team

Coders are the research team members who directly assign codes to the data, reading all material and systematically labelling relevant data with appropriate codes. Ideally, at least two researchers would code every discrete data document, such as one interview transcript. 25 If this task is not possible, individual coders can each code a subset of the data that is carefully selected for key characteristics (sometimes known as purposive selection). 26 When using this approach, we recommend that at least 10% of data be coded by two or more coders to ensure consistency in codebook application. We also recommend coding teams of no more than four to five people, for practical reasons concerning maintaining consistency.

Clinicians, patients, and care partners bring unique perspectives to coding and enrich the analytical process. 27 Therefore, we recommend choosing coders with a mix of relevant experiences so that they can challenge and contextualise each other’s interpretations based on their own perspectives and opinions ( box 3 ). We recommend including both coders who collected the data and those who are naive to it, if possible, given their different perspectives. We also recommend all coders review the summary memos from the reading step so that key concepts identified by those not involved in coding can be integrated into the analytical process. In practice, this review means coding the memos themselves and discussing them during the code development process. This approach ensures that the team considers a diversity of perspectives.

Coding teams in context

The recommendation to use multiple coders is a departure from Braun and Clarke. 28 29 When the views, experiences, and training of each coder (sometimes known as positionality) 30 are carefully considered, having multiple coders can enhance interpretation and enrich findings. When these perspectives are combined in a team setting, researchers can create shared meaning from the data. Along with the practical consideration of distributing the workload, 31 inclusion of these multiple perspectives increases the overall quality of the analysis by mitigating the impact of any one coder’s perspective. 30

Coding tools

Qualitative analysis software facilitates coding and managing large datasets but does not perform the analytical work. The researchers must perform the analysis themselves. Most programs support queries and collaborative coding by multiple users. 32 Important factors to consider when choosing software can include accessibility, cost, interoperability, the look and feel of code reports, and the ease of colour coding and merging codes. Coders can also use low tech solutions, including highlighters, word processors, or spreadsheets.

Drafting effective codes

To draft effective codes, we recommend that the coders review each document line by line. 33 As they progress, they can assign codes to segments of data representing passages of interest. 34 Coders can also assign multiple codes to the same passage. Consensus among coders on what constitutes a minimum or maximum amount of text for assigning a code is helpful. As a general rule, meaningful segments of text for coding are shorter than one paragraph, but longer than a few words. Coders should keep the study objective in mind when determining which data are relevant ( box 4 ).

Code types in context

Similar to Braun and Clarke’s approach, practical thematic analysis does not specify whether codes are based on what is evident from the data (sometimes known as semantic) or whether they are based on what can be inferred at a deeper level from the data (sometimes known as latent). 4 12 35 It also does not specify whether they are derived from the data (sometimes known as inductive) or determined ahead of time (sometimes known as deductive). 11 35 Instead, it should be noted that health services researchers conducting qualitative studies often adopt all these approaches to coding (sometimes known as hybrid analysis). 3

In practical thematic analysis, codes should be more descriptive than general categorical labels that simply group data with shared characteristics. At a minimum, codes should form a complete (or full) thought. An easy way to conceptualise full thought codes is as complete sentences with subjects and verbs ( table 1 ), although full sentence coding is not always necessary. With full thought codes, researchers think about the data more deeply and capture this insight in the codes. This coding facilitates the entire analytical process and is especially valuable when moving from codes to broader themes. Experienced qualitative researchers often intuitively use full thought or sentence codes, but this practice has not been explicitly articulated as a path to higher quality coding elsewhere in the literature. 6

Example transcript with codes used in practical thematic analysis 36

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Depending on the nature of the data, codes might either fall into flat categories or be arranged hierarchically. Flat categories are most common when the data deal with topics on the same conceptual level. In other words, one topic is not a subset of another topic. By contrast, hierarchical codes are more appropriate for concepts that naturally fall above or below each other. Hierarchical coding can also be a useful form of data management and might be necessary when working with a large or complex dataset. 5 Codes grouped into these categories can also make it easier to naturally transition into generating themes from the initial codes. 5 These decisions between flat versus hierarchical coding are part of the work of the coding team. In both cases, coders should ensure that their code structures are guided by their research questions.

Developing the codebook

A codebook is a shared document that lists code labels and comprehensive descriptions for each code, as well as examples observed within the data. Good code descriptions are precise and specific so that coders can consistently assign the same codes to relevant data or articulate why another coder would do so. Codebook development is iterative and involves input from the entire coding team. However, as those closest to the data, coders must resist undue influence, real or perceived, from other team members with conflicting opinions—it is important to mitigate the risk that more senior researchers, like principal investigators, exert undue influence on the coders’ perspectives.

In practical thematic analysis, coders begin codebook development by independently coding a small portion of the data, such as two to three transcripts or other units of analysis. Coders then individually produce their initial codebooks. This task will require them to reflect on, organise, and clarify codes. The coders then meet to reconcile the draft codebooks, which can often be difficult, as some coders tend to lump several concepts together while others will split them into more specific codes. Discussing disagreements and negotiating consensus are necessary parts of early data analysis. Once the codebook is relatively stable, we recommend soliciting input on the codes from all manuscript authors. Yet, coders must ultimately be empowered to finalise the details so that they are comfortable working with the codebook across a large quantity of data.

Assigning codes to the data

After developing the codebook, coders will use it to assign codes to the remaining data. While the codebook’s overall structure should remain constant, coders might continue to add codes corresponding to any new concepts observed in the data. If new codes are added, coders should review the data they have already coded and determine whether the new codes apply. Qualitative data analysis software can be useful for editing or merging codes.

We recommend that coders periodically compare their code occurrences ( box 5 ), with more frequent check-ins if substantial disagreements occur. In the event of large discrepancies in the codes assigned, coders should revise the codebook to ensure that code descriptions are sufficiently clear and comprehensive to support coding alignment going forward. Because coding is an iterative process, the team can adjust the codebook as needed. 5 28 29

Quantitative coding in context

Researchers should generally avoid reporting code counts in thematic analysis. However, counts can be a useful proxy in maintaining alignment between coders on key concepts. 26 In practice, therefore, researchers should make sure that all coders working on the same piece of data assign the same codes with a similar pattern and that their memoing and overall assessment of the data are aligned. 37 However, the frequency of a code alone is not an indicator of its importance. It is more important that coders agree on the most salient points in the data; reviewing and discussing summary memos can be helpful here. 5

Researchers might disagree on whether or not to calculate and report inter-rater reliability. We note that quantitative tests for agreement, such as kappa statistics or intraclass correlation coefficients, can be distracting and might not provide meaningful results in qualitative analyses. Similarly, Braun and Clarke argue that expecting perfect alignment on coding is inconsistent with the goal of co-constructing meaning. 28 29 Overall consensus on codes’ salience and contributions to themes is the most important factor.

Definition of themes

Themes are meta-constructs that rise above codes and unite the dataset ( box 6 , fig 2 ). They should be clearly evident, repeated throughout the dataset, and relevant to the research questions. 38 While codes are often explicit descriptions of the content in the dataset, themes are usually more conceptual and knit the codes together. 39 Some researchers hypothesise that theme development is loosely described in the literature because qualitative researchers simply intuit themes during the analytical process. 39 In practical thematic analysis, we offer a concrete process that should make developing meaningful themes straightforward.

Themes in context

According to Braun and Clarke, a theme “captures something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set.” 4 Similarly, Braun and Clarke advise against themes as domain summaries. While different approaches can draw out themes from codes, the process begins by identifying patterns. 28 35 Like Braun and Clarke and others, we recommend that researchers consider the salience of certain themes, their prevalence in the dataset, and their keyness (ie, how relevant the themes are to the overarching research questions). 4 12 34

Use of themes in practical thematic analysis

Constructing meaningful themes

After coding all the data, each coder should independently reflect on the team’s summary memos (step 1), the codebook (step 2), and the coded data itself to develop draft themes (step 3). It can be illuminating for coders to review all excerpts associated with each code, so that they derive themes directly from the data. Researchers should remain focused on the research question during this step, so that themes have a clear relation with the overall project aim. Use of qualitative analysis software will make it easy to view each segment of data tagged with each code. Themes might neatly correspond to groups of codes. Or—more likely—they will unite codes and data in unexpected ways. A whiteboard or presentation slides might be helpful to organise, craft, and revise themes. We also provide a template for coproducing themes (supplemental material 3). As with codebook justification, team members will ideally produce individual drafts of the themes that they have identified in the data. They can then discuss these with the group and reach alignment or consensus on the final themes.

The team should ensure that all themes are salient, meaning that they are: supported by the data, relevant to the study objectives, and important. Similar to codes, themes are framed as complete thoughts or sentences, not categories. While codes and themes might appear to be similar to each other, the key distinction is that the themes represent a broader concept. Table 2 shows examples of codes and their corresponding themes from a previously published project that used practical thematic analysis. 36 Identifying three to four key themes that comprise a broader overarching theme is a useful approach. Themes can also have subthemes, if appropriate. 40 41 42 43 44

Example codes with themes in practical thematic analysis 36

Thematic analysis session

After each coder has independently produced draft themes, a carefully selected subset of the manuscript team meets for a thematic analysis session ( table 3 ). The purpose of this session is to discuss and reach alignment or consensus on the final themes. We recommend a session of three to five hours, either in-person or virtually.

Example agenda of thematic analysis session

The composition of the thematic analysis session team is important, as each person’s perspectives will shape the results. This group is usually a small subset of the broader research team, with three to seven individuals. We recommend that primary and senior authors work together to include people with diverse experiences related to the research topic. They should aim for a range of personalities and professional identities, particularly those of clinicians, trainees, patients, and care partners. At a minimum, all coders and primary and senior authors should participate in the thematic analysis session.

The session begins with each coder presenting their draft themes with supporting quotes from the data. 5 Through respectful and collaborative deliberation, the group will develop a shared set of final themes.

One team member facilitates the session. A firm, confident, and consistent facilitation style with good listening skills is critical. For practical reasons, this person is not usually one of the primary coders. Hierarchies in teams cannot be entirely flattened, but acknowledging them and appointing an external facilitator can reduce their impact. The facilitator can ensure that all voices are heard. For example, they might ask for perspectives from patient partners or more junior researchers, and follow up on comments from senior researchers to say, “We have heard your perspective and it is important; we want to make sure all perspectives in the room are equally considered.” Or, “I hear [senior person] is offering [x] idea, I’d like to hear other perspectives in the room.” The role of the facilitator is critical in the thematic analysis session. The facilitator might also privately discuss with more senior researchers, such as principal investigators and senior authors, the importance of being aware of their influence over others and respecting and eliciting the perspectives of more junior researchers, such as patients, care partners, and students.

To our knowledge, this discrete thematic analysis session is a novel contribution of practical thematic analysis. It helps efficiently incorporate diverse perspectives using the session agenda and theme coproduction template (supplemental material 3) and makes the process of constructing themes transparent to the entire research team.

Writing the report

We recommend beginning the results narrative with a summary of all relevant themes emerging from the analysis, followed by a subheading for each theme. Each subsection begins with a brief description of the theme and is illustrated with relevant quotes, which are contextualised and explained. The write-up should not simply be a list, but should contain meaningful analysis and insight from the researchers, including descriptions of how different stakeholders might have experienced a particular situation differently or unexpectedly.

In addition to weaving quotes into the results narrative, quotes can be presented in a table. This strategy is a particularly helpful when submitting to clinical journals with tight word count limitations. Quote tables might also be effective in illustrating areas of agreement and disagreement across stakeholder groups, with columns representing different groups and rows representing each theme or subtheme. Quotes should include an anonymous label for each participant and any relevant characteristics, such as role or gender. The aim is to produce rich descriptions. 5 We recommend against repeating quotations across multiple themes in the report, so as to avoid confusion. The template for coproducing themes (supplemental material 3) allows documentation of quotes supporting each theme, which might also be useful during report writing.

Visual illustrations such as a thematic map or figure of the findings can help communicate themes efficiently. 4 36 42 44 If a figure is not possible, a simple list can suffice. 36 Both must clearly present the main themes with subthemes. Thematic figures can facilitate confirmation that the researchers’ interpretations reflect the study populations’ perspectives (sometimes known as member checking), because authors can invite discussions about the figure and descriptions of findings and supporting quotes. 46 This process can enhance the validity of the results. 46

In supplemental material 4, we provide additional guidance on reporting thematic analysis consistent with COREQ. 18 Commonly used in health services research, COREQ outlines a standardised list of items to be included in qualitative research reports ( box 7 ).

Reporting in context

We note that use of COREQ or any other reporting guidelines does not in itself produce high quality work and should not be used as a substitute for general methodological rigor. Rather, researchers must consider rigor throughout the entire research process. As the issue of how to conceptualise and achieve rigorous qualitative research continues to be debated, 47 48 we encourage researchers to explicitly discuss how they have looked at methodological rigor in their reports. Specifically, we point researchers to Braun and Clarke’s 2021 tool for evaluating thematic analysis manuscripts for publication (“Twenty questions to guide assessment of TA [thematic analysis] research quality”). 16

Avoiding common pitfalls

Awareness of common mistakes can help researchers avoid improper use of qualitative methods. Improper use can, for example, prevent researchers from developing meaningful themes and can risk drawing inappropriate conclusions from the data. Braun and Clarke also warn of poor quality in qualitative research, noting that “coherence and integrity of published research does not always hold.” 16

Weak themes

An important distinction between high and low quality themes is that high quality themes are descriptive and complete thoughts. As such, they often contain subjects and verbs, and can be expressed as full sentences ( table 2 ). Themes that are simply descriptive categories or topics could fail to impart meaningful knowledge beyond categorisation. 16 49 50

Researchers will often move from coding directly to writing up themes, without performing the work of theming or hosting a thematic analysis session. Skipping concerted theming often results in themes that look more like categories than unifying threads across the data.

Unfocused analysis

Because data collection for qualitative research is often semi-structured (eg, interviews, focus groups), not all data will be directly relevant to the research question at hand. To avoid unfocused analysis and a correspondingly unfocused manuscript, we recommend that all team members keep the research objective in front of them at every stage, from reading to coding to theming. During the thematic analysis session, we recommend that the research question be written on a whiteboard so that all team members can refer back to it, and so that the facilitator can ensure that conversations about themes occur in the context of this question. Consistently focusing on the research question can help to ensure that the final report directly answers it, as opposed to the many other interesting insights that might emerge during the qualitative research process. Such insights can be picked up in a secondary analysis if desired.

Inappropriate quantification

Presenting findings quantitatively (eg, “We found 18 instances of participants mentioning safety concerns about the vaccines”) is generally undesirable in practical thematic analysis reporting. 51 Descriptive terms are more appropriate (eg, “participants had substantial concerns about the vaccines,” or “several participants were concerned about this”). This descriptive presentation is critical because qualitative data might not be consistently elicited across participants, meaning that some individuals might share certain information while others do not, simply based on how conversations evolve. Additionally, qualitative research does not aim to draw inferences outside its specific sample. Emphasising numbers in thematic analysis can lead to readers incorrectly generalising the findings. Although peer reviewers unfamiliar with thematic analysis often request this type of quantification, practitioners of practical thematic analysis can confidently defend their decision to avoid it. If quantification is methodologically important, we recommend simultaneously conducting a survey or incorporating standardised interview techniques into the interview guide. 11

Neglecting group dynamics

Researchers should concertedly consider group dynamics in the research team. Particular attention should be paid to power relations and the personality of team members, which can include aspects such as who most often speaks, who defines concepts, and who resolves disagreements that might arise within the group. 52

The perspectives of patient and care partners are particularly important to cultivate. Ideally, patient partners are meaningfully embedded in studies from start to finish, not just for practical thematic analysis. 53 Meaningful engagement can build trust, which makes it easier for patient partners to ask questions, request clarification, and share their perspectives. Professional team members should actively encourage patient partners by emphasising that their expertise is critically important and valued. Noting when a patient partner might be best positioned to offer their perspective can be particularly powerful.

Insufficient time allocation

Researchers must allocate enough time to complete thematic analysis. Working with qualitative data takes time, especially because it is often not a linear process. As the strength of thematic analysis lies in its ability to make use of the rich details and complexities of the data, we recommend careful planning for the time required to read and code each document.

Estimating the necessary time can be challenging. For step 1 (reading), researchers can roughly calculate the time required based on the time needed to read and reflect on one piece of data. For step 2 (coding), the total amount of time needed can be extrapolated from the time needed to code one document during codebook development. We also recommend three to five hours for the thematic analysis session itself, although coders will need to independently develop their draft themes beforehand. Although the time required for practical thematic analysis is variable, teams should be able to estimate their own required effort with these guidelines.

Practical thematic analysis builds on the foundational work of Braun and Clarke. 4 16 We have reframed their six phase process into three condensed steps of reading, coding, and theming. While we have maintained important elements of Braun and Clarke’s reflexive thematic analysis, we believe that practical thematic analysis is conceptually simpler and easier to teach to less experienced researchers and non-researcher stakeholders. For teams with different levels of familiarity with qualitative methods, this approach presents a clear roadmap to the reading, coding, and theming of qualitative data. Our practical thematic analysis approach promotes efficient learning by doing—experiential learning. 12 29 Practical thematic analysis avoids the risk of relying on complex descriptions of methods and theory and places more emphasis on obtaining meaningful insights from those close to real world clinical environments. Although practical thematic analysis can be used to perform intensive theory based analyses, it lends itself more readily to accelerated, pragmatic approaches.

Strengths and limitations

Our approach is designed to smooth the qualitative analysis process and yield high quality themes. Yet, researchers should note that poorly performed analyses will still produce low quality results. Practical thematic analysis is a qualitative analytical approach; it does not look at study design, data collection, or other important elements of qualitative research. It also might not be the right choice for every qualitative research project. We recommend it for applied health services research questions, where diverse perspectives and simplicity might be valuable.

We also urge researchers to improve internal validity through triangulation methods, such as member checking (supplemental material 1). 46 Member checking could include soliciting input on high level themes, theme definitions, and quotations from participants. This approach might increase rigor.

Implications

We hope that by providing clear and simple instructions for practical thematic analysis, a broader range of researchers will be more inclined to use these methods. Increased transparency and familiarity with qualitative approaches can enhance researchers’ ability to both interpret qualitative studies and offer up new findings themselves. In addition, it can have usefulness in training and reporting. A major strength of this approach is to facilitate meaningful inclusion of patient and care partner perspectives, because their lived experiences can be particularly valuable in data interpretation and the resulting findings. 11 30 As clinicians are especially pressed for time, they might also appreciate a practical set of instructions that can be immediately used to leverage their insights and access to patients and clinical settings, and increase the impact of qualitative research through timely results. 8

Practical thematic analysis is a simplified approach to performing thematic analysis in health services research, a field where the experiences of patients, care partners, and clinicians are of inherent interest. We hope that it will be accessible to those individuals new to qualitative methods, including patients, care partners, clinicians, and other health services researchers. We intend to empower multidisciplinary research teams to explore unanswered questions and make new, important, and rigorous contributions to our understanding of important clinical and health systems research.

Acknowledgments

All members of the Coproduction Laboratory provided input that shaped this manuscript during laboratory meetings. We acknowledge advice from Elizabeth Carpenter-Song, an expert in qualitative methods.

