synthesis of a literature review

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• Lit Review Prep Use this template to help you evaluate your sources, create article summaries for an annotated bibliography, and a synthesis matrix for your lit review outline.

Synthesize your Information

Synthesize: combine separate elements to form a whole.

Synthesis Matrix

A synthesis matrix helps you record the main points of each source and document how sources relate to each other.

After summarizing and evaluating your sources, arrange them in a matrix or use a citation manager to help you see how they relate to each other and apply to each of your themes or variables.  

By arranging your sources by theme or variable, you can see how your sources relate to each other, and can start thinking about how you weave them together to create a narrative.

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• Last Updated: Sep 26, 2023 10:25 AM
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Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

By: Derek Jansen (MBA) | Expert Reviewer: Eunice Rautenbach (DTech) | August 2023

One of the most common mistakes that students make when writing a literature review is that they err on the side of describing the existing literature rather than providing a critical synthesis of it. In this post, we’ll unpack what exactly synthesis means and show you how to craft a strong literature synthesis using practical examples.

This post is based on our popular online course, Literature Review Bootcamp . In the course, we walk you through the full process of developing a literature review, step by step. If it’s your first time writing a literature review, you definitely want to use this link to get 50% off the course (limited-time offer).

Overview: Literature Synthesis

• What exactly does “synthesis” mean?
• Aspect 1: Agreement
• Aspect 2: Disagreement
• Aspect 3: Key theories
• Aspect 4: Contexts
• Aspect 5: Methodologies
• Bringing it all together

What does “synthesis” actually mean?

As a starting point, let’s quickly define what exactly we mean when we use the term “synthesis” within the context of a literature review.

Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study’s research aims and questions .

Put another way, a good synthesis tells the reader exactly where the current research is “at” in terms of the topic you’re interested in – specifically, what’s known , what’s not , and where there’s a need for more research .

So, how do you go about doing this?

Well, there’s no “one right way” when it comes to literature synthesis, but we’ve found that it’s particularly useful to ask yourself five key questions when you’re working on your literature review. Having done so,  you can then address them more articulately within your actual write up. So, let’s take a look at each of these questions.

1. Points Of Agreement

The first question that you need to ask yourself is: “Overall, what things seem to be agreed upon by the vast majority of the literature?”

For example, if your research aim is to identify which factors contribute toward job satisfaction, you’ll need to identify which factors are broadly agreed upon and “settled” within the literature. Naturally, there may at times be some lone contrarian that has a radical viewpoint , but, provided that the vast majority of researchers are in agreement, you can put these random outliers to the side. That is, of course, unless your research aims to explore a contrarian viewpoint and there’s a clear justification for doing so. 

Identifying what’s broadly agreed upon is an essential starting point for synthesising the literature, because you generally don’t want (or need) to reinvent the wheel or run down a road investigating something that is already well established . So, addressing this question first lays a foundation of “settled” knowledge.

Need a helping hand?

2. Points Of Disagreement

Related to the previous point, but on the other end of the spectrum, is the equally important question: “Where do the disagreements lie?” .

In other words, which things are not well agreed upon by current researchers? It’s important to clarify here that by disagreement, we don’t mean that researchers are (necessarily) fighting over it – just that there are relatively mixed findings within the empirical research , with no firm consensus amongst researchers.

This is a really important question to address as these “disagreements” will often set the stage for the research gap(s). In other words, they provide clues regarding potential opportunities for further research, which your study can then (hopefully) contribute toward filling. If you’re not familiar with the concept of a research gap, be sure to check out our explainer video covering exactly that .

3. Key Theories

The next question you need to ask yourself is: “Which key theories seem to be coming up repeatedly?” .

Within most research spaces, you’ll find that you keep running into a handful of key theories that are referred to over and over again. Apart from identifying these theories, you’ll also need to think about how they’re connected to each other. Specifically, you need to ask yourself:

• Are they all covering the same ground or do they have different focal points  or underlying assumptions ?
• Do some of them feed into each other and if so, is there an opportunity to integrate them into a more cohesive theory?
• Do some of them pull in different directions ? If so, why might this be?
• Do all of the theories define the key concepts and variables in the same way, or is there some disconnect? If so, what’s the impact of this ?

Simply put, you’ll need to pay careful attention to the key theories in your research area, as they will need to feature within your theoretical framework , which will form a critical component within your final literature review. This will set the foundation for your entire study, so it’s essential that you be critical in this area of your literature synthesis.

If this sounds a bit fluffy, don’t worry. We deep dive into the theoretical framework (as well as the conceptual framework) and look at practical examples in Literature Review Bootcamp . If you’d like to learn more, take advantage of our limited-time offer to get 60% off the standard price.

4. Contexts

The next question that you need to address in your literature synthesis is an important one, and that is: “Which contexts have (and have not) been covered by the existing research?” .

For example, sticking with our earlier hypothetical topic (factors that impact job satisfaction), you may find that most of the research has focused on white-collar , management-level staff within a primarily Western context, but little has been done on blue-collar workers in an Eastern context. Given the significant socio-cultural differences between these two groups, this is an important observation, as it could present a contextual research gap .

In practical terms, this means that you’ll need to carefully assess the context of each piece of literature that you’re engaging with, especially the empirical research (i.e., studies that have collected and analysed real-world data). Ideally, you should keep notes regarding the context of each study in some sort of catalogue or sheet, so that you can easily make sense of this before you start the writing phase. If you’d like, our free literature catalogue worksheet is a great tool for this task.

5. Methodological Approaches

Last but certainly not least, you need to ask yourself the question: “What types of research methodologies have (and haven’t) been used?”

For example, you might find that most studies have approached the topic using qualitative methods such as interviews and thematic analysis. Alternatively, you might find that most studies have used quantitative methods such as online surveys and statistical analysis.

But why does this matter?

Well, it can run in one of two potential directions . If you find that the vast majority of studies use a specific methodological approach, this could provide you with a firm foundation on which to base your own study’s methodology . In other words, you can use the methodologies of similar studies to inform (and justify) your own study’s research design .

On the other hand, you might argue that the lack of diverse methodological approaches presents a research gap , and therefore your study could contribute toward filling that gap by taking a different approach. For example, taking a qualitative approach to a research area that is typically approached quantitatively. Of course, if you’re going to go against the methodological grain, you’ll need to provide a strong justification for why your proposed approach makes sense. Nevertheless, it is something worth at least considering.

Regardless of which route you opt for, you need to pay careful attention to the methodologies used in the relevant studies and provide at least some discussion about this in your write-up. Again, it’s useful to keep track of this on some sort of spreadsheet or catalogue as you digest each article, so consider grabbing a copy of our free literature catalogue if you don’t have anything in place.

Bringing It All Together

Alright, so we’ve looked at five important questions that you need to ask (and answer) to help you develop a strong synthesis within your literature review.  To recap, these are:

• Which things are broadly agreed upon within the current research?
• Which things are the subject of disagreement (or at least, present mixed findings)?
• Which theories seem to be central to your research topic and how do they relate or compare to each other?
• Which contexts have (and haven’t) been covered?
• Which methodological approaches are most common?

Importantly, you’re not just asking yourself these questions for the sake of asking them – they’re not just a reflection exercise. You need to weave your answers to them into your actual literature review when you write it up. How exactly you do this will vary from project to project depending on the structure you opt for, but you’ll still need to address them within your literature review, whichever route you go.

The best approach is to spend some time actually writing out your answers to these questions, as opposed to just thinking about them in your head. Putting your thoughts onto paper really helps you flesh out your thinking . As you do this, don’t just write down the answers – instead, think about what they mean in terms of the research gap you’ll present , as well as the methodological approach you’ll take . Your literature synthesis needs to lay the groundwork for these two things, so it’s essential that you link all of it together in your mind, and of course, on paper.

Psst… there’s more!

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

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• University of Oregon Libraries
• Research Guides

How to Write a Literature Review

• 6. Synthesize
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to synthesis.

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

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Literature Review Basics

• What is a Literature Review?
• Synthesizing Research
• Using Research & Synthesis Tables
• Additional Resources

Synthesis: What is it?

First, let's be perfectly clear about what synthesizing your research isn't :

• - It isn't  just summarizing the material you read
• - It isn't  generating a collection of annotations or comments (like an annotated bibliography)
• - It isn't  compiling a report on every single thing ever written in relation to your topic

When you  synthesize  your research, your job is to help your reader understand the current state of the conversation on your topic, relative to your research question.  That may include doing the following:

• - Selecting and using representative work on the topic
• - Identifying and discussing trends in published data or results
• - Identifying and explaining the impact of common features (study populations, interventions, etc.) that appear frequently in the literature
• - Explaining controversies, disputes, or central issues in the literature that are relevant to your research question
• - Identifying gaps in the literature, where more research is needed
• - Establishing the discussion to which your own research contributes and demonstrating the value of your contribution

Essentially, you're telling your reader where they are (and where you are) in the scholarly conversation about your project.

Synthesis: How do I do it?

Synthesis, step by step.

This is what you need to do  before  you write your review.

• Identify and clearly describe your research question (you may find the Formulating PICOT Questions table at  the Additional Resources tab helpful).
• Collect sources relevant to your research question.
• Organize and describe the sources you've found -- your job is to identify what  types  of sources you've collected (reviews, clinical trials, etc.), identify their  purpose  (what are they measuring, testing, or trying to discover?), determine the  level of evidence  they represent (see the Levels of Evidence table at the Additional Resources tab ), and briefly explain their  major findings . Use a Research Table to document this step.
• Study the information you've put in your Research Table and examine your collected sources, looking for  similarities  and  differences . Pay particular attention to  populations ,   methods  (especially relative to levels of evidence), and  findings .
• Analyze what you learn in (4) using a tool like a Synthesis Table. Your goal is to identify relevant themes, trends, gaps, and issues in the research.  Your literature review will collect the results of this analysis and explain them in relation to your research question.

Analysis tips

• - Sometimes, what you  don't  find in the literature is as important as what you do find -- look for questions that the existing research hasn't answered yet.
• - If any of the sources you've collected refer to or respond to each other, keep an eye on how they're related -- it may provide a clue as to whether or not study results have been successfully replicated.
• - Sorting your collected sources by level of evidence can provide valuable insight into how a particular topic has been covered, and it may help you to identify gaps worth addressing in your own work.
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Library Guides

Literature reviews: synthesis.

• Criticality

Synthesise Information

So, how can you create paragraphs within your literature review that demonstrates your knowledge of the scholarship that has been done in your field of study?  

You will need to present a synthesis of the texts you read.  

Doug Specht, Senior Lecturer at the Westminster School of Media and Communication, explains synthesis for us in the following video:  

Synthesising Texts  

What is synthesis? 

Synthesis is an important element of academic writing, demonstrating comprehension, analysis, evaluation and original creation.  

With synthesis you extract content from different sources to create an original text. While paraphrase and summary maintain the structure of the given source(s), with synthesis you create a new structure.  

The sources will provide different perspectives and evidence on a topic. They will be put together when agreeing, contrasted when disagreeing. The sources must be referenced.  

Perfect your synthesis by showing the flow of your reasoning, expressing critical evaluation of the sources and drawing conclusions.  

When you synthesise think of "using strategic thinking to resolve a problem requiring the integration of diverse pieces of information around a structuring theme" (Mateos and Sole 2009, p448). 

Synthesis is a complex activity, which requires a high degree of comprehension and active engagement with the subject. As you progress in higher education, so increase the expectations on your abilities to synthesise. 

How to synthesise in a literature review: 

Identify themes/issues you'd like to discuss in the literature review. Think of an outline.  

Read the literature and identify these themes/issues.  

Critically analyse the texts asking: how does the text I'm reading relate to the other texts I've read on the same topic? Is it in agreement? Does it differ in its perspective? Is it stronger or weaker? How does it differ (could be scope, methods, year of publication etc.). Draw your conclusions on the state of the literature on the topic.  

Start writing your literature review, structuring it according to the outline you planned.  

Put together sources stating the same point; contrast sources presenting counter-arguments or different points.  

Present your critical analysis.  

Always provide the references. 

The best synthesis requires a "recursive process" whereby you read the source texts, identify relevant parts, take notes, produce drafts, re-read the source texts, revise your text, re-write... (Mateos and Sole, 2009). 

What is good synthesis?  

The quality of your synthesis can be assessed considering the following (Mateos and Sole, 2009, p439):  

Integration and connection of the information from the source texts around a structuring theme. 

Selection of ideas necessary for producing the synthesis. 

Appropriateness of the interpretation.  

Elaboration of the content.  

Example of Synthesis

Original texts (fictitious): 

Synthesis: 

Animal experimentation is a subject of heated debate. Some argue that painful experiments should be banned. Indeed it has been demonstrated that such experiments make animals suffer physically and psychologically (Chowdhury 2012; Panatta and Hudson 2016). On the other hand, it has been argued that animal experimentation can save human lives and reduce harm on humans (Smith 2008). This argument is only valid for toxicological testing, not for tests that, for example, merely improve the efficacy of a cosmetic (Turner 2015). It can be suggested that animal experimentation should be regulated to only allow toxicological risk assessment, and the suffering to the animals should be minimised.   

Bibliography

Mateos, M. and Sole, I. (2009). Synthesising Information from various texts: A Study of Procedures and Products at Different Educational Levels. European Journal of Psychology of Education,  24 (4), 435-451. Available from https://doi.org/10.1007/BF03178760 [Accessed 29 June 2021].

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Literature Review How To

• Things To Consider
• Synthesizing Sources
• Video Tutorials
• Books On Literature Reviews

What is Synthesis

What is Synthesis? Synthesis writing is a form of analysis related to comparison and contrast, classification and division. On a basic level, synthesis requires the writer to pull together two or more summaries, looking for themes in each text. In synthesis, you search for the links between various materials in order to make your point. Most advanced academic writing, including literature reviews, relies heavily on synthesis. (Temple University Writing Center)  

How To Synthesize Sources in a Literature Review

Literature reviews synthesize large amounts of information and present it in a coherent, organized fashion. In a literature review you will be combining material from several texts to create a new text – your literature review.

You will use common points among the sources you have gathered to help you synthesize the material. This will help ensure that your literature review is organized by subtopic, not by source. This means various authors' names can appear and reappear throughout the literature review, and each paragraph will mention several different authors. 

When you shift from writing summaries of the content of a source to synthesizing content from sources, there is a number things you must keep in mind: 

• Look for specific connections and or links between your sources and how those relate to your thesis or question.
• When writing and organizing your literature review be aware that your readers need to understand how and why the information from the different sources overlap.
• Organize your literature review by the themes you find within your sources or themes you have identified. 
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Literature Reviews

• 5. Synthesize your findings
• Getting started
• Types of reviews
• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results

How to synthesize

Approaches to synthesis.

• 6. Write the review
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In the synthesis step of a literature review, researchers analyze and integrate information from selected sources to identify patterns and themes. This involves critically evaluating findings, recognizing commonalities, and constructing a cohesive narrative that contributes to the understanding of the research topic.

Here are some examples of how to approach synthesizing the literature:

💡 By themes or concepts

🕘 Historically or chronologically

📊 By methodology

These organizational approaches can also be used when writing your review. It can be beneficial to begin organizing your references by these approaches in your citation manager by using folders, groups, or collections.

Create a synthesis matrix

A synthesis matrix allows you to visually organize your literature.

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Topic: Chemical exposure to workers in nail salons

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Literature Review - A Self-Guided Tutorial

• Literature Reviews: A Recap
• Reading Journal Articles
• Does it describe a Literature Review?
• 1. Identify the question
• 2. Review discipline styles
• Searching article databases - video
• Finding the article full-text
• Citation chaining
• When to stop searching
• 4. Manage your references
• 5. Critically analyze and evaluate
• 6. Synthesize
• 7. Write literature review

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Locate your University Library's subject librarian  for personalized assistance.

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You can sort the literature in various ways, for example:

Synthesis Matrix Example

From Jennifer Lim

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How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

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Saul Mcleod, PhD

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BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

When you write a literature review or essay, you have to go beyond just summarizing the articles you’ve read – you need to synthesize the literature to show how it all fits together (and how your own research fits in).

Synthesizing simply means combining. Instead of summarizing the main points of each source in turn, you put together the ideas and findings of multiple sources in order to make an overall point.

At the most basic level, this involves looking for similarities and differences between your sources. Your synthesis should show the reader where the sources overlap and where they diverge.

