a systematic review and thematic synthesis

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

Affiliations.

1 Imperial College Healthcare NHS Trust, Education Centre, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK. [email protected].
2 Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK. [email protected].
3 Imperial College Healthcare NHS Trust, Education Centre, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
4 Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
5 Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.
PMID: 33926441
PMCID: PMC8082861
DOI: 10.1186/s12913-021-06354-y

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

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

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

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

Keywords: Allied health professions; Clinical academics; Midwifery; Nursing; Research impact; Systematic review; Thematic synthesis.

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The authors declare no competing interests.

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

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

Lisa newington.

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

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

Adine Adonis

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

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

Caroline M. Alexander

Associated data.

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

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

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

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

Conclusions

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

Supplementary Information

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

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

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

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

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

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

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

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

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

Selection criteria

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

Review inclusion and exclusion criteria

INCLUSION CRITERIA	EXCLUSION CRITERIA
This included: nurses; midwives; allied health professionals (art therapists, dietitians, drama therapists, music therapists, occupational therapists, orthoptists, operating department practitioners, osteopaths, podiatrists, prosthetists/orthotists, paramedics, physiotherapists, radiographers, and speech and language therapists); clinical psychologists; healthcare scientists and pharmacists. Assistants, technicians and support workers for these professions were also included.	Mixed research teams involving medical and non-medical healthcare professionals were excluded unless data were reported separately for the non-medical healthcare professionals.
Involvement of practising clinicians in clinical research. This included specific research roles, protected research time and other opportunities to be involved in research.	Both are routinely required components of clinical roles and were therefore not defined as clinical academic activity. Research based in a higher education institute without impact on healthcare organisations or the staff working in these organisation.
The types of impact were not pre-defined and could include the assessment of clinical, economic, workforce or other outcomes that were attributed to the clinical academic activity.	Studies reporting the outcome of clinical research questions, rather than the impact of the research activity, were excluded.
Where eligible systematic reviews were identified, their primary papers were included and screened separately.
To identify the impact of clinical academic activity in the context of current and recent past practice, the review was restricted to the past 20 years.	Due to rapidly evolving healthcare environments, it was felt that such articles would not represent current practice.

INCLUSION CRITERIA

EXCLUSION CRITERIA

This included: nurses; midwives; allied health professionals (art therapists, dietitians, drama therapists, music therapists, occupational therapists, orthoptists, operating department practitioners, osteopaths, podiatrists, prosthetists/orthotists, paramedics, physiotherapists, radiographers, and speech and language therapists); clinical psychologists; healthcare scientists and pharmacists. Assistants, technicians and support workers for these professions were also included.

Mixed research teams involving medical and non-medical healthcare professionals were excluded unless data were reported separately for the non-medical healthcare professionals.

Involvement of practising clinicians in clinical research. This included specific research roles, protected research time and other opportunities to be involved in research.

Both are routinely required components of clinical roles and were therefore not defined as clinical academic activity.

Research based in a higher education institute without impact on healthcare organisations or the staff working in these organisation.

The types of impact were not pre-defined and could include the assessment of clinical, economic, workforce or other outcomes that were attributed to the clinical academic activity.

Studies reporting the outcome of clinical research questions, rather than the impact of the research activity, were excluded.

Where eligible systematic reviews were identified, their primary papers were included and screened separately.

To identify the impact of clinical academic activity in the context of current and recent past practice, the review was restricted to the past 20 years.

Due to rapidly evolving healthcare environments, it was felt that such articles would not represent current practice.

Search strategy

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

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Object name is 12913_2021_6354_Fig1_HTML.jpg

PRISMA flowchart

Eligibility assessment

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

Quality assessment

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

Data extraction

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

Data extraction items

CHARACTERISTICS OF THE STUDY	CATEGORY OF IMPACT REPORTED
Years of publication and data collection	Impacts to patients (or families/carers)
Location (country and clinical setting)	Changes to service provision
Type of publication	Impacts to research profile of the organisation
Study design	Economic impacts
Clinical background and number of participants	Impacts to staff recruitment or retention
Study aims/objectives	Contribution to knowledge exchange
Nature of the clinical academic activity	Impacts to the individual clinical academic
	Any other impacts