Coproduction Laboratory group contributors: Stephanie C Acquilano ( http://orcid.org/0000-0002-1215-5531 ), Julie Doherty ( http://orcid.org/0000-0002-5279-6536 ), Rachel C Forcino ( http://orcid.org/0000-0001-9938-4830 ), Tina Foster ( http://orcid.org/0000-0001-6239-4031 ), Megan Holthoff, Christopher R Jacobs ( http://orcid.org/0000-0001-5324-8657 ), Lisa C Johnson ( http://orcid.org/0000-0001-7448-4931 ), Elaine T Kiriakopoulos, Kathryn Kirkland ( http://orcid.org/0000-0002-9851-926X ), Meredith A MacMartin ( http://orcid.org/0000-0002-6614-6091 ), Emily A Morgan, Eugene Nelson, Elizabeth O’Donnell, Brant Oliver ( http://orcid.org/0000-0002-7399-622X ), Danielle Schubbe ( http://orcid.org/0000-0002-9858-1805 ), Gabrielle Stevens ( http://orcid.org/0000-0001-9001-178X ), Rachael P Thomeer ( http://orcid.org/0000-0002-5974-3840 ).

Contributors: Practical thematic analysis, an approach designed for multidisciplinary health services teams new to qualitative research, was based on CHS’s experiences teaching thematic analysis to clinical teams and students. We have drawn heavily from qualitative methods literature. CHS is the guarantor of the article. CHS, AS, CvP, AMK, JRK, and JAP contributed to drafting the manuscript. AS, JG, CMM, JAP, and RWY provided feedback on their experiences using practical thematic analysis. CvP, LCL, SLB, AVC, GE, and JKL advised on qualitative methods in health services research, given extensive experience. All authors meaningfully edited the manuscript content, including AVC and RKS. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Not commissioned; externally peer reviewed.

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The Literature Review: 5. Organizing the Literature Review

• 1. Introduction
• 2. Why Do a Literature Review?
• 3. Methods for Searching the Literature
• 4. Analysing the Literature
• 5. Organizing the Literature Review
• 6. Writing the Review

1. Organizing Principles

A literature review is a piece of discursive prose, not a list describing or summarizing one piece of literature after another. It should have a single organizing principle:

• Thematic - organize around a topic or issue
• Chronological - sections for each vital time period
• Methodological - focus on the methods used by the researchers/writers

4. Selected Online Resources

• Literature Review in Education & Behavioral Sciences This is an interactive tutorial from Adelphi University Libraries on how to conduct a literature review in education and the behavioural sciences using library databases
• Writing Literature Reviews This tutorial is from the Writing section of Monash University's Language and Learning Online site
• The Literature Review: A Few Tips on Conducting It This guide is from the Health Services Writing Centre at the University of Toronto
• Learn How to Write a Review of the Literature This guide is part of the Writer's Handbook provided by the Writing Center at the University of Wisconsin-Madison

2. Structure of the Literature Review

Although your literature review will rely heavily on the sources you read for its information, you should dictate the structure of the review. It is important that the concepts are presented in an order that makes sense of the context of your research project.

There may be clear divisions on the sets of ideas you want to discuss, in which case your structure may be fairly clear. This is an ideal situation. In most cases, there will be several different possible structures for your review.

Similarly to the structure of the research report itself, the literature review consists of:

• Introduction

Introduction - profile of the study

• Define or identify the general topic to provide the context for reviewing the literature
• Outline why the topic is important
• Identify overall trends in what has been published about the topic
• Identify conflicts in theory, methodology, evidence, and conclusions
• Identify gaps in research and scholarlship
• Explain the criteria to be used in analysing and comparing the literature
• Describe the organization of the review (the sequence)
• If necessary, state why certain literature is or is not included (scope)

Body - summative, comparative, and evaluative discussion of literature reviewed

For a thematic review:

• organize the review into paragraphs that present themes and identify trends relevant to your topic
• each paragraph should deal with a different theme - you need to synthesize several of your readings into each paragraph in such a way that there is a clear connection between the sources
• don't try to list all the materials you have identified in your literature search

From each of the section summaries:

• summarize the main agreements and disagreements in the literature
• summarize the general conclusions that have been drawn
• establish where your own research fits in the context of the existing literature

5. A Final Checklist

• Have you indicated the purpose of the review?
• Have you emphasized recent developments?
• Is there a logic to the way you organized the material?
• Does the amount of detail included on an issue relate to its importance?
• Have you been sufficiently critical of design and methodological issues?
• Have you indicated when results were conflicting or inconclusive and discussed possible reasons?
• Has your summary of the current literature contributed to the reader's understanding of the problems?

3. Tips on Structure

A common error in literature reviews is for writers to present material from one author, followed by information from another, then another.... The way in which you group authors and link ideas will help avoid this problem. To group authors who draw similar conclusions, you can use linking words such as:

• additionally

When authors disagree, linking words that indicate contrast will show how you have analysed their work. Words such as:

• on the other hand
• nonetheless

will indicate to your reader how you have analysed the material. At other times, you may want to qualify an author's work (using such words as specifically, usually, or generally ) or use an example ( thus, namely, to illustrate ). In this way you ensure that you are synthesizing the material, not just describing the work already carried out in your field.

Another major problem is that literature reviews are often written as if they stand alone, without links to the rest of the paper. There needs to be a clear relationship between the literature review and the methodology to follow.

• << Previous: 4. Analysing the Literature
• Next: 6. Writing the Review >>
• Last Updated: May 9, 2024 10:36 AM
• URL: https://libguides.uwi.edu/litreviewsoe

• Research article
• Open access
• Published: 10 July 2008

Methods for the thematic synthesis of qualitative research in systematic reviews

• James Thomas 1 &
• Angela Harden 1  

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

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

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

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

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

Peer Review reports

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

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

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

The review used as an example in this paper

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

Qualitative research and systematic reviews

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

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

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

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

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

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

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

Quality assessment

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

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

Extracting data from studies

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

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

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

Detailed methods for thematic synthesis

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

Stages one and two: coding text and developing descriptive themes

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

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

line-by-line coding in EPPI-Reviewer.

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

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

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

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

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

relationships between descriptive themes.

Stage three: generating analytical themes

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

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

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

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

Context and rigour in thematic synthesis

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

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

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

Study quality and sensitivity analyses

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

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

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

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

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

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

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

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Acknowledgements

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

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Thomas, J., Harden, A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 8 , 45 (2008). https://doi.org/10.1186/1471-2288-8-45

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Literature Reviews

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Organization

Organization of your Literature Review

What is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? What order should you present them?

Just like most academic papers, literature reviews must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper.

Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.

Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).

Conclusions/Recommendations: Discuss what you have drawn from reviewing the literature so far. Where might the discussion proceed?

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario and then three typical ways of organizing the sources into a review:

You've decided to focus your literature review on materials dealing with sperm whales. This is because you've just finished reading Moby Dick, and you wonder if that whale's portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980's. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Chronological

If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.

By publication

Order your sources chronologically by publication if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.

Another way to organize sources chronologically is to examine the sources under a trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Using this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.

Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most: the development of the harpoon or the harpoon technology.

More authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as "evil" in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.

Methodological

A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Once you've decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

Current Situation: Information necessary to understand the topic or focus of the literature review.

History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.

Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

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Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

• formulating the research question(s) and objective(s),
• searching the extant literature,
• screening for inclusion,
• assessing the quality of primary studies,
• extracting data, and
• analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health ( m-health ) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

• Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
• Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
• Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
• Analyzing data using quantitative or qualitative methods.
• Presenting results in summary of findings tables.
• Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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• Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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• Translation

Deciding between the Chronological and Thematic approaches to a Literature Review

By charlesworth author services.

• Charlesworth Author Services
• 25 June, 2022

Depending on the discipline that your research is located in and your specific research project, there are broadly two different ways in which you can approach organising, reading for and writing your literature review : either chronologically or thematically . This article explores some of the factors to consider as you begin to plan your literature review .

Note : This is not to say that you must decide on and take only one approach exclusively for the whole of the review. You may start a review thematically, but organise and review the literature within a theme in a chronological fashion, as illustrated in the examples towards the end.

Purpose of conducting a literature review

Regardless of the approach, either chronological or thematic, both have the same purpose – to contextualise and identify the need for your specific research. As such, the literature review is never purely descriptive, but should ultimately be analytical and argumentative. 

Whichever approach you take, your literature review needs to demonstrate that you have a clear understanding of the existing relevant literature in your field. You seek to acknowledge what has been accomplished, but also to identify gaps , problems or unanswered questions within these studies. Ultimately, you aim to show how your research relates to the existing body of work . In other words, this section explains how you will address those gaps or questions and how this study will contribute to and extend that knowledge.

Defining key terms and concepts for your literature review

A useful way to start your literature review is to reflect upon how a specific term or concept has been understood and how the definition has developed. You can then proceed as follows.

• Explain why and how you wish to understand, frame and engage with that term/concept for your research.
• Review the literature on the topic based on that definition or understanding of a key term.
• Assess exactly what approaches you can take to that topic – whether chronologically or thematically, theoretically and/or methodologically. 

Deciding between the approaches

Taking the chronological approach.

Where there have been clear developments sequentially, over a period of time , then it makes sense to track these developments chronologically. You establish and express your academic credibility here through your identification of the most significant and relevant authors/studies at each stage. Your readers will note whom you see as being worthy of mention and whose work you are using to contextualise your own. 

Going with the thematic approach

With this approach, you are examining and discussing existing literature/studies not by their chronological development but by the principal themes, debates, perspectives or approaches that they address. This thematic approach offers you the advantage of determining and structuring the order of themes to fit the narrative and development of your research. It also helps you to more clearly identify the links between disparate literatures , as well as to play a more actively engaged role in evaluating the literature you’ve selected. 

In this extract taken from an article on writing introductions to research articles , you can see both types of organisation being used. (Note the highlighted parts.) The first paragraph of the article is a broad thematic review of the research on journal articles. The second paragraph from this article focuses on a (mostly) chronological review but organised within themes.

Broadly thematic approach

Over the last 20 years, a large number of studies on academic writing have been devoted to the research article, in particular, its structure, social construction and historical evolution. A number of these studies have concerned themselves with the overall organization of various parts of the research article , such as the introduction (e.g. Swales, 1981, Swales, 1990, Swales and Najjar, 1987), the results sections (Brett, 1994, Thompson, 1993), discussions (Hopkins & Dudley-Evans, 1988) and even the abstracts that accompany the research articles (Salager-Meyer, 1990, Salager-Meyer, 1992). Various lexico-grammatical features of the research article (RA) have also been explored, ranging from tense choice to citation practices. Beyond the textual structure of this genre, research has also focused on the historical development of the research article (Bazerman, 1988, Atkinson, 1993, Salager-Meyer, 1999, Vande Kopple, 1998) and the social construction of this genre (Myers, 1990).

Mostly chronological approach

One aspect of the RA [research article] that has perhaps been most studied is the introduction. Since Swales’ (Swales, 1981 , Swales, 1990 ) seminal work on the move structure of RA introductions, there has been considerable interest in applying the proposed model to other sets of texts. Crookes ( 1986 ), for example, through further analysis, has pointed to the cyclical nature of introductions. Jacoby ( 1987 ) has investigated in greater detail the use of references in introductions. Scholars have also used Swales’ model to examine texts written in different languages (such as Malay and Swedish) and cultures and have concluded that RA introductions are influenced by linguistic and cultural differences (Fredrickson and swales, 1994 , Ahmad, 1997 ). There has been less research, however, on the variations in RA introductions across disciplines despite the growing interest in disciplinary differences in academic writing. Some recent studies have focused on disciplinary variation in RAs as a whole. Posteguillo’s ( 1999 ) study of RAs in computer science and Nwogu’s ( 1997 ) study of medical science nicely illustrate variations in the whole genre across disciplines and underscores the need for further research on disciplinary variation. However, there have been only a few studies which have focused primarily on the introduction. Swales and Najjar ( 1987 ) examined RAs from educational psychology and physics focusing on the presence of principal findings in Move 3 of introductions. A much more recent study by Anthony ( 1999 ) of RA introductions from engineering reveals that Swales’ Create-A-Research-Space (CARS) model does not account for some important features of the introduction, such as the presence of definitions of terms, exemplifications of difficult concepts, and evaluation of the research presented.

Whichever approach you decide to take, return frequently to the original premise of your study to keep yourself focused on exactly what you are trying to find out and what you need to know from existing literature to do that effectively. This will help you to be more selective with the literature, studies and authors you include in your own study.

Read next (second) in series: How to structure and write a Chronological Literature Review

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• Open access
• Published: 14 August 2024

Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis

• Hannah Webb 1 ,
• Maria Griffiths 1 &
• Ulrike Schmidt 2 , 3  

Journal of Eating Disorders volume  12 , Article number:  115 ( 2024 ) Cite this article

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Eating disorders are complex difficulties that impact the individual, their supporters and society. Increasing numbers are being admitted to intensive treatment settings (e.g., for inpatient treatment, day-patient treatment or acute medical treatment). The lived experience perspectives of what helps and hinders eating disorder recovery during intensive treatment is an emerging area of interest. This review aims to explore patients’ perspectives of what helps and hinders recovery in these contexts.

A systematic review was conducted to identify studies using qualitative methods to explore patients’ experiences of intensive treatment for an eating disorder. Article quality was assessed using the Critical Appraisal Skill Programme (CASP) checklist and thematic synthesis was used to analyse the primary research and develop overarching analytical themes.

Thirty articles met inclusion criteria and were included in this review. The methodological quality was mostly good. Thematic synthesis generated six main themes; collaborative care supports recovery; a safe and terrifying environment; negotiating identity; supporting mind and body; the need for specialist support; and the value of close others. The included articles focused predominantly on specialist inpatient care and were from eight different countries. One clear limitation was that ethnicity data were not reported in 22 out of the 30 studies. When ethnicity data were reported, participants predominantly identified as white.

Conclusions

This review identifies that a person-centred, biopsychosocial approach is necessary throughout all stages of eating disorder treatment, with support from a sufficiently resourced and adequately trained multidisciplinary team. Improving physical health remains fundamental to eating disorder recovery, though psychological support is also essential to understand what causes and maintains the eating disorder and to facilitate a shift away from an eating disorder dominated identity. Carers and peers who instil hope and offer empathy and validation are valuable additional sources of support. Future research should explore what works best for whom and why, evaluating patient and carer focused psychological interventions and dietetic support during intensive treatment. Future research should also explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

Plain English summary

Some people with eating disorders will need intensive treatment (e.g., inpatient treatment, day-patient treatment or acute medical treatment) during the course of their illness. Understanding what helps and hinders eating disorder recovery during intensive treatment is an important part of developing effective interventions. This review summarises research exploring people with eating disorders’ perspectives of intensive treatment, with the aim of identifying what helps and hinders eating disorder recovery. We searched in scientific databases for all published qualitative studies that explored people with eating disorders’ perspectives of intensive treatment. Thirty studies meet the inclusion criteria of this literature review. The results sections of these studies were analysed by extracting relevant findings relating to eating disorder recovery. We found that a person-centred, holistic approach is necessary throughout all stages of eating disorder treatment, with support from healthcare professionals and carers with specialist knowledge of how to support people with eating disorders. Improving physical health is fundamental to eating disorder recovery. However, psychological support is also essential to help people with eating disorders to understand what causes and maintains the eating disorder and support them to move away from an eating disorder dominated identity. Areas for future research are outlined.

Introduction

Eating disorders (EDs) are a group of mental health disorders, such as anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), that are characterised by severe disturbances of attitudes and behaviours related to food, weight, and shape, and that seriously impact mental and physical health [ 1 ]. ED onset is typically during late adolescence and early adulthood [ 2 ]. With the potential to impact every organ system, EDs can be life threatening, reportedly having the highest mortality rate of all mental health disorders [ 3 , 4 , 5 ]. EDs are burdensome to the individual, their supporters and society [ 6 ]. Covid-19 has only exacerbated this burden: increases in incidence rates, ED symptomatology and hospital admissions have been widely reported [ 7 , 8 , 9 ].

Treatment for people with eating disorders (PwEDs) depends on the severity and chronicity of difficulty [ 10 ]. Most PwEDs are first offered outpatient psychological therapy, which can be complemented with pharmacotherapy, medical monitoring, nursing and/or dietetic support [ 11 ]. For those who do not respond to outpatient treatment, or whose ED cannot be managed safely as an outpatient, intensive treatment may be offered. This typically ranges from day-patient treatment or partial hospitalisation to inpatient or residential treatment in an ED or general psychiatric unit. Though varied, these more intensive treatments typically involve greater multidisciplinary input and direct meal supervision [ 11 ]. Alongside specialist intensive treatments, increasing numbers of PwEDs are being admitted to general medical settings to manage the medical complications associated with EDs [ 12 , 13 ]. Care in medical settings is highly variable, with varying levels of specialist input [ 11 , 13 ]. Importantly, whilst the relative merits of each form of intensive treatment continue to be debated, demand appears to be rising internationally [ 14 , 15 , 16 ].

Clinicians supporting PwEDs encounter challenges due to the egosyntonic nature of the illness [ 17 ]. Many people attach positive value to their ED [ 18 ], as it gives a perceived sense of control, and means of obtaining identity and avoiding negative affect [ 19 , 20 ]. Consequently, PwEDs are often ambivalent towards treatment and display low motivation to change [ 21 , 22 ]. Current treatment efficacy is modest [ 23 ]. A recent rapid review suggested between 30% and 41% of PwEDs relapse within two years of receiving treatment and that less than half achieve recovery at long-term follow up [ 24 ]. Furthermore, across all EDs, 62–70% of people who have received inpatient treatment still meet full diagnostic criteria or have remaining ED symptoms at long-term follow-up [ 6 ].

To improve treatment outcomes for PwEDs, it is vital that we better understand the lived experiences of those who use ED services [ 25 , 26 ]. As such, emerging research explores lived experience perspectives of ED treatment. For example, Babb and colleagues [ 27 ] reviewed qualitative studies exploring PwEDs’ general experiences of ED treatment. This review called for more individualised care and psychological support. Whilst valuable, it did not specifically focus on recovery. It also only identified studies exploring inpatient and outpatient experiences. Yet, some studies have explored PwEDs’ perspectives of other treatment settings, such as day-patient or acute medical settings, which may add important insights. The lifespan approach taken in this review may also mean that a review focused on adult populations is warranted as there are differences in ED treatment accessibility and delivery between child, adolescent and adult services. For instance, the duration of untreated ED (DUED) varies strongly between age groups, with younger age groups seeing shorter DUEDs [ 28 ] and in child and adolescent ED treatment, greater emphasis is placed on family involvement [ 29 ].

Other reviews seek to conceptualise ED recovery from lived experience perspectives. These have led to recovery being described as a complex psychological process that requires commitment, responsibility, development of insight into the function and consequences of the ED, acceptance by others and of the self, and development of meaningful relationships [ 30 ]. Recovery has also been said to include remission of ED symptoms alongside psychological well-being and adaptability, and involves hope, reclaiming identity, meaning and purpose, empowerment and self-compassion as key components [ 31 , 32 , 33 ]. Whilst valuable findings, these reviews do not focus specifically on what aspects of treatment help or hinder recovery.

More recently, two qualitative reviews synthesised literature exploring the lived experiences of inpatient treatment for all EDs [ 34 ] and AN only [ 35 ] within ED-specific treatment settings. These reviews highlight the complex and multifaceted nature of inpatient experiences and the importance of person-centred treatment that involves medical and psychological intervention [ 34 , 35 ]. Undeniably, these reviews provide insight into a neglected area of research. However, they include differing all-age studies and exclude studies exploring different intensities and aspects of intensive treatment (such as the experience of involuntary admission). Yet, many PwEDs move through different intensive treatments, some outside ED-specific treatment settings, and all aspects of intensive treatment may relate to recovery.