Unsynthesized Example

Franz (2008) studied undergraduate online students. He looked at 17 females and 18 males and found that none of them liked APA. According to Franz, the evidence suggested that all students are reluctant to learn citations style. Perez (2010) also studies undergraduate students. She looked at 42 females and 50 males and found that males were significantly more inclined to use citation software ( p < .05). Findings suggest that females might graduate sooner. Goldstein (2012) looked at British undergraduates. Among a sample of 50, all females, all confident in their abilities to cite and were eager to write their dissertations.

Synthesized Example

Studies of undergraduate students reveal conflicting conclusions regarding relationships between advanced scholarly study and citation efficacy. Although Franz (2008) found that no participants enjoyed learning citation style, Goldstein (2012) determined in a larger study that all participants watched felt comfortable citing sources, suggesting that variables among participant and control group populations must be examined more closely. Although Perez (2010) expanded on Franz’s original study with a larger, more diverse sample…

Step 1: Organize your sources

After collecting the relevant literature, you’ve got a lot of information to work through, and no clear idea of how it all fits together.

Before you can start writing, you need to organize your notes in a way that allows you to see the relationships between sources.

One way to begin synthesizing the literature is to put your notes into a table. Depending on your topic and the type of literature you’re dealing with, there are a couple of different ways you can organize this.

Summary table

A summary table collates the key points of each source under consistent headings. This is a good approach if your sources tend to have a similar structure – for instance, if they’re all empirical papers.

Each row in the table lists one source, and each column identifies a specific part of the source. You can decide which headings to include based on what’s most relevant to the literature you’re dealing with.

For example, you might include columns for things like aims, methods, variables, population, sample size, and conclusion.

For each study, you briefly summarize each of these aspects. You can also include columns for your own evaluation and analysis.

The summary table gives you a quick overview of the key points of each source. This allows you to group sources by relevant similarities, as well as noticing important differences or contradictions in their findings.

Synthesis matrix

A synthesis matrix is useful when your sources are more varied in their purpose and structure – for example, when you’re dealing with books and essays making various different arguments about a topic.

Each column in the table lists one source. Each row is labeled with a specific concept, topic or theme that recurs across all or most of the sources.

Then, for each source, you summarize the main points or arguments related to the theme.

The purposes of the table is to identify the common points that connect the sources, as well as identifying points where they diverge or disagree.

Step 2: Outline your structure

Now you should have a clear overview of the main connections and differences between the sources you’ve read. Next, you need to decide how you’ll group them together and the order in which you’ll discuss them.

For shorter papers, your outline can just identify the focus of each paragraph; for longer papers, you might want to divide it into sections with headings.

There are a few different approaches you can take to help you structure your synthesis.

If your sources cover a broad time period, and you found patterns in how researchers approached the topic over time, you can organize your discussion chronologically .

That doesn’t mean you just summarize each paper in chronological order; instead, you should group articles into time periods and identify what they have in common, as well as signalling important turning points or developments in the literature.

If the literature covers various different topics, you can organize it thematically .

That means that each paragraph or section focuses on a specific theme and explains how that theme is approached in the literature.

Source Used with Permission: The Chicago School

If you’re drawing on literature from various different fields or they use a wide variety of research methods, you can organize your sources methodologically .

That means grouping together studies based on the type of research they did and discussing the findings that emerged from each method.

If your topic involves a debate between different schools of thought, you can organize it theoretically .

That means comparing the different theories that have been developed and grouping together papers based on the position or perspective they take on the topic, as well as evaluating which arguments are most convincing.

Step 3: Write paragraphs with topic sentences

What sets a synthesis apart from a summary is that it combines various sources. The easiest way to think about this is that each paragraph should discuss a few different sources, and you should be able to condense the overall point of the paragraph into one sentence.

This is called a topic sentence , and it usually appears at the start of the paragraph. The topic sentence signals what the whole paragraph is about; every sentence in the paragraph should be clearly related to it.

A topic sentence can be a simple summary of the paragraph’s content:

“Early research on [x] focused heavily on [y].”

For an effective synthesis, you can use topic sentences to link back to the previous paragraph, highlighting a point of debate or critique:

“Several scholars have pointed out the flaws in this approach.” “While recent research has attempted to address the problem, many of these studies have methodological flaws that limit their validity.”

By using topic sentences, you can ensure that your paragraphs are coherent and clearly show the connections between the articles you are discussing.

As you write your paragraphs, avoid quoting directly from sources: use your own words to explain the commonalities and differences that you found in the literature.

Don’t try to cover every single point from every single source – the key to synthesizing is to extract the most important and relevant information and combine it to give your reader an overall picture of the state of knowledge on your topic.

Step 4: Revise, edit and proofread

Like any other piece of academic writing, synthesizing literature doesn’t happen all in one go – it involves redrafting, revising, editing and proofreading your work.

Checklist for Synthesis

•   Do I introduce the paragraph with a clear, focused topic sentence?
•   Do I discuss more than one source in the paragraph?
•   Do I mention only the most relevant findings, rather than describing every part of the studies?
•   Do I discuss the similarities or differences between the sources, rather than summarizing each source in turn?
•   Do I put the findings or arguments of the sources in my own words?
•   Is the paragraph organized around a single idea?
•   Is the paragraph directly relevant to my research question or topic?
•   Is there a logical transition from this paragraph to the next one?

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

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How to Write a Psychology Essay

Writing a Literature Review

• What is a Literature Review?
• Step 1: Choosing a Topic
• Step 2: Finding Information
• Step 3: Evaluating Content
• Step 4: Taking Notes
• Step 5: Synthesizing Content
• Step 6: Writing the Review
• Step 7: Citing Your Sources
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Tips on Synthesizing

By step 5 you are well into the literature review process. This next to last step is when you take a moment to reflect on the research you have, what you have learned, how the information fits into you topic, and what is the best way to present your findings.

Some tips on how to organize your research-

• Organize research by topic. Feel free to create subtopics as a means of connecting your research and ideas.
• Consider what points from each topic you want to address in your literature review. This is the time to start thinking about what areas you will discuss in your review and what pieces of research you will use to support your conclusions.
• After reviewing your notes, try summarizing the main points in one to two sentences.
• Draft an outline of your literature review. Start with a point, then list supporting arguments and resources. Repeat this process for each of your paper's main points.
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Synthetic literature reviews: An introduction

By Steve Wallis and Bernadette Wright 26/05/2020

Whether you are writing a funding proposal or an academic paper, you will most likely be required to start with a literature review of some kind. Despite (or because of) the work involved, a literature review is a great opportunity to showcase your knowledge on a topic. In this post, we’re going to take it one step further. We’re going to tell you a very practical approach to conducting literature reviews that allows you to show that you are advancing scientific knowledge before your project even begins. Also – and this is no small bonus – this approach lets you show how your literature review will lead to a more successful project.

Literature review – start with the basics

A literature review helps you shape effective solutions to the problems you (and your organisation) are facing. A literature review also helps you demonstrate the value of your activities. You can show how much you add to the process before you spend any money collecting new data. Finally, your literature review helps you avoid reinventing the wheel by showing you what relevant research already exists, so that you can target your new research more efficiently and more effectively.

We all want to conduct good research and have a meaningful impact on people’s lives. To do this, a literature review is a critical step. For funders, a literature review is especially important because it shows how much useful knowledge the writer already has.

Past methods of literature reviews tend to be focused on ‘muscle power’, that is spending more time and more effort to review more papers and adhering more closely to accepted standards. Examples of standards for conducting literature reviews include the PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions and the guidelines for assessing the quality and applicability of systematic reviews developed by the Task Force on Systematic Review and Guidelines . Given the untold millions of papers in many disciplines, even a large literature review that adheres to the best guidelines does little to move us toward integrated knowledge in and across disciplines.

In short, we need we need to work smarter, not harder!

Synthetic literature reviews

One approach that can provide more benefit is the synthetic literature review. Synthetic meaning synthesised or integrated, not artificial. Rather than explaining and reflecting on the results of previous studies (as is typically done in literature reviews), a synthetic literature review strives to create a new and more useful theoretical perspective by rigorously integrating the results of previous studies.

Many people find the process of synthesis difficult, elusive, or mysterious. When presenting their views and making recommendations for research, they tend to fall back on intuition (which is neither harder nor smarter).

After defining your research topic (‘poverty’ for example), the next step is to search the literature for existing theories or models of poverty that have been developed from research. You can use Google Scholar or your institutional database, or the assistance of a research librarian. A broad topic such as ‘poverty’, however, will lead you to millions of articles. You’ll narrow that field by focusing more closely on your topic and adding search terms. For example, you might be more interested in poverty among Latino communities in central California. You might also focus your search according to the date of the study (often, but not always, more recent results are preferred), or by geographic location. Continue refining and focusing your search until you have a workable number of papers (depending on your available time and resources). You might also take this time to throw out the papers that seem to be less relevant.

Skim those papers to be sure that they are really relevant to your topic. Once you have chosen a workable number of relevant papers, it is time to start integrating them.

Next, sort them according to the quality of their data.

Next, read the theory presented in each paper and create a diagram of the theory. The theory may be found in a section called ‘theory’ or sometimes in the ‘introduction’. For research papers, that presented theory may have changed during the research process, so you should look for the theory in the ‘findings’, ‘results’, or ‘discussion’ sections.

That diagram should include all relevant concepts from the theory and show the causal connections between the concepts that have been supported by research (some papers will present two theories, one before and one after the research – use the second one – only the hypotheses that have been supported by the research).

For a couple of brief and partial example from a recent interdisciplinary research paper, one theory of poverty might say ‘Having more education will help people to stay out of poverty’, while another might say ‘The more that the economy develops, the less poverty there will be’.

We then use those statements to create a diagram as we have in Figure 1.

Figure 1. Two (simple, partial) theories of poverty. (We like to use dashed lines to indicate ’causes less’, and solid lines to indicate ’causes more’)

When you have completed a diagram for each theory, the next step is to synthesise (integrate) them where the concepts are the same (or substantively similar) between two or more theories. With causal diagrams such as these, the process of synthesis becomes pretty direct. We simply combine the two (or more) theories to create a synthesised theory, such as in Figure 2.

Figure 2. Two theories synthesised where they overlap (in this case theories of poverty)

Much like a road map, a causal diagram of a theory with more concepts and more connecting arrows is more useful for navigation. You can show that your literature review is better than previous reviews by showing that you have taken a number of fragmented theories (as in Figure 1) and synthesised them to create a more coherent theory (as in Figure 2).

To go a step further, you may use Integrative Propositional Analysis (IPA) to quantify the extent to which your research has improved the structure and potential usefulness of your knowledge through the synthesis. Another source is our new book from Practical Mapping for Applied Research and Program Evaluation (see especially Chapter 5). (For the basics, you can look at Chapter One for free on the publisher’s site by clicking on the ‘Preview’ tab here. )

Once you become comfortable with the process, you will certainly be working ‘smarter’ and showcasing your knowledge to funders!

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Chapter 7: Synthesizing Sources

Learning objectives.

At the conclusion of this chapter, you will be able to:

• synthesize key sources connecting them with the research question and topic area.

7.1 Overview of synthesizing

7.1.1 putting the pieces together.

Combining separate elements into a whole is the dictionary definition of synthesis.  It is a way to make connections among and between numerous and varied source materials.  A literature review is not an annotated bibliography, organized by title, author, or date of publication.  Rather, it is grouped by topic to create a whole view of the literature relevant to your research question.

Your synthesis must demonstrate a critical analysis of the papers you collected as well as your ability to integrate the results of your analysis into your own literature review.  Each paper collected should be critically evaluated and weighed for “adequacy, appropriateness, and thoroughness” ( Garrard, 2017 ) before inclusion in your own review.  Papers that do not meet this criteria likely should not be included in your literature review.

Begin the synthesis process by creating a grid, table, or an outline where you will summarize, using common themes you have identified and the sources you have found. The summary grid or outline will help you compare and contrast the themes so you can see the relationships among them as well as areas where you may need to do more searching. Whichever method you choose, this type of organization will help you to both understand the information you find and structure the writing of your review.  Remember, although “the means of summarizing can vary, the key at this point is to make sure you understand what you’ve found and how it relates to your topic and research question” ( Bennard et al., 2014 ).

As you read through the material you gather, look for common themes as they may provide the structure for your literature review.  And, remember, research is an iterative process: it is not unusual to go back and search information sources for more material.

At one extreme, if you are claiming, ‘There are no prior publications on this topic,’ it is more likely that you have not found them yet and may need to broaden your search.  At another extreme, writing a complete literature review can be difficult with a well-trod topic.  Do not cite it all; instead cite what is most relevant.  If that still leaves too much to include, be sure to reference influential sources…as well as high-quality work that clearly connects to the points you make. ( Klingner, Scanlon, & Pressley, 2005 ).

7.2 Creating a summary table

Literature reviews can be organized sequentially or by topic, theme, method, results, theory, or argument.  It’s important to develop categories that are meaningful and relevant to your research question.  Take detailed notes on each article and use a consistent format for capturing all the information each article provides.  These notes and the summary table can be done manually, using note cards.  However, given the amount of information you will be recording, an electronic file created in a word processing or spreadsheet is more manageable. Examples of fields you may want to capture in your notes include:

• Authors’ names
• Article title
• Publication year
• Main purpose of the article
• Methodology or research design
• Participants
• Measurement
• Conclusions

  Other fields that will be useful when you begin to synthesize the sum total of your research:

• Specific details of the article or research that are especially relevant to your study
• Key terms and definitions
• Strengths or weaknesses in research design
• Relationships to other studies
• Possible gaps in the research or literature (for example, many research articles conclude with the statement “more research is needed in this area”)
• Finally, note how closely each article relates to your topic.  You may want to rank these as high, medium, or low relevance.  For papers that you decide not to include, you may want to note your reasoning for exclusion, such as ‘small sample size’, ‘local case study,’ or ‘lacks evidence to support assertion.’

This short video demonstrates how a nursing researcher might create a summary table.

7.2.1 Creating a Summary Table

  Summary tables can be organized by author or by theme, for example:

For a summary table template, see http://blogs.monm.edu/writingatmc/files/2013/04/Synthesis-Matrix-Template.pdf

7.3 Creating a summary outline

An alternate way to organize your articles for synthesis it to create an outline. After you have collected the articles you intend to use (and have put aside the ones you won’t be using), it’s time to identify the conclusions that can be drawn from the articles as a group.

  Based on your review of the collected articles, group them by categories.  You may wish to further organize them by topic and then chronologically or alphabetically by author.  For each topic or subtopic you identified during your critical analysis of the paper, determine what those papers have in common.  Likewise, determine which ones in the group differ.  If there are contradictory findings, you may be able to identify methodological or theoretical differences that could account for the contradiction (for example, differences in population demographics).  Determine what general conclusions you can report about the topic or subtopic as the entire group of studies relate to it.  For example, you may have several studies that agree on outcome, such as ‘hands on learning is best for science in elementary school’ or that ‘continuing education is the best method for updating nursing certification.’ In that case, you may want to organize by methodology used in the studies rather than by outcome.

Organize your outline in a logical order and prepare to write the first draft of your literature review.  That order might be from broad to more specific, or it may be sequential or chronological, going from foundational literature to more current.  Remember, “an effective literature review need not denote the entire historical record, but rather establish the raison d’etre for the current study and in doing so cite that literature distinctly pertinent for theoretical, methodological, or empirical reasons.” ( Milardo, 2015, p. 22 ).

As you organize the summarized documents into a logical structure, you are also appraising and synthesizing complex information from multiple sources.  Your literature review is the result of your research that synthesizes new and old information and creates new knowledge.

7.4 Additional resources:

Literature Reviews: Using a Matrix to Organize Research / Saint Mary’s University of Minnesota

Literature Review: Synthesizing Multiple Sources / Indiana University

Writing a Literature Review and Using a Synthesis Matrix / Florida International University

 Sample Literature Reviews Grid / Complied by Lindsay Roberts

Select three or four articles on a single topic of interest to you. Then enter them into an outline or table in the categories you feel are important to a research question. Try both the grid and the outline if you can to see which suits you better. The attached grid contains the fields suggested in the video .

Literature Review Table  

Test yourself.

• Select two articles from your own summary table or outline and write a paragraph explaining how and why the sources relate to each other and your review of the literature.
• In your literature review, under what topic or subtopic will you place the paragraph you just wrote?