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

Data synthesis

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

Study characteristics

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

Details of the included studies

AUTHOR, PUBLICATION TYPE AND YEAR	LOCATION (SITE AND COUNTRY)	STUDY DESIGN	CLINICAL DISCIPLINE	NUMBER OF PARTICIPANTS	STUDY/REPORT AIMS	NATURE OF CLINICAL ACADEMIC ACTIVITY
Bäck-Pettersson [ ] Journal article 2012	Healthcare organisations & universities, Western Sweden	Qualitative: focus groups	Nursing	12	Describe clinical nurses’ experiences of participating in a Research and Development Programme and the influence on research interest and ability to conduct and apply nursing research	Research and Development Programme 2 years Conducted and presented a research project from idea to publication Masters degree
Higgins [ ] Journal article 2010	Acute care & community settings, Australia	Qualitative: nominal group technique	Nursing	Not reported	Explore experiences of nurses who have undertaken clinically based research and document the issues, challenges and benefits	Clinicians, academics and researchers Not applicable Not reported Not reported
Kluijtmans [ ] Journal article 2017	Single university, Netherlands	Qualitative: semi-structured interviews	Nursing, physiotherapy	14	Explore how recent nurse- and physiotherapist-scientists perceive their professional identities and experience the crossing of boundaries between care and research	Clinician-Scientist Programme 3 years, 20 h/week Not reported 1-year pre-masters and 2-year masters programmes
Siedlecki [ ] Journal article 2016	Large healthcare system, Midwest USA	Qualitative: semi-structured interviews	Nursing	26	Develop a theoretical understanding of the conduct of research by clinical nurses	Research-active nurses Not applicable Principal investigator for clinical nursing research study (not in fulfilment of educational training) Not reported
Wenke [ ] Journal article 2017	State healthcare organisation, Victoria, Australia	Qualitative research: semi-structured interviews & focus group	Allied health professions	Interviews: 8 research practitioners and 8 line managers Focus groups: 28	Identify and explore the impact of funded research positions on building allied health research capacity within the organisation. Describe the mechanisms that enable and/or hinder the impact of the research positions in building allied health research capacity	Allied health research practitioners (postdoctoral) Not applicable Provided research support and conduct their own research Provide research supervision and training for allied health professionals
Brooks Carthon [ ] Journal article 2017	Single healthcare organisation & university, USA	Unclear – descriptive case study	Nursing	2	Overview and description of a Research Scholars Programme, including: design, conceptual framework, resource requirements and effect on institutional partners and participants	Research Scholars Programme 1.5-years, 16 h/month Involved with existing research team : Delivered by postdoctoral researcher
Association of UK University Hospitals [ ] Report 2016	National university hospitals, UK	Unclear – descriptive case studies	Nursing, midwifery, allied health professions	32	Provide healthcare providers with practical advice to develop and sustain clinical academic roles with illustrative case studies	Clinical academic roles Mixed Clinically focused pre-doctoral, doctoral and postdoctoral schemes
Department of Health and Social Care [ ] Report 2012	Department of health and Social Care, UK	Unclear – descriptive case studies	Nursing, midwifery, physiotherapy	3	Provide support for a strategy to develop the role of clinical academic researchers within nursing, midwifery and allied health professions	Clinical Academic Training Programmes Mixed Clinically focused pre-doctoral, doctoral and postdoctoral schemes
Nursing, Midwifery and Allied Health Professions Research Unit [ ] Report, 2017	Healthcare organisations & universities, Scotland	Unclear –descriptive case studies	Nursing, midwifery and allied health professions	11	Showcase the benefits to health and social care of adopting a clinical academic approach	Clinical academic approach Mixed Clinically focused pre-doctoral, doctoral and postdoctoral schemes
Chan [ ] Journal article 2010	Cancer care, tertiary hospital, Australia	Unclear – quantitative case study	Nursing	1	Review the design, implementation and evaluation of a Nurse Researcher Project led by an advanced practice level nurse researcher	Nurse Research Project Development, coordination, implementation and evaluation of nursing research projects Not reported