ED recovery is a process rather than a singular event, which can begin before and continue beyond inpatient treatment. Therefore, this review aims to extend previous reviews exploring the lived experiences of inpatient treatment. With a focus on recovery, it aims to elucidate what helps and hinders recovery for adults with EDs across all types and aspects of intensive treatment and to provide recommendations for research and clinical practice.

Search strategy

This systematic review was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 36 ] and was pre-registered on PROSPERO (ID: CRD42023426052).

Systematic literature searches were carried out using electronic databases (EMBASE, MEDLINE, PsychINFO, and Web of Science), searched from conception to 6th June 2023. Search terms and inclusion and exclusion criteria were formed using the ‘Sample, Phenomenon of Interest, Design, Evaluation and Research type’ (SPIDER) tool [ 37 ], outlined in Table  1 . The search strategy employed was informed by preliminary internet searches and previous reviews. It covered four concepts: [ 1 ] EDs, [ 2 ] intensive treatment, [ 3 ] qualitative methodology, and [ 4 ] lived experiences. Various combinations of search terms were trialled before settling on a broad search strategy that explored all free text to maximise search sensitivity.

Study selection and eligibility criteria

The first author completed the literature search, which yielded 2590 articles. Duplicates were removed, and the titles and abstracts of the remaining articles were screened against predetermined inclusion and exclusion criteria, outlined in Table  2 . Qualitative or mixed method studies (if qualitative results were reported separately) that explored adults’ experiences or views of any aspect of intensive treatment directly related to an eating disorder diagnosis were considered for eligibility. Only studies originally published in English and in peer-reviewed journals were accepted. A decision was made not to search the grey literature due to time constraints and wanting to ensure adequate space and consideration was given to the included studies. Further, grey literature studies are not necessarily subject to the same rigorous academic peer-review processes as non-grey literature studies. Nonetheless, some potentially relevant studies may have been missed.

Eligibility screening resulted in 71 articles which were read in full. Full-text screening excluded a further 45 articles, resulting in a total of 26 articles. The first author also screened the reference lists of included manuscripts to identify other studies that may have met the inclusion criteria and conducted additional searches through Google Scholar throughout the review process. This resulted in an additional four articles, meaning that 30 articles were included in this review. Throughout this process, any discrepancies were discussed with the second author (MG) until a consensus was reached. The complete procedure is detailed in the PRISMA diagram (Fig.  1 ).

PRISMA Flow Diagram

Quality assessment

Though what constitutes “validity” or “quality” in qualitative research is debated, quality appraisal remains a crucial part of any qualitative review [ 38 ]. The Critical Appraisal Skill Programme (CASP) checklist, a commonly used research appraisal tool, offers ten questions that facilitate assessment of qualitative studies. The Cochrane Qualitative and Implementation Methods Group recommends to avoid providing numerical scores, as CASP is not recommended as an absolute score of quality [ 39 ]. Instead, studies are considered according to whether criteria are: “yes well addressed”; “can’t tell”; or “no not addressed”. In this review, “can’t tell” was chosen when insufficient information was reported to make a judgement, as quality issues may be due to poor methodology and/or inadequate reporting [ 40 , 41 ]. The first author conducted the quality assessment and any ambiguities were discussed with the review team until a consensus was reached.

Given the large number of studies in this review, whilst absolute scores were avoided, quality appraisal was used to organise the thematic synthesis, as has been recommended previously [e.g., 41 , 42 ]. This meant studies ( n  = 10) for which “yes” was chosen for all ten questions were first reviewed to generate the coding framework. This was used to code the remaining studies. When particularly meaningful, new codes were generated. No studies were deemed to be low quality, as all studies provided valuable contributions to a limited evidence base. If there had been low quality studies, no new codes would have been generated, though these studies would not have been excluded.

Method of synthesis

Thematic synthesis was chosen to integrate findings of multiple qualitative studies to answer a specific review question and extend what is already known [ 43 ]. All text from “results” or “findings” sections, and any findings in abstracts, were extracted and treated as data. Thematic synthesis followed three iterative stages. Stage one involved line-by-line coding of text according to meaning and content. Stage two involved grouping of codes into hierarchical structures, to develop descriptive themes that remained data-driven and close to the primary studies. Stage three involved the generation of analytical themes through inference of descriptive themes, which go beyond the primary studies to generate new interpretive explanations.

Reflexivity

Reflexivity, the conscious, collaborative appraisal and critique of how one’s subjectivity and context influence the research processes, is an essential component of qualitative research [ 44 , 45 ]. We, the three authors, have psychology/psychiatry and academic and clinical backgrounds. The first author is a trainee clinical psychologist with lived experience of an ED as well as academic and clinical experience in EDs/mental health. The second author is a clinical psychologist with academic and clinical experience in mental health, in particular with adults with experiences of psychosis. The third author is a consultant psychiatrist and expert in the field of EDs, with experience of developing national and international initiatives to improve ED policy and practice. One of us was an insider to the experience of ED treatment and we are all insiders to a culture of working in mental health services with often high levels of need and limited resource. We made every attempt to ensure potential biases (e.g., our combined clinical, academic and experiential understanding that intensive treatment can be challenging for many) were kept in awareness and endeavored to pay attention to the full range of findings. Coding extracts and theme developments were discussed with all authors to check for disagreements or uncertainties before being finalised. Additionally, the first and second author met for monthly supervision to discuss the review development and analysis, and to support a continuous process of self-reflection. This collaborative approach supported development of themes that captured important nuances in the lived experiences of ED treatment, for example identifying the tension between physical versus psychological support. Nonetheless, as with all qualitative research, a different group of researchers who sought to answer the same research question may have extracted different themes from the data.

Studies identified

Thirty papers were identified as relevant. These are summarised in Table  3 .

Included studies totalled 495 participants ranging from 17 to 56 years. 96% identified as female, 2% identified as male, 0.4% identified as non-binary and 0.6% were not reported. 65% of participants were diagnosed with AN, 6.3% with BN, 0.6% with BED, 9.1% with EDNOS, 0.4% with OSFED, and 18.6% as missing or not reported. Ethnicity data were not reported in 22 studies. When ethnicity data were reported, 98.9% of participants identified as white (94/95 participants in reporting studies) and 1% identified as Other.

Included studies were predominantly conducted in the United Kingdom ( N  = 17). Other countries included Australia ( N  = 4), Canada ( N  = 3), Sweden ( N  = 2), Denmark ( N  = 1), Israel ( N  = 1), Norway ( N  = 1) and the USA ( N  = 1). Most studies focused on specialist inpatient units only ( N  = 19), with three studies focusing on inpatient and day-patient settings and one study focusing on inpatient and general psychiatric units. Three studies focused on day-patient settings only and two studies focused on medical settings only. One study focused on intensive community treatment and one study did not report the setting (though it focused on experiences in intensive settings). Most (27/30) studies did not report length of stay and those that did reported a wide range of 0.14 to 27 months.

Recruitment was carried out using various methods, inviting both current and past receivers of treatment. A range of data analysis approaches were used, though half of the studies used thematic analysis. Most studies ( N  = 23) used semi-structured interviews. Other data collection methods included open-ended questions in discharge/feedback questionnaires, narrative interviews, focus groups, diary entries and medical documents.

Quality appraisal

Included studies were of variable quality, but none were considered inadequate (see Table  4 ). All studies provided clear statements of the aims and appropriateness of qualitative methodology. The research design was unclear in three studies [ 46 , 47 , 48 ] and one study [ 49 ] did not explain consideration of ethics. Ten studies did not describe their recruitment strategy and thirteen studies did not provide any/adequate consideration of the relationship between the researcher(s) and participants. This contrasted with many studies that provided clear descriptions of their recruitment strategy (e.g., [ 50 , 51 ]) and researcher reflexivity (e.g., [ 52 , 53 ]). In line with their study methodology, some studies provided more descriptive analyses (e.g., [ 54 , 55 ]) and others provided more in-depth analyses (e.g., [ 48 , 49 , 56 ]). Studies that did not provide sufficient qualitative data for the quality of their analysis to be considered and analysed as part of this review were excluded at the point of screening. All studies showed sufficient rigour, providing clear statements of findings and situating these within the wider literature.

Studies varied significantly in the time-point of data collection (e.g., during treatment, immediately after, retrospectively or a combination), with only some reflecting on the chosen time-point(s). Most studies focused on experiences relating to specialist inpatient treatment and only some adequately described the treatment setting. Moreover, several studies did not provide key participant characteristics, samples were not representative and no study focused exclusively on any ED other than AN.

Thematic synthesis

Six themes were generated from the data: Collaborative Care Supports Recovery; A Safe and Terrifying Environment; Negotiating Identity; Supporting Mind and Body; The Need for Specialist Support; and The Value of Close Others. Themes and subthemes are outlined in Table  5 and discussed below.

Theme 1: collaborative care supports recovery

Active involvement in treatment.

Collaborative care supported recovery across intensive settings. “ Working together ” [ 51 ] and supporting PwEDs to “ make their own decisions ” [ 50 ] strengthened participants’ motivation. However, collaboration was “ often felt to be absent ” [ 54 ]. Several studies identified that participants felt “ alienated from the decision-making process ” [ 55 ], especially those admitted involuntarily. Feeling unheard negatively impacted upon self-esteem and anxiety. Lack of transparency between PwEDs and treatment providers affected treatment experiences and subsequent recovery. Lack of clarity about ward rounds led to “power differences… and anxiety ” [ 57 ]. Participants in both studies exploring medical settings voiced not knowing who was chiefly responsible for their care and “ feeling deceived or given a punishment ” [ 55 ] when starting a refeeding protocol or being detained, due to lack of information. This negatively impacted upon treatment engagement. One study identified that providers should make expectations and regimes clearer and repeat them frequently “ to ensure patients have time to process and understand them ” [ 50 ]. In another study, the option to self-admit (to inpatient treatment) strengthened participants’ agency and motivation, and promoted partnership. However, for some, it risked too much decision-making power – “ too much say… it’ll be bad for me ” [ 56 ].

Collaboration was particularly key during transitions of care. Lack of information and “ uncertainty in what was going to happen ” [ 53 ] contributed to fear and feeling overwhelmed, hindering ongoing recovery. Many studies concurred that “ a graded and planned discharge helped… [re] integration ” [ 58 ]. This involved “ a phased , supportive approach ” [ 61 ], “ communication… with clear goals ” [ 54 ] and consideration of potential “ obstacles and challenges ” [ 63 ]. Several studies identified that treatment intensity dropped too quickly, that little or no further support was offered, or that participants were placed on lengthy outpatient waitlists. Continuity of support was essential.

Temporarily handing over responsibility

Whilst collaborative care generally supported recovery, there were instances in which, for short periods of time, participants found it helpful to not be so involved in care decisions. Several inpatient studies identified that, whilst challenging, many participants actually felt “ saved ” [ 58 ] when providers took responsibility (e.g., implementing clear boundaries around dietary change). “ Handing over” [ 59 ] control was sometimes viewed as a necessary step towards recovery. However, for some, sudden loss of control contributed to heightened distress and “ amped up the ED ” [ 50 ]. For those experiencing involuntary treatment in particular (e.g., forced nasogastric feeding) this led to disconnection from one’s care. One study identified that “ hopelessness and resentment ” [ 58 ] developed. As Fox and Diab [ 49 ] outlined, the ED “ gave participants a sense of control and a method of coping …” and “ refeeding… led to an intense feeling of losing control” – supporting participants to understand the reasons behind care decisions and to process the intensive emotions these activated appeared fundamental to recovery.

Theme 2: a safe and terrifying environment

A bubble that was hard to replicate.

For some, the safety and security afforded by intensive treatment supported recovery. Inpatient and day-patient treatment granted “ permission ” [ 53 , 58 ] to focus on recovery. Inpatients was described as a “ respite from overwhelming everyday demands ” [ 56 ]. Participants felt they “ belonged somewhere ” [ 64 ], finding “ comfort in predictable routines ” [ 65 ]. Inpatients also provided relief for carers. Several studies suggested non-negotiable boundaries supported change – “ completing meals was non-negotiable ” [ 66 ]. Two studies recognised when healthcare professionals (HCPs) made alterations to rules, it gave the ED “ leverage to pathologically negotiate ” [ 65 ]. Nonetheless, one participant identified that the existence of certain rules (e.g., prohibiting of water loading) alerted them to new possibilities.

It was recognised that the certainty and boundaries inpatients afforded was “ not easily replicated ” [ 52 ]. Their loss after discharge contributed to difficulties with continuing recovery. Indeed, inpatients was called a “ bubble ” [ 58 , 59 ], “ greenhouse ” [ 60 ] and “lab… [with] very exact and measured conditions ” [ 60 ]. It left participants “ frozen… and dependent on the unit ” [ 59 ]. Various studies identified that intensive treatment (particularly inpatient treatment) put “ life on hold ” [ 61 ]. For some, this contributed to dependence on treatment and the ED. As O’Connell [ 66 ] outlined, the ED became “ the standpoint from which I related to others ”. A few studies highlighted the importance of providers “ showcasing interest and highlighting aspects of patients’ lives outside of their ED ” [ 50 ] to provide relief from institutionalisation and support motivation. As PwEDs transitioned out of intensive treatment, returning to or beginning careers, relationships, leisure and personal development activities supported “ a sense of routine and purpose ” [ 61 ].

A punitive, distressing environment

Words such as “ miserable ”, “ horrific ”, “ hostile ”, “ traumatic ”, “ distressing ”, “ inhumane ”, “ terrifying ” and “ an assault ” were used to describe treatment (in inpatient and medical settings only) [ 48 , 49 , 54 , 60 , 64 ]. For some, feeling dehumanised, restricted or traumatised negatively impacted upon motivation, engagement and subsequent recovery. Several studies suggested participants felt “ under inspection ” [ 58 ] and treatment was described as “ doing time ” [ 67 ]. “ Exposure to… [and experiences of] distressing events ” [ 54 ] were difficult – described as “ something I’ll never forget ” [ 48 ]. Participants sometimes experienced “ corrective measures as punitive or disciplinary ” [ 65 ]. Moreover, across several studies, participants felt certain boundaries were arbitrary, employed without adequate explanation, or “ rigid and unable to be maintained ” [ 58 ], leaving them feeling disempowered.

Theme 3: negotiating identity

Separating the self and the ed.

Across many studies, attachment to the ED hindered recovery. The ED afforded safety, control and confidence in its success and provided “ emotional and physical detachment ” [ 62 ]. Intensive treatment “ created a state of internal coercion ” [ 48 ]. Several studies identified that a mismatch between treatment requirements and participants’ readiness to change could result in treatment refusal or termination, strengthening attachment to the ED. For those who experienced repeated admissions, lengthy stays or passing between services, “ feelings of hopelessness ” [ 49 ] and “ feelings of failure ” [ 56 ] were prevalent. Consequently, participants “ gripped more tightly onto AN ” [ 66 ] (and the ED identity).

Indeed, being “ reduced to a number and a disorder ” [ 55 ] in inpatient and medical settings hindered recovery. Various studies suggested participants disliked feeling defined by their illness and treated as “ a collective ” [ 60 ] or in accordance with “ an assumed group identity ” [ 68 ]. This “one-size-fits-all approach ” [ 67 ] left participants feeling “ misunderstood , invalidated and stereotyped ” [ 66 ]. There was a desire for “ different tracks for people with different needs ” [ 55 ] and a wish for providers to “ humanise the patient ” [ 50 ]. Indeed, personalised, flexible treatment supported recovery across intensive settings. Day-patients was viewed as more flexible than inpatients, though both groups desired a more “tailored approach ” [ 61 ] (e.g., better consideration of differences in sexuality, gender identity and comorbidities). Intensive community treatment was considered individualised, with “ specific and obtainable goals ” [ 62 ]. Moreover, several studies highlighted that, for some participants, being supported to externalise the ED as separate to their sense of self - recognising “ AN as pathology separate to who they were ” [ 65 ] - supported change and recovery.

Beginning to want something different

Indeed, ambivalence towards treatment, particularly initially, was common. Recovery required moving from ambivalence to acceptance and/or determination. Reflecting back, one participant suggested others should “ surrender a little bit … trust in the treatment ” [ 50 ]. For some, this was difficult. Several studies identified that compliance resulted in discharge, but not necessarily recovery. One participant “ humour [ed]” [ 63 ] providers and another aimed to “ eat their way out ” [ 58 ]. It was these participants where relapse was most likely. Self-criticism, shame, worthlessness and hopelessness kept participants stuck.

Conversely, several studies outlined the value of motivation. In their study exploring experiences of recovered versus relapsed PwEDs, participants’ “ own drive ” [ 63 ] was prevalent in the recovered group. One participant described eventually “ wanting something different ” [ 66 ] and another study noted EDs require “ extremely hard work to be fought against ” [ 62 ]. Key to recovery was self-acceptance, hopefulness, and awareness and insight into the ED: “ compassion… and self-care ” [ 58 ] and “ a sense of self ” [ 64 ] were necessary.

Theme 4: supporting mind and body

Weight restoration and dietary change.

Many participants retrospectively saw intensive treatment as “ saving lives ” [ 48 ], specifically regarding medical stabilisation. However, across inpatient and medical settings, participants struggled with discrepancy between “ normal [weight restored] bodies ” and continued “ anorexic thoughts ” [ 63 ], leading to other maladaptive behaviours or relapse. Overfocus on biological markers, for example “ micro-monitoring of the participant’s weight ” [ 67 ], negatively impacted recovery. Across studies, participants wished for a “ slow pace of change with focus on all aspects of their difficulties ” [ 62 ].

Nonetheless, across specialist settings (i.e., not general medical), support in understanding and implementing dietary changes facilitated recovery. Meal support, plans and routines developed “ behavioural patterns that supported recovery ” [ 52 ] and “ staff eating alongside ” [ 46 ] normalised mealtimes. Nutritional education was also valued. Learning about “ daily nutritional requirements” [ 52 ] and “ their bodies’ need for food ” [ 47 ] helped participants make dietary changes. Similarly, opportunities to engage in practical food groups (e.g., grocery shopping, outings to restaurants/cafes and meal preparation activities) were considered important and increased “confidence to attempt repeating the challenges outside” [ 69 ]. Practicing dietary related cognitive skills and coping strategies supported a “ gradual shift to more independent eating ” [ 70 ].

Psychological awareness and understanding

Understanding what caused and maintained the ED arose as integral to recovery, through individual and group therapy and wider psychological support. Individual therapy supported PwEDs to understand the ED and “ challenge… maladaptive thinking styles and behaviours ” [ 71 ]. A “ strong [therapeutic] connection ” [ 70 ] was essential. Similarly, a range of therapeutic groups, including Cognitive Behavioural Therapy, Dialectical Behavioural Therapy and the Maudsley Anorexia Nervosa Treatment for Adults groups, as well as perfectionism, mindfulness, and value-based groups, were appreciated. Many recognised “the importance of sharing experiences and learning from each other” [ 72 ], though for a minority, the perceived intensity of groups was challenging. A holistic therapy, acupuncture, was “ relaxing , both emotionally and physically ” [ 73 ] particularly after meals. Nonetheless, for some, therapy was “ too structured ” [ 74 ]. There was desire “ for more guidance and practice to help with real life application ” [ 71 ] and several studies identified a need for longer therapeutic intervention. One study identified insufficient psychological input in ward rounds, though one participant did not want their formulation shared due to it being “ very personal ” [ 57 ].

Learning to identify, express and manage emotions emerged as beneficial across intensive settings. For example, developing strategies to “ manage… and label emotions ” [ 74 ] and communicate one’s feelings supported recovery during and after treatment. Self-examination skills (e.g., journaling) helped PwEDs “ continue to work on recovery after discharge ” [ 52 ]. Several studies identified that emotional suppression and avoidance of negative affect limited progress.