Image attribution

Literature Reviews for Education and Nursing Graduate Students Copyright © by Linda Frederiksen is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Writing in the Health and Social Sciences: Literature Reviews and Synthesis Tools

• Journal Publishing
• Style and Writing Guides
• Readings about Writing
• Citing in APA Style This link opens in a new window
• Resources for Dissertation Authors
• Citation Management and Formatting Tools
• What are Literature Reviews?
• Conducting & Reporting Systematic Reviews
• Finding Systematic Reviews
• Tutorials & Tools for Literature Reviews

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

• The different types of literature reviews, including systematic reviews and other evidence synthesis methods
• Tools & Tutorials

Literature Review & Systematic Review Steps

• Develop a Focused Question
• Scope the Literature  (Initial Search)
• Refine & Expand the Search
• Limit the Results
• Download Citations
• Abstract & Analyze
• Create Flow Diagram
• Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

• PICO Question Help
• Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

• Background sources (books, point-of-care tools)
• Article databases
• Trial registries
• Grey literature
• Cited references
• Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

• Combine separate concepts with AND  (resulting in a narrower search)
• Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

• Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
• Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

• database thesauri
• reference lists
• relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

• a personal database account (e.g., MyNCBI for PubMed)
• Log in with your NYU credentials
• Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

• Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
• Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

• Filters in PubMed
• CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

• Citation Managers - General Guide

6. Abstract and Analyze

• Migrate citations to data collection/extraction tool
• Screen Title/Abstracts for inclusion/exclusion
• Screen and appraise full text for relevance, methods, 
• Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

• Covidence Support
• Critical Appraisal Tools
• Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

• PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
• PRISMA Diagram Templates  (Word and PDF)
• Make a copy of the file to fill out the template
• Image can be downloaded as PDF, PNG, JPG, or SVG
• Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

• Reporting Guidelines for Systematic Reviews
• Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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Writing a Literature Review: Organize, Synthesize, Evaluate

• Literature Review Process
• Literature Search
• Record your Search
• Organize, Synthesize, Evaluate
• Getting help

Table of Contents

On this page you will find:

Organizing Literature and Notes

How to scan an article.

• Reading for Comprehension
• Synthesis Matrix Information

Steps to take in organizing your literature and notes:

• Find common themes and organize the works into categories.
• Develop a subject level outline with studies you’ve found
• Expand or limit your search based on the information you found.
• How the works in each category relate to each other
• How the categories relate to each other and to your overall theme.

Available tools:

• Synthesis Matrix The "synthesis matrix" is an approach to organizing, monitoring, and documenting your search activities.
• Concept Mapping Concept Maps are graphic representations of topics, ideas, and their relationships. They allow users to group information in related modules so that the connections between and among the modules become more readily apparent than they might from an examination of a list. It can be done on paper or using specific software.
• Mind Mapping A mind map is a visual representation of hierarchical information that includes a central idea surrounded by connected branches of associated topics.
• NVIVO NVIVO is a qualitative data analysis software that can be applied for engineering literature review.

Synthesis Matrix

• Writing A Literature Review and Using a Synthesis Matrix Writing Center, Florida International University
• The Matrix Method of Literature Reviews Article from Health Promotion Practice journal.

Sample synthesis matrix

Synthesis matrix video

Skim the article to get the “big picture” for relevancy to your topic. You don’t have to understand every single idea in a text the first time you read it.

• Where was the paper published?
• What kind of journal it is? Is the journal peer-reviewed?
• Can you tell what the paper is about?
• Where are they from?
• What are the sections of the article?
• Are these clearly defined?  
• Can you figure out the purpose of the study, methodology, results and conclusion?
• Mentally review what you know about the topic
• Do you know enough to be able to understand the paper? If not, first read about the unfamiliar concepts  
• What is the overall context?
• Is the problem clearly stated?
• What does the paper bring new?
• Did it miss any previous major studies?
• Identify all the author’s assumptions.  
• Analyze the visuals for yourself and try to understand each of them. Make notes on what you understand. Write questions of what you do not understand. Make a guess about what materials/methods you expect to see. Do your own data interpretation and check them against the conclusions.  
• Do you agree with the author’s opinion?
• As you read, write down terms, techniques, unfamiliar concepts and look them up  
• Save retrieved sources to a reference manager

Read for Comprehension and Take Notes

Read for comprehension

• After first evaluation of sources, critically read the selected sources. Your goal is to determine how much of it to accept, determine its value, and decide whether you plan to include it in your literature review.
• Read the whole article, section by section but not necessarily in order and make sure you understand:

Introduction : What is known about the research and what is still unknown. Methods : What was measured? How was measured? Were the measurement appropriate? Did they offer sufficient evidence? Results : What is the main finding? Were there enough data presented? Were there problems not addressed? Discussions : Are these conclusions appropriate? Are there other factors that might have influenced? What does it need to be done to answer remaining questions?

• Find answers to your question from first step
• Formulate new questions and try to answer them
• Can you find any discrepancies? What would you have done differently?
• Re-read the whole article or just sections as many times you feel you need to
• When you believe that you have understood the article, write a summary in your own words (Make sure that there is nothing left that you cannot understand)

As you read, take (extensive) notes. Create your own system to take notes but be consistent. Remember that notes can be taken within the citation management tool.

What to write in your notes:

• identify key topic, methodology, key terms
• identify emphases, strengths, weaknesses, gaps (if any)
• determine relationships to other studies
• identify the relationship to your research topic
• new questions you have  
• suggestions for new directions, new sources to read
• everything else that seems relevant
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Synthesis and Literature Reviews

Why do we seek to understand the ways that authors or sources “converse” with one another?

So that we can synthesize various perspectives on a topic to more deeply understand it .

In academic writing, this understanding of the “conversation” may become the content of an explanatory synthesis paper – a paper in which you, the writer, point out various various themes or key points from a conversation on a particular topic.

Or, another assignment that you may complete in college is a literature review , which applies your synthesis skills. Literature reviews are often found in the beginning of scholarly journal articles. Literature reviews synthesize previous research that has been done on a particular topic, summarizing important works in the history of research on that topic.

• Literature reviews can be arranged by topic or theme , much like a traditional explanatory synthesis paper.
• Literature reviews can also be arranged chronologically , according to various time periods of research on a topic (i.e., what was published ten years ago, five years ago, and within the last year, for example).
• Finally, literature reviews can be arranged by discipline or field (i.e., what is the current research being done by biologists on this topic? What is the current research being done by psychologists on this topic? What is the current research being done by [insert academic discipline] on this topic?).

Just like in an explanatory synthesis paper, a Literature Review offers  only  a report on what others have already written about. The Literature Review does not reflect the author’s own argument or contributions to the field of research. Instead, it indicates that the author has read others’ important contributions and understands what has come before him or her.

The Literature Review provides context for the author’s own new research. It is the basis and background out of which the author’s research grows. Context = credibility in academic writing. When authors have broad Literature Review, they demonstrate their credibility as researchers.

English 102: Reading, Research, and Writing by Emilie Zickel is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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What Synthesis Methodology Should I Use? A Review and Analysis of Approaches to Research Synthesis

Kara schick-makaroff.

1 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada

Marjorie MacDonald

2 School of Nursing, University of Victoria, Victoria, BC, Canada

Marilyn Plummer

3 College of Nursing, Camosun College, Victoria, BC, Canada

Judy Burgess

4 Student Services, University Health Services, Victoria, BC, Canada

Wendy Neander

Associated data, additional file 1.

When we began this process, we were doctoral students and a faculty member in a research methods course. As students, we were facing a review of the literature for our dissertations. We encountered several different ways of conducting a review but were unable to locate any resources that synthesized all of the various synthesis methodologies. Our purpose is to present a comprehensive overview and assessment of the main approaches to research synthesis. We use ‘research synthesis’ as a broad overarching term to describe various approaches to combining, integrating, and synthesizing research findings.

We conducted an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis. We searched five databases, reviewed websites of key organizations, hand-searched several journals, and examined relevant texts from the reference lists of the documents we had already obtained.

We identified four broad categories of research synthesis methodology including conventional, quantitative, qualitative, and emerging syntheses. Each of the broad categories was compared to the others on the following: key characteristics, purpose, method, product, context, underlying assumptions, unit of analysis, strengths and limitations, and when to use each approach.

Conclusions

The current state of research synthesis reflects significant advancements in emerging synthesis studies that integrate diverse data types and sources. New approaches to research synthesis provide a much broader range of review alternatives available to health and social science students and researchers.

1. Introduction

Since the turn of the century, public health emergencies have been identified worldwide, particularly related to infectious diseases. For example, the Severe Acute Respiratory Syndrome (SARS) epidemic in Canada in 2002-2003, the recent Ebola epidemic in Africa, and the ongoing HIV/AIDs pandemic are global health concerns. There have also been dramatic increases in the prevalence of chronic diseases around the world [1] – [3] . These epidemiological challenges have raised concerns about the ability of health systems worldwide to address these crises. As a result, public health systems reform has been initiated in a number of countries. In Canada, as in other countries, the role of evidence to support public health reform and improve population health has been given high priority. Yet, there continues to be a significant gap between the production of evidence through research and its application in practice [4] – [5] . One strategy to address this gap has been the development of new research synthesis methodologies to deal with the time-sensitive and wide ranging evidence needs of policy makers and practitioners in all areas of health care, including public health.

As doctoral nursing students facing a review of the literature for our dissertations, and as a faculty member teaching a research methods course, we encountered several ways of conducting a research synthesis but found no comprehensive resources that discussed, compared, and contrasted various synthesis methodologies on their purposes, processes, strengths and limitations. To complicate matters, writers use terms interchangeably or use different terms to mean the same thing, and the literature is often contradictory about various approaches. Some texts [6] , [7] – [9] did provide a preliminary understanding about how research synthesis had been taken up in nursing, but these did not meet our requirements. Thus, in this article we address the need for a comprehensive overview of research synthesis methodologies to guide public health, health care, and social science researchers and practitioners.

Research synthesis is relatively new in public health but has a long history in other fields dating back to the late 1800s. Research synthesis, a research process in its own right [10] , has become more prominent in the wake of the evidence-based movement of the 1990s. Research syntheses have found their advocates and detractors in all disciplines, with challenges to the processes of systematic review and meta-analysis, in particular, being raised by critics of evidence-based healthcare [11] – [13] .

Our purpose was to conduct an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis [14] – [15] . We synthesize and critique the main approaches to research synthesis that are relevant for public health, health care, and social scientists. Research synthesis is the overarching term we use to describe approaches to combining, aggregating, integrating, and synthesizing primary research findings. Each synthesis methodology draws on different types of findings depending on the purpose and product of the chosen synthesis (see Additional File 1 ).

3. Method of Review

Based on our current knowledge of the literature, we identified these approaches to include in our review: systematic review, meta-analysis, qualitative meta-synthesis, meta-narrative synthesis, scoping review, rapid review, realist synthesis, concept analysis, literature review, and integrative review. Our first step was to divide the synthesis types among the research team. Each member did a preliminary search to identify key texts. The team then met to develop search terms and a framework to guide the review.

Over the period of 2008 to 2012 we extensively searched the literature, updating our search at several time points, not restricting our search by date. The dates of texts reviewed range from 1967 to 2015. We used the terms above combined with the term “method* (e.g., “realist synthesis” and “method*) in the database Health Source: Academic Edition (includes Medline and CINAHL). This search yielded very few texts on some methodologies and many on others. We realized that many documents on research synthesis had not been picked up in the search. Therefore, we also searched Google Scholar, PubMed, ERIC, and Social Science Index, as well as the websites of key organizations such as the Joanna Briggs Institute, the University of York Centre for Evidence-Based Nursing, and the Cochrane Collaboration database. We hand searched several nursing, social science, public health and health policy journals. Finally, we traced relevant documents from the references in obtained texts.

We included works that met the following inclusion criteria: (1) published in English; (2) discussed the history of research synthesis; (3) explicitly described the approach and specific methods; or (4) identified issues, challenges, strengths and limitations of the particular methodology. We excluded research reports that resulted from the use of particular synthesis methodologies unless they also included criteria 2, 3, or 4 above.

Based on our search, we identified additional types of research synthesis (e.g., meta-interpretation, best evidence synthesis, critical interpretive synthesis, meta-summary, grounded formal theory). Still, we missed some important developments in meta-analysis, for example, identified by the journal's reviewers that have now been discussed briefly in the paper. The final set of 197 texts included in our review comprised theoretical, empirical, and conceptual papers, books, editorials and commentaries, and policy documents.

In our preliminary review of key texts, the team inductively developed a framework of the important elements of each method for comparison. In the next phase, each text was read carefully, and data for these elements were extracted into a table for comparison on the points of: key characteristics, purpose, methods, and product; see Additional File 1 ). Once the data were grouped and extracted, we synthesized across categories based on the following additional points of comparison: complexity of the process, degree of systematization, consideration of context, underlying assumptions, unit of analysis, and when to use each approach. In our results, we discuss our comparison of the various synthesis approaches on the elements above. Drawing only on documents for the review, ethics approval was not required.

We identified four broad categories of research synthesis methodology: Conventional, quantitative, qualitative, and emerging syntheses. From our dataset of 197 texts, we had 14 texts on conventional synthesis, 64 on quantitative synthesis, 78 on qualitative synthesis, and 41 on emerging syntheses. Table 1 provides an overview of the four types of research synthesis, definitions, types of data used, products, and examples of the methodology.

Although we group these types of synthesis into four broad categories on the basis of similarities, each type within a category has unique characteristics, which may differ from the overall group similarities. Each could be explored in greater depth to tease out their unique characteristics, but detailed comparison is beyond the scope of this article.

Additional File 1 presents one or more selected types of synthesis that represent the broad category but is not an exhaustive presentation of all types within each category. It provides more depth for specific examples from each category of synthesis on the characteristics, purpose, methods, and products than is found in Table 1 .

4.1. Key Characteristics

4.1.1. what is it.

Here we draw on two types of categorization. First, we utilize Dixon Woods et al.'s [49] classification of research syntheses as being either integrative or interpretive . (Please note that integrative syntheses are not the same as an integrative review as defined in Additional File 1 .) Second, we use Popay's [80] enhancement and epistemological models .

The defining characteristics of integrative syntheses are that they involve summarizing the data achieved by pooling data [49] . Integrative syntheses include systematic reviews, meta-analyses, as well as scoping and rapid reviews because each of these focus on summarizing data. They also define concepts from the outset (although this may not always be true in scoping or rapid reviews) and deal with a well-specified phenomenon of interest.

Interpretive syntheses are primarily concerned with the development of concepts and theories that integrate concepts [49] . The analysis in interpretive synthesis is conceptual both in process and outcome, and “the product is not aggregations of data, but theory” [49] , [p.12]. Interpretive syntheses involve induction and interpretation, and are primarily conceptual in process and outcome. Examples include integrative reviews, some systematic reviews, all of the qualitative syntheses, meta-narrative, realist and critical interpretive syntheses. Of note, both quantitative and qualitative studies can be either integrative or interpretive

The second categorization, enhancement versus epistemological , applies to those approaches that use multiple data types and sources [80] . Popay's [80] classification reflects the ways that qualitative data are valued in relation to quantitative data.

In the enhancement model , qualitative data adds something to quantitative analysis. The enhancement model is reflected in systematic reviews and meta-analyses that use some qualitative data to enhance interpretation and explanation. It may also be reflected in some rapid reviews that draw on quantitative data but use some qualitative data.

The epistemological model assumes that quantitative and qualitative data are equal and each has something unique to contribute. All of the other review approaches, except pure quantitative or qualitative syntheses, reflect the epistemological model because they value all data types equally but see them as contributing different understandings.

4.1.2. Data type

By and large, the quantitative approaches (quantitative systematic review and meta-analysis) have typically used purely quantitative data (i.e., expressed in numeric form). More recently, both Cochrane [81] and Campbell [82] collaborations are grappling with the need to, and the process of, integrating qualitative research into a systematic review. The qualitative approaches use qualitative data (i.e., expressed in words). All of the emerging synthesis types, as well as the conventional integrative review, incorporate qualitative and quantitative study designs and data.

4.1.3. Research question

Four types of research questions direct inquiry across the different types of syntheses. The first is a well-developed research question that gives direction to the synthesis (e.g., meta-analysis, systematic review, meta-study, concept analysis, rapid review, realist synthesis). The second begins as a broad general question that evolves and becomes more refined over the course of the synthesis (e.g., meta-ethnography, scoping review, meta-narrative, critical interpretive synthesis). In the third type, the synthesis begins with a phenomenon of interest and the question emerges in the analytic process (e.g., grounded formal theory). Lastly, there is no clear question, but rather a general review purpose (e.g., integrative review). Thus, the requirement for a well-defined question cuts across at least three of the synthesis types (e.g., quantitative, qualitative, and emerging).