Nazer [ ] Journal article 2017	University hospital, Jordan	Quantitative service evaluation	Pharmacy	13	Describe the development of a structured Research Training Programme and evaluate the number of departmental research projects and publications. Data collection over 5 years	Pharmacy Research Training Programme Not reported Conducted individual research projects Tailored education sessions and assignments
Pomeroy [ ] Journal article 2003	Research & Development Directorate, North West England, UK	Quantitative survey	Nursing, midwifery, allied health professions	18	Describe the structure and process of a ‘hands-on’ Clinical Research Secondment scheme with the Stroke Associate Therapy Research Unit	Research Secondment 1 year (part time) Involved in existing projects withing the research unit Training: Research learning programme
Black [ ] Journal article 2019	Academic health science organisation, Western Canada	Mixed methods: survey & semi-structured interviews	Nursing and other disciplines (e.g. dietetics, pharmacy, social work)	Survey: 31 Interviews: 11	Review of Research Training Programme after 5 years, including: extent of changes to practice; impact on evidence-based practice; interest in advance education; research engagement; dissemination activities	Research Training Programme Not reported : Conducted research project in own clinical setting (funding provided) Research workshops
Bramley [ ] Journal article 2018	University hospital, UK	Mixed methods: survey, case studies & quantitative service evaluation	Nursing	7	Pilot the Chief Nurse Excellence in Care Junior Fellowship, document process of implementation and capture outcomes in relation to fellows, patients and the wider organisation	Chief Nurse Excellence in Care Junior Fellowship 1 (part time) Undertook quality/practice improvement activity within clinical area Bespoke training
Hiley [ ] Report 2018	Health Education England, West Midlands, UK	Mixed methods: survey & semi-structed interviews	Nursing, midwifery, allied health profession, healthcare scientists, pharmacists	Survey: 53 Interviews: 25	Understand the value of Clinical Academic Programmes for participants and employing healthcare organisations. To determine the barriers and enablers to continuing a clinical academic career	Clinical Academic Internship Programme and Masters to Doctorate Bridging Programme 6 to 9-months (part time) Completed research placements Bespoke training to develop clinical academic portfolio
Leung [ ] Journal article 2012	University hospitals, Toronto, Canada	Mixed methods: survey & quantitative service evaluation	Nursing	9	Report development, delivery and evaluation of a research training and mentorship programme	Oncology/Supportive Care Research Mentorship Programme 9 months (part time) Conducted research and/or disseminated findings with academic and mentorship support Research training sessions
McKee [ ] Journal article 2017	Acute hospital, Ireland	Mixed methods: survey, quantitative service evaluation & focus groups	Nursing	7	Describe and evaluate the creation of small research groups for nurses supported by academics and research fellows, and aimed at increasing research participation in advanced clinical nursing roles	The intervention 1-year Individual research projects Experiential learning, research methodology and bespoke training
Trusson [ ] Journal article 2019	Healthcare organisations, East Midlands, UK	Mixed methods: survey & in-depth interview	Nursing, midwives, allied health professions	Survey: 67 Interviews: 16	Track progression of clinical academics to explore challenges in combining academic study with clinical practice, and to demonstrate impact on patient outcomes	Clinical academic Careers Mixed Clinically focused East Midlands Clinical Academic practitioner network
Turkel [ ] Journal article 2008	Community hospital, USA	Mixed methods: survey & appreciative inquiry	Nursing	7	Develop and run a Research Fellowship Programme. Measure impacts on the participants; present the research projects and evaluate their impacts; and present the financial costs of the programme	Nursing Research Fellowship 1 year (part time) developed research proposal, conducted the study, disseminated findings Structured educational programme and mentoring
Wenke [ ] Journal article 2018	Healthcare organisation, Queensland, Australia	Mixed methods: longitudinal survey, quantitative & qualitative aspects	Allied health professions	16	Evaluation of a short-term Research Funding Initiative on clinician research capacity, research output and satisfaction	Research Funding Initiative 6 months (part time) Varied activities including ethics applications, data collection, data analysis, systematic review, writing for publication Mentorship and support from the Allied Health Research Fellow