Theme 5: the need for specialist support

Genuine care, alliance and trust.

Genuine care, trust and therapeutic alliance between PwEDs and HCPs was important for recovery. Participants wished to be treated with dignity and respect. They valued HCPs who were “ approachable and friendly ” [ 51 ], empathic and non-judgemental, and who validated and managed participants’ emotions. For some, feeling cared for involved nurses adopting a “ motherly or sisterly role ” [ 65 ] and HCPs who went “ beyond their roles ” [ 54 , 75 ]. Several studies noted the importance of strong therapeutic alliances with key workers, characterised by honesty, trust and openness. This promoted “ hope and optimism ” [ 75 ] and led participants to feel “ held or supported ” [ 62 ]. Without a good keyworker relationship “ challenges could feel insurmountable ” [ 51 ].

Correspondingly, across several studies, feeling uncared for negatively impacted recovery. Participants sometimes felt dismissed, patronised or ignored. They struggled with HCPs who “ failed to follow through with promises ” [ 58 ], “ overlooked [them] in comparison to newly admitted patients ” [ 59 ], or offered a “lack of a predictable response” [ 68 ]. Distrust between PwEDs and HCPs was “ an important precursor to some difficult interactions ” [ 67 ]. Described in several studies, conflict often led to further rebellion as the participant sought to “ retain their sense of control ” [ 46 ]. Poor connections resulted in increased anxiety and distrust, which impacted participants’ self-esteem, motivation, and desire to remain in treatment.

Skilled and well Resourced Multidisciplinary Care

Several studies outlined the importance of PwEDs being care for by a skilled and well resourced multidisciplinary team, with “ staff from different disciplines… contributing to residents’ recovery ” [ 70 ]. Changing teams, HCP shortages and use of non-permanent staff decreased standards of care and hindered recovery. Whereas, well trained and skilled HCPs displayed empathy, understanding, knowledge and clear boundaries. Indeed, “ trust and belief in practitioner’s expertise were… fundamentally important ” [ 49 ]. Skilled HCPs were able to separate the person from the ED, facilitate honesty and openness, and develop strong therapeutic alliances.

Theme 6: the Value of Close others

Peer support and comparison.

Peer support and comparison affected recovery. Across intensive settings, “ physical and behavioural comparisons ” [ 59 ] and competitiveness negatively affected “group cohesion and personal recovery ” [ 53 ]. Many found it distressing and triggering being admitted alongside others at various stages of recovery and with differing levels of illness severity. Indeed, participants were susceptible to adopting “new [unhelpful] ED practices ” [ 60 ]. Participants in two studies described comparing themselves (not under section) to those under section. This comparison increased participants’ guilt for choosing to eat and negatively impacted recovery. Correspondingly, participants in one study valued spending time with people without EDs who “ value aspects of life other than shape and weight ” [ 52 ].

In contrast, many of the same studies recognised that being alongside other PwEDs also supported recovery. Peers who understood and were non-judgmental were valued and contributed to connectedness, acceptance and belonging. Peer support “ increased knowledge of effective coping skills and hope for recovery ” [ 59 ]. Several studies noted participants made “ close and lasting friendships… through a sense of camaraderie ” [ 60 ]. Relatedly, one participant valued a peer mentor who had “ been there and got through ” [ 53 ].

Carer Support and understanding

Carer support and understanding during, and upon leaving, intensive treatment supported recovery. Across settings, participants desired for carers to “ provide love , a listening ear ” [ 50 ], particularly “ during the transition period ” [ 61 ]. Carer support groups were also valued. Returning home with “ insufficient or unhelpful social support ” [ 69 ], as well as “ continual emphasis on body weight and dieting within the family or social environment ” [ 63 ], hindered recovery.

Moving from loneliness to connection

Isolation hindered recovery. Particularly upon admission, participants described an emptiness, loneliness and difficulty trusting others. Difficulties developing and maintaining relationships contributed to negative attributions of the self and others and pushed participants further into their ED. Admissions sometimes exacerbated these difficulties as participants were removed from friends and family. Fostering “ meaningful connections after treatment ” [ 52 ] and moving from “ loneliness… to interpersonal connection ” [ 62 ] supported PwEDs to move towards recovery.

This review explored what helps and hinders recovery during intensive treatment for PwEDs. Participants acknowledged that intensive treatment was often necessary, particularly with regards to biomedical recovery. As higher discharge BMI predicts more positive outcomes (for AN) [ 76 ], promoting adequate weight restoration remains a priority. Nonetheless, consistent with existing literature [ 30 , 35 ], a biomedical focus often took precedence over addressing underlying psychosocial difficulties. Participants were weight-restored but not recovered and often discharged without a period of consolidation or without adequate step-down support, placing them at higher risk of relapse following discharge [ 31 ]. Providers should be careful to not over-focus on biological markers and should ensure pace of change is acceptable to the individual.

Correspondingly, a therapeutic milieu, comprising individual and group therapy and the wider care environment, was valued and necessary for recovery, though was not always present or sufficient. Consistent with existing literature [ 77 , 78 ], psychological interventions that supported PwEDs to understand the function and maintenance of their ED, as well as to identify, express and process emotions, facilitated recovery. Externalisation also arose as an important therapeutic technique across the wider care environment to foster separation from an illness identity [ 79 , 80 ].

Ambivalence, resistance to change and hopelessness hindered recovery. Commonly identified as barriers to recovery [ 81 , 82 , 83 ], if these factors were not attended to, change was difficult, and relapse was likely. Imposing actions (e.g., through boundaries and routines) may be necessary for an individual’s safety, but carry a risk of driving them further into their ED, increasing resistance and decreasing motivation and compliance [ 84 ]. These findings support research highlighting the role of holding and actively sharing hope [ 33 , 85 ] and of motivational interviewing [ 86 ].

Consistent dietary support should be embedded into intensive treatment. Across intensive settings (except in medical settings, where they were not mentioned), structured mealtimes, meal support, modelling normal eating, meal plans, nutritional education, and food groups supported PwEDs to move towards recovery. Supporting a small body of literature [ 87 , 88 ], dietary-related interventions allowed PwEDs to practice adaptive coping strategies, improve eating behaviours and self-efficacy, and address social challenges associated with eating.

Compassionate and yet boundaried HCPs were essential. Across intensive settings, collaborative, person-centred care strengthened hope and engagement. PwEDs desired active involvement in treatment, though for some, having responsibility removed initially was a necessary part of recovery. As clinicians have highlighted, balancing PwEDs’ desires with beneficence can be challenging [ 85 , 89 ], however the dominant medical paradigm, that positions HCPs as expert authorities, may harmfully limit choice, autonomy and opportunities for treatment participation. When PwEDs feel unheard or that their needs are not being met, premature treatment termination may result [ 90 ]. Whilst those in intensive settings are often at higher risk, where possible, it remains important to offer choice and clear information. Although few in number, studies exploring day-patient and intensive community settings suggested they afforded greater choice and collaboration, though this may be as these settings generally support less severe ED populations [ 91 ].

Experiences of care were highly individual. At times, intensive environments facilitated recovery. They were safe and supportive, due to firm boundaries, clear routines, and, in inpatient settings, escape from life stressors. Yet, consistent with ED clinicians’ concerns [ 85 ], intensive treatment (especially inpatient) also contributed to treatment dependence and estrangement from life outside. Transition out of intensive treatment was highlighted as a particularly vulnerable period. Day-patient and intensive community treatment discharges were experienced as somewhat more graded and skills learnt as more transferable, perhaps leading to a greater likelihood of maintenance. These findings underscore the value of intensive treatment but also the need for a gradual discharge process. Occupational therapists may be particularly well placed to support development of necessary skills for continuing recovery, supporting PwED’s to identify purpose outside of the ED, cope with external triggers and resume educational, vocational and/or family roles [ 87 ].

Intensive environments (in inpatient and medical settings only) were also experienced as restrictive and traumatising, due to experiences of coercion, scrutiny, and being subjected to, or witnessing of, distressing practices. These iatrogenic factors may hinder recovery and have long-lasting effects, contributing to more severe psychopathology and/or trauma-related symptoms. To date, limited work has explored what aspects render the experience of psychiatric hospitalisation distressing, though experiences of coercion, stress and trauma appear common and distressing [ 92 ]. Moreover, whilst compulsory treatment can be necessary to save lives, the long-term effects are largely unknown [ 93 ].

Adding to the growing literature base surrounding the value of carer support for adults with EDs [ 94 , 95 ], carer support was valued when carers were able to understand the ED and challenges of treatment and offer empathy and validation. Given that carers’ distress and ways of coping can inadvertently maintain or reinforce the ED [ 96 ], this finding affirms the necessity for carers to receive their own support [ 95 ]. Currently, a range of carer interventions show positive outcomes for PwEDs undergoing intensive treatment, though implementation is patchy, and research has predominantly focused on young people with AN and the experiences of mothers [ 95 ].

Peer comparison, competition and contagion were common in intensive settings and often reinforced the ED-dominant identity. Nonetheless, peer support and identification were also common, and frequently decreased isolation while motivating individuals towards recovery. One study also highlighted the value of a peer mentor. As a growing area of research and clinical practice, peer mentors may instil hope and increase motivation for treatment [ 97 ]. Treatment alongside other PwEDs being both helpful and hindering for recovery is a widely reported juxtaposition [ 27 , 85 ]. Helpful peer influence appears to depend on dis-identification with the ED-dominant identity and identification with a recovery identity. Indeed, a sense of shared identity with others in ED recovery promoted recovery in an online support group [ 98 ]. Specialist support is necessary and valued by PwEDs and this generally means PwEDs are treated alongside peers. Peer influence should therefore be considered as part of each individual’s formulation, to explore the potential for support and harm and how this may relate to the ED identity.

Clinical and research implications

To enhance likelihood of ED recovery, a multidisciplinary approach is required across intensive settings. Restoring physical health remains fundamental. However, psychological support is also necessary. Whilst several psychological treatments have evidence supporting use in outpatients, minimal evidence guides implementation of evidence-based practices in intensive settings [ 99 , 100 ]. Interventions that enhance motivation to change [ 86 , 101 ], foster separation from an ED-dominant identity [ 102 , 103 ] and support emotion recognition, regulation and expression [ 104 , 105 ] should be prioritised. Research must determine what works best for whom and why, tailoring processes to PwEDs’ unique needs, contexts and goals [ 30 ] and comorbidities [ 106 ].

Specialist dietetic support should also be employed. Dieticians possess unique skills and knowledge, but the extent to which they are involved in intensive treatment is largely unknown [ 88 ] and limited research guides the content of dietetic interventions or explores the effect of including dietetics [ 107 , 108 ]. Further research should explore what constitutes effective dietetic support across intensive settings [ 87 , 108 ].

Time to consolidate recovery gains alongside planned and phased discharges are vital for ED recovery. Research has begun to explore novel ways to support intensive treatment transitions [ 109 ] and intensive stepped-care treatment programs highlight the value of longer-term multidisciplinary care for PwEDs [ 110 , 111 ]. Further research must explore how to support maintenance of recovery, particularly as PwEDs return to daily life stressors.

Clinical practice guidelines recommend carer involvement in adult ED treatment [ 112 , 113 ] and carers and PwEDs recognise the value of carer support [ 96 , 114 ]. Current carer support is inconsistent, interventions vary, and a sufficient evidence base is lacking, particularly for adult ED populations [ 94 , 115 ]. Carer capacity, skill and knowledge vary and interventions need to be tailored accordingly [ 95 , 96 ]. To develop more routine and individualised care, research needs to elucidate which carer interventions works best for whom and why, taking consideration of different carer types, EDs other than AN, and stages of illness [ 94 , 96 ].

Perhaps most notably, this review highlights the complexity of intensive support for PwEDs. Findings highlight several dilemmas that HCPs face: helpful boundaries and containment versus restriction and coercion; peer support versus contagion; and physical versus psychological recovery. There is a clear need for sufficient resource, specialist training and opportunities for HCPs to engage in reflective spaces. Organisational pressures alongside client complexity mean HCPs can find working with PwEDs emotionally draining, leading to negative judgements, frustration, hopelessness and worry [ 99 , 116 ]. Perhaps it is these feelings that lead HCPs to strive for a practice of safe-certainty (e.g., administering standardised protocols) [ 116 ]. Time and space for reflection may support adoption of positions of safe-uncertainty, and consequently more flexible, person-centred approaches based on formulation and evidence-based interventions [ 116 ].

Specialist skills and knowledge, alongside trust and openness, reduce conflict and enhance therapeutic relationships and treatment engagement [ 117 , 118 , 119 ]. Within intensive settings, HCPs must balance firmness and empathy, communicating with clear boundaries to ensure certain behaviours are minimised whilst at the same time recognising and understanding the defensive nature of the ED and its adaptive function [ 22 ]. Future studies should explore what aspects of intensive treatment may be causing harm and any long-term effects. Moreover, there is need for specialist training and research in general medical settings, given the extent of negative experiences in this area.

Strengths and limitations

This review brings together 495 participants’ perspectives across thirty studies. Extending findings of previous reviews [ 34 , 35 ], this study explores what helps and hinders recovery across the spectrum of intensive treatment specifically for adults with EDs. A rigorous methodological process was employed in the selection, evaluation and interpretation of studies. To ensure findings remained contextualised, details of each included article’s aims, sample, setting, methods and methodological quality were included. However, a number of limitations must also be considered. As grey literature was not searched, some potentially relevant studies may have been missed. However, the sample is purposive rather than exhaustive, as this review aims to offer interpretive explanation and not prediction, therefore it may not be necessary to locate every available study [ 43 ]. The majority of included studies explored inpatient treatment experiences. Whilst the number of studies exploring lived experiences in non-inpatient settings is limited, the included studies offer a glimpse into experiences of these settings and highlight an important research gap. Further research is needed into lived experiences of intensive treatment settings other than specialist inpatient treatment for PwEDs (e.g., exploring lived experiences of day-patient treatment/partial hospitalisation, residential care, intensive community treatment, home-based treatments and acute medical admissions). Moreover, many studies also inadequately described the treatment setting. Given the diversity of intensive treatment approaches for PwEDs, authors should endeavour to describe treatment settings adequately to support transferability of findings [ 120 ]. Additionally, included studies omitted several key participant characteristics, and as has been identified previously, samples lacked ethnic, gender and diagnostic diversity. This limits the generalisability of findings to groups other than white women with AN. Researchers must include ethnicity data, as its absence further maintains underrepresentation. Research prioritising the treatment experiences of marginalised groups is urgently required [ 121 ].

This review explores what helps and hinders recovery during intensive treatment for PwEDs. A sufficiently resourced and adequately trained multidisciplinary service, which includes physical, psychological, dietetic and social support, supports ED recovery. Findings emphasised the vital role psychological support and understanding can have in supporting PwEDs to move from an ED-dominant identity to a sense of self outside of the illness and the value of carers and peers who instil hope and offer empathy and validation. Nonetheless, HCPs face several challenges when supporting PwEDs in intensive settings, as what is helpful for one person may be harmful for another. A person-centred, biopsychosocial approach is necessary throughout all stages of treatment. Further research must evaluate patient and carer focused psychological interventions and the role of dietetic support during intensive treatment. It must explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

Data availability

Data is provided within the manuscript. Further data is available on request.

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Webb, H., Griffiths, M. & Schmidt, U. Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis. J Eat Disord 12 , 115 (2024). https://doi.org/10.1186/s40337-024-01061-5

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Accessibility of entrepreneurship training programs for individuals with disabilities: a literature review.

1. Introduction

2. methodology, 2.1. eligibility criteria, 2.2. information sources and search strategy, 2.3. selection process and quality assessment, 2.4. synthesis methods, 3.1. limited access to quality education, 3.2. challenges in tailoring entrepreneurship education, 3.3. strategy to overcome barriers and application to entrepreneurship training programs.

• Equitable use: Educational services must be tailored to learners’ needs and capabilities, ensuring utility and accessibility for all. This principle necessitates consideration of both pedagogical methods and the physical or virtual learning environments.
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• Simple and intuitive design: Learning materials and teaching methods must be simplified to ensure comprehensibility and ease of use, accommodating diverse learner experiences and competencies.
• Perceptible information: Educational content must be accessible to all learners, regardless of sensory abilities, which may involve adapting content delivery methods.
• Tolerance for error: It is necessary to accommodate different learning abilities and speeds, aiming to minimize frustration and maximize learning outcomes through adaptable teaching strategies.
• Low physical effort: Digital tools, such as Massive Open Online Courses (MOOCs), can reduce physical barriers to education, making learning more accessible to those with physical disabilities or those facing geographical constraints.
• Size and space for approach and use: Physical and virtual learning spaces must be designed considering all learners’ access and usability requirements, ensuring that no one is excluded from the educational process due to physical limitations.

3.4. Tailored Education

3.5. the shift toward active, learner-centred methodologies, 3.6. use of information technology, 3.7. supportive communities, 4. limitations of this study, 5. further research, 6. conclusions, author contributions, institutional review board statement, data availability statement, conflicts of interest.

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Tiasakul, S.; Abdulzaher, R.; Bazan, C. Accessibility of Entrepreneurship Training Programs for Individuals with Disabilities: A Literature Review. Adm. Sci. 2024 , 14 , 187. https://doi.org/10.3390/admsci14080187

Tiasakul S, Abdulzaher R, Bazan C. Accessibility of Entrepreneurship Training Programs for Individuals with Disabilities: A Literature Review. Administrative Sciences . 2024; 14(8):187. https://doi.org/10.3390/admsci14080187

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• Published: 23 August 2024

Prevalence of nonalcoholic fatty liver disease in Pakistan: a systematic review and meta-analysis

• Fazal Hassan 1 ,
• Maria Farman 3 ,
• Kauser Aftab Khan 2 ,
• Muhammad Awais 3 &
• Sohail Akhtar 1  

Scientific Reports volume  14 , Article number:  19573 ( 2024 ) Cite this article

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• Liver diseases

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver condition globally and the leading cause of liver-related death and morbidity. The goal of this study was to collect current data in order to calculate the pooled prevalence of NAFLD in Pakistan. We conducted a comprehensive literature search on four electronic databases until March 2024 to find studies on the prevalence of NAFLD in Pakistan. Pooled prevalence estimates of NAFLD were obtained using random-effects meta-analytic models. The chi-square test was used to account for study heterogeneity, whereas the I 2 statistic was used to assess inconsistency. The data were stratified by the general population (average risk) and individuals with metabolic diseases (high risk). Two reviewers thoroughly and independently screened, reviewed, and assessed all studies. In total, 468 studies were reviewed, and 34 were included. The pooled NAFLD prevalence in the general population was 29.82% (95% CI 21.39–39.01%; prediction interval: 2.98–68.92%) based on 13 studies. In individuals with metabolic disorders, the prevalence of NAFLD in patients with diabetes, hypertension, and obesity, was 58.47% (95% CI 54.23–62.64%; prediction interval: 38.16–77.40%), 74.08% (95% CI 60.50–85.70%), and 47.43% (95% CI 30.49–64.66%), respectively. There was no evidence of publication bias, although a statistically significant level of heterogeneity was seen among the studies ( I 2 ranged from 57.5 to 98.69%). The findings of this study indicate a substantial prevalence of NAFLD in the population of Pakistan. The Pakistani government must formulate a comprehensive approach and plan aimed at augmenting awareness, control, prevention, and treatment of fatty liver disease.

Prospero Registration no: CRD42022356607.