4.1.4. Quality appraisal

This is a contested issue within and between the four synthesis categories. There are strong proponents of quality appraisal in the quantitative traditions of systematic review and meta-analysis based on the need for strong studies that will not jeopardize validity of the overall findings. Nonetheless, there is no consensus on pre-defined criteria; many scales exist that vary dramatically in composition. This has methodological implications for the credibility of findings [83] .

Specific methodologies from the conventional, qualitative, and emerging categories support quality appraisal but do so with caveats. In conventional integrative reviews appraisal is recommended, but depends on the sampling frame used in the study [18] . In meta-study, appraisal criteria are explicit but quality criteria are used in different ways depending on the specific requirements of the inquiry [54] . Among the emerging syntheses, meta-narrative review developers support appraisal of a study based on criteria from the research tradition of the primary study [67] , [84] – [85] . Realist synthesis similarly supports the use of high quality evidence, but appraisal checklists are viewed with scepticism and evidence is judged based on relevance to the research question and whether a credible inference may be drawn [69] . Like realist, critical interpretive syntheses do not judge quality using standardized appraisal instruments. They will exclude fatally flawed studies, but there is no consensus on what ‘fatally flawed’ means [49] , [71] . Appraisal is based on relevance to the inquiry, not rigor of the study.

There is no agreement on quality appraisal among qualitative meta-ethnographers with some supporting and others refuting the need for appraisal. [60] , [62] . Opponents of quality appraisal are found among authors of qualitative (grounded formal theory and concept analysis) and emerging syntheses (scoping and rapid reviews) because quality is not deemed relevant to the intention of the synthesis; the studies being reviewed are not effectiveness studies where quality is extremely important. These qualitative synthesis are often reviews of theoretical developments where the concept itself is what is important, or reviews that provide quotations from the raw data so readers can make their own judgements about the relevance and utility of the data. For example, in formal grounded theory, the purpose of theory generation and authenticity of data used to generate the theory is not as important as the conceptual category. Inaccuracies may be corrected in other ways, such as using the constant comparative method, which facilitates development of theoretical concepts that are repeatedly found in the data [86] – [87] . For pragmatic reasons, evidence is not assessed in rapid and scoping reviews, in part to produce a timely product. The issue of quality appraisal is unresolved across the terrain of research synthesis and we consider this further in our discussion.

4.2. Purpose

All research syntheses share a common purpose -- to summarize, synthesize, or integrate research findings from diverse studies. This helps readers stay abreast of the burgeoning literature in a field. Our discussion here is at the level of the four categories of synthesis. Beginning with conventional literature syntheses, the overall purpose is to attend to mature topics for the purpose of re-conceptualization or to new topics requiring preliminary conceptualization [14] . Such syntheses may be helpful to consider contradictory evidence, map shifting trends in the study of a phenomenon, and describe the emergence of research in diverse fields [14] . The purpose here is to set the stage for a study by identifying what has been done, gaps in the literature, important research questions, or to develop a conceptual framework to guide data collection and analysis.

The purpose of quantitative systematic reviews is to combine, aggregate, or integrate empirical research to be able to generalize from a group of studies and determine the limits of generalization [27] . The focus of quantitative systematic reviews has been primarily on aggregating the results of studies evaluating the effectiveness of interventions using experimental, quasi-experimental, and more recently, observational designs. Systematic reviews can be done with or without quantitative meta-analysis but a meta-analysis always takes place within the context of a systematic review. Researchers must consider the review's purpose and the nature of their data in undertaking a quantitative synthesis; this will assist in determining the approach.

The purpose of qualitative syntheses is broadly to synthesize complex health experiences, practices, or concepts arising in healthcare environments. There may be various purposes depending on the qualitative methodology. For example, in hermeneutic studies the aim may be holistic explanation or understanding of a phenomenon [42] , which is deepened by integrating the findings from multiple studies. In grounded formal theory, the aim is to produce a conceptual framework or theory expected to be applicable beyond the original study. Although not able to generalize from qualitative research in the statistical sense [88] , qualitative researchers usually do want to say something about the applicability of their synthesis to other settings or phenomena. This notion of ‘theoretical generalization’ has been referred to as ‘transferability’ [89] – [90] and is an important criterion of rigour in qualitative research. It applies equally to the products of a qualitative synthesis in which the synthesis of multiple studies on the same phenomenon strengthens the ability to draw transferable conclusions.

The overarching purpose of emerging syntheses is challenging the more traditional types of syntheses, in part by using data from both quantitative and qualitative studies with diverse designs for analysis. Beyond this, however, each emerging synthesis methodology has a unique purpose. In meta-narrative review, the purpose is to identify different research traditions in the area, synthesize a complex and diverse body of research. Critical interpretive synthesis shares this characteristic. Although a distinctive approach, critical interpretive synthesis utilizes a modification of the analytic strategies of meta-ethnography [61] (e.g., reciprocal translational analysis, refutational synthesis, and lines of argument synthesis) but goes beyond the use of these to bring a critical perspective to bear in challenging the normative or epistemological assumptions in the primary literature [72] – [73] . The unique purpose of a realist synthesis is to amalgamate complex empirical evidence and theoretical understandings within a diverse body of literature to uncover the operative mechanisms and contexts that affect the outcomes of social interventions. In a scoping review, the intention is to find key concepts, examine the range of research in an area, and identify gaps in the literature. The purpose of a rapid review is comparable to that of a scoping review, but done quickly to meet the time-sensitive information needs of policy makers.

4.3. Method

4.3.1. degree of systematization.

There are varying degrees of systematization across the categories of research synthesis. The most systematized are quantitative systematic reviews and meta-analyses. There are clear processes in each with judgments to be made at each step, although there are no agreed upon guidelines for this. The process is inherently subjective despite attempts to develop objective and systematic processes [91] – [92] . Mullen and Ramirez [27] suggest that there is often a false sense of rigour implied by the terms ‘systematic review’ and ‘meta-analysis’ because of their clearly defined procedures.

In comparison with some types of qualitative synthesis, concept analysis is quite procedural. Qualitative meta-synthesis also has defined procedures and is systematic, yet perhaps less so than concept analysis. Qualitative meta-synthesis starts in an unsystematic way but becomes more systematic as it unfolds. Procedures and frameworks exist for some of the emerging types of synthesis [e.g., [50] , [63] , [71] , [93] ] but are not linear, have considerable flexibility, and are often messy with emergent processes [85] . Conventional literature reviews tend not to be as systematic as the other three types. In fact, the lack of systematization in conventional literature synthesis was the reason for the development of more systematic quantitative [17] , [20] and qualitative [45] – [46] , [61] approaches. Some authors in the field [18] have clarified processes for integrative reviews making them more systematic and rigorous, but most conventional syntheses remain relatively unsystematic in comparison with other types.

4.3.2. Complexity of the process

Some synthesis processes are considerably more complex than others. Methodologies with clearly defined steps are arguably less complex than the more flexible and emergent ones. We know that any study encounters challenges and it is rare that a pre-determined research protocol can be followed exactly as intended. Not even the rigorous methods associated with Cochrane [81] systematic reviews and meta-analyses are always implemented exactly as intended. Even when dealing with numbers rather than words, interpretation is always part of the process. Our collective experience suggests that new methodologies (e.g., meta-narrative synthesis and realist synthesis) that integrate different data types and methods are more complex than conventional reviews or the rapid and scoping reviews.

4.4. Product

The products of research syntheses usually take three distinct formats (see Table 1 and Additional File 1 for further details). The first representation is in tables, charts, graphical displays, diagrams and maps as seen in integrative, scoping and rapid reviews, meta-analyses, and critical interpretive syntheses. The second type of synthesis product is the use of mathematical scores. Summary statements of effectiveness are mathematically displayed in meta-analyses (as an effect size), systematic reviews, and rapid reviews (statistical significance).

The third synthesis product may be a theory or theoretical framework. A mid-range theory can be produced from formal grounded theory, meta-study, meta-ethnography, and realist synthesis. Theoretical/conceptual frameworks or conceptual maps may be created in meta-narrative and critical interpretive syntheses, and integrative reviews. Concepts for use within theories are produced in concept analysis. While these three product types span the categories of research synthesis, narrative description and summary is used to present the products resulting from all methodologies.

4.5. Consideration of context

There are diverse ways that context is considered in the four broad categories of synthesis. Context may be considered to the extent that it features within primary studies for the purpose of the review. Context may also be understood as an integral aspect of both the phenomenon under study and the synthesis methodology (e.g., realist synthesis). Quantitative systematic reviews and meta-analyses have typically been conducted on studies using experimental and quasi-experimental designs and more recently observational studies, which control for contextual features to allow for understanding of the ‘true’ effect of the intervention [94] .

More recently, systematic reviews have included covariates or mediating variables (i.e., contextual factors) to help explain variability in the results across studies [27] . Context, however, is usually handled in the narrative discussion of findings rather than in the synthesis itself. This lack of attention to context has been one criticism leveled against systematic reviews and meta-analyses, which restrict the types of research designs that are considered [e.g., [95] ].

When conventional literature reviews incorporate studies that deal with context, there is a place for considering contextual influences on the intervention or phenomenon. Reviews of quantitative experimental studies tend to be devoid of contextual considerations since the original studies are similarly devoid, but context might figure prominently in a literature review that incorporates both quantitative and qualitative studies.

Qualitative syntheses have been conducted on the contextual features of a particular phenomenon [33] . Paterson et al. [54] advise researchers to attend to how context may have influenced the findings of particular primary studies. In qualitative analysis, contextual features may form categories by which the data can be compared and contrasted to facilitate interpretation. Because qualitative research is often conducted to understand a phenomenon as a whole, context may be a focus, although this varies with the qualitative methodology. At the same time, the findings in a qualitative synthesis are abstracted from the original reports and taken to a higher level of conceptualization, thus removing them from the original context.

Meta-narrative synthesis [67] , [84] , because it draws on diverse research traditions and methodologies, may incorporate context into the analysis and findings. There is not, however, an explicit step in the process that directs the analyst to consider context. Generally, the research question guiding the synthesis is an important factor in whether context will be a focus.

More recent iterations of concept analysis [47] , [96] – [97] explicitly consider context reflecting the assumption that a concept's meaning is determined by its context. Morse [47] points out, however, that Wilson's [98] approach to concept analysis, and those based on Wilson [e.g., [45] ], identify attributes that are devoid of context, while Rodgers' [96] , [99] evolutionary method considers context (e.g., antecedents, consequences, and relationships to other concepts) in concept development.

Realist synthesis [69] considers context as integral to the study. It draws on a critical realist logic of inquiry grounded in the work of Bhaskar [100] , who argues that empirical co-occurrence of events is insufficient for inferring causation. One must identify generative mechanisms whose properties are causal and, depending on the situation, may nor may not be activated [94] . Context interacts with program/intervention elements and thus cannot be differentiated from the phenomenon [69] . This approach synthesizes evidence on generative mechanisms and analyzes contextual features that activate them; the result feeds back into the context. The focus is on what works, for whom, under what conditions, why and how [68] .

4.6. Underlying Philosophical and Theoretical Assumptions

When we began our review, we ‘assumed’ that the assumptions underlying synthesis methodologies would be a distinguishing characteristic of synthesis types, and that we could compare the various types on their assumptions, explicit or implicit. We found, however, that many authors did not explicate the underlying assumptions of their methodologies, and it was difficult to infer them. Kirkevold [101] has argued that integrative reviews need to be carried out from an explicit philosophical or theoretical perspective. We argue this should be true for all types of synthesis.

Authors of some emerging synthesis approaches have been very explicit about their assumptions and philosophical underpinnings. An implicit assumption of most emerging synthesis methodologies is that quantitative systematic reviews and meta-analyses have limited utility in some fields [e.g., in public health – [13] , [102] ] and for some kinds of review questions like those about feasibility and appropriateness versus effectiveness [103] – [104] . They also assume that ontologically and epistemologically, both kinds of data can be combined. This is a significant debate in the literature because it is about the commensurability of overarching paradigms [105] but this is beyond the scope of this review.

Realist synthesis is philosophically grounded in critical realism or, as noted above, a realist logic of inquiry [93] , [99] , [106] – [107] . Key assumptions regarding the nature of interventions that inform critical realism have been described above in the section on context. See Pawson et al. [106] for more information on critical realism, the philosophical basis of realist synthesis.

Meta-narrative synthesis is explicitly rooted in a constructivist philosophy of science [108] in which knowledge is socially constructed rather than discovered, and what we take to be ‘truth’ is a matter of perspective. Reality has a pluralistic and plastic character, and there is no pre-existing ‘real world’ independent of human construction and language [109] . See Greenhalgh et al. [67] , [85] and Greenhalgh & Wong [97] for more discussion of the constructivist basis of meta-narrative synthesis.

In the case of purely quantitative or qualitative syntheses, it may be an easier matter to uncover unstated assumptions because they are likely to be shared with those of the primary studies in the genre. For example, grounded formal theory shares the philosophical and theoretical underpinnings of grounded theory, rooted in the theoretical perspective of symbolic interactionism [110] – [111] and the philosophy of pragmatism [87] , [112] – [114] .

As with meta-narrative synthesis, meta-study developers identify constructivism as their interpretive philosophical foundation [54] , [88] . Epistemologically, constructivism focuses on how people construct and re-construct knowledge about a specific phenomenon, and has three main assumptions: (1) reality is seen as multiple, at times even incompatible with the phenomenon under consideration; (2) just as primary researchers construct interpretations from participants' data, meta-study researchers also construct understandings about the primary researchers' original findings. Thus, meta-synthesis is a construction of a construction, or a meta-construction; and (3) all constructions are shaped by the historical, social and ideological context in which they originated [54] . The key message here is that reports of any synthesis would benefit from an explicit identification of the underlying philosophical perspectives to facilitate a better understanding of the results, how they were derived, and how they are being interpreted.

4.7. Unit of Analysis

The unit of analysis for each category of review is generally distinct. For the emerging synthesis approaches, the unit of analysis is specific to the intention. In meta-narrative synthesis it is the storyline in diverse research traditions; in rapid review or scoping review, it depends on the focus but could be a concept; and in realist synthesis, it is the theories rather than programs that are the units of analysis. The elements of theory that are important in the analysis are mechanisms of action, the context, and the outcome [107] .

For qualitative synthesis, the units of analysis are generally themes, concepts or theories, although in meta-study, the units of analysis can be research findings (“meta-data-analysis”), research methods (“meta-method”) or philosophical/theoretical perspectives (“meta-theory”) [54] . In quantitative synthesis, the units of analysis range from specific statistics for systematic reviews to effect size of the intervention for meta-analysis. More recently, some systematic reviews focus on theories [115] – [116] , therefore it depends on the research question. Similarly, within conventional literature synthesis the units of analysis also depend on the research purpose, focus and question as well as on the type of research methods incorporated into the review. What is important in all research syntheses, however, is that the unit of analysis needs to be made explicit. Unfortunately, this is not always the case.

4.8. Strengths and Limitations

In this section, we discuss the overarching strengths and limitations of synthesis methodologies as a whole and then highlight strengths and weaknesses across each of our four categories of synthesis.

4.8.1. Strengths of Research Syntheses in General

With the vast proliferation of research reports and the increased ease of retrieval, research synthesis has become more accessible providing a way of looking broadly at the current state of research. The availability of syntheses helps researchers, practitioners, and policy makers keep up with the burgeoning literature in their fields without which evidence-informed policy or practice would be difficult. Syntheses explain variation and difference in the data helping us identify the relevance for our own situations; they identify gaps in the literature leading to new research questions and study designs. They help us to know when to replicate a study and when to avoid excessively duplicating research. Syntheses can inform policy and practice in a way that well-designed single studies cannot; they provide building blocks for theory that helps us to understand and explain our phenomena of interest.

4.8.2. Limitations of Research Syntheses in General

The process of selecting, combining, integrating, and synthesizing across diverse study designs and data types can be complex and potentially rife with bias, even with those methodologies that have clearly defined steps. Just because a rigorous and standardized approach has been used does not mean that implicit judgements will not influence the interpretations and choices made at different stages.

In all types of synthesis, the quantity of data can be considerable, requiring difficult decisions about scope, which may affect relevance. The quantity of available data also has implications for the size of the research team. Few reviews these days can be done independently, in particular because decisions about inclusion and exclusion may require the involvement of more than one person to ensure reliability.