Participants

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

Methodological assessment

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

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Object name is 12913_2021_6354_Fig2_HTML.jpg

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

Reported impacts of clinical academic activity

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

Themes of impact reported in the included papers

	PATIENTS	SERVICE PROVISION		RESEARCH PROFILE, CULTURE & CAPACITY			ECONOMIC	RECRUITMENT & RETENTION	KNOWLEDGE EXCHANGE	INDIVIDUAL
	PATIENTS						ECONOMIC	RECRUITMENT & RETENTION	KNOWLEDGE EXCHANGE	INDIVIDUAL
Bäck-Pettersson [ ]	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Higgins [ ]	✓	✓	✓	–	✓	✓	✓	–	✓	✓
Kluijtmans [ ]	✓	✓	✓	–	✓	–	✓	✓	✓	✓
Siedlecki [ ]	✓	✓	–	–	✓	✓	–	–	✓	✓
Wenke [ ]	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Brooks Carthon [ ]	✓	✓	✓	–	✓	✓	✓	✓	✓	✓
AUHUK [ ]	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
DHSC [ ]	✓	✓	✓	✓	✓	✓	–	–	✓	✓
NMAHP-RU [ ]	✓	✓	✓	–	✓	✓	✓	✓	✓	✓
Chan [ ]	✓	–	✓	✓	✓	–	✓	–	✓	✓
Nazer [ ]	–	–	✓	✓	✓	–	✓	–	✓	✓
Pomeroy [ ]	–	✓	✓	✓	✓	✓	✓	✓	✓	✓
Black [ ]	✓	✓	–	✓	✓	✓	–	–	✓	✓
Bramley [ ]	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Hiley [ ]	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Leung [ ]	–	✓	✓	✓	✓	–	–	–	✓	✓
McKee [ ]	✓	✓	✓	✓	✓	✓	✓	–	✓	✓
Trusson [ ]	✓	✓	✓	–	✓	✓	✓	✓	✓	✓
Turkel [ ]	✓	✓	✓	–	✓	✓	✓	✓	✓	✓
Wenke [ ]	–	✓	✓	–	✓	✓	✓	✓	✓	✓

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

Impacts for patients

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

“This project demonstrated significant improvements in the neutropenic patient pathway, enhancing experience and outcomes for patients and a reduction in unnecessary admissions.” [ 27 ]

“Behaviours learned during the programmes provided benefits for improving the quality of care delivered within services … Respondents reported they discussed evidence with colleagues, searched the literature for evidence updates, questioned and used evidence to inform their practice following completion of the programme.” [ 16 ]

“My research has demonstrated the benefits of these kinds of approaches both to patients’ quality of life, and patients, carers, friends and families’ experience of palliative care services.” [ 36 ]

"[It is a] synergistic relationship, as research knowledge improves the care I provide, but the close patient contact allows me to identify areas that require further research." [ 29 ]

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

Impacts on service provision and workforce

I. clinical service provision.

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

“Research positions supported projects that led to changes in service delivery models, with [one] manager commenting, ‘ … it’s amazed me that through the research grant that she got for that project, she has now generated for the Health Service recurrent money for the full time [implementation of the] … rural allied health model’.” [ 41 ]

“One participant’s intervention removes the need for GPs’ referral for physiotherapy, potentially saving ‘multimillion pounds’ across the NHS [National Health Service], and has subsequently been recognised in the NHS long-term plan.” [ 39 ]

“As a clinical academic midwife my aim is to bring more evidence into practice and assist other midwives in doing the same.” [ 29 ]

“Most of this reported activity focused on reviewing published evidence in relation to clinical practice but participants also reported involvement in facilitating/enhancing research skills in other clinicians.” [ 37 ]

“Release from the workplace, despite the employer grant, was in some cases problematic. Finding appropriately skilled staff to cover services particularly in highly specialised areas and, or recruiting to short term, often part time, vacancies were challenges. In contrast some managers saw this as an opportunity to give other staff the chance to act up, for succession planning, or worked creatively to make release possible.” [ 16 ]

“Protected time for the APNs [Advanced Practice Nurses] (i.e., at least one day a week) to engage in research activities was crucial to the program and, at times, difficult to achieve.” [ 32 ]

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

ii. Clinical academic workforce

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

“Clinical and academic mentorship exposed the Chief Nurse Fellows to clinical academic career role models, which in turn raised the profile of this alternative career route.” [ 27 ]

“There’s a huge untapped workforce … with the right support and time we could be doing things more effectively and more efficiently, but that isn’t necessarily valued in organisations. We’ve got to see this many patients, (we’re) not using our skills of criticality, reflectivity; we’re not going to innovate and change practice.” [ 39 ]

"Imagine being able to continue my research and tie the results directly to clinical practice. I would like there to be an opportunity of this kind. However, there is a lack of services for nurses with higher academic qualifications who want to develop clinical practice.” [ 25 ]

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

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

“I have a very supportive divisional head nurse and have been appointed into a trailblazer post; we haven’t got anything similar within the organisation. So there’s real potential to forge out innovative ways in which clinical academics can fulfil that remit of working in clinical practice and undertaking research, but also pave the way for others that want to come up.” [ 39 ]

“Biggest challenge: Getting managers on board, in particular releasing staff to take advantage of internship opportunities offered by HEE [Health Education England] Wessex, and recognising that research is essential to the core business of the Trust.” [ 17 ]