Introduction

Nonalcoholic fatty liver disease (NAFLD) is a commonly occurring chronic liver disease with a global prevalence 1 . This syndrome primarily affects individuals with diabetes and obesity 2 . NAFLD encompasses a continuum of pathological manifestations, beginning with hepatic lipid accumulation and progressing to nonalcoholic steatohepatitis, characterized by varying degrees of necrotic inflammation, cirrhosis, and fibrosis 3 . NAFLD is associated with an increased vulnerability to hepatocellular carcinoma, cardiovascular disorders, and problems related to type 2 diabetes, such as neuropathy and nephropathy 4 , 5 , 6 . The global prevalence of NAFLD affects around 15–20% of women and 30–40% of men worldwide 7 . The prevalence is even higher among individuals with type-2 diabetes, with up to 70% of them being affected 8 . The increasing cases of NAFLD coincide with the rise of obesity in Asia 9 , where it is estimated to affect 29.6% of the population, potentially surpassing Western countries. This is likely due to age, urbanization, growing economies, a sedentary lifestyle, insulin resistance (type-2 diabetes), and poor health awareness 10 . Because of more significant visceral fat deposition, Asians are more prone to obesity-related problems. Despite having a BMI of less than 25 kg/m2, Asians exhibit a notable prevalence of type-2 diabetes and cardiovascular risk factors 11 , 12 .

In Pakistan, the prevalence of NAFLD has been increasing over recent years. This is mostly because of changed lifestyles, urbanization, and changes in diet that lead to a more calorie-dense diet and a less active lifestyle. The high prevalence of type-2 diabetes 13 , 14 , 15 , 16 , obesity 17 , and metabolic syndrome 18 in the population contributes to the increasing burden of NAFLD. Several regional studies have been published on the prevalence of NAFLD in Pakistan, but there is no nationwide data or survey on the prevalence of NAFLD in Pakistan. Therefore, the main purpose of this study is to systematically collect, summarize, synthesize, and quantify the pool prevalence of NAFLD in Pakistan.

The preferred reporting items for systematic reviews and meta-analyses guidelines were followed in this work 19 . The study protocol was registered in the PROSPERO database with the registration number CRD42022356607.

Search strategy

From inception to March 30, 2024, two investigators (F.H. and S.A.) independently performed an electronic literature search in MEDLINE (via PubMed), Web of Science, Embase (via Ovid), Scopus and local databases by using a combination of MeSh terms related to NAFLD in Pakistan. We searched (“NAFLD”, “nonalcoholic fatty liver disease”, “non-alcoholic fatty liver disease” OR “fatty liver” OR “fatty liver*” OR “nonalcoholic steatohepatitis*” OR “steatohepatitis*” OR “liver steatosis*”) AND (“Pakistan” OR “Pakistani”) AND (“prevalence” OR “incidence” OR “epidemiology” OR “frequency”). Furthermore, we carefully examined the reference lists of all relevant original and review papers to find potential new data sources.

Inclusion and exclusion

For inclusion, studies had to meet the following criteria: (1) the studies should be cross-sectional or longitudinal in nature and reflect the prevalence of NAFLD, or the prevalence can be calculated using the data provided. (2) Only studies that reported the prevalence of NAFLD in Pakistan were included. We excluded articles if (1) they were focused mainly on individuals younger than 18 years; (2) research was conducted on a Pakistani population but outside of Pakistan; (3) they were case reports, letters to editors, perspectives, communications, reviews, or reports of studies; (4) there were duplicate studies found within and across the databases; and (5) studies lacked sufficient data.

Data extraction

Two authors (F.H. and S.A.) independently extracted the data from individual studies, with disagreements being resolved by discussion and mutual consensus between the two investigators. A standardized data extraction form using Microsoft Excel was used to collect information on the first author’s surname, geographical location, publication year, survey period, study design, setting (urban vs rural), data collection timing, median or mean age of the participants, and proportion of females, as well as the number of participants with NAFLD.

Data analysis

To account the expected between-study heterogeneity, the prevalence of NAFLD was combined across studies, systematically using models with random effects. We generated pooled proportions using DerSimonian and Laird random effects models and stabilized the variances of the raw proportions before combining the data 20 . The findings of the meta-analyses are displayed in forest plots, which illustrate the prevalence proportions together with their corresponding 95% confidence intervals for each individual study as well as the overall random-effects pooled estimate. Statistical software R (ver. 4.3.3) with two packages (‘ meta ’ and ‘ metafor ’) was used to conduct the analysis. In pooled studies, we utilized the I 2 index to measure between-study heterogeneity 21 . We investigated publication bias visually with funnel plots and statistically with Begg-Mazumdar 22 and Egger linear regression 23 tests. To evaluate the probable sources of heterogeneity, subgroup analysis, and univariable meta-regression were performed. We did not create a multivariable meta-regression model due to the limited number of observations. The R 2 statistic was employed to quantitatively assess the extent to which factors in meta-regression models accounted for the overall between-study heterogeneity. To investigate the influence of individual studies on the overall effect size, sensitivity analyses were conducted by systematically removing each study in a sequential manner 24 . Using the Cohen kappa coefficient, we evaluated inter-rater agreement for article inclusion and methodological quality 25 .

Our database searches yielded 468 potentially relevant articles. 196 study titles and abstracts were evaluated after removing duplicates Fig. 1 . We evaluated 63 full-text papers for eligibility criteria, 29 were removed from the meta-analysis. Screening titles and abstracts (Kappa = 0.81) and entire texts (Kappa = 0.83) had strong inter-rater reliability.

PRISMA flow chart of the prevalence of NAFLD in Pakistan.

Study characteristics

The study characteristics and quality rating of all 34 selected studies 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 are presented in (Table 1 ). In total, 12995 participants were included. The selected articles were published between 2008 and 2024, with the majority (89%) being published within the last decade. The study encompassed a range of sample sizes, from 51 to 2007 participants. The median sample size was 202 participants, with an interquartile range of 132–202 participants. The age range of participants was documented in a total of 33 studies, with the reported average ages spanning from 23 to 58 years. A total of 17 studies 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 55 , 56 , 57 (50%) were conducted in Punjab province, 8 studies 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 (24%) in Sindh, and 7 26 , 27 , 28 , 29 , 30 , 31 , 58 (21%) in Khyber Pakhtunkhwa while one 59 study was conducted in Baluchistan. In addition, one 32 study was conducted nationwide. 13 26 , 33 , 35 , 36 , 41 , 42 , 43 , 44 , 46 , 49 , 55 , 58 , 59 of the total number of studies reviewed were determined to have a low risk of bias, while 21 27 , 28 , 29 , 30 , 31 , 32 , 34 , 37 , 38 , 39 , 40 , 45 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 56 , 57 were determined to have a moderate risk. There was no high risk of bias in any of the studies.

NAFLD prevalence in the general population

The NAFLD prevalence in the general population was assessed in 13 studies, encompassing a total of 8461 participants (Table 2 ). The NAFLD prevalence ranged from 13.73% (95% CI 8.70–20.21%) to 60.84% (95% CI 58.00–63.64%). The pooled NAFLD prevalence in the general population was 29.82% (95% CI 21.39–39.01%; prediction interval: 2.98–68.92%) with significant heterogeneity ( I 2  = 98.9%, p < 0.001) Fig. 2 . The Egger linear regression test (t = 0.65, p-value = 0.65), Begg-Mazumdar test (z = 1.29, p-value = 0.1970), and the visual evaluation of the funnel plot Fig. 3 collectively indicate the absence of publication bias in the conducted meta-analysis. The findings of the sensitivity analysis demonstrated that the pooled NAFLD prevalence ranged from 27.33% (95% CI 19.87–35.50%) to 31.40% (95% CI 22.63–40.89%) when each study was systematically excluded (Supplementary file S1 ). The results revealed no significant impact on the pooled outcome when any individual study was excluded systematically. This suggests that our meta-analysis is statistically robust and stable.

Forest plot of the prevalence of NAFLD in general population in Pakistan.

Funnel plot of the prevalence of NAFLD in general population in Pakistan.

When the data were stratified into different publication years, the pooled NAFLD prevalence estimates were found to be 23.83 (95% CI 14.49–36.65%) for the period between 2008 and 2014, and 35.30% (95% CI 22.61–49.14%) for the period between 2015 and 2024. When the data was stratified by gender, the pooled prevalence estimates were found to be (26.68%; 95% CI 15.63–39.41%) in the female group and 27.82% (95% CI 14.13–43.98%) in the male group. Regarding the geographical distribution, the pooled prevalence estimates were found to be 25.38% (95% CI 18.07–33.46%) in the Khyber Pakhtunkhwa province, 30.26% (95% CI 11.87–52.74%) in Sindh, and 34.03 (95% CI 21.33–48.02%) in the Punjab.

The meta-regression analysis indicated that there was no significant association in the prevalence estimations based on the year of publication (slope = 0.0052; 95% CI −0.0165–0.0270; p-value = 0.6392), baseline survey year (slope = 0.0053; 95% CI −0.0328–0.0222; p-value = 0.7065), average age (slope = 0.0056, 95% CI −0.0072–0.0185; p-value = 0.3900), and methodological quality (slope = −0.0006, 95% CI −0.0250–00.0238; p-value = 0.9640).

NAFLD prevalence in individuals with metabolic disorders

The prevalence of NAFLD in individuals with diabetes was assessed in 23 studies, encompassing a total of 4534 patients. The NAFLD prevalence in patients with diabetes ranged from 40.84% (95% CI 34.83–47.06%) to 78.74% (95% CI 70.60–85.50%). The pooled NAFLD prevalence in the individuals with diabetes was 58.47% (95% CI 54.23–62.64%; prediction interval: 38.17–77.40%) with significant heterogeneity (I 2  = 88.0%, p < 0.01) Fig. 4 . Egger linear regression test (t = 0.98, p-value = 0.34), Begg-Mazumdar (0.50, p-value = 0.58) and the visual evaluation of the funnel plot collectively Fig. 5 indicate the absence of publication bias in the conducted meta-analysis. The findings of the sensitivity analysis demonstrated that the pooled NAFLD prevalence ranged from 57.54% (95% CI 52.84–62.16%) to 59.32% (95% CI 55.24–63.34%) when each study was systematically excluded. The sensitivity analysis findings indicate that the inclusion or exclusion of any individual study did not have a significant impact on the overall effect seen in our meta-analysis (see Supplementary file S2 ). This suggests that our meta-analysis is statistically robust and stable. Furthermore, the NAFLD prevalence in obese people was 74.08% (95% CI 60.50–85.70%; prediction interval: 12.73–100.00%) while the NAFLD prevalence in hypertensive patients was (47.43; 95% CI 30.49–64.66; prediction interval: 1.20–97.20%).

Forest plot the prevalence of the NAFLD in patients with diabetes in Pakistan.

Funnel plot of the prevalence of NAFLD in diabetes patients.

According to subgroup meta-analysis, the prevalence of NAFLD among patients with diabetes was found to be 56.54% (95% CI 48.08–64.82%) between 2008 and 2018, and 59.74% (95% CI 55.23–64.17%) between 2019 and 2024. When looking at gender differences, the prevalence was 63.17% (95% CI 49.98–75.45%) among females and 53.90% (95% CI 47.39–60.36%) among males. Geographically, the prevalence varied with 54.80% (95% CI 50.10–60.83%) in Khyber Pakhtunkhwa, 55.30% (95% CI 46.73–63.72%) in Baluchistan, 59.97% (95% CI 53.51–66.27%) in Punjab, and 60.20% (95% CI:53.51–66.27%) in Sindh.

The meta-regression analysis indicated that there was no significant association in the prevalence estimations based on the year of publication (slope = 0.0035; 95% CI −0.0089–0.0159; p-value = 0.5810), baseline survey year (slope = 0.0008; 95% CI 0.0036–0.0053; p-value = 0.7169), average age (slope = 0.0026, 95% CI 0.0060–0.0113; p-value = 0.5494), and methodological quality (slope = 0.0676, 95% CI −0.0375–0.1728; p-value = 0.2075).

NAFLD is an increasingly important cause of morbidity, disability, and mortality worldwide. Addressing the root cause of NAFLD is imperative to alleviate the burden of diseases associated with excessive caloric intake and metabolic dysfunction from a societal perspective 7 , 8 . The rise in obesity and its associated comorbidities, such as NAFLD, in Pakistan can be attributed to significant shifts in the lifestyle patterns of the Pakistani population. The primary objective of this research was to collect information about the prevalence of NAFLD and the risk factors that are associated with NAFLD in Pakistan. This meta-analysis is expected to contribute to the mitigation of NAFLD and its associated problems by providing valuable information that can support public health initiatives. The pooled NAFLD prevalence in general (low risk) population was 29.82%, which is comparable with the similar meta-analysis conducted on South Asia 60 (26.9%) and global level 61 (30.01%). The prevalence of NAFLD in patients with metabolic disease (high-risk population) is significantly higher than the general population. The NAFLD pooled prevalence in patients with diabetes was found to be 61.22%. The results are in line with the recent meta-analysis 60 (59.69%) and the neighboring country India 62 (57%). The pooled prevalence of NAFLD in patients with diabetes higher than the recent meta-analysis on South Asian (54.1%) 60 .

The data stratification revealed interesting patterns. The prevalence of NAFLD appeared to increase over time, with estimates of 23.83% for the period between 2008 and 2014, and 35.30% for the period between 2015 and 2024. This increasing trend might reflect changes in lifestyle factors, diagnostic criteria, or increased awareness of NAFLD over the years. Furthermore, there were also notable disparities in gender and geographic factors. The prevalence estimates obtained from pooling the data were slightly higher in males (27.82%) than in females (26.68%). Geographically, there were noticeable differences in prevalence rates among different provinces. The highest prevalence was seen in Punjab (34.03%), followed by Sindh (30.27%) and Khyber Pakhtunkhwa (25.38%).

The subgroup analyses revealed that the prevalence of NAFLD in patients with metabolic disease was highest in obese population 74.08% (95% CI 60.50–85.70%), followed by patients with diabetes 58.47% (95% CI 54.23–62.64%) and hypertension patients 47.43% (95% CI 30.49–64.66%). The patients with diabetes are twice as likely to get fatty liver as compared to the general Pakistani population. This is because elevated glucose levels in individuals with diabetes or prediabetes contribute to an increased availability of substrates for triglyceride synthesis 58 . Furthermore, the diminished secretion of very low-density lipoprotein, a condition often associated with insulin resistance, exacerbates the buildup of fat in the liver 63 .

There are several limitations to our meta-analyses that should be considered when interpreting the findings. Firstly, the meta-analytical component of this investigation was constrained by substantial heterogeneity observed among the studies, which could not be investigated or elucidated through subgroup analysis or meta-regression. However, this is a recognized characteristic of meta-analyses concerning prevalence rates 64 . Secondly, most of the studies did not have a nationally representative sample, as they were based in a single center. As such, larger studies across multiple centers are needed to investigate true prevalence. The low number of included studies set in the low and high-risk populations is also a limitation of this study as we were unable to use multivariable meta-regression models to check the significance of risk factors combined. In addition, it is important to note that our analysis solely relied on published reports, so excluding the potential insights that could have been derived from the unpublished grey literature. This omission may have implications for the overall findings and conclusions of our study. Nevertheless, despite these limitations, this is the first meta-analysis to provide pooled prevalence of NAFLD in Pakistan. Prior to commencing the study, we published a protocol delineating our technique and methodology, and we utilized scientific and statistical methodologies to gather and aggregate data. We conducted subgroup studies and random effect meta-regression analyses to assess several factors that could influence our estimate.

The prevalence of NAFLD in Pakistan from 2008 to 2024 is thoroughly described in this study. This study suggests that while the pooled NAFLD prevalence in the general population was 29.02%, the prevalence among patients with diabetes is almost double, at 58.70%. With the rising prevalence of NAFLD in Pakistan, the government should implement diabetes management initiatives nationwide. The Pakistani government should develop a comprehensive plan and strategy to enhance knowledge about fatty liver, as well as to improve its control, prevention, and treatment, thereby reducing the prevalence of the disease in the country.

Data availability

All data are included in this manuscript and presented in Table 1 .

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Conceptualization: S.A. and F.H., Investigation: S.A., F.H. and K.A.K., Methodology: M.A. and S.A, Writing—original draft: F.H., M.F., K.A.K., M.A., Writing and editing: S.A. All authors reviewed the manuscript.

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• Published: 18 August 2024

Entrustable professional activities for bedside clinical teachers

• Ayesha Rafiq 1 &
• Ahsan Sethi 2  

BMC Medical Education volume  24 , Article number:  887 ( 2024 ) Cite this article

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Bedside teaching is an important modality for training medical students and postgraduate trainees in clinical settings. Despite its significance, the effective practice of Bedside teaching has been declining over the past few decades. The literature highlighted the need for structured training, assessment, and certification or in other words entrustment of bedside teachers. The current study aims to develop and validate the Entrustable Professional Activities (EPAs) for bedside clinical teachers.

A multi-method study with clinical teachers, medical educationists, and postgraduate medical students was conducted from July 2021-22. First, a nominal group using the jigsaw puzzle technique was conducted with 16 participants to identify EPAs. Then these EPAs were mapped and validated by the skills/competencies identified in the literature. Next, the EPAs were evaluated using the EQual rubric by 3 medical educationists. This was followed by two-rounds of modified Delphi to develop consensus among 90 participants in round-one and 69 in round-two. For qualitative data, a thematic analysis was conducted. For quantitative data, means and standard deviations were calculated.

The study identified five EPAs for bedside clinical teachers: developing bedside teaching program, planning bedside teaching session, conducting bedside teaching, conducting bedside assessments and evaluating bedside teaching.

Conclusions

This study comprehensively developed and validated a full description of EPAs for bedside clinical teachers. The EPAs identified in the study can serve as a guiding framework for bedside clinical teachers’ training, assessment, and entrustment.

Peer Review reports

Bedside teaching (BST) is one of the most important aspects of undergraduate and postgraduate medical education [ 1 ] It allows learners to develop effective history-taking, physical examinations, clinical reasoning, communication and problem-solving skills in real life clinical settings [ 2 ] BST also helps in learning professionalism and medical ethics. Despite its significance, the effective practice of BST has been declining over the past few decades [ 1 ]. Several reasons have been cited for its decline such as a lack of resources and incentives by hospitals, patients’ discomfort and their unavailability during rounds, increased advancements in technology, increased workload of clinicians, and most importantly their lack of training for BST [ 3 ]. Many clinical teachers learn to teach BST through observation and experimentation and remain ignorant of the educational theories, andragogical principles, and teaching methods [ 1 , 3 , 4 ].

Over the last few decades, there have been expectations from clinical teachers to develop certain educational competencies for effective clinical teaching. In this regard, various educational competency frameworks, guidelines, and training programs have been introduced globally. Literature described several competency frameworks for faculty members such as those proposed by Hesketh et al., [ 5 ] Tigelaar et al., [ 6 ] Molenaar et al., [ 7 ] Milner et al., [ 8 ] Hatem et al., [ 9 ] Srinivasan et al., [ 10 ] Ross et al., [ 11 ] Daouk-Oyry et al., [ 12 ] and Walsh et al. [ 13 ]. However, these frameworks do not guide the teachers on implementing them in their context. Several guidelines for providing effective clinical supervision such as Recognizing and approving trainers by General Medical Council (UK) [ 14 ]; the American Psychological Association’s Guidelines for Clinical Supervision of Health Service Psychologists [ 15 ]; the New Zealand Psychologists Board Guidelines on Supervision [ 16 ]; and the Psychology Board of Australia Guidelines for Supervisors and Supervision Training Providers [ 17 ] are also available. There is also a clinician educator milestone project for the assessment of the educational skills of teaching faculty, which is a joint effort of the Accreditation Council for Graduate Medical Education, the Accreditation Council for Continuing Medical Education, the Association of American Medical Colleges, and the American Association of Colleges of Osteopathic Medicine [ 18 ]. In Pakistan, the College of Physicians and Surgeons [ 19 ] conducts four training workshops which are mandatory to become a clinical supervisor. Unfortunately, these frameworks or trainings for clinical supervisors neither guarantee the transfer of training to the workplace nor ensure the maintenance of competence. Except for some developed countries such as USA, UK, and Canada [ 20 ], the educational competencies of clinical supervisors are not formally assessed in many countries.