For all types of synthesis, it is likely that in areas with large, amorphous, and diverse bodies of literature, even the most sophisticated search strategies will not turn up all the relevant and important texts. This may be more important in some synthesis methodologies than in others, but the omission of key documents can influence the results of all syntheses. This issue can be addressed, at least in part, by including a library scientist on the research team as required by some funding agencies. Even then, it is possible to miss key texts. In this review, for example, because none of us are trained in or conduct meta-analyses, we were not even aware that we had missed some new developments in this field such as meta-regression [117] – [118] , network meta-analysis [119] – [121] , and the use of individual patient data in meta-analyses [122] – [123] .

One limitation of systematic reviews and meta-analyses is that they rapidly go out of date. We thought this might be true for all types of synthesis, although we wondered if those that produce theory might not be somewhat more enduring. We have not answered this question but it is open for debate. For all types of synthesis, the analytic skills and the time required are considerable so it is clear that training is important before embarking on a review, and some types of review may not be appropriate for students or busy practitioners.

Finally, the quality of reporting in primary studies of all genres is variable so it is sometimes difficult to identify aspects of the study essential for the synthesis, or to determine whether the study meets quality criteria. There may be flaws in the original study, or journal page limitations may necessitate omitting important details. Reporting standards have been developed for some types of reviews (e.g., systematic review, meta-analysis, meta-narrative synthesis, realist synthesis); but there are no agreed upon standards for qualitative reviews. This is an important area for development in advancing the science of research synthesis.

4.8.3. Strengths and Limitations of the Four Synthesis Types

The conventional literature review and now the increasingly common integrative review remain important and accessible approaches for students, practitioners, and experienced researchers who want to summarize literature in an area but do not have the expertise to use one of the more complex methodologies. Carefully executed, such reviews are very useful for synthesizing literature in preparation for research grants and practice projects. They can determine the state of knowledge in an area and identify important gaps in the literature to provide a clear rationale or theoretical framework for a study [14] , [18] . There is a demand, however, for more rigour, with more attention to developing comprehensive search strategies and more systematic approaches to combining, integrating, and synthesizing the findings.

Generally, conventional reviews include diverse study designs and data types that facilitate comprehensiveness, which may be a strength on the one hand, but can also present challenges on the other. The complexity inherent in combining results from studies with diverse methodologies can result in bias and inaccuracies. The absence of clear guidelines about how to synthesize across diverse study types and data [18] has been a challenge for novice reviewers.

Quantitative systematic reviews and meta-analyses have been important in launching the field of evidence-based healthcare. They provide a systematic, orderly and auditable process for conducting a review and drawing conclusions [25] . They are arguably the most powerful approaches to understanding the effectiveness of healthcare interventions, especially when intervention studies on the same topic show very different results. When areas of research are dogged by controversy [25] or when study results go against strongly held beliefs, such approaches can reduce the uncertainty and bring strong evidence to bear on the controversy.

Despite their strengths, they also have limitations. Systematic reviews and meta-analyses do not provide a way of including complex literature comprising various types of evidence including qualitative studies, theoretical work, and epidemiological studies. Only certain types of design are considered and qualitative data are used in a limited way. This exclusion limits what can be learned in a topic area.

Meta-analyses are often not possible because of wide variability in study design, population, and interventions so they may have a narrow range of utility. New developments in meta-analysis, however, can be used to address some of these limitations. Network meta-analysis is used to explore relative efficacy of multiple interventions, even those that have never been compared in more conventional pairwise meta-analyses [121] , allowing for improved clinical decision making [120] . The limitation is that network meta-analysis has only been used in medical/clinical applications [119] and not in public health. It has not yet been widely accepted and many methodological challenges remain [120] – [121] . Meta-regression is another development that combines meta-analytic and linear regression principles to address the fact that heterogeneity of results may compromise a meta-analysis [117] – [118] . The disadvantage is that many clinicians are unfamiliar with it and may incorrectly interpret results [117] .

Some have accused meta-analysis of combining apples and oranges [124] raising questions in the field about their meaningfulness [25] , [28] . More recently, the use of individual rather than aggregate data has been useful in facilitating greater comparability among studies [122] . In fact, Tomas et al. [123] argue that meta-analysis using individual data is now the gold standard although access to the raw data from other studies may be a challenge to obtain.

The usefulness of systematic reviews in synthesizing complex health and social interventions has also been challenged [102] . It is often difficult to synthesize their findings because such studies are “epistemologically diverse and methodologically complex” [ [69] , p.21]. Rigid inclusion/exclusion criteria may allow only experimental or quasi-experimental designs into consideration resulting in lost information that may well be useful to policy makers for tailoring an intervention to the context or understanding its acceptance by recipients.

Qualitative syntheses may be the type of review most fraught with controversy and challenge, while also bringing distinct strengths to the enterprise. Although these methodologies provide a comprehensive and systematic review approach, they do not generally provide definitive statements about intervention effectiveness. They do, however, address important questions about the development of theoretical concepts, patient experiences, acceptability of interventions, and an understanding about why interventions might work.

Most qualitative syntheses aim to produce a theoretically generalizable mid-range theory that explains variation across studies. This makes them more useful than single primary studies, which may not be applicable beyond the immediate setting or population. All provide a contextual richness that enhances relevance and understanding. Another benefit of some types of qualitative synthesis (e.g., grounded formal theory) is that the concept of saturation provides a sound rationale for limiting the number of texts to be included thus making reviews potentially more manageable. This contrasts with the requirements of systematic reviews and meta-analyses that require an exhaustive search.

Qualitative researchers debate about whether the findings of ontologically and epistemological diverse qualitative studies can actually be combined or synthesized [125] because methodological diversity raises many challenges for synthesizing findings. The products of different types of qualitative syntheses range from theory and conceptual frameworks, to themes and rich descriptive narratives. Can one combine the findings from a phenomenological study with the theory produced in a grounded theory study? Many argue yes, but many also argue no.

Emerging synthesis methodologies were developed to address some limitations inherent in other types of synthesis but also have their own issues. Because each type is so unique, it is difficult to identify overarching strengths of the entire category. An important strength, however, is that these newer forms of synthesis provide a systematic and rigorous approach to synthesizing a diverse literature base in a topic area that includes a range of data types such as: both quantitative and qualitative studies, theoretical work, case studies, evaluations, epidemiological studies, trials, and policy documents. More than conventional literature reviews and systematic reviews, these approaches provide explicit guidance on analytic methods for integrating different types of data. The assumption is that all forms of data have something to contribute to knowledge and theory in a topic area. All have a defined but flexible process in recognition that the methods may need to shift as knowledge develops through the process.

Many emerging synthesis types are helpful to policy makers and practitioners because they are usually involved as team members in the process to define the research questions, and interpret and disseminate the findings. In fact, engagement of stakeholders is built into the procedures of the methods. This is true for rapid reviews, meta-narrative syntheses, and realist syntheses. It is less likely to be the case for critical interpretive syntheses.

Another strength of some approaches (realist and meta-narrative syntheses) is that quality and publication standards have been developed to guide researchers, reviewers, and funders in judging the quality of the products [108] , [126] – [127] . Training materials and online communities of practice have also been developed to guide users of realist and meta-narrative review methods [107] , [128] . A unique strength of critical interpretive synthesis is that it takes a critical perspective on the process that may help reconceptualize the data in a way not considered by the primary researchers [72] .

There are also challenges of these new approaches. The methods are new and there may be few published applications by researchers other than the developers of the methods, so new users often struggle with the application. The newness of the approaches means that there may not be mentors available to guide those unfamiliar with the methods. This is changing, however, and the number of applications in the literature is growing with publications by new users helping to develop the science of synthesis [e.g., [129] ]. However, the evolving nature of the approaches and their developmental stage present challenges for novice researchers.

4.9. When to Use Each Approach

Choosing an appropriate approach to synthesis will depend on the question you are asking, the purpose of the review, and the outcome or product you want to achieve. In Additional File 1 , we discuss each of these to provide guidance to readers on making a choice about review type. If researchers want to know whether a particular type of intervention is effective in achieving its intended outcomes, then they might choose a quantitative systemic review with or without meta-analysis, possibly buttressed with qualitative studies to provide depth and explanation of the results. Alternately, if the concern is about whether an intervention is effective with different populations under diverse conditions in varying contexts, then a realist synthesis might be the most appropriate.

If researchers' concern is to develop theory, they might consider qualitative syntheses or some of the emerging syntheses that produce theory (e.g., critical interpretive synthesis, realist review, grounded formal theory, qualitative meta-synthesis). If the aim is to track the development and evolution of concepts, theories or ideas, or to determine how an issue or question is addressed across diverse research traditions, then meta-narrative synthesis would be most appropriate.

When the purpose is to review the literature in advance of undertaking a new project, particularly by graduate students, then perhaps an integrative review would be appropriate. Such efforts contribute towards the expansion of theory, identify gaps in the research, establish the rationale for studying particular phenomena, and provide a framework for interpreting results in ways that might be useful for influencing policy and practice.

For researchers keen to bring new insights, interpretations, and critical re-conceptualizations to a body of research, then qualitative or critical interpretive syntheses will provide an inductive product that may offer new understandings or challenges to the status quo. These can inform future theory development, or provide guidance for policy and practice.

5. Discussion

What is the current state of science regarding research synthesis? Public health, health care, and social science researchers or clinicians have previously used all four categories of research synthesis, and all offer a suitable array of approaches for inquiries. New developments in systematic reviews and meta-analysis are providing ways of addressing methodological challenges [117] – [123] . There has also been significant advancement in emerging synthesis methodologies and they are quickly gaining popularity. Qualitative meta-synthesis is still evolving, particularly given how new it is within the terrain of research synthesis. In the midst of this evolution, outstanding issues persist such as grappling with: the quantity of data, quality appraisal, and integration with knowledge translation. These topics have not been thoroughly addressed and need further debate.

5.1. Quantity of Data

We raise the question of whether it is possible or desirable to find all available studies for a synthesis that has this requirement (e.g., meta-analysis, systematic review, scoping, meta-narrative synthesis [25] , [27] , [63] , [67] , [84] – [85] ). Is the synthesis of all available studies a realistic goal in light of the burgeoning literature? And how can this be sustained in the future, particularly as the emerging methodologies continue to develop and as the internet facilitates endless access? There has been surprisingly little discussion on this topic and the answers will have far-reaching implications for searching, sampling, and team formation.

Researchers and graduate students can no longer rely on their own independent literature search. They will likely need to ask librarians for assistance as they navigate multiple sources of literature and learn new search strategies. Although teams now collaborate with library scientists, syntheses are limited in that researchers must make decisions on the boundaries of the review, in turn influencing the study's significance. The size of a team may also be pragmatically determined to manage the search, extraction, and synthesis of the burgeoning data. There is no single answer to our question about the possibility or necessity of finding all available articles for a review. Multiple strategies that are situation specific are likely to be needed.

5.2. Quality Appraisal

While the issue of quality appraisal has received much attention in the synthesis literature, scholars are far from resolution. There may be no agreement about appraisal criteria in a given tradition. For example, the debate rages over the appropriateness of quality appraisal in qualitative synthesis where there are over 100 different sets of criteria and many do not overlap [49] . These differences may reflect disciplinary and methodological orientations, but diverse quality appraisal criteria may privilege particular types of research [49] . The decision to appraise is often grounded in ontological and epistemological assumptions. Nonetheless, diversity within and between categories of synthesis is likely to continue unless debate on the topic of quality appraisal continues and evolves toward consensus.

5.3. Integration with Knowledge Translation

If research syntheses are to make a difference to practice and ultimately to improve health outcomes, then we need to do a better job of knowledge translation. In the Canadian Institutes of Health Research (CIHR) definition of knowledge translation (KT), research or knowledge synthesis is an integral component [130] . Yet, with few exceptions [131] – [132] , very little of the research synthesis literature even mentions the relationship of synthesis to KT nor does it discuss strategies to facilitate the integration of synthesis findings into policy and practice. The exception is in the emerging synthesis methodologies, some of which (e.g., realist and meta-narrative syntheses, scoping reviews) explicitly involve stakeholders or knowledge users. The argument is that engaging them in this way increases the likelihood that the knowledge generated will be translated into policy and practice. We suggest that a more explicit engagement with knowledge users in all types of synthesis would benefit the uptake of the research findings.

Research synthesis neither makes research more applicable to practice nor ensures implementation. Focus must now turn seriously towards translation of synthesis findings into knowledge products that are useful for health care practitioners in multiple areas of practice and develop appropriate strategies to facilitate their use. The burgeoning field of knowledge translation has, to some extent, taken up this challenge; however, the research-practice gap continues to plague us [133] – [134] . It is a particular problem for qualitative syntheses [131] . Although such syntheses have an important place in evidence-informed practice, little effort has gone into the challenge of translating the findings into useful products to guide practice [131] .

5.4. Limitations

Our study took longer than would normally be expected for an integrative review. Each of us were primarily involved in our own dissertations or teaching/research positions, and so this study was conducted ‘off the sides of our desks.’ A limitation was that we searched the literature over the course of 4 years (from 2008–2012), necessitating multiple search updates. Further, we did not do a comprehensive search of the literature after 2012, thus the more recent synthesis literature was not systematically explored. We did, however, perform limited database searches from 2012–2015 to keep abreast of the latest methodological developments. Although we missed some new approaches to meta-analysis in our search, we did not find any new features of the synthesis methodologies covered in our review that would change the analysis or findings of this article. Lastly, we struggled with the labels used for the broad categories of research synthesis methodology because of our hesitancy to reinforce the divide between quantitative and qualitative approaches. However, it was very difficult to find alternative language that represented the types of data used in these methodologies. Despite our hesitancy in creating such an obvious divide, we were left with the challenge of trying to find a way of characterizing these broad types of syntheses.

6. Conclusion

Our findings offer methodological clarity for those wishing to learn about the broad terrain of research synthesis. We believe that our review makes transparent the issues and considerations in choosing from among the four broad categories of research synthesis. In summary, research synthesis has taken its place as a form of research in its own right. The methodological terrain has deep historical roots reaching back over the past 200 years, yet research synthesis remains relatively new to public health, health care, and social sciences in general. This is rapidly changing. New developments in systematic reviews and meta-analysis, and the emergence of new synthesis methodologies provide a vast array of options to review the literature for diverse purposes. New approaches to research synthesis and new analytic methods within existing approaches provide a much broader range of review alternatives for public health, health care, and social science students and researchers.

Acknowledgments

KSM is an assistant professor in the Faculty of Nursing at the University of Alberta. Her work on this article was largely conducted as a Postdoctoral Fellow, funded by KRESCENT (Kidney Research Scientist Core Education and National Training Program, reference #KRES110011R1) and the Faculty of Nursing at the University of Alberta.

MM's work on this study over the period of 2008-2014 was supported by a Canadian Institutes of Health Research Applied Public Health Research Chair Award (grant #92365).

We thank Rachel Spanier who provided support with reference formatting.

List of Abbreviations (in Additional File 1 )

Conflict of interest: The authors declare that they have no conflicts of interest in this article.

Authors' contributions: KSM co-designed the study, collected data, analyzed the data, drafted/revised the manuscript, and managed the project.

MP contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

JB contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

WN contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

All authors read and approved the final manuscript.

Additional Files: Additional File 1 – Selected Types of Research Synthesis

This Additional File is our dataset created to organize, analyze and critique the literature that we synthesized in our integrative review. Our results were created based on analysis of this Additional File.

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Open Access

Study Protocol

A protocol for a critical realist systematic synthesis of interventions to promote pupils’ wellbeing by improving the school climate in low- and middle-income countries

Roles Conceptualization, Funding acquisition, Writing – original draft

* E-mail: [email protected]

Affiliations Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom, School of Education, University of Aberdeen, Aberdeen, United Kingdom

Roles Funding acquisition, Writing – review & editing

Roles Writing – review & editing

Affiliations Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom, Aberdeen Centre for Data Science, University of Aberdeen, Aberdeen, United Kingdom

• Pamela Abbott, 
• Rachel Shanks, 
• Isabel Stanley, 
• Lucia D’Ambruoso

• Published: May 15, 2024
• https://doi.org/10.1371/journal.pone.0286489
• Reader Comments

Introduction

The review described in this protocol will be the first critical realist review of the literature reporting on the impact of interventions to promote pupils’ wellbeing by improving the school climate in Low- and Middle-Income Countries. The review is being carried out to inform the programme theory for a critical realist evaluation of a whole school mindfulness intervention in Ethiopia and Rwanda to improve pupils’ mental wellbeing. Our initial programme theory hypothesises that pupils’ (and teachers’) responses to the mindfulness intervention as well as changing the behaviour and attitudes of individual pupils and teachers, will change the ’school climate’ in ways that have a positive impact on mental wellbeing. This literature review will facilitate the identification of mechanisms for change working at the level of the whole school climate, something which is only infrequently discussed in evaluations of mindfulness interventions.