“It’s not the scheme, but greater staff access to relevant software (such as SPSS) would be useful.” [ 13 ]

Impacts to the research profile, culture and capacity

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

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

“As a result of the research activities, seven manuscripts were submitted and accepted for peer-reviewed publications.” [ 28 ]

“Improved attitudes towards research were noted by a clinician, ‘ … research isn’t this incredibly difficult thing that only very special people can do. Actually, it’s attainable by many and it was quite inspiring actually … I don’t know that that would have been their view prior to this position developing that profile.” [ 41 ]

“It’s about allowing people to engage with research and become enthused by it. It’s also about having the right leaders who are able to take the step back and say: ‘This is a good use of your time’. You can find better ways of giving care if you have a culture that values research.” [ 36 ]

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

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

“I now exhort other colleagues to question day-to-day practice and we have introduced a journal club.” [ 29 ]

“The group process allowed scholars to participate in joint problem solving and enhanced their ability to apply current research to questions arising from clinical practice. The scholars were expected to serve as clinical resources to others in the healthcare system.” [ 33 ]

“We have increasing numbers of staff involved in research activity, studying for MRes and PhDs, and their research is closely related to their professional practice and aims to improve care. We have five research themes with [the healthcare organisation’s] nurses/midwives leading these and staff linking into these themes for their masters or doctoral study and we are starting to build groups of staff at different points on a clinical academic career pathway. Many staff present their research nationally and internationally and publish widely and some are part of national expert groups, linked to their research.” [ 17 ]

“People can choose where they want to work. They’ll be looking for organisations that are aspirational. So actually offering innovative career pathways that can intellectually challenge, but also have that direct patient care element, is going to be attractive to a lot of people.” [ 39 ]

Economic impacts

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

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

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

“Management are more than happy to support research initiatives in principle, however, [they are] usually unable to provide [this] support as they have extremely tight budgets and other clinical management demands.” [ 30 ]

“The initiative was resourced by the reallocation of nursing/ODP vacancy funding within each clinical division.” [ 27 ]

“The amount of money saved by using the scanner and avoiding catheterisation was estimated to be around £1.2m per year. This did not include the cost of bacteraemia attributed to urinary tract infections. Savings associated with using a scanner, such as fewer treatment delays and overnight stays in hospital, were recognised as additional savings. The set up and running costs of a scanner were estimated to be met within six months to two years, after which significant ongoing cost efficiencies would be realised over its eight to ten year lifespan.” [ 17 ]

“The work had led to a decrease in patients’ clinical stay following surgery from six to four days, resulting in savings that allowed additional needs and demands to be met. We were very open and transparent with the data, and clinical practice changed. We calculated that there was a total of 28,000 bed-days saved per year as a result of this work.” [ 36 ]

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

“The presenters had to either self-fund their travel and conference registration, or apply for travel scholarships through internal or external opportunities.” [ 28 ]

Impacts on staff recruitment and retention

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

“The organisational system is perceived as unfamiliar with, and unsupportive of, non-physician clinician scientist positions, and, in consequence, active job crafting is necessary to obtain positions in which such individuals can exert both roles. Dual positions are often a personal combination of jobs instead of being offered from within one institution.” [ 31 ]

"Unfortunately, I wasn’t offered the chance to implement the results of my study in my organisation, due to the lack of development positions. So, as a result, I have applied for, and been given, a position as a teacher at the university college." [ 25 ]

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

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

“Since completing their year as a fellow, the entire pilot cohort still works within the organisation, with five of them having moved into junior leadership positions. Although we cannot assume that this would not have been their career trajectory had they not undertaken this fellowship, the skills developed and demonstrated through the initiative are essential for the job specifications of more senior posts.” [ 27 ]

“Interviewees reported that their department was seen as a more ‘attractive employer’ and was ‘attracting higher calibre staff’. Clinicians described staying in the health service to undertake research, ‘because these opportunities do exist, these really fabulous clinicians that we have just might stay’.” [ 41 ]

Impacts to knowledge exchange

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

“Interviewees provided numerous and diverse examples of presentations at grand rounds, poster presentations and oral presentations at both local and international conferences, including one interviewee who noted her team had presented their research project findings at three international and three local conferences. Another interviewee stated, ‘We have presented at a couple of conferences and we presented at a … convention or meeting and we actually got an award for our poster’.” [ 26 ]

“Individuals need time in the role as well to get some momentum, get the relationships in the department, get the research programs going and there's usually a delay until you start to see the pure research outputs.” [ 41 ]