Medical students and trainees have reported dissatisfaction with clinical teachers’ competence to understand the level of learners, observe patient-trainee encounters, provide a safe learning environment, demonstrate clinical tasks consistently, deliver constructive feedback, and encourage reflections [ 21 , 22 , 23 ] They reported experiencing opportunistic learning, which varies from one preceptor to another [ 24 ] This necessitates attention towards the selection, training, and preparation of clinical teachers for effective supervision of students [ 25 , 26 ]. To develop, maintain, and bring continuous improvements in teaching competence, there is a need for structured training, assessments, and periodic certification of Bedside Clinical Teachers [ 25 ] or in other words Entrustment of Bedside Clinical Teachers.

Entrustable Professional Activities (EPAs) are defined as a set of professional tasks that can be fully entrusted to a learner to perform independently once they have attained the required specific competencies [ 27 ]. EPAs were first introduced in 2005 for graduate medical students [ 27 ]. Later, the use of EPAs has been increasingly taken up by various health professions with the intent to improve patient safety in the workplace [ 28 ]. EPAs embrace the concept of Competency-Based Medical Education (CBME) which in turn emphasizes the attainment and demonstration of required competencies that are crucial for job performance [ 29 ]. EPAs ground competencies in daily clinical practice & make them assessable. EPAs lay more emphasis on outcome-based, learner-centered, and skills-oriented flexible education, while less on time-barred training, which distinguishes it from the traditional training approaches [ 30 ]. Development of EPAs for BST can help inform faculty training in this important modality for training medical students. These can also be used for training of residents to reduce the burden of clinical teachers [ 31 ] The use of EPAs will also enhance the confidence, insight, and motivation of clinical teachers, while reducing the discomfort of patients and medical students in the process [ 25 , 26 ]. Dewey et al., [ 25 ] proposed the use of EPAs for teaching faculty as well. Iqbal et al., [ 32 ] also emphasized on expanding EPAs for faculty training on specific teaching domains such as bedside teaching, mentoring, small group discussions, etc. In the literature, we could only find one study that developed an EPA for BST [ 33 ]. They used a focus group discussion and open-ended questionnaires via e-mail to collect participants’ perspectives on BST definitions and its essential features to develop an EPA for BST. However, their participants did not involve medical educationists who are the stakeholders in designing, implementing, and evaluating BST. Also, they did not use an EPA evaluation tool such as EQual rubric [ 34 ] for quality or ensured a national consensus or validation [ 35 ] of the final set of EPAs. The current study aims to develop and validate Entrustable Professional Activities (EPAs) for bedside clinical teachers through a rigorous multimethod approach.

Multimethod study design. Abbreviations: JPT, Jigsaw puzzle technique; NGT, Nominal group technique

A multi-method study was conducted in Pakistan from July 2021 - July 2022 (Fig.  1 ). Ethical approval was obtained from the Ethical Review Board of Medical Teaching Institution Abbottabad (Approval Code/Ref.No.RC-2022/EA-01/143 dated 24.05.2021). As an EPA expert has not been precisely defined in the literature, therefore we invited clinical teachers, medical educationists, and postgraduate medical students involved with BST for the study. Participants were selected through purposive maximum variation sampling. The inclusion criteria were set as clinical teachers with a relevant qualification of Member of College of Physicians and Surgeons (MCPS)/ Fellow of College of Physicians and Surgeons (FCPS), a minimum of three years’ field experience, and a designation of Assistant Professor or above. For medical educationists, a relevant qualification of Master in Health Professions Education (MHPE)/ PhD in Health Professions Education, a minimum of three years of experience, and a designation of Assistant Professor or above. Postgraduate students of any age, gender, specialty, and having willingness to participate in the study, were included. The participants were invited through a seminar and email including an information sheet and consent form.

In phase 1, we identified EPAs for BST. We invited 16 participants at Ayub Medical and Teaching Institution Abbottabad, which is a 1460-bedded tertiary care teaching hospital in Pakistan, and currently caters to around 1482 medical students and 546 postgraduate residents in different disciplines of Medicine, Surgery, and Dentistry. Participants were given orientation on study objectives. As the EPA concept was relatively novel to most of them, a detailed presentation encompassing substantial information on EPAs was given by the authors to ensure a common understanding among the participants. The first set of EPAs was developed using the Nominal Group Technique (NGT). In NGT, the experts are involved in independent activities and group interactions for quality ideas (in this research EPAs) generation and consensus development [ 36 ]. As part of NGT, a jigsaw puzzle technique [ 37 ] was used to generate EPAs’ description i.e., title; specifications and limitations; potential risks in case of failure; required competencies; required knowledge, skills, attitudes, and experience; resources for assessment; level of supervision and expiry period [ 38 ]. Jigsaw puzzle technique helped to develop a comprehensive description of all the EPAs through collaborative ideas of all participants in one session. Participants were grouped into four jigsaw groups, where each member of the group was tasked to develop the assigned aspect of EPAs description for all the EPAs. Members (from each jigsaw group) with the same assigned task were then regrouped as expert groups to discuss and compare their ideas with others. Next participants were returned to their original jigsaw groups, where they revised their descriptions to develop a full set of descriptions for all EPAs. Lastly, each group presented their sets of descriptions to other groups for discussion and clarification resulting in the final set of EPAs with descriptions.

The EPAs developed in phase 1 were then validated with the literature review [ 39 ]. A search was made with keywords (EPAs, bedside teaching, and clinical teachers) and by using their synonyms and various combinations in Medline, Embase, Cochrane, ERIC, ScienceDirect, and Google Scholar (Additional file 1 ). Inclusion criteria were set as full text, original articles, and systematic and scoping reviews in the English language with a focus on Medicine specialty. Search also involved controlled vocabulary and free text terms combined using Boolean operators ‘AND’ and ‘OR’.

In this phase, the EQual rubric was used to evaluate the structure and content of EPAs because it reliably measures the alignment of the key domains of EPAs with literature defined standards. It consists of 14 questions which are classified under three sub-scales: EPAs as discrete units of work; EPAs as entrustable, essential, and important tasks of the profession; and EPAs’ curricular role [ 34 ]. An online survey was created using QuestionPro ® (Survey Analytics LLC, Beaverton, Oregon, USA) based on 14 items of the EQual rubric along with three additional questions regarding EPAs improvement (Additional file 2 ). An orientation video on the EQual rubric was also inserted into the first page of the survey for participants’ guidance [ 40 ]. A modified Angoff approach was used for the determination of a cut-off score of 3.95 for EPAs adequacy. Three expert medical educationists with qualifications and experience in clinical teaching and medical education reviewed each EPA using the rubric.

Data was analyzed using means, standard deviations, and level of agreement for each EPA. Free text comments were summarized as standalone qualitative data [ 41 ]. Changes were made when suggested by at least two experts for items with mean scores below 3.95.

This phase used a modified Delphi technique to seek national consensus on EPAs identified in the earlier phases [ 42 ]. Participants of this phase included clinical teachers and postgraduate students from multiple specialties as well as medical educationists. By using purposive maximum variation sampling, participants across Pakistan with known contacts were sent invitations through emails for participation. To increase the sample size, we also employed snowball sampling which is a non-probability sampling method and involves asking initially willing participants to suggest other diverse and information-rich participants with similar characteristics from among their acquaintances. Participants’ number reached 90, which is considered appropriate in Delphi studies involving diverse groups [ 41 ].

A piloted and electronically developed questionnaire via QuestionPro was distributed to participants in two rounds. Participants were provided with AMEE Guide No.140 on recommended description of an EPA, to use as a reference guide [ 38 ]. Participants’ agreement was asked on a 5-point Likert scale from strongly agree to strongly disagree. Round-one survey’s first part was about participants’ demographics and the second part had two sections, A and B. Section A consisted of seven questions repeated for each EPA. The first six questions were about participants’ agreement on the provided title; specifications; limitations; potential risks in case of failure; competencies; and knowledge, skills, and attitude, while the seventh question asked for suggestions for improvements. Section B had four questions. The first two questions asked for participants’ agreement on the provided EPA level and required resources of entrustment. The last two questions asked for participants’ comments on the expiry period and suggestions on the overall EPAs’ description (Additional file 3 ). Round-two survey had ten questions for EPAs’ descriptions, which received below 80% agreement or had major revisions based on round-one (Additional file 4 ).

Data were analyzed using means, standard deviations, and level of agreements. The consensus was set as ≥ 80% agreement for a minimum score of 4 out of 5 on a 5-point Likert scale. Suggestions were incorporated when recommended by at least two participants and after thorough review and discussions amongst the authors.

Initial 16 EPAs were refined through different phases into 5 EPAs. Demographic details of participants who were clinical teachers, medical educationists, and postgraduate medical students are given in Table  1 . Participants belonged to a diverse range of specialties and from different cities grouped into four provinces of Pakistan.

The participants included 10 (62.5%) males and 6 (37.5%) females (Table  1 ). This phase resulted in a set of 16 EPAs and their descriptions (Table  2 ). However, a definitive consensus could not be obtained for the expiry period of EPAs, so it was included for comments in the round-one Delphi survey.

Five new EPAs i.e., EPAs 7, 12, 17, 20, and 21 were added via literature review through selected databases resulting in 21 EPAs (Table  2 ).

Of 21 EPAs, 11 made below the 3.95 cut-off score and were nested with other EPAs as suggested by the participants resulting in 10 EPAs (Table  2 ).

Phase 4 - Delphi

Of 144 invitees, 90 agreed to participate in the study. The response rate to round-one was 85.5%(77/90 responses). Four EPAs scored ≥ 80% agreements, while titles of six EPAs scored < 80% agreements. Modifications were also made to those EPAs’ descriptions that had already scored ≥ 80% agreement if suggested by at least two participants or with consensus among researchers reviewing the comments. Guided by participants’ feedback, EPAs 2, 6, and 10 were nested under the recommended title as “developing BST program”; EPAs 1 and 5 as “planning BST”, EPAs 3, 4, and 9 as “conducting BST”; EPA 8 was retained as “conducting BST assessments” and EPA 7 as “evaluating BST” resulting into five EPAs (Table  2 ). Levels of entrustment for all EPAs had scored > 80% agreement, so, it was not repeated in round-two. Regarding required resources for entrustment, “minutes of meeting” failed to achieve ≥ 80% agreement and was eliminated from the list (Summary of results of round-one of a modified delphi study is available as Additional file 5 ).

Round-two was completed by 69 participants. Eight participants could not fill in the survey because of other commitments. The response rate for round-two was 89.6% (69/77 responses). In this round, all five EPAs, and their descriptions scored ≥ 80% agreement (Summary of the results of round-two of a modified Delphi study is available as Additional file 5 and 6 ) (Insert Table  2 here provided as a separate file of Tables  1 and 2 ).

Five EPAs were developed through four phases of a multimethod approach for bedside teachers of both undergraduate and postgraduate students (Additional file 6 ). The primary set of 16 EPAs was gradually refined through these phases under the guidance of the participants’ feedback to a final set of five EPAs. Some EPAs were nested with others as sub-activities which is consistent with the literature, advocating EPAs to be broader in design that provide less detailed guidance to the trainee on their expected work [ 43 ].

Resulting EPAs are developing BST program, planning BST session, conducting BST, conducting bedside assessments, and evaluating BST. Each of these EPAs encompasses a full set of descriptions and requires standalone entrustment because a bedside teacher can attain certification for developing BST sessions, but is not yet able to plan or conduct BST.

First EPA ensured an organized and well-defined set of tasks for bedside teachers. It was related to planning and developing a complete BST program that encompassed the development of BST curriculum, study guides, assessment policies, written ethical guidelines, feedback, and evaluation forms in collaboration with all stakeholders. It also included a suggestion from a participant of round-two Delphi to use an evidence-based approach while designing the BST curriculum as supported by literature studies [ 44 , 45 , 46 , 47 , 48 ] Second EPA was planning individual BST sessions for ensuring timely and smooth information delivery to students. It included lesson planning, pre-briefing the patients, and orienting the students before BST [ 33 , 49 , 50 ] Participants endorsed this EPA in avoiding untoward situations between doctors and patients or their attendants. Third EPA incorporated steps for BST conduction based on principles of evidence-based teaching and this was in line with previous studies [ 51 , 52 , 53 ] Fourth EPA is the ability of bedside teachers to design and conduct standardized assessments using multiple workplace-based assessment tools [ 54 , 55 ]. This is important because carefully designed assessments lead to professional competence in medical students. The last EPA encompassed tasks related to the evaluation of BST sessions and program, vital for any ongoing dynamic process. This EPA will serve to bring improvements in the overall EPAs structure by identifying BST tasks not yet recognizable in this study. Nearly all study participants deemed these EPAs important, but they also pointed out that these tasks might not be practical in terms of bigger workload of clinical faculty.

Only one study in the literature developed EPA for BST [ 33 ]. However that study did not involve diverse stakeholders including medical educationaists and only used focus group discussion and survey for developing BST definitions and features. On the other hand, the current study involved medical educationists involved in professional development, clinical teachers and postgraduate students and used a four-phased multimethod approach for EPAs development and validation [ 56 ]. Moreover, this study also focused on the development of a full set of descriptions of individual EPAs [ 38 ] to provide explicit details for bedside teachers training programs. Also, Participants chose competency domains required for each EPA from the teaching competency framework for the medical educators proposed by Srinivasan et al., [ 10 ] We have used this framework because it included six core competencies, based on the ACGME competencies framework: medical knowledge; learner-centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice and four specialized competencies: program design/implementation, evaluation/scholarship, leadership, and mentorship. These competencies were also cross-referenced with educator roles, from CanMEDS, to ascertain role-specific skills [ 10 ].

For summative entrustment, bedside teachers need to be evaluated by experts using multiple assessment methods at various stages of their training and professional development. Assessment methods which are also supported by other studies include direct observation [ 57 ] 360◦ feedback [ 58 ] reflective portfolio [ 59 ] Objective Structured Teaching Examinations [ 60 ] etc. This study used three instead of the original five entrustment levels as proposed for small group facilitators [ 61 ]. Levels of indirect supervision and entrusted to supervise others had not been used as indirect supervision may not be instantly available to teachers during an ongoing session, and without additional courses, a teacher is not competent enough to train other teachers [ 61 ]. It is our opinion that an EPA may expire if bedside teachers do not undergo appraisals for three consecutive years. This is because, unlike clinical skills, teaching skills may not immediately decay over time but would need re-entrustment after the expiry.

Implications

These EPAs can empower bedside teachers for capacity building by recognizing gaps in their BST practice and accordingly improving them. This would also benefit students, patients, program developers, and medical institutions. As recommended for EPA-based programs [ 38 ] this study also entailed that experienced teachers should train, and assess beginner levels and give appraisals to them for their performance. Teachers can then be awarded certification for independent BST after attaining the required entrustment level. As suggested, a ‘statement of awarded responsibility’ (STAR) can be given to a teacher achieving adequate expertise in an EPA [ 25 ] to signify that a certain task has now been entrusted to the awarded teacher to be performed proficiently. Entrusted teachers can be given reasonable points for the attained STARs to be used for recruitment and promotion [ 62 ] These EPAs can also be adopted as structured faculty development or continuing professional development programs to operationalize BST training at the workplace [ 63 ].

The strength of this study was that to our knowledge, it is the first study that used a multimethod approach to develop and validate a full set of descriptions of EPAs for bedside teachers in collaboration with clinical teachers, medical educationists, and postgraduate students to maximally accommodate their requirements and perspectives. This study design can serve as a guide for other researchers to develop EPAs in other fields.

This study also had some limitations. The study was confined to the context of Pakistan where EPAs’ concept is relatively novel and the majority of the participants had minimal prior experience of EPAs development. However, we tried to cope with this limitation, by providing substantial information on EPAs to the participants before each phase and throughout the study whenever required. Participants were mainly selected for their experience with BST. However, there is still a possibility of lacking one or more items in EPAs description relevant to work of bedside teachers, necessitating these EPAs to be field tested, revisited, and modified if required. Regarding the limitation section in EPAs description, the majority of participants of round-one Delphi misunderstood it as barriers of BST, therefore, their comments were not included. Although this was clarified to them again in round-two, however, some participants commented that limitations can be better identified once EPAs are executed. This study only focused on BST, therefore, its findings would be difficult to generalize to other teaching settings.

This study comprehensively developed and validated a full description of EPAs for bedside clinical teachers. The EPAs identified in the study can serve as a guiding framework for the training, assessment, and entrustment of bedside clinical teachers. Future research should explore the long-term impact of implementing EPAs on bedside clinical teachers’ performance, student outcomes, and overall patient safety.

Data availability

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

Abbreviations

The International Association for Medical Education

Bedside Teaching

Competency Based Medical Education

• Entrustable Professional Activities

Education Resources Information Center

Fellow Of College of Physicians and Surgeons

Jigsaw Puzzle Technique

Member Of College of Physicians and Surgeons

Masters In Health Professions Education

Nominal Group Technique

Doctor Of Philosophy

Statement of Awarded Responsibility

United Kingdom

United States of America

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Acknowledgements

The authors would like to thank all the participants for their active contribution to this research project. We would also like to thank Dr. Najia Sajjad Khan and Dr. Anam Rafiq for their valuable feedback and support throughout the project. The study was conducted as part of First author’s MHPE dissertation under the supervision of Dr Ahsan Sethi.

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Rafiq, A., Sethi, A. Entrustable professional activities for bedside clinical teachers. BMC Med Educ 24 , 887 (2024). https://doi.org/10.1186/s12909-024-05876-3

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• Balazs C. Lengyel 1 , 2 ,
• Ponraj Chinnadurai 1 ,
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• Alan B. Lumsden 1 &
• Charudatta S. Bavare 1  

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179–2186, 2005; Patel in Lancet 388:2366–2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8–93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158–161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479–488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on “vascular” applications of the robotic system, evolving training pathways and future perspectives.

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Introduction

The robotic-assisted laparoscopic approach has transformed many surgical subspecialties; however, it has yet to gain momentum and play a central role in vascular surgery [ 1 , 2 , 3 , 4 ]. Other surgical specialties such as thoracic surgery, general surgery, and urology have embraced robotic technology into clinical routine and now providing minimally invasive surgical options to patients while mastering the vascular skill sets imperative for these procedures. In the meantime, endovascular surgery has revolutionized the field of vascular surgery, delivering the promise of minimally invasive therapeutic options to our patients. However, one could argue that the durability of open surgical vascular reconstruction and repair has been compromised, in this pursuit of percutaneous endovascular technologies, as evidenced by the re-intervention rates for endovascular procedures [ 5 , 6 , 7 ]. The lack of early adoption of surgical robotics could be potentially due to the lack of surgical laparoscopic skills/training among vascular specialists, fear and risk of uncontrolled bleeding, and the inherent difficulties of creating laparoscopic vascular anastomosis.