Methods and analysis

A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school climate can promote the wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations and synthesising these to provide a conceptual understanding of the impact of interventions to improve school climate.

The review findings will inform a critical realist evaluation of a mindfulness intervention in schools that we will be carrying out. The findings from the review will enable us to focus more precisely and transparently on what policymakers and other stakeholders need to know about how school climate changes due to introducing mindfulness to the curriculum and how this impacts pupils’ wellbeing [and for which pupils]. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media.

PROSPERO registration number: CRD42023417735 .

Citation: Abbott P, Shanks R, Stanley I, D’Ambruoso L (2024) A protocol for a critical realist systematic synthesis of interventions to promote pupils’ wellbeing by improving the school climate in low- and middle-income countries. PLoS ONE 19(5): e0286489. https://doi.org/10.1371/journal.pone.0286489

Editor: Vanessa Carels, PLoS ONE, UNITED STATES

Received: May 16, 2023; Accepted: May 22, 2023; Published: May 15, 2024

Copyright: © 2024 Abbott et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analyzed during the current study. All relevant data from this study will be made available upon study completion.

Funding: The research is funded by the National Institute for Health and Care Research (NIHR133712) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. The funders did not and will not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

The review described in this protocol will be the first systematic critical realist review of the literature reporting on the impact of the ’school climate’ (defined here as schools’ structural, interpersonal relations and teaching practices, and cultural norms and values) on pupils’ wellbeing in Low- and Middle-Income Countries (LMICs). The review is being carried out to inform the programme theory for a critical realist evaluation of a whole school-based mindfulness intervention (SBMI) in Ethiopia and Rwanda on pupils’ mental wellbeing [ 1 , 2 ]. Our initial programme theory hypothesises that pupils (and teachers) will be able to use the psychological resources they gain through the mindfulness intervention to change the ’school climate’ in ways that positively impact pupils’ mental wellbeing.

Our review is novel. Existing literature on the impact of mindfulness interventions focuses on individual psychological outcomes. It rarely considers the pathways to improved mental wellbeing through changes in the social structural or cultural contexts due to changes in the behaviour of pupils and teachers wrought by mindfulness interventions [ 3 – 5 ]. This literature review will yield a framework of existing theories as a guide to identifying and understanding the underlying process (mechanisms) that shape the ’school climate’ and identify those that may be triggered by a whole school mindfulness intervention and promote pupils’ mental wellbeing.

Critical realists recognise that not every intervention will work for each person in the same way or different contexts in the same way. While traditional reviews have been concerned with descriptive outcomes and average effects, critical realists are more concerned with exploring how interventions work, for whom and under what circumstances. The broad purpose of the review is to move from empirical observation to develop a theorised understanding of the impact of school climate on pupils’ wellbeing in LMICs and identify aspects of school climate that can be linked to mechanisms triggered by mindfulness interventions. This will produce knowledge that enables us to make recommendations to improve practice, that is, improve the school climate and deliver mindfulness interventions in schools [ 6 ]. The main purpose is to build a middle-range theory [ 7 ] that models the underlying mechanisms influencing the school climate. We will use the critical realist RRRIREI© (resolution, redescription, retroduction, retrodiction, elimination, identification, correction) framework for explanatory interdisciplinary research [ 8 , 9 ]. The findings will enable us to refine the programme theory for research we are carrying out examining the potential for school-based mindfulness interventions to promote the mental wellbeing of children and adolescents in Rwanda and Ethiopia. The findings will also support policymakers and others to implement policies to improve the school climate and promote the wellbeing of children and adolescents in LMICs more generally by providing an understanding of under what conditions and for which pupils’ interventions make the school climate more positive.

The quality of school life (the school climate) is determined by a combination of the structural, interpersonal relations and teaching practices, and the cultural norms and values of the school as influenced by the wider social (’laminated’) system ( Table 1 ) in which it is embedded [ 10 ]. It is crucial for promoting safer, more supportive and more civil schools [ 11 ]. School climate improvement measures make schools friendlier, pupils (and teachers) more connected to the school and prevent dropout [ 11 – 14 ]. Four sub-constructs of the school climate have been identified in the literature that impacts pupils’ wellbeing: safety (feeling safe in school), relationships (e.g. school connectedness/engagement, social support, leadership and pupils’ perception of the school climate), teaching and learning (academic environment) and the institutional environment (school connectedness) [ 11 – 14 ]. The authors argue that these four sub-constructs are interconnected, influencing each other and being influenced by the broader context (laminated system) in which schools are located.

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Schools contain both risk and protective factors for pupils’ wellbeing. An extensive body of evidence, mainly from research carried out in the global North, shows that the school climate impacts pupils’ and their teachers’ wellbeing and that there is an association between a positive school climate and wellbeing [ 11 , 12 , 14 – 29 ]. A positive school climate influences academic outcomes [ 11 , 15 , 16 , 29 ], reduces the rates of violence in schools [ 11 , 17 , 18 , 28 , 29 ], supports skills development [ 19 , 28 ], promotes wellbeing and reduces the risk of mental health disorders [ 11 , 12 , 20 , 21 , 28 ]. Systematic reviews have found the strongest association between pupils’ psychological wellbeing, mental health and risk behaviours on the one hand and the quality of their relationships with their fellow pupils and teachers on the other [ 12 , 14 , 24 , 26 , 29 ]. Bullying and harassment, particularly, are associated with poor wellbeing and low educational achievement. A positive school climate also promotes teachers’ well-being and improves their relationship with pupils, which positively impacts pupils’ wellbeing [ 23 ].

While much of the research is non-experimental and cross-sectional, experimental and longitudinal research has found that the school-level socio-educational environments at baseline predict students’ wellbeing at three years follow-ups. Student perceptions of the socio-educational environment also predict their wellbeing [ 21 , 22 ]. However, it should be noted that there is possibly a publication bias as the findings from research on interventions that have not led to improvements in the school climate are less likely to be published. Nevertheless, the evidence is sufficient to indicate an established ’demi-regularity’ that there is, at least in some contexts and for some pupils, an association between an intervention designed to make the school climate more positive and improving pupils’ wellbeing. It is this that needs to be explained [ 30 ].

The evidence base for a relationship between school climate and student wellbeing outcomes in LMICs is more limited. A recent (end date of search January 2019) systematic review of the association between school climate and socio-cultural, behavioural, and academic outcomes in LMICs found 35 peer-reviewed articles that met their inclusion criteria [ 27 ]. All but two of the included studies reported a positive association between an intervention to improve the school climate and positive outcomes, with similar associations found as in research in high-income countries (HICs). More specifically, the findings from the review suggest a relationship between a negative school climate and bullying and violence and a positive school climate and academic achievement and wellbeing. Only seven studies included a low-income country.

However, few studies address the question of how school-based climate interventions work. Systematic reviews (and the studies included in the reviews) examine the empirical evidence on the health, behavioural and attainment effects of school environments. Still, they do not usually consider what theories might explain those changes or how they came about. One systematic review of theories of how school-based climate interventions (SBCIs) work built a comprehensive interdisciplinary theory of school effects drawing on 24 theories that partially explain the pathway from SBCIs to impact. This enabled the authors to integrate upstream, medical and downstream aspects of causal pathways [ 31 ] and test the interdisciplinary theory they built in a randomised control trial [ 32 ]. The integrated theoretical model takes account of complexity and feedback loops and theorises that school climate influences pupils at multiple interacting levels: student-school commitment, student peer-commitment, student cognition and student behaviours. Imperfect measures constrained the trial. A low teacher response rate, the positive impact on pupils’ health outcomes and positive views on the changes in the school climate only became evident at the end of the trial. Nevertheless, the findings suggest that observed positive changes in pupils’ health, including mental health were the outcome of modifying the school climate.

Aim and objectives

This review will build on previous research on the relationship between school climate and pupil wellbeing by:

• Including all documents from LMICs that can help with answering our research questions, including the grey literature, reports of reviews of research and discussions of theories relevant to the impact of school climate on pupil’s wellbeing;
• Using a critical realist methodology to build a theory of what makes SBCIs work, how, where, with whom, and to what extent, focusing on LMICs.
• Identifying context and intervention mechanisms to inform the programme theory of change for SBMI designed to promote the mental wellbeing of children and adolescents in Rwanda and Ethiopia.

The aims of the review are to:

• describe plausible explanations for the effectiveness of SBCIs designed to promote pupils’ wellbeing in LMICs;
• create transferable theories that can inform programme design and implementation in different settings;
• use the findings together with our findings from systematic reviews of mindfulness interventions and theories explaining how SBMIs impact pupils’ mental wellbeing to refine our initial programme theory of how mindfulness interventions work to promote pupils’ mental wellbeing.

To achieve the aims, the objectives are to identify:

• theories about how SBCIs work in schools;
• the contexts and mechanisms that may facilitate or hinder implementation;
• how pupils and teachers respond to SBCIs (agency);
• how school contexts (social, structural, and cultural) influence the agency of pupils in responding to SBCIs and trigger mechanisms that change the context and lead to positive outcomes;
• how the school system changes (roles and relationships), including pupil-teacher relations and pupil-pupil-relations;
• how school attitudes and values change (culture), and;
• the outcomes resulting from the interventions.

Methodology

To achieve our aims and objectives, we will conduct a systematic critical realist synthesis review to identify how SBCIs promote pupils’ wellbeing. A critical realist review is explanatory; it seeks to explain how interventions work and generate different outcomes in different contexts [ 33 , 34 ]. We will explore how SBCIs are supported or inhibited by contextual mechanisms in schools, how pupils and teachers respond to them and the outcomes that result from the interaction between the intervention and contextual mechanisms and the response of pupils and teachers. In doing so, we will identify the ’demi-regularities’, the contexts over time and space in which SBCIs enable pupils’ agency to trigger mechanisms that promote their wellbeing and improve their attainment [ 30 ]. Because critical realism affirms the reality of objects, agents, and mechanisms, which cannot be viewed directly but only deduced from their effects, it seeks to identify, by retroduction and retrodiction, and judgemental rationalism, the middle-range interdisciplinary theory(s) ( Table 1 ) that most comprehensively explain how SBCIs work. Such theories are always open to refinement in the light of new evidence.

There is no agreed standard or guide for critical realist reviews. However, a critical realist meta-theory underpins them, and they draw on some elements of the realist review methodology of Roy Pawson [ 6 ]. We have adapted the standard for realist reviews [ 35 , 36 ] and taken into account recommendations for traditional systematic reviews [ 37 – 39 ]. PRISMA offers transparency, validity, replicability, and updateability ( S1 Checklist ).

A critical realist research paradigm

Our methodology is informed by critical realist meta-theory. It has informed the development of methods for systematic reviews and impact evaluations that are designed to explain how and why interventions work in the ways they do [ 40 – 43 ]. It also provides guidelines for inter/transdisciplinary research [ 9 , 44 – 46 ], including research on promoting wellbeing [ 9 , 47 ]. Wellbeing is a bio-psycho-social phenomenon, and the outcomes of SBCIs are likely due to the complex interaction of biological, psychological, social-structural and cultural mechanisms and require the development of middle-range theories that integrate theories from these disciplines [ 47 – 50 ].

The main elements of critical realism are: a depth ontology, that society is real but is only knowable through its effects; a relativist epistemology, that our understanding of the real is always partial and open to refinement or refutation; rational judgment is used to determine what explanations (social theories) are most plausible; that structure and agency are both important; that people are shaped by the context in which they live but that they can change it through their agency; that the social world is an open system and complex; and a commitment to social justice, to improve the lives of people.

Critical realism has influenced a number of approaches to carrying out social and health research, and our approach draws on Margaret Archer’s practical morphogenic approach [ 51 , 52 ]. This methodology complements critical realism’s social ontology [ 53 ]. She argues that every theory about the social involves understanding the relationship between structure, agency, and culture. The context in which agents live shapes their beliefs, desires, and opportunities and limits their agency–contextual conditioning. However, the interaction between context and agency shapes and reshapes the context; agency can change the context (morphogenesis) or reproduce it (morphostasis). An intervention designed to improve the school climate gives pupils and teachers the resources to trigger mechanisms that can lead to material and cultural change. Their responses to the intervention are shaped, but not determined, by the context, and individuals generate outcomes through actions and interactions. When actors trigger new mechanisms (material and/or cultural), the context changes. However, pupils and teachers can resist, redefine, repudiate, suspend, or circumvent engagement with the intervention.

Methods/design

Step 1: establishing the scope of the work..

The review will focus on SBCIs designed to promote the wellbeing of pupils in LMICs. We will document differences between SBCIs underpinned by different theories, aims, approaches and techniques and delivered differently for various lengths of time [ 54 , 55 ]. The review will also capture other individual differences and programme characteristics that can affect programme reception by pupils and teachers and impact [ 56 ]. We will only include documents relevant to the relationship between pupils’ academic achievement, behavioural, cognitive, and mental wellbeing and outcomes. Nevertheless, outcomes will likely vary by the precise nature of the SBCIs.

Step 2: Search for evidence.

Search techniques . A rigorous systematic Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach will be used to search for literature [ 57 ]. A PRISMA diagram will show the steps of the inclusion and exclusion of documents ( S1 File ). The literature search will be in three phases: searching electronic databases, searching other sources such as relevant journals and core publishers, and citation tracking to ensure all relevant studies are included. The aim is to include as wide a range as possible of academic and grey literature without restrictions on study type or publication date. Literature from all LMICs will be included. Databases that index health, psychology, sociology and/or education literature will be searched. The search will be restricted to publications in the English language. The search terms and the databases used are based on the advice of an academic librarian.

The Search terms will be:

’school’ or ’educational context’ and ’ethos’ or’ environment’ or ’culture’ or ’governance’ or ’context’ or ’climate’ or ’structure’ or ’relations’ or ’relationships’ and ’children’ or ’adolescents’ or ’youth’ or ’young people’ or ’juvenile’ or ’teen’ or ’young adult’ or ’teenager’ or ’pupils’ and ’wellbeing’ or ’mental health’ or ’resilience’ or ’attainment’ or’ school grades’ or ’motivation’ or ’connectedness’ or ’engagement’ or ’suicidal behaviour’ or ’depression’ or ’suicidal ideation’ or ’prosocial behaviour’ or ’risk’ or ’risk behaviour’ or ’burnout’ or ’school adjustment’ or ’attitudes’ or ’psychosomatic complaints’ or ’Post-traumatic stress disorder’ or ’life satisfaction’ or ’quality of life’ or ’emotional’ or ’communication’ or ’supportive’ or ’support’ or ’caring’ or ’respect’ or ’belonging’ or’ quality of education’ or ’anxiety’ or ’conflict’ or ’conduct’ or ’bullying’ or ’harassment’ or’ violence’ or ’aggression’ or ’corporal punishment’ or ’discipline’ or ’disruptive behaviour’ or ’rules’ or ’safety’ or ’inclusive’ or ’teaching practices’ or ’involvement’ and ’mechanisms’ or ’theory’ or ’theorisation’ or ’conceptual’ or conceptualisation’ or ’concept’ or ’mediators’ or ’moderators’ or ’process’ or ’effects’ or ’scholarship’ or ’drivers’ or ’correlation’ or ’causation’ or ’association’ or ’impact’ or ’causal pathway’ and ’low income’ or ’middle income’ or ’low and middle income’ or [list of low- and middle-income countries in 2023] (see Table 2 for the search terms for SciELO Citation Index and Scopus).

https://doi.org/10.1371/journal.pone.0286489.t002

Inclusion/exclusion criteria.

Inclusion .

• Study design: Any that provides evidence to help with answering our research questions.
• Documents: LMICs.
• Publication date: any.
• Document type: any document type that will inform the review.
• Population: includes pupils aged 7–16 years.
• Type of report: reporting primary research, a review of research or a theory relevant to the impact of school climate on pupils’ wellbeing in LMICs.
• Setting: conducted in statutory education settings in LMICs.
• Language: English.

