Critical reflection of the methodology and methods used in paper two two

3.4.1 Why a qualitative thematic synthesis?

This review sought to understand why individuals affected by cancer seek, accept or decline help for distress and what influences these actions. The goal of this research was interpretative in that the review sought to enhance our understanding of the phenomenon of help-seeking.

Thus, a qualitative synthesis was chosen as a congruent approach to produce an interpretive translation of studies by deriving themes or constructs across studies rather than an aggregative summary of studies (Booth 2016; Grant et al. 2009). Several methods of synthesising qualitative evidence exist (Ring et al. 2011). Barnett-Page and Thomas (2009) reflect that thematic synthesis pioneered by Thomas and Harden (2008) was developed

‘out of a need to conduct reviews that addressed questions relating to intervention need, appropriateness and acceptability – as well as those relating to effectiveness – without compromising on key principles developed in systematic reviews.’ (p.6)

Given that the aim of this review related to the need for help it was considered that thematic synthesis presents the most appropriate choice of method available. Moreover, the clear and

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unambiguous guidance of the method was attractive. Thomas et al.’s method of thematic synthesis advocates familiar techniques such as the use of computer software to facilitate data storage, coding and retrieval to simplify data management was appealing as I had never undertaken a qualitative synthesis before. Moreover, data analysis techniques borrowed from qualitative techniques such as an inductive approach using line by line coding and constant comparative methods with which I was familiar. (Barnett-Page et al. 2009). Hence, while the choice of method was congruent with the underlying aim of the study I found the method had appeal as I had never undertaken a qualitative synthesis before.

3.4.2 Search methods

A recent criticism levied at qualitative synthesis is that authors have concentrated their energies on the technical aspects of the review i.e. searching, tabulating and displaying studies rather than focussing on interpretation of studies; this they argue produces an aggregative superficial product rather than synthesised novel integrated findings (Thorne 2015; Thorne 2017). Yet as Cooper argues, confidence in the conduct of meta-synthesis and sound retrieval of studies is vital (Cooper 2010). Furthermore, Britten et al. (2017) counter Thorne’s criticisms by pointing out that currently in the absence of further definitive guidance on the conduct of qualitative synthesis prospective authors adherence to technical aspects of the search is a necessary pre-requisite to ensure publication. Britten et al. indicate that Thorne’s criticism of searches which retrieve thousands of hits is not necessarily problematic but accept that further guidance is merited. Notwithstanding the pressing need for definitive guidance, Booth’s (2016) recent structured methodological review highlights that poor empirical evidence informs current practice in search methods and inclusion of studies in qualitative systematic reviews or qualitative evidence syntheses.

The SPIDER tool was chosen as a preferred search strategy tool in paper two because tools such as PICO (Population, Intervention, Comparison, Outcome) may not necessarily translate to qualitative systematic reviews (Cooke et al. 2012). Indeed, reflecting on the generation of search terms used during this qualitative synthesis generating search terms using SPIDER was more intuitive than using PICO given that the domain of comparison is generally not a feature of qualitative studies. However, a recent study by Methley (2014) has questioned the assumption that intuitive use of SPIDER equates to empirical evidence to support its use.

Methley et al. (2014) compared the use of SPIDER and PICO tools to a modified version of PICO with added qualitative search terms (PICOS) across three databases, MEDLINE, EMBASE and

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CINAHL. The study reported that while SPIDER had the greatest specificity it demonstrated a lower sensitivity than the other tools; PICOS tool demonstrated the greatest sensitivity of all the tools. Whilst accepting PICOS demonstrated greatest sensitivity given the relative resource and time constraints of the review within a program of PhD research the use of SPIDER probably remained a pragmatic choice to maximise specificity. Besides as Booth (2016) argues, qualitative data synthesis need not necessarily need exhaustive searches but rather they should be appropriate and comprehensive searches.

Paper two drew criticism by a leading expert in the field for not including ‘enduring’ in its search or reporting. In her recent article ‘Theoretical Coalescence: A Method to Develop Qualitative Theory’ Janice Morse describes theoretical coalescence as a method of theory development.

Morse chronicles the evolution of the lay concept of enduring to a scientific concept within her

‘Theory of Suffering’ by drawing from 16 studies which she has authored. The theory of suffering delineates dual processes which occur in response to trauma such as cancer; namely enduring in which emotions are suppressed and emotional suffering in which emotions are released.

Morse argues that advancing theory is a slow process with studies contributing to her theory spanning 23 years (1991-2014) and outlines several challenges in theory advancement. Morse (2018) then levies the following criticism of paper two in limiting advancement of theory development

‘Of greater concern, research that introduces new insights or concepts tends to be ignored by methods of meta-synthesis, perhaps because of the mechanics of research terms. For instance, a recent systematic review (2000–2016) of emotional distress and help-seeking in cancer, focused on emotional states of distress and ignored states of enduring (Carolan, Smith, Davies, & Forbat 2017)’ (p.185).

However, I consider that are salient reasons why ‘enduring’ did not feature within paper two.

First, as Morse keenly points out in the very same article

‘Astonishingly, enduring is virtually absent from the scientific literature, including nursing’ (p.184)

I would argue that it is challenging to discover a concept if it is absent from the literature unless one has personal knowledge of an author’s work. Secondly, the titles of the studies which Morse has derived her concept of suffering merit scrutiny. The titles of the studies include no easily discernible direct reference to or allude to concepts pertinent to our review, several do not relate to cancer populations, and finally many are not reported in peer-review journals but rather books. Taken together, I would argue that it is challenging to discover work which is not easily discoverable. Admittedly, I accept that Morse’s programme of work was evolutionary

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and hence why earlier titles do not readily incorporate or signal distress, suffering and enduring.

Additionally, on reflection, paper two’s subtheme of emotional space does resonate with Morse’ subtheme of enduring and hence I accept that discussion of the findings of paper two with reference to Morse’s theory of suffering would have strengthened paper two.

Nonetheless, such debates raise questions about authors’ ethical responsibilities during research dissemination. I consider that within the ethical frameworks of beneficence non-maleficence and justice (Beauchamp and Childress 2003), authors should endeavour to publish articles which have easily discoverable titles. This will ensure that their work can contribute fully to the development of evidence-based care to ensure beneficence and non-maleficence in clinical care and to ensure justice to those who funded and participated in their research.