A surgical procedure can be broadly divided into two parts: firstly, the core therapeutic part (i.e., the only portion which the patient benefits from) and secondly, the delivery system—the part that provides access/conduit to deliver the intended core therapeutic option. For example, to sew in a piece of Dacron into the aorta—as initially described by Dr. DeBakey—is easily the most durable repair described for aortic aneurysmal disease [ 8 ]. However, the delivery system—either a laparotomy thoracotomy or thoracoabdominal incision is very unappealing to most patients and associated with higher perioperative complication rates than endovascular alternatives [ 9 ]. Endovascular aortic repair has a very appealing delivery system namely a small incision or puncture site, however, the core therapeutic part of stent graft placement is fraught with long-term problems and is nowhere near the durability of the Dacron-based vascular reconstruction for abdominal aneurysmal disease [ 8 , 9 ]. These endovascular procedures also became an early target for steerable, robotic catheter technology; however, its routine adoption has been limited and also redirected recently toward image-guided, robotic endobronchial interventions, where it is transforming diagnosis and therapeutic care for patients with malignant lung nodules [ 10 , 11 , 12 ].

The concept that the robotic approach is an equivalent of an open operation delivered with a minimally invasive technique, due to the dynamic wristed instruments, which are essentially mimicking the hand movements of a surgeon, inside the body, makes it dramatically different from the traditional laparoscopic approach. An intriguing question is whether robotic surgery introduced in the vascular surgery world could retain the core therapeutic components that have been validated for decades while at the same time making the delivery of such repairs more acceptable and tolerable to patients. It is this intriguing concept that stimulated us to evaluate the role of robotics.

The outline of this review article is as follows: a brief history of robotic-assisted vascular surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on vascular applications of the robotic system, evolving robotic training pathways of vascular surgeons and future perspectives of robotic vascular surgery with novel techniques/instrumentation.

Brief history of robotic surgical platforms

Early surgical robots were specialty focused, like the Robodoc, which was first developed in the late 1980s, for orthopedic surgery, or another urologic robot—developed for prostate surgery. Later advancements were propelled by the US military, which wanted to develop a telemedical unit that could provide surgical care in close proximity of the battlefield, operated by a surgeon in the safe zone. This led to the pioneering development of the Green Telepresence System, which consisted of a surgeon’s workstation and a remote surgical unit. This robot laid the basis for today’s surgical robotic appliances. Although it was first developed for open surgery, only after one of the developers, Colonel Satava, saw the presentation of Dr. Perrisat on one of the first videotaped laparoscopic cholecystectomy, the system was transitioned toward laparoscopic surgery. Interestingly, the first procedures that have been tested on robotic surgical systems were mostly vascular operations, such as running suture on bovine aorta, patch angioplasty, and PTFE graft anastomosis with the contribution of Jon Bowersox, a vascular surgeon from the Stanford Medical Center. They were all successful attempts, but were significantly slow, due to the lack of wristed instruments in early robots that were only introduced in the mid-1990s. Along with the above-mentioned efforts of the Stanford Research Institute and the Defense Advanced Research Projects Agency (DARPA), two private companies, Computer Motion and Intuitive Surgical, raced for the development of the ultimate surgical robotic system. Their competition ended with merging in 2003. Computer Motion’s Zeus system was discontinued for the sake of Intuitive Surgical’s more versatile robot, the da Vinci. The prototype of the da Vinci surgical system—called Lenny, was developed in 1995. It had to be attached to the surgical table and had fixed instrumentation. Later with the introduction of exchangeable instrumentation, Mona was developed, and was first used in human trials in 1997. It lacked a camera holding arm, so an assistant had to be present manipulating the camera on the instructions of the operating surgeon. Further improvements in visualization and the addition of a stand-alone cart—housing the patient-side components, were revealed one year later, forming the first surgical robot with the name da Vinci. After successful human trials, it received FDA approval in 2000 for general surgery indications in the USA [ 13 , 14 ]. Since then, the surgical robot has gone through significant upgrades and now represents state-of-the-art technology (Fig.  1 ).

Evolution of Intuitive Surgical’s da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA, USA)

Intuitive Surgical reported that by September 2023, more than 13 million procedures were performed on the da Vinci system. More than 8200 da Vinci robots are available worldwide. The industry is exponentially growing and mostly led by general surgeons, urologists, and gynecologists, while other specialists, including vascular surgeons, only take part in a small fraction of procedures performed [ 1 ]. However, many of these procedures include essential vascular techniques, most vascular surgeons are yet to receive training on the robot. It is not only problematic in terms of practicing vascular operations, but also when it comes to treating rare, life-threatening vascular complications using the same robotic platform.

Introduction to the da Vinci surgical robotic system

The most used laparoscopic robot, the da Vinci system can be subdivided into three subsystems, namely the surgeon console, the patient-side cart, and the vision cart. The surgeon who is performing the operation is physically disconnected from the patient, sitting in an ergonomic control unit, controlling a master–slave teleoperation architecture with an intermediary of a computerized control system. The patient-side manipulators are mounted on the transportable patient-side cart. The robot has four arms that work in the sterile field. Each of these can hold either an endoscopic camera or a surgical instrument. Since the input by the surgeon runs through a computer, it can filter out unwanted signals, such as the tremor of the surgeon’s hand, or it can scale motions to facilitate enhanced precision when it is required. But it could go both ways: the robot could inform the surgeon, based on visual or other imaging clues—aiding orientation, giving warning signs on critical steps, and ultimately enhancing patient safety. Certainly, it is the topic of the future, and innovation has limitless potential in this field [ 15 ].

Also contributing to better orientation, the state-of-the-art visualization system offers 3D vision by a stereo endoscopic camera that records in 4 K resolution [ 16 ].

Since the most widely available robotic systems do not support haptic feedback, one of the most important perceptions is lost. This forms huge limitations in vascular procedures, where tactile feedback is often paramount. However, in March 2024, Intuitive Surgical revealed the new, fifth-generation da Vinci robotic system, which will support haptic feedback, a long-awaited feature in robotic surgery. With this, tissue handling, and possibly suture handling, will improve. One of the hardships of today’s robotic instruments is that they can break monofilament sutures like Prolene (Ethicon, Raritan, NJ, USA) very easily, due to handling by the needle drivers, which is why most vascular robotic surgeons use PTFE sutures which are proven to be a bit more durable.

The biggest advantage of robotic surgery in contrast to laparoscopy is the utilization of wristed instruments that can be operated in an ergonomic and intuitive manner. These articulated instruments can allow up to seven degrees of freedom including grasping. These can essentially act as an extension of the surgeon`s arm, allowing a wide range of motion.

In the fourth-generation da Vinci system, visual clues help to overcome the lack of tactile feedback. As opposed to open vascular procedures, where one of the key techniques of locating blood vessels is palpation, on the robotic platform, localization mostly relies on visual clues. One of the existing imaging technologies that could help in the visualization of blood vessels is FireFly®—which is a near-infrared fluorescence imaging technology, where with the intravenous injection of indocyanine green, blood vessels can be highlighted [ 16 ].

The da Vinci Xi robot can be synchronized with the TRUMPF Medical TruSystem 7000dV operating table (TRUMPF Medezin Systeme, Saalfeld, Germany), which allows the surgical team to move the table without redocking the robot. The robot automatically adjusts the gantry and instruments to maintain position relative to the patient`s anatomy. This provides more efficiency and optimal exposure during multi-quadrant operations [ 16 ].

Currently, the most widely used robotic surgical system is represented by the da Vinci Xi robot, which was introduced in 2014. Compared to the previous model—the Si, it offers several advantages. It comes with an endoscopic camera that fits in an 8 mm port and supports 4 k resolution and 3D vision with magnification. A significant improvement over the previous generation is that the endoscope can be mounted on either of the robotic arms, which creates more freedom for port placement. If using the 30-degree optics, the surgeon can flip the camera 180 degrees with a simple touch of the touchscreen, without having the assistant do it manually. The touchscreen on the surgeon console can control the electrocautery and several other functions can be adjusted on the go. The patient-side cart’s top-mounted rotating boom enables multi-quadrant surgery without having to redock the robot. Laser guidance helps the faster docking process. The autotarget function optimizes the position of the robotic arms—which are significantly sleeker and can reach further, so they can move more freely without colliding. A synchronizeable table—as mentioned before, enables table movements during the operation without the need for redocking. All these advancements create a much more intuitive and user-friendly platform than laparoscopy. Along with the technical details, there is great emphasis on training, which in the case of the robotic system can be performed in computer simulation in a structured manner through Intuitive Surgical’s Learning platform.

Advantages and disadvantages of the robotic surgical platforms

The advantages of robot-assisted surgery include the capability of 3D visualization, seven degrees of freedom provided by the Endo-wrist technology, elimination of the fulcrum effect, and physiologic tremors. It also has the ability to scale motions and even to perform telesurgeries if needed. The system allows the surgeon to take up a more ergonomic posture than what traditional laparoscopy would require [ 17 , 18 ]. Although sitting in front of the surgeon console is considered more ergonomic, it has its challenges, like the possible development of upper body fatigue and neck pain; therefore, the correct use of the armrest and individual adjustment of the seating position is important [ 19 ].

One of the main drawbacks of the robotic approach is the lack of tactile or haptic feedback, which is present in laparoscopy. The system requires additionally trained staff to operate and a large enough space for the equipment [ 17 ]. Finally, its long-term outcome benefit is yet to be proven in vascular surgery. Today, only relatively small single-center studies and case series have been published.

A significant limitation of the widespread adoption of robotic surgery is its high cost. The price makes the equipment inaccessible to most hospitals, not to mention the high annual maintenance fees and additional cost of disposable instruments. Its use is generally limited to centers, although it’s sensible, considering the need for high expertise, which can be gained only through a high volume of cases. However, cost issues could be counterbalanced by reduced length of stay, lower morbidity, and better surgical outcomes as reported in urology and colorectal surgery compared to other techniques [ 20 , 21 ].

Besides the most widespread da Vinci robotic system, several other—possibly more cost-effective—robots are either under development or undergoing clinical trials to compete with the current generation. These could eventually create healthy competition in the market leading to lower costs and urging innovations [ 22 ].

In 2010, Stefanidis et al. highlighted the intuitive nature and steep learning curve of robotic procedures with their experiment involving 34 medical students with no prior laparoscopic or robotic experience. They performed suturing tasks using laparoscopy and the da Vinci robot on a live porcine model. Results showed faster suturing, higher assessment scores, and fewer errors per knot with the robot. Laparoscopic performance did not significantly improve over rounds, while robotic assistance led to significant improvement [ 23 ].

Challenges in the adoption of surgical robotic technology in vascular surgery

The da Vinci Surgical System is approved for cardiac, thoracic, urologic, gynecologic, otorhinolaryngologic, colorectal, and general surgical uses. Despite numerous robotic procedures involving core vascular surgical techniques, the vascular application is still considered off-label [ 3 ]. The question is why did most vascular surgeons neglect this technology?

Every surgical specialty aspires to find less invasive ways to treat patients. Vascular surgery is no exception. We use vasculature as a pathway to reach and fix the disease with wires, catheters, balloons, and stents. Endovascular techniques have evolved in such a way, that in many areas of vascular surgery, it became the primary choice of care [ 24 , 25 , 26 , 27 ]. Most notably in cases of aortic aneurysmal disease or aortoiliac occlusive disease (AIOD), endovascular techniques offer less perioperative mortality, shorter hospital stay, comparable long-term durability, and survival. Despite these important factors, endovascular procedures often come with an increased re-intervention rate, and the need for lifelong surveillance, not to mention the elevated costs [ 5 , 6 , 28 ].

Recent studies have pointed out that the better long-term durability and need for less invasive surveillance methods and decreased exposure to radiation because of frequent CTA scans may outweigh the higher perioperative morbidity of open abdominal aortic aneurysm repair, also providing a better quality of life [ 6 ].

Not every patient is fit for open repair, even so in the case of most of the typical population requiring vascular surgery. These patients often have multi-systemic disease, limiting their ability to endure the surgical stress of an open reconstruction, subsequently suffering from high perioperative morbidity and mortality. Besides the possibility of endovascular interventions, robotic reconstruction could be the third operative option to choose from.

The failure of the adoption of laparoscopy in vascular surgery

Although laparoscopic aortic surgery has been available for more than 20 years, only a handful of centers have adopted the technique. The main reasons for it include the lack of interest, focus on endovascular treatment options, required steep learning curve, and most notably the difficulties of creating a vascular anastomosis, subsequently longer clamping times, and prolonged operation times [ 3 ]. Vascular surgical laparoscopy is extremely difficult to master.

Apart from technical difficulties, the laparoscopic approach could retain most of its attributed benefits when used for vascular reconstructions. A comparative study between open abdominal aortic repair and total laparoscopic repair found that there was no significant difference in short-term morbidity and mortality, but with laparoscopy, the operative times were significantly longer, mainly due to a longer anastomosis creation time. Interestingly, more bleeding was observed in laparoscopic cases [ 29 ]. This could be accounted for by several problems, such as the lack of effective tamponade, the negative effect of suction on the pneumoperitoneum, and consequently the loss of visual control. Possibly, the most feared complication of laparoscopy is major vascular injury, which can lead to severe complications, even death of the patient. Perhaps the lack of safe vascular control, mostly derived from the lack of appropriate laparoscopic clamps, was one of the main aversive factors against laparoscopy for the vascular community. This issue is still present in robotic surgery, which is why the development of reliable dedicated robotic vascular instruments is essential for the ability to perform more arterial cases with the robot.

The laparoscopic technique was associated with benefits including shorter hospitalization, reduced need for pain medication, and reduced time of postoperative bowel dysfunction [ 29 ]. Long-term results of laparoscopic aortic reconstruction yielded comparably good results to open repair in terms of survival and need for re-intervention, but with the additional benefit of the lack of laparotomy-related complications [ 30 ].

Despite the above-mentioned results, originating from only a handful of centers worldwide, laparoscopy was not appealing enough for vascular surgeons to invest in, due to inherent technical difficulties and the lack of laparoscopic training in vascular surgical education.

Although the robotic approach is based on the fundamentals of laparoscopy, it is a dramatically different technique. The main difference lies in the wristed robotic instruments and intuitive controls that facilitate surgical manipulation, resulting in shorter learning curves, allowing for faster vascular anastomosis and consequently shorter clamping times [ 31 ].

Current vascular procedures performed with robotic assistance

The following section describes vascular procedures currently performed using the da Vinci system. In terms of procedural volumes, most of these are performed by non-vascular specialists, who have mastered essential vascular surgical skills with the use of the robot. We believe that there are many techniques to be learned from these specialties, to adopt this technology in the vascular field. (Table  1 ).

Robot-assisted infrarenal aortic and aortoiliac aneurysm repair

Performing aortic reconstruction requires the ability to control high-pressure arteries, often heavily calcified. Choosing the right place for clamping heavily relies on preoperative imaging, as haptic feedback is unavailable (except the latest-generation da Vinci robot), although there are some visual clues like the color of the vessel wall or how it reacts to movement and palpation with the instruments, which might help the decision. Clamping can be done either by inserting a laparoscopic clamp through an assist port or by inserting a DeBakey clamp through a small incision. Balloon occlusion of the iliac arteries can be performed as well. However, we have to point out that no specialty-focused vascular robotic instruments, like dedicated aortic robotic clamps, are available so far.

Identification and control of lumbar arteries before opening the aneurysm sac is another key element in the safety of these operations, as uncontrolled bleeding from these can cause major issues. Preoperative imaging and image fusion could play a major role in this topic. There is an extensive need for further research in this regard.

Despite these concerns, Stadler and Lin have published case series with successful surgeries and acceptable operation times, when compared to laparoscopy, with improved clamping times and tolerable bleeding [ 32 , 33 , 34 , 35 , 36 ]. The latest report from Dr. Stadler included 61 patients operated on for aortoiliac aneurysms. The median operation time was 253 min (range, 185–360), the median clamping time was 93 min, and the anastomosis time was 31 min. Conversion to laparotomy was required in eight cases (13%), and median blood loss was 1210 ml. The median hospital stay was 7 days [ 36 ]. Although reported numbers prove that robot-assisted reconstruction is feasible and can be performed with good results, most of the studies come from a few centers and a relatively small number of cases. Further studies are needed to assess the place of robotic surgery in this field as well as to prove whether it has comparable results to open reconstruction and endovascular approaches.

Aortoiliac occlusive disease (AIOD)

There is extensive literature on the results of robotic aortic reconstruction with the indication of AIOD, but mostly from a few centers [ 36 ]. Wisselink and colleagues were the first to publish a successful aortobifemoral bypass with robotic assistance in 2002 [ 37 ]. Later, in 2009 Martinez et al. published the first totally robotic aortobifemoral bypass surgery [ 38 ].

Stadler reported the largest number of cases. During a nine-year period, 224 patients underwent robot-assisted reconstruction with the indication of AIOD. The median operation time was 194 (range, 127–315) min with a median clamping time of 37 min, of which the median anastomosis time was 24 min. Median bleeding was estimated to be 320 ml and the median length of stay was 5 days. According to pooled data including patients operated on aneurysmal disease, perioperative complications rate was 3% and 30-day mortality 0.3% [ 36 ].

In a recent study, early and midterm outcomes of robotic aortoiliac reconstruction were published. Out of 70 cases, conversion was required in three cases, two of which were because of bleeding complications. Early complications occurred in 14 cases, with 10 needing reoperation. Mortality was 1.4% (one out of 70 patients). Primary patency at 12 and 48 months was reported to be 94% and 92%, respectively, while secondary patency was 100% and 98.1% [ 39 ]. Although the above-mentioned results suggest that the operation is feasible and safe, and provides appropriate mid-term durability, it did not reach widespread acceptance; only a few centers made attempts with the technique due to partly technical problems such as missing dedicated vascular instrumentation or legal issues [ 39 ].

Furthermore, such as in the case of aortic aneurysms, in the case of AIOD, endovascular procedures have become more and more practiced with relatively low complication rates and acceptable durability, limiting the attention to other minimally invasive alternatives [ 40 , 41 , 42 ].

Robot-assisted thoracofemoral bypass

Thoracofemoral bypass has better patency rates than axillofemoral bypass, but requires a patient who can tolerate thoracic exposure and clamping of the descending aorta. By using robotic assistance, the time taken for the anastomosis can be shortened. However, this procedure is rarely done, due to the narrow group of ideal patients, and to the advances in endovascular therapy [ 43 ].

Robotic treatment of type II endoleak after endovascular aortic repair (EVAR)

Type II endoleak after EVAR can be a challenging diagnosis. Guidelines recommend re-intervention in the presence of sac enlargement during follow-up [ 24 ]. Most treatment options consist of endovascular techniques, but when these fail, open reconstruction may be required.

In a recent meta-analysis, results of eight studies, comprising 196 patients undergoing semiconversion (open conversion with endograft preservation), were analyzed. In 70% the indication was isolated type II endoleak. In 45.8%, previous endovascular attempts were made to close the endoleak. Aortic clamping was not necessary in 92% of the cases, but the sac was opened in 96%, and ligation or suture of the culprit arteries was performed. 30-Day pooled mortality was a non-negligible 5.3% with major systemic complications in 13.4% of the cases. Recurrence of endoleak was seen in 12.6%. Overall survival rate was 84.6% [ 44 ]. EVAR is generally considered a less durable, but minimally invasive procedure than traditional open repair, and thus offered to more frail patients or because of the intent to avoid high surgical risk. Where the reason for EVAR is to avoid complications associated with open repair, an open reoperation is a contradictory choice. When endovascular options fail, less invasive treatment can be provided by robot-assisted techniques.