Exclusion .

• Studies reporting only on curricular-based interventions or designed to improve individual knowledge.
• Studies report only on interventions designed to improve the physical infrastructure of the school or classroom.
• Studies containing information on the school climate and wellbeing but not examining the links between the two.
• Studies that do not provide sufficient detail to allow identification of specific aspects of the school climate and wellbeing.
• Not a study of the effects of the school climate on pupils
• Only includes special needs schools.
• Only includes pupils outside the 7–16 years age range.
• In languages other than English.

Article screening . Covidence will be used to manage article screening and data extraction.

• Remove duplicates and citations without abstracts or summaries;
• Two reviewers (PA and RS) will review the titles and abstracts of all retrieved documents captured by our search strategy and code them as ’potentially relevant’ and ’not relevant’. Any disagreements will be resolved by discussion or, if necessary, bringing in a third reviewer (LD);
• Download the full text of potentially relevant documents.

Step 3: Document appraisal and data extraction.

Extract information from the documents, as relevant, that potentially meet our inclusion criteria into an Excel spreadsheet:

• Document details–title, authors, year of publication, location of study;
• Country, income group (low, lower-middle, upper-middle) (country income group classified as at the time the research was done);
• Journal discipline;
• Aims and objectives of the study;
• The description–details of the intervention, trainers, design, aim/purpose, length of training;
• Sample characteristics- age of pupils, sex/gender, socioeconomic status, ethnicity, type of school;
• The study design and if it is fit for purpose (quality/rigour);
• The conceptualisation of school climate;
• Rational for SBCCIs, including any social justice framing;
• Inner contextual factors (mechanisms) (i.e. the structure, culture and resources of schools that support or inhibit the effectiveness of measures taken to improve the school climate before the intervention was introduced);
• Outer contextual factors (i.e. the cultural, administrative and policy context within which schools operate that support or inhibit the effectiveness of measures taken to improve the school climate before the intervention was introduced);
• Proximal outcomes measured;
• How proximal outcomes were measured–instruments used to measure dimensions of school climate and wellbeing;
• Student outcomes, behaviour, and experience of interventions;
• Teacher outcomes, behaviour, and experience of interventions;
• Agency, stakeholders, including pupils’, teachers’ and parents’ interactions and responses to interventions designed to improve the school climate;
• Generative mechanisms triggered by the intervention that could have supported change (positive mechanisms), e.g. increased student engagement;
• Generative mechanisms triggered by the intervention that could have restricted/prevented change (negative mechanisms), e.g. resistance by pupils;
• Contextual mechanisms that could have supported change (positive mechanisms) commitment of school administration to positive change;
• Contextual mechanisms that restricted/prevented change (negative mechanisms) ingrained norms and values which support bullying and harassment;
• Any theoretical explanations identified for explaining the outcomes and the level of the explanation that is, psychological or social;
• Changes in context following the introduction of SBCIs.

The extraction tool will be piloted. PA, RS, LD, and IS will independently read two documents and complete the extraction table. They will then meet, compare their extraction tables, and agree on necessary modifications.

PA will extract all information. PA will remove any documents containing insufficient relevant data to inform how and why the intervention worked (or did not work) and/or not using credible and trustworthy methods. Documents will be considered relevant if they can help to answer the research questions; that is, they report findings from research on school climate. They will be included as credible if the methods used are adequate for generating the findings; documents will be excluded if they are not based on credible research or are purely anecdotal. The reasons for the exclusion of any document will be noted. A critical realist synthesis does not require that two independent reviewers complete screening for quality or data relevance. However, RS will review any documents PA identifies as not contributing or not using credible and trustworthy methods, with differences being resolved by discussion and, if necessary, by bringing in a third reviewer, LD.

We will provide a descriptive narrative summary of the findings from this stage of the review.

Step 4: Analysis and reporting.

The analysis will aim to identify a middle-range interdisciplinary theory that explains how school climate impacts pupils’ wellbeing. It will ’open the black box’ and identify the mechanisms the interventions triggered that explain how the interventions caused the reported outcomes using the critical realist framework for interdisciplinary research resolution, redescription, retroduction, elimination, identification and refinement (RRREIR) ( Table 3 ) [ 8 , 9 ]. An interdisciplinary middle-range theory will then be developed that explains how SBCCIs work, recognising that outcomes will likely differ in different contexts.

https://doi.org/10.1371/journal.pone.0286489.t003

To do this, we will mine the findings from the review to identify the changes that have occurred as a result of the intervention (outcomes), the mechanisms that were triggered by pupils’ (and teachers’) agency and how the context supported or restricted the impact of the interventions CAIMO configurations [ 40 , 58 ] and develop the hypothetical causal links between context, agency, mechanisms and outcomes. To do this, we will use Template Analysis to code the data and identify relevant context, agency, mechanisms and outcomes because it permits using predetermined codes as well as identifying new codes [ 59 ]. Within each category, findings will be broken down thematically and reported narratively to distinguish between different contexts, agency responses, mechanisms triggered, and outcomes. The key themes that describe processes and causal mechanisms for explaining SBCI outcomes in schools will then be identified. Hypothetical links will then be made between the CAIMO themes, creating potential pathways that account for the impacts of SBCCIs on pupils and why, for whom and under what circumstances these impacts occur.

To account for complexity, it will be necessary to develop non-linear pathways of change showing how the complex interaction of mechanisms (context mechanisms that predate the intervention and those triggered by the intervention) leads to the observed outcomes [ 43 , 60 – 62 ]. To do this, we will use feedback loop diagrams to model change, showing both mechanisms triggered by the intervention that cause change, those already in the context that supported change (+ve mechanism) and those already in the context and mechanisms triggered by the intervention that restricted or prevented change (-ve mechanisms). Outcomes will likely be more complex than a dichotomy between morphogenesis (structural change) and morphostasis (structural reproduction) ( Table 1 and Fig 1 ).

https://doi.org/10.1371/journal.pone.0286489.g001

Formal ethics approval is not required for a literature review. However, ethical approval has been obtained from the University of Aberdeen (20 th June 2022), Addis Ababa University Ref 111/22/Psy, 21 st December 2022), and the University of Rwanda (Ref 03/DRI-CE/012/EN/gi/2023, 25 th January 2023) for the research programme, of which this critical realist review forms an integral element.

Dissemination

We will publish at least one article in a peer review journal reporting the findings from the literature review, conforming to RAMESES publication standards [ 36 ] and a policy brief intended for policymakers with the target audience including WHO, UNESCO, UNICEF, the Rwandan and Ethiopian Governments, and the UK and Scottish Governments. Findings from the review will be disseminated via an article in The Conversation, seminar and conference presentations, and podcasts posted on the project website and disseminated by social media.

Our review will be the first critical realist review of the literature on SBCCIs. In the review, we aim to identify the generative mechanisms and social structures that explain how and why SBCCIs promote the wellbeing of pupils. This will enable policymakers and school leaders to understand under what circumstances SBCIs promote pupils’ wellbeing and improve their attainment and for which pupils they work.

The main challenges are likely to be that: there will be little information in the documents on the pre-existing context, and; the documents may not include details of the theoretical reasoning underpinning interventions to enable us to develop middle-range theories.

Supporting information

S1 checklist. prisma-p 2015 checklist..

https://doi.org/10.1371/journal.pone.0286489.s001

S1 File. Search strategy.

https://doi.org/10.1371/journal.pone.0286489.s002

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Review article, hope as experienced by people with acquired brain injury in a rehabilitation—or recovery process: a qualitative systematic review and thematic synthesis.

• 1 Neurorehabilitation Copenhagen, Municipality of Copenhagen, Copenhagen, Denmark
• 2 Department of Communication and Psychology, Aalborg University, Aalborg, Denmark

Background: There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad population of people with acquired brain injury (ABI). Furthermore a majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI.

Methods: A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adults with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology.

Results: Through a thematic synthesis eleven subthemes were identified relating to experiences of hope. These were grouped into four analytical themes: (1) hope a two folded phenomenon; (2) time and temporality; (3) progress, goals and visibility and (4) the alliance; a balancing act requiring good communication skills.

Conclusion: This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

1 Introduction

When thinking of hope, one might come across stories of the nurse Florence Nightingale, also called “the Lady with the Lamp”. Florence Nightingale is particularly known for walking through the infirmaries at night with a lamp in her hand—tending to the wounded, often with a comforting word on her lips. It is therefore often referenced that Florence Nightingale walked the dark corridors and spread hope and light to the patients ( 1 ).

Since the 1950s, the concept of hope has gained relevance across disciplines and research cultures such as positive psychology, psychiatry, and nursing research ( 2 – 4 ). Many researchers have depicted the meaning of hope to human beings and described hope in numerous ways ( 5 – 8 ). However, researchers across disciplines agree that hope is both universal and specific (concrete) ( 5 , 8 , 9 ). Universal hope, according to Hammer, can be described as “a general belief in the future and a safeguard for human being by illuminating life itself”, whereas specific hope is described by Hammer as “connected to time and object” ( 8 ). Snyder et al. ( 10 ) have worked on a definition of hope (within rehabilitation) where hope is described as a goal-directed cognitive motivational process focused on the importance of particularized hope and goals ( 10 ). In contrast, research on hope within the field of chronic illness is defined and described differently. The researcher Barnard for instance says: “hoping is a posture, not a motive for achievement of a particular goal. It is a mode of experiencing oneself in relation to reality and time” ( 11 ).

Earlier studies often focused on hopelessness rather than hope, especially for persons with mental illness. But as researchers began to expand their horizons, they ended up exploring the construct of hope across diverse illness contexts, including the chronically ill, critically ill and terminally ill ( 9 ). Later, also research within vulnerable groups such as people with dual diagnosis have been explored as to how hope is experienced by people with co-occurring mental health and substance use problems ( 12 – 14 ), just as hope within the population of patients with spinal cord injury has been explored in recent years ( 15 – 19 ). Hope is therefore a well-known theme in relation to serious illness and disability. Many anthropological and sociological studies have emphasized the despair that can follow chronic and serious conditions ( 20 – 25 ), often connected with lack of hope or the struggle for hope ( 26 ).

1.1 Hope and acquired brain injury

When a person acquires a brain injury, something happens not only to the brain and body, but also the anticipated future. Experiencing an ABI can thus be conceptualized as a “critical event” that disrupts the structure of everyday life, The sociologist Bury refers to this event as a form of biographical disruption ( 23 ). In other words, an unexpected interruption of an otherwise expected normal course of life.

An acquired brain injury may be caused by stroke, hemorrhages in the brain other than stroke, trauma, tumors (benign and malignant), infections, poisoning, lack of oxygen (e.g., by drowning accidents and cardiac arrest with successful resuscitation) etc. ( 27 ). The consequences of brain injury can be physical, cognitive, psychological, linguistic, and communicative and often have a major impact on a person's life and identity According to Cantor et al., persons with ABI live with two images of the self: “Who I am now” and “Who I was before” ( 28 ). This identity reconstruction process is a dynamic process of contraction and expansion in which the person with ABI strikes a tentative balance between new and old selves. This process might call for professional support to revise self-narratives and to validate the loss of some identities (e.g., working identity) ( 29 ).

The rehabilitation of people with acquired brain injury strives for a holistic approach, where the bio-psycho-social model forms the basis for all rehabilitation ( 30 , 31 ). However, Danish research within brain injury rehabilitation has shown that rehabilitation continues to mostly focus on the rehabilitation of practical functions in everyday life (Activities of Daily Living), physical functions and vocational rehabilitation ( 29 , 32 , 33 ). Thus, rehabilitation is primarily aimed at physical and functional rehabilitation, and not a holistic focus where the person's existential and emotional situation is also considered. Within a bio-psycho-social rehabilitation framework, there has been an increasing interest in the concept of hope. Having a hopeful stance and being able to identify possible pathways into a meaningful future is essential in times of uncertainty and despair.

Nochi ( 34 ) found that hope of recovery was used as a strategy by persons who had sustained a traumatic brain injury to reduce this experience of “loss of self”. Kuipers and colleagues ( 35 ), have identified a need for clinically relevant research on hope, which can guide practitioners in fostering hope to enhance the experiences and outcomes for persons with ABI and their family members ( 35 ).

1.1.1 Reviews on hope and stroke

In 2011, Bright and colleagues conducted a systematic review on hope after stroke ( 36 ). Nineteen articles were included, but only seven of these articles sought to explore hope ( 37 – 43 ). For the remaining 12 articles, hope was a key finding that was present when related topics such as recovery or quality of life were explored ( 36 ). Bright et al.'s review revealed that hope was complex and multidimensional. Moreover, hope was influenced by internal and external sources and had a positive impact on recovery following stroke. Their proposed conceptualization identified three attributes of hope: (1) an inner state, (2) outcome orientation, and (3) an active process ( 2 , 36 ).

Soundy and colleagues published two reviews in 2014 ( 44 , 45 ). The first being a narrative review focusing on factors promoting or hindering hope in persons with stroke or spinal cord injury. Moreover, it focused on identifying how (health) professionals could support the promotion of hope during rehabilitation ( 44 ). The second review proposed a framework for hope, arguing for a more generalized view of understanding why a certain hope exists or is identified by a patient ( 45 ).

Whereas Bright et al. included nineteen studies in their review, Soundy et al. ended up including ten studies. A total of four studies overlapped and were thus included in both reviews ( 37 , 38 , 43 , 46 ). The above-mentioned reviews have contributed both in enhancing our understanding of hope. However, we still do not know much about the role of hope in persons following an ABI as both research teams only focused on people with stroke. Furthermore, more than half of the included studies in the three reviews either completely excluded persons with communication difficulties or only included persons if they didn't have pronounced communication difficulties. As a result, we know even less about experiences of hope when it comes to persons with communication difficulties ( 47 ).

Therefore, the purpose of this review is to capture the phenomenon of hope as experienced by the broad population of persons with ABI. Through a systematic search in relevant databases and a thematic synthesis, we aim to expand our understanding of hope as experienced and described by persons with acquired brain injury during a rehabilitation or recovery process. This knowledge can inform rehabilitation theory and practice further.

1.1.2 Review question

The specific question guiding this review is: “How is hope (as a phenomenon) experienced in the rehabilitation or recovery process of persons with acquired brain injury”? The qualitative PICo worksheet adapted from Miller, S.A. (2001) was used as a framework for building the search strategy 1 ( 48 ). The different search terms for each of the three blocks in PICo are presented in Table 1 .

Table 1 . PICo describing database search strategy.

A qualitative systematic literature review was conducted, and the approach and reporting were guided by the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement ( 49 ) and the PRISMA statement ( 50 ). To answer the research question, study results were synthesized, applying a thematic synthesis, as described by Thomas and Harden ( 51 ).

The research team conducting the search, screening and final inclusions of studies consist of the two authors (CHN and CG). The first author has several years of clinical experience within the field of ABI rehabilitation. The second author has done research within the field of ABI rehabilitation for more than 10 years and also holds clinical rehabilitation experience. Having a phenomenological standpoint, the authors are interested in exploring the lived experience of hope, thereby looking at hope from a first person perspective (persons with ABI).

2.1 Search strategy

A “subject-based strategy” was chosen since the approach has been shown to be more effective than the alternative (“research methodology-based strategy”) in retrieving qualitative patient-reported health-related quality of life research ( 52 ).

To develop relevant keywords (synonyms, near synonyms, broader and narrower concepts), pilot searches in selected databases were conducted ( 52 , 53 ). The search was initially conducted in December 2021 with a follow up search in January 2023 (see Supplementary Appendices S1, S2 for search protocols) to ensure that any new studies meeting the inclusion criteria were included. However, no relevant studies were identified in this new search. The literature search included English and Scandinavian peer-reviewed articles published between 2000 and 2023.

In the attempt to find relevant studies in journals across different subjects—and research areas—a thorough and extensive search of seven databases was performed ( 53 ). To secure high recall without compromising precision, the following terms were included for block two about the phenomenon: “hope”, “hopeful”, “hopefulness”, “meaning making (process)”, “optimism”, “wish”, “wishful thinking” (see Supplementary Appendix S1 for the search in its entirety). Both “rehabilitation” and “recovery” were used as search terms for block three, as we wanted to include studies performed in an inpatient, as well as in an outpatient setting. Recovery is often linked to hope, thus a relevant term to include. The search terms and keywords were modified with input from an experienced librarian. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were undertaken together with SocINDEX, Social Work Abstracts, Eric and Web of Science (for further considerations on the choice of databases and the final search strategy see Supplementary Appendix S2 ). Any relevant protocol papers or conference abstracts identified from the database searches were followed up. A manual search of reference lists of relevant studies was also performed to complement the database search ( 53 , 54 ).