“What I notice clearly is that I’m very well informed about scientific evidence and sharing this information with my colleagues. [I ask them] did you read this? And [I] pass on knowledge in that way.” [ 31 ]

“After being able to demonstrate the success of the approach locally, David was asked to help with a national roll out, organising with colleagues an audit of all 22 orthopaedic units across Scotland over 12 weeks.” [ 36 ]

Impacts to the clinical academic

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

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

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

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

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

“The majority agreed or strongly agreed that they felt more confident developing a research question (94%/49), searching (87%/45) and appraising (90%/47) literature, challenging practice using evidence (85%/44), assisting others to use critical appraisal skills (79%/41) and engage in the clinical academic training pathway (87%/45).” [ 16 ]

“Despite their achievements during the PhD, many participants expressed anxieties about their future careers, having been made to move aside clinically in order to progress their academic ambitions, rather than being able to develop their academic and clinical skills in tandem. For example a dietician said: Recently I’ve had to step out of my area of expertise … I’m just doing general, allergies, weight management, which is not my area, but I need to pay the mortgage.” [ 39 ]

“It is actually exciting to learn that the world does not work the way you thought it did”. 70 [ 38 ]. “I want to do this for me, but I also want to do it for my daughters to show that women can be in science and can lead in these fields and yes we might have to juggle family things and children, but you can do it.” [ 39 ]

“What accomplishments are you most proud of? Knowing that I am now a subject expert – I get phone calls asking, `How would you handle this?’.” [ 40 ]

“When you are really interested in something or passionate about it, you use whatever time you have, even if it means writing your proposal after your regular hours at home.” [ 38 ]

“The time taken to do research is often underestimated and considerable time and effort is often put into preparing a grant application which ultimately may not be successful. Focusing on meeting deadlines and the progress of a project means that less attention can be given to other aspects of work roles. Ultimately, doing research without adequate support or funding becomes a constant juggle.” [ 30 ]

“The demanding expectations surrounding a clinical academic role were described by interviewees (participants and managers) and the characteristics and behaviours that were perceived as required for success. These included confidence, doggedness and resilience, reflective skills, criticality, and growing political know-how to better navigate organisations.” [ 16 ]

“Mentorship (from nursing, midwifery and medical colleagues), determination, tenacity, resilience and serendipity have been key factors in achieving success.” [ 17 ]

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

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

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

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

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

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

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

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

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

Limitations

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

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

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

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

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

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

Acknowledgements

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

Abbreviations

AHP	allied health professional (includes: art therapists; drama therapists; music therapists; chiropodists/podiatrists; dietitians; occupational therapists; operating department practitioners; orthoptists; osteopaths; paramedics; physiotherapists; prosthetists and orthotists; radiographers; and speech and language therapists)
AUKUK	Association of UK University Hospitals
DHSC	Department of Health and Social Care (UK)
MMAT	Mixed Methods Appraisal Tool
NMAHPs	nurses, midwives and allied health professionals
NMAHP-RU	Nursing, Midwifery and Allied Health Professions Research Unit (Scotland)
PRISMA	preferred reporting items for systematic reviews and meta-analyses
VICTOR	making Visible the ImpaCT Of Research framework, a research impact capture tool

Authors’ contributions

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

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

Availability of data and materials

Declarations.

Ethics approval was not required for this systematic review.

Not applicable.

The authors declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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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James Thomas and Angela Harden contributed equally to this work.

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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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DOI : https://doi.org/10.1186/1471-2288-8-45

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

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Conclusions

Supplementary Information

Selection criteria

Search strategy

Eligibility assessment

Quality assessment

Data extraction

Data synthesis

Study characteristics

Participants

Methodological assessment

Reported impacts of clinical academic activity

Impacts for patients

Impacts on service provision and workforce

ii. Clinical academic workforce

Impacts to the research profile, culture and capacity

Economic impacts

Impacts on staff recruitment and retention

Impacts to knowledge exchange

Impacts to the clinical academic

Limitations

Acknowledgements

Abbreviations

Authors’ contributions

Availability of data and materials

Methods for the thematic synthesis of qualitative research in systematic reviews

The review used as an example in this paper

Qualitative research and systematic reviews

Quality assessment

Extracting data from studies

Detailed methods for thematic synthesis

Stages one and two: coding text and developing descriptive themes

Stage three: generating analytical themes

Context and rigour in thematic synthesis

Study quality and sensitivity analyses

Pre-publication history

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