There are a few small case series with robot-assisted surgery published on this topic. In 2009, Lin et al. presented a case, with successful robot-assisted ligation of the inferior mesenteric artery, which was the source of a type II endoleak, causing sac enlargement in an 84 old male. The total operation time was 249 min, of which 180 min was the time of robotic assistance. The estimated blood loss was only 50 ml. The patient tolerated the procedure well and was discharged home without complications on the 2nd postoperative day. The 3-month follow-up CT scan confirmed the occlusion of the IMA and the stabilization of the aneurysm sac size [ 45 ].

In 2019, Morelli shared their experience with their first two patients who underwent total robotic type II endoleak repair. They reported promising results. The average length of surgeries was 183 min, and average hospitalization was 2.5 days. The operation consisted of two phases: firstly, the ligation of the IMA and then the posterior mobilization of the aneurysm sac to make the selective clipping of lumbar arteries. Preoperative CTA imaging was used for the identification of feeding vessels in these cases. After target ligation was complete verification of the absence of backflow was carried out with a dedicated US probe, inserted through one of the assistant ports [ 46 ].

The above-mentioned literature shows that robot-assisted type II endoleak repair is feasible and safe, but more studies are required to evaluate its potential among other approaches. One of the biggest challenges lies in identifying the correct feeding vessels on preoperative imaging and translating this finding to the robotic platform. Creating an imaging-based navigation system, possibly with the help of augmented reality, could be an answer. Studies on how existing imaging can help intraoperative navigation and orientation are warranted.

Another challenge is finding an efficient method to expose both the left- and right-sided lumbar arteries, or the medial sacral artery, which often presents as a cause of endoleaks. The modified transperitoneal approach described by Stadler et al. is adequate for exposing the left-sided side branches, but going under an often heavily calcified aorta to reach feeding branches on the other side is a risky maneuver, which can easily result in bleeding complications requiring conversion [ 47 ]. Exposing the aorta from the right side is unlikely the answer to this dilemma due to the closeness of the inferior vena cava and the need for redocking and repositioning of ports, which would make the operation significantly longer and more complex. A hybrid approach mixing robotic exposure with endovascular techniques might present a solution, but this area is still in an experimental phase and needs further studies in terms of feasibility and safety.

Robot-assisted splenic aneurysm repair

Splenic artery aneurysm is the most common type of visceral aneurysm, with a prevalence of around 0.8% in the general population. Generally, diameters exceeding 30 mm are to be treated especially in pregnant women (regardless of the size) and symptomatic cases. The first treatment of choice if feasible is an endovascular procedure, but open reconstructions also provide viable options. Laparoscopic or robotic procedures could be proposed if the patient is not a candidate for endovascular treatment and open surgery predicts poor prognosis [ 48 , 49 ].

Median arcuate ligament syndrome (MALS)

In median arcuate ligament syndrome compression of the celiac artery by the interweaving fibers of the two diaphragmatic pillars causes most typically postprandial epigastric abdominal pain, but can also be an incidentally found radiologic sign, often asymptomatic. Prevalence is 2/100,000 patients and it is more common in women, mainly affecting younger patients. Exclusion of other possible causes of abdominal discomfort is usually part of the evaluation [ 50 ]. Traditionally, the solution was carried out via open surgery, then laparoscopy emerged, offering a minimally invasive alternative. However, operating in tight spaces, the need for thorough clearance of the celiac plexus, controlling bleeding, or even performing vascular anastomosis made these surgeries challenging.

A few studies have presented small to medium amounts of cases of MALS release with robotic assistance. All reports show favorable outcomes and technical feasibility with minimal conversion rates and short in-hospital stays, providing good long-term results in terms of symptom relief and decrease of peak systolic velocity during ultrasound control. Re-interventions may be necessary in relatively small numbers [ 50 , 51 , 52 , 53 ].

In a recent case report, a patient who was not a candidate for open surgical reconstruction presented with pancreaticoduodenal and gastroduodenal artery aneurysm with celiac artery compressive occlusion. A three-step procedure was performed, where the robot-assisted release of the celiac artery was followed by stenting of the celiac artery and coil occlusion of the aneurysms [ 54 ].

Comparison of laparoscopic vs. robotic MAL release resulted in an equally effective decrease in measured PSV (peak systolic velocity) on duplex ultrasound postoperatively. Operative times were longer in the robotic group (mean of 86 min vs. 134 min). This could be attributed to the inherent mechanics of the robotic platform and the extended dissection performed in robotic cases. The latter could be associated with significant relief of postprandial symptoms and chronic nausea compared to laparoscopically operated patients. The authors also pointed out that robotic operations required significantly more junior first assistants and less frequently required second assistants, which can balance out the elevated costs of robotic equipment, while helping with the training of young residents [ 55 ] (Fig.  2 ).

A Intraoperative view of the median arcuate ligament (red arrow) causing a visible compression at the origin of the celiac artery. B 3D CTA reconstruction image of the same patient. The yellow arrow marks the compressed celiac artery

Left renal vein transposition for nutcracker syndrome

Renal nutcracker syndrome is a rare phenomenon characterized by the compression of the left renal vein, causing diverse symptoms, but most notably flank pain, hematuria, pelvic congestion syndrome in women, or left varicocele in men [ 56 ]. Consensus on the standard treatment of this phenomenon has not yet been reached. Several treatment options include open surgical or laparoscopic transposition of the left renal vein, kidney auto-transplantation, endovascular procedures, and recently robot-assisted techniques [ 57 ]. Several small case series were published, reporting favorable outcomes with low complication rates and good clinical outcomes in terms of symptom relief [ 57 , 58 , 59 ]. However renal auto-transplantation, even with robotic techniques is not a complication-free procedure and requires careful patient selection and high level of experience [ 56 ]. (Fig.  3 ).

Steps of a robotic renal vein transposition. A Rommel tourniquet on the supra- and infrarenal IVC, right renal vein, and laparoscopic bulldog clamp on the left renal vein and a lumbar vein. B Closing the defect of the IVC after the transection of the left renal vein. C Creation of the cavorenal anastomosis more distally. D Completed transposition of the left renal vein

Robot-assisted IVC filter removal

Whereas the FDA (US Food and Drug Administration) recommends IVC filter removal once the risk of embolization is gone, the retrieval rate is only around 25–30% in the USA [ 60 ]. Endovascular approach is considered the first choice when an IVC filter is to be removed; however, sometimes these attempts are unsuccessful or considered high risk because of possible extrusion of the filer. Robot-assisted surgery can be an alternative to an open approach, providing a minimally invasive solution. Few case series have been published on robot-assisted IVC filter removal, each of which presents good results, with high success rate, low number of postoperative complications, and short length of stay [ 59 , 61 , 62 ] (Fig.  4 ).

Robot-assisted IVC filter removal. In picture A and B protrusion of the filter’s struts can be appreciated on CT imaging, marked with a red arrow. C Intraoperative view of the infrarenal IVC with the protruding struts of the filter

Robot-assisted first rib resection

A case series of 83 patients undergoing robotic first rib resection with the indication of Paget–Schroetter syndrome was presented in 2018. The robot was used for the dissection of the first rib, disarticulation of the costosternal joint, and division of the scalene muscles. The operative time was 127 min (±20 min). Median hospitalization was 4 days, and no surgical or neurovascular complication was reported [ 63 ].

A systematic review comprising 12 studies of 379 patients with TOS suggested that the robotic technique is an effective method in the treatment of TOS. It offers improved exposure, reduced risk of neurovascular injury, and shorter hospitalization [ 64 ].

Robot-assisted nephrectomy and IVC thrombectomy

The gold standard technique of open radical nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma presenting with IVC thrombus is more and more challenged by a robot-assisted approach. Since the first published case series in 2011, a growing number of surgeons attempted to adopt the technique with a promise of an equally effective but less invasive approach [ 65 ]. While this procedure involves dissection and even opening of major vessels, it’s mainly performed by urologists, who have mastered specific vascular surgical skills with the robot. In 2022, a meta-analysis evaluating robotic IVC thrombectomies versus open surgeries concluded that the minimally invasive method is feasible, effective, and safe. It is associated with fever perioperative complications, lower postoperative transfusion rates, and shorter in-hospital stays, although it is still a relatively infrequent procedure apart from a few high-volume centers. Most possibly this is due to the considerable complexity of these cases, involving manipulation of major vessels with a significant risk of major bleeding complications [ 66 ].

One of the main challenges of this operation is to acquire control over the main vessels. Temporary occlusion of the IVC can be done by clamps introduced to the abdomen through an assist port or simple stab incision. Another technique is to apply vessel loops circumferentially and then create a modified Rummel tourniquet using a small rubber tube. This can be later reinforced by the application of laparoscopic bulldog clamps.

Kundavaram et al. described a technique when the temporary occlusion of the IVC is obtained by an intracaval 9 Fr Fogarty catheter inserted through a 5 mm assist port into the abdomen. The IVC is punctured, the catheter is introduced, then inflated. The position of the balloon is either confirmed by laparoscopic ultrasonography or transesophageal echocardiography [ 67 ]. Later, this approach was modified by the insertion of a Reliant compliant balloon (Medtronic, Minneapolis, MN, USA) into the IVC through the right internal jugular vein under fluoroscopic and intraoperative ultrasonographic guidance [ 68 ].

Robot-assisted kidney transplantation

Open kidney transplantation is the gold standard of care in end-stage renal disease. Since first performed in 1954 by Doctor Joseph E. Murray, the technique has not changed much.

In the 1990s, advances in minimally invasive surgery warranted the adoption of these techniques in the field of transplant surgery. The first laparoscopic donor nephrectomy was reported by Ratner et al. in 1995, and not much later it gained widespread acceptance and has become the standard technique for kidney donation. Laparoscopy’s adoption into renal implantation on the other hand was challenging. Since the first laparoscopic kidney transplant in 2009, it was rarely performed, because of the challenge of completing intracorporeal vascular anastomosis with instrumentation lacking articulation, limited movement range, and fulcrum effect. This highly demanding task, requiring high levels of expertise in laparoscopy, was difficult to master and this ultimately led to longer warm ischemia times and poor graft function [ 2 , 69 ].

Robotic assistance, however, has helped overcome the difficulties of laparoscopic renal transplantation. Since its first description, it is now becoming more and more accepted and performed. In a meta-analysis published in 2022, it was demonstrated that robot-assisted kidney transplant is safe and feasible, compared to the open approach it is associated with a lower risk of surgical site infection, less postoperative pain, and shorter length of hospital stay, while there is no difference in renal function, graft, and patient survival. It can be especially beneficial for obese patients due to the assessed lower risk of surgical site infections [ 70 ]. A notable limitation of the procedure for now is that most centers exclude all patients with calcified iliac arteries from the robotic approach, while chronic renal insufficiency is notoriously associated with atherosclerosis. This limits the use of this technique in more frail patients who would possibly benefit most from a minimally invasive approach.

Calcification of the arteries creates a change for robotic surgery because of the potential disastrous complications of vascular injury or inefficient clamping. In an experiment conducted by Le et al. in 2013, it was proven that robotic bulldog clamps exerted significantly less clamp force compared to laparoscopic clamps [ 71 ]. This issue could be potentially overcome by developing more robust robotic vascular clamps.

Robot-assisted lung transplantation

In 2023, as reported by Emerson et al., the first robot-assisted lung transplantation was performed successfully. The robot was used for the removal of the recipient’s diseased right lung and after the donor’s lung was inserted into the chest, the bronchial and the left atrial anastomosis were created with robotic assistance. The pulmonary artery anastomosis was then performed under direct vision due to the longer ischemic time at that point. The patient recovered without any major adverse events and was discharged on the 11th postoperative day. Since then, several more robot-assisted lung transplants have been performed by the team [ 72 ].

Portal vein reconstruction in robot-assisted pancreaticoduodenectomy

Pancreatic cancer is widely recognized as one of the most vicious tumors, with only 5% combined 5-year survival rate. Although surgical therapy is the most effective treatment, a minority of the patients are candidates for it, due to locally invasive disease or the presence of distant metastasis. Pancreaticoduodenectomy (PD) as described by Whipple in 1935 is the gold standard procedure for pancreatic head tumors to this day. It is considered one of the most complex surgeries of the alimentary tract due to the challenge of careful dissection along critical vascular structures and then the restoration of the enteric continuity, requiring three anastomoses (pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy). This demanding operation has high morbidity and mortality rates even at high-volume centers [ 73 ]. Like in the case of many previously described areas, laparoscopy could not gain widespread popularity, although it was first described more than 20 years ago [ 74 ]. The technically challenging requirement of retroperitoneal dissection in close proximity to major vascular structures and the need to perform the reconstruction with laparoscopic instruments made it difficult to master this procedure. Robot-assisted surgery promises to overcome many boundaries of the traditional minimally invasive approach.

When the tumor involves the superior mesenteric or portal vein, portomesenteric resection is now considered the standard of care. A patient is considered a candidate for robotic PD in case of venous involvement is less than 180° circumferentially and the vein is patent [ 75 , 76 ]. After resection is complete, reconstruction is required, which is an essentially vascular surgical procedure, performed with robotic assistance. According to the International Study Group of Pancreatic Surgery (ISGP) classification, types of vein resection can be divided into four categories. Type 1 resection means a small side wall resection, which can be closed with direct suture. In case of type 2 resection, patch closure is required. In the case of type 3 and 4 resections, a complete segmental resection is required, which can be reconstructed with direct repair in the former, and only with interposition in the latter. If the resection involves the splenomesenteric junction, the surgeon has to sew in a mini-Y graft with three robot-assisted anastomoses to preserve the flow [ 76 ]. This requires high-level vascular surgical skills and can be easily considered a “vascular” operation.

Robotic coronary artery bypass grafting

Although the first reported endoscopic bypass grafting was performed in 1998, by a French group, this approach faced similar criticism as other vascular surgical procedures [ 77 ]. These were the lack of haptic feedback, steep learning curve, high costs, lack of standardized training, concerns regarding the conversion rates, difficulties of creating multi-vessel revascularization, and long-term durability [ 78 ]. Recently, Balkhy et al. published their experience with totally endoscopic coronary artery bypass (TECAB) in 544 patients. 56% had multi-vessel revascularization and 242 patients underwent hybrid revascularization. Only one patient required conversion with sternotomy due to bleeding and there were six reoperations (1.1%) with four requiring sternotomies. Early mortality was 0.9% and at a median follow-up of 36 months, cardiac-related mortality was 2.4%, with freedom from MACE being 93% [ 79 ].

One of the critical points of TECAB is the creation of vascular anastomosis. There have been proprietary devices developed to ease this procedure, including the C-Port Flex A distal anastomosis device, and the PAS-port proximal anastomosis device (Cardica, Redwood, CA, USA). Utilization of such an anastomotic device significantly shortened operation times, but did not significantly affect patency compared to the sutured approach in a large single-center retrospective analysis [ 80 ].

Transitioning skills learned and devices developed for cardiac procedures have the potential to advance the adoption of vascular surgical procedures in the realm of robotics.

Training pathway to becoming a vascular robotic surgeon

As previously demonstrated, many “vascular” procedures are constantly being performed, many by other specialties; however, vascular surgery performed with robotic assistance is still considered barred by many. Although these procedures have core vascular surgical elements, the current generation of vascular surgeons receive no training in robotics, which also means they lack the skills to solve occasional vascular complications, without the need for a conversion when called into the OR emergently. That is why setting a training pathway for fellows and vascular surgical residents is of paramount importance. Fellows coming to vascular surgery may have basic training in laparoscopy or even robotic surgery; therefore, their expertise in this field can be built upon.

Our current strategy is to focus on individuals having experience with laparoscopy to train them in robotic surgery through a complex pathway. This includes basic robotic training, simulation on the manufacturer’s platform, wet lab practice, and case observations. This is followed by five robotic cases with the supervision of an external proctor. We determined a graduated increase in case complexity, starting from low complexity high-volume cases, such as peritoneal dialysis catheter insertion with lysis of intraabdominal adhesions through gradually more complex cases like venous repairs to highly complex and more demanding operations, like median arcuate ligament release, visceral aneurysm repair, and type 2 endoleak repair after stentgraft placement. This graduality in case complexity along with the increasing volume of cases allows appropriate experience to be gained to handle the more complex procedures. However, neither vascular robotic surgery nor this method has been accepted by the vascular community. We need further discussion and a concurrent position statement on this topic.

Future perspectives of robotic vascular surgery

Future robotic surgical systems could include the following improvements to the current generation of robotic systems. The concept of “master–slave” controls in robotic systems can be reimagined to reflect the levels of surgical autonomy and provide real-time assistance to surgeons with a smart robotic setup and positioning, including a certain level of automation of repetitive surgical tasks [ 81 ]. The current concept of streaming a set of imagery (laparoscopic camera, patient hemodynamics, preoperative imaging) and letting the surgeon integrate the relevant procedural stage-specific information could be adapted to a surgical-state intelligence system that provides integrated imaging, sensing, and feedback to the surgeon in the console. This could include better visualization of preoperative and intraoperative 3D imagery using novel image visualization systems [ 82 ]. Integration of intraoperative imaging systems for real-time visualization of robotic devices and changes in vascular anatomy can be adopted to improve imaging, visualization, and ‘integrated navigation” of future robotic systems [ 83 ]. Real-time image processing systems can impact how intraoperative imagery is generated and visualized during surgical procedures. This could include automatic tissue/target organ recognition and delineation of surgical tools/steps and complications using machine-learning algorithms. The major difference between conventional open surgery and robotic-assisted laparoscopic surgery is the lack of tactile sensation. Latest-generation robotic systems have been exploring the added clinical value of providing tactile feedback to the user using sensors and trackers built into the robotic instrument [ 84 ]. Automated recognition of surgical gestures, including quantification of surgical performance could be an insightful way of understanding surgical skills, and potentially optimize surgical performance and predict patient outcomes for robotic surgical procedures [ 85 ].

In the field of robotic surgery, there has been a dramatic improvement in technology, technique, and adoption of a wide array of specialties. In vascular surgery, the robotic approach is still in its infancy, despite many “vascular procedures” being performed by non-vascular specialists. Although this technique holds the promise of delivering the core therapeutic elements of an open approach through a keyhole incision, it is still to be determined whether the same durability can be achieved. Promising data originating from only a handful of centers worldwide. There is still a huge need for dedicated robotic vascular instruments, namely forceps and aortic clamps to be developed. In addition, dedicated robotic surgery training pathways for vascular surgeons have to be developed and embraced by the vascular community.

Data availability

No datasets were generated or analyzed during the current study.

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Balazs C. Lengyel, Ponraj Chinnadurai, Stuart J. Corr, Alan B. Lumsden & Charudatta S. Bavare

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BCL: conceptualization, methodology, data curation, writing—original draft, and visualization; PC: data curation, writing—original draft, review, and editing; SJC: writing—review and editing; ABL: conceptualization, writing—original draft, review and editing, and supervision; CSB: writing—review and editing, supervision.

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BCL, SC, and CSB have no competing interests. PC is a consultant senior scientist at Occam Labs LLC, Santa Cruz, CA, and interventional consultant at Siemens Medical Solutions, USA Inc., Malvern, PA. ABL received research support from W. L. Gore & Associates, he also consults with Boston Scientific, W. L. Gore & Associates, Siemens, and is a shareholder in Hatch Medical.

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Lengyel, B.C., Chinnadurai, P., Corr, S.J. et al. Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives. J Robotic Surg 18 , 328 (2024). https://doi.org/10.1007/s11701-024-02087-2

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