2.1.1 Study selection

Search results from the seven databases were combined in the bibliographic software RefWorks and duplicates removed. The primary aim was to identify studies exploring the perspective of persons with ABI, where the phenomenon of interest was hope. From initial pilot searches, it quickly became clear that the inclusion criteria had to be adjusted if the review was to include more than five or six studies. Thus, inclusion criteria were revised so that studies were included if they had hope as a substantial part of their findings even if hope had not been the initial focus of the study. Although this final search strategy also generated a significant number of irrelevant hits, it was seen as a necessary process to ensure that appropriate literature was captured.

2.1.2 Eligibility criteria

The inclusion and exclusion criteria shown in Table 2 were used to determine eligible papers for study inclusion.

Table 2 . Inclusion and exclusion criteria for study selection.

The selection of studies followed a two-stage process of screening and final selection. In order to ensure, systematicity and transparency the software Covidence was used in this process. Stage 1 (Screening): Titles and abstracts were screened against the inclusion and exclusion criteria and items deemed ineligible were removed. Stage 2 (Final selection): When articles appeared possibly to fit the inclusion criteria, full text copies of the articles were obtained. If it was not possible to determine the relevance by the title or abstract, a full text was also obtained to confirm or deny eligibility for inclusion ( 55 ). Full-text articles were then screened to ensure they met the inclusion and exclusion criteria and were relevant to the research question. Moreover, reference lists of the included studies were screened for further relevant studies.

2.1.3 Quality assessment

After having completed full-text readings of the final studies, the Critical Appraisal Skills Program (CASP), a checklist for qualitative research, was used for the evaluation of the ten studies. The CASP toolkit consists of 10 questions to facilitate rapid evaluation ( 56 ). All articles were determined to be of good quality and although some studies were small scale studies, they could potentially be a of valuable contribution to understanding the experience of hope. Full details of the CASP quality appraisal are provided in Table 3 .

Table 3 . CASP quality appraisal for all ten articles.

2.1.4 Data extraction and synthesis methodology

The included studies were categorized according to their primary focus. For each study, the following data were obtained and put into the result table: Author & year, aim (of study), time since injury, sample (size, sex, and population), methods (e.g., type of qualitative study), data analysis and results.

To syntizese findings, the thematic synthesis methodology developed by Thomas and Harden was used ( 51 ). The approach outlines a three-step process to guide the thematic synthesis. It involves (1) close reading of text to identify data-driven patterns that become “categories for analysis” ( 67 ). (2) Next, codes are developed inductively using the results sections from the first article and transfere these to the succeeding articles after which new codes are added. Based on this process, authors then develop descriptive themes representative of groups of identified codes, that align closely to the literature being synthesized. The last step of the process is where (3) authors develop analytical themes which require them to apply their own interpretation of article findings ( 51 ). Both authors ( 51 ) read the articles multiple times. The initial reading was performed to develop an understanding of the topic and to get an overview on how each study met the purpose of this review. First author did the initial coding and extracted information about hope in the article findings, leaving out sections/themes that did not deal with this topic. Afterwards both authors discussed all the initial codes. Finally the first author established broader descriptive themes based on codes and with confirmed consistency of the ascribed text. Descriptive themes were put into a matrix and organized into analytical themes which were discussed by the authors to ensure agreement.

Figure 1 provides the results of the database search in total within a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) flow diagram ( 50 ). A total of 4,722 abstracts were identified. After the removal of duplicate records and records marked as ineligible by automation tools, 1,239 abstracts were left. Following review of titles and abstracts, 40 publications were identified for potential inclusion. The full texts of these were read and assessed for eligibility.

Figure 1 . Prisma flow diagram.

Of the 40 studies retrieved for full text reading, only nine studies met the inclusion criteria. Hand-searching of the included articles' reference lists was also employed, where 29 studies were retrieved for full text reading, but only one additional study was identified which made a total of ten. The characteristics of these ten studies are presented in Table 4 .

Table 4 . Characteristics of included studies.

3.1 Characteristics of the included studies

As shown in Table 4 , half of the studies were carried out in the UK, Norway and Sweden ( 57 , 58 , 62 , 65 , 66 ) two in New Zealand ( 60 , 61 ), and the rest in the USA ( 64 ), Australia ( 59 ), and Malaysia ( 63 ). The numbers of participants across studies varied considerably from three ( 64 ) to 33 participants ( 57 ). The age of the persons with ABI varied from 21 to 88 years old.

Six of the studies ( 59 – 62 , 64 , 65 ) used semi-structured or in-depth interviews to collect data whereas four of the studies collected data through a wider range of ethnographic approaches ( 57 , 58 , 63 , 66 ) such as observations, diary entries, and video recordings. While eight of the studies focused on the experience of the person with an ABI, two examined the perspective of both the person with the ABI and of the professionals ( 58 , 66 ). In these cases, only the persons with acquired brain injury's experiences of hope were included. All ten studies tended to include both female and male participants, but with a preponderance of male participants (46 females and 87 males).

The ten included studies in this review support the claim that most research on the phenomenon of hope has been conducted within the stroke population. Eight studies had persons with stroke as their population of interest, leaving only two on ABI as a broad population, including both people with stroke and traumatic brain injuries etc. ( 58 , 59 ). A total of four studies focused specifically on persons with stroke and aphasia ( 60 – 62 , 64 ).

Most studies were performed in the post-acute to chronic phase. Across studies, time since injury ranged from 2 months to 57 years. Bellon et al. and Antelius focused on the chronic phase with Bellon having participants ranging from one to 57 years since injury (median age of 14 years) ( 59 ), and Antelius exploring the understanding of hope through fieldwork in the context of a daily activity center rather than a rehabilitation center ( 58 ). On the other hand, Bright et al. ( 60 ) and Tutton et al. ( 66 ) focused on the post-acute phase, namely outpatient community-based rehabilitation at two to four months after injury at a regional acute stroke unit.

The qualitative studies revealed hope to be a very fluid and paradoxical notion. However, at the same time also something of great importance for the persons' rehabilitation or recovery process. This will be unfolded in the thematic synthesis of findings.

3.2 Thematic synthesis

Four analytical themes and eleven sub-themes were identified in the thematic synthesis and are shown in Table 5 . Only two out of ten studies included persons with ABI (e.g., stroke and TBI etc.) thereby having a primary interest in the broad population of people with ABI. In all four analytical themes, studies with participants with TBI as well as participants with stroke are represented. Thus, themes were identified across the broad ABI population. The four analytical themes being: (1) hope a two folded phenomenon; (2) time and temporality; (3) progress, goals, and visibility; and (4) the alliance; a balancing act requiring good communication skills. The themes are described in the following section and selected quotations from the reviewed studies are used to support the analysis.

Table 5 . The four analytical themes and sub-themes, with examples of quotes.

3.2.1 Theme 1: hope a two folded phenomenon

Hope turned out to be a very paradoxical phenomenon in which both a positive and negative side was embedded. Two sub-themes were identified in hope as a phenomenon.

3.2.1.1 Sub-theme: hope as a driving force

Four of the studies identified hope as having a protective effect, supporting persons with ABI to continue and not give up ( 59 , 60 , 65 , 66 ). Taule et al. went so far as to describe hope as the most important driving force in the person's struggle to make their situation comprehensible and worthwhile ( 65 ). According to Tutton et al., there was a real contrast between persons with stroke who were highly motivated and determined and for whom hope came easily, and those that felt low, lacking motivation or “flat with dense weakness and apparently had no hope” ( 66 ). As described by one of the participants with ABI in the study by Bellon: “I think if you haven’t got hope … you might as well die, yep” ( 59 ).

Two of the studies identified the fact that hope became something that allowed persons with ABI to have a positive mindset ( 59 , 63 ). Through interviews, Mairami et al. identified that hope could originate either from within the person or from those around them, fostering optimism for a functional life ( 63 ). Factors identified by Bellon et al. as “drivers” for maintaining or increasing hope were, among other things:

• support

• having something to look forward to

• mental health ( 59 ).

For people with communication difficulties such as aphasia, the most common source of hope was social relations (other people) as well as spiritual beliefs ( 60 ). The meaning of faith and spiritual experiences was also mentioned in other studies. Mairami found that some people who were not spiritual or religious before the stroke turned to faith after their injury. This faith provided them with solace and hope for recovery ( 63 ). Similarly, persons with ABI in the study by Bellon et al. felt that faith was an important factor influencing hope: “I have faith and that gives me hope” ( 59 ).

3.2.1.2 Sub-theme: hope as a source of despair

A connection between unfulfilled hopes and despair or emotional distress was identified in several studies, making it the flip side of hope ( 57 , 59 , 60 , 65 , 66 ). Persons with stroke experienced how hope could become a source of distress when it was connected to thoughts about the future ( 57 ). For persons with aphasia, hope was generally experienced as a good thing, but at the same time also difficult, since it could go unfulfilled ( 60 ). Uncertainty combined with thoughts about the future and having to redefine it, seemed to make persons with stroke vulnerable to feelings of distress and despair. Also, if the person had previous experiences of things gone wrong, they could be afraid that this would happen again and thus afraid to hope: “You can hope for lots of stuff but then half the time it's going to disappear” ( 60 ).

In the study by Bellon et al. some of the persons with ABI said that it could be difficult to gain hope and that hope was not always there:

“I guess I put hope in the same place I put happiness. Because … you’re always wanting to achieve it, or you’re always wanting to be in that state, but is that a realistic possibility? I don’t know” ( 59 ).

In a similar vain, one study described feelings of despair that could undermine hope and risk individuals falling into depression ( 66 ). Taken as a whole, the results indicate that hope is a multifaceted concept which can also have a negative side.

3.2.2 Theme 2: time and temporality

Three of the studies included in this review illuminated the temporality connected to hope and hoping ( 58 , 60 , 61 ). Three sub-themes were identified in relation to this analytical theme.

3.2.2.1 Sub-theme: living one day at a time

A present form of hope was identified as being dominant in people with stroke and aphasia. “Living in the moment” or “living one day at a time” was for many a response to the uncertainty inherent in thinking of the future—in effect, a way not to think about the future and to deal with the vulnerability that surfaced ( 60 ). In another study looking at how people with aphasia experienced hope one year post stroke and how it may have changed in that year ( 61 ), it was illustrated that the sense of hope was entwined with persons' views of their past and their present. Their perception of their poststroke recovery, well-being and view of the future was crucial in fostering—or threatening—their sense of hope for the future. Interestingly, Bright et al.'s study from 2020 suggested that the reference point for past comparisons shifted over time: in the post-acute phase, the comparisons were with their pre-stroke experience, whereas in the chronic phase they were with their immediate post-stroke experience ( 61 ). This could be seen as representing a process in which the persons revisited their hopes for the future and adjusted these based on their sense of what was possible and desirable: “I don’t believe hope can be the same [over time] as you [are not] the same” ( 61 ).

Bright et al. considered this movement in time to reflect the individual's desire, readiness, and capacity to move forward in life, actively constructing a future that they found both meaningful and imaginable ( 61 ).

3.2.2.2 Sub-theme: a fixed future in later stages of the rehabilitation process

The concept of time and temporality was amplified when people were in later stages of their rehabilitation or recovery process, especially regarding the present. In a study in persons with severe brain injuries at a day center in Sweden, the future of the persons (in this stage of rehabilitation) was characterized as less open and limited in possibilities ( 58 ). In the quote below, a young seemed to have a less positive view of impressionable possibilities:

Interviewer (I): “If you hadn’t been in that car accident, what do you think would have happened then”?

Paul (P): “Chef. Chef”.

I: “Chef? Right, you were going to train to be a chef”?

P: “I was”

I: “You were in chef training? [P nods.] In high school”?

P: “KOMVUX” [municipal adult education].

I: “Do you still want to be that?”

P: “Aa”

I: “Do you think it's possible”?

P: “No” ( 58 ).

To him the horizon seemed rather distant as the future did not hold the possibility of becoming a chef again ( 58 ).

Persons with ABI resided in the present because they would never fully recover. Some of the persons with ABI talked about a fragile time horizon, dependent on their physical abilities in the future, and located their hope in their ability in the present to maintain their functional level ( 58 ). In temporal terms, you might therefore say that the horizon was further away than in the earlier stages of the persons' rehabilitation or recovery process.

For persons with stroke and aphasia it was described that a sense of hope persisted in the light of challenges, and the hope of things could be better was pivotal to getting through each day ( 61 ). By contrast, actively engaging in a future-oriented hope was identified by Bright et al. as quite troublesome for people with stroke and aphasia ( 60 ). Nevertheless, Strong et al. suggested that participation in a co-construction process 2 with a speech-language pathologist was supporting persons with aphasia to engage in an intentional exploration of this process of actively hoping ( 64 ) making it into a sort of bridge and offering the possibility of getting the individual closer to that horizon.

3.2.2.3 Sub-theme: self, identity, and desirable futures

Both studies that focused on self and identity centered on persons with stroke and aphasia ( 60 , 64 ). It was experienced by persons in these studies that there was a disruption to their identity, leading to feelings of loss of identity. This loss of identity could also influence their experience of hope:

“I sort of thought ‘Oh, maybe. Maybe it's me’ and then I then I I thought about it you know, again the other night and I thought ‘Oh nah, it's not me’ and I just, I just I just can’t agree whether it's me or not” ( 60 ).

It was found that hope arose from what was perceived as meaningful to the participants and their sense of self, e.g., roles in life, sense of identity, faith, or an outlook on life. Hopes appeared to be relatively easy to identify and appeared from reflecting on past hopes and ways of being, the present and on their possible future ( 60 ). However, actively hoping could be more difficult for persons with communication difficulties as it was strongly language-based and involved identification of specific hopes. Hope, identity, and social connectedness were closely intertwined as hope could enable people with aphasia both to dwell in the present and to move towards to more desirable futures ( 61 ). The same study also found that persons with aphasia recalibrated their hopes for the future. This calibration process was influenced by the person's corresponding journey of identity re and co-construction. These two factors were therefore identified as significant in the recalibration of hope ( 61 ).

Strong et al. also found that the process of co-constructing a personal narrative with persons with stroke and aphasia was experienced as being positive ( 64 ). One of the individuals in this study felt it changed his life, suggesting that this process supported a positive view of identity. Hope engendered by the co-construction experience seemed to empower persons with stroke and aphasia with new levels of confidence, not only in their communication skills but also in themselves:

“You know. I know now there's hope. I’m I’m going to make it you know. I’ll be okay. I’ll get better and better. And and take time, but I’m getting better and better. And I I can do it. You know? I can I can I can do anything” ( 64 ).

As described earlier, Antelius stated in her study that: “In temporal terms there might be a horizon far away, but in narrative terms it is not an open one” ( 58 ). Applying a co-constructing intervention, as Strong et al. did in their study, seems to be a process that supports persons with communication difficulties (aphasia) to engage in an intentional exploration of the process of actively hoping ( 64 ), thus having the potential to open the horizon in narrative terms as well.

3.2.3 Theme 3: progress, goals and visibility

Four of the included studies dealt specifically with progress and its significance in relation to hope ( 59 – 62 ). Three sub-themes were identified.

3.2.3.1 Subtheme: progress intwined with hope and facilitated by rehabilitation professionals and peers

Seeing one's own progress as well as the progress of others was something that persons with stroke found to be a source of hope. Hope and progress appeared to have a mutually reinforcing effect ( 60 , 61 , 63 ).

For persons with aphasia, meeting other persons with aphasia was found to be important and instilled hope. Many had never heard of aphasia before, just as they had never met someone with aphasia, making it impossible for them to know what kind of progress was possible ( 60 ). In another study four persons were interviewed one year after their stroke, focusing on how hope might have changed during that year. The interviewees described increased hope for the future when they perceived they were making progress; conversely, a lack of progress threatened their sense of hope ( 60 ).

One study investigated the subjective experiences and reflections of persons with communication difficulties (aphasia) about constructing and maintaining therapeutic alliances in rehabilitation ( 62 ). In this process, the relationship between the person with aphasia and the health professional was shown to be of great importance. Even though this study focused on a specific group of professionals (speech and language therapists), the same may be true for other rehabilitation professionals. When progress was perceived as slow or imperceptible by the person, feedback from the therapist was of great importance as it was found to inculcate confidence and hope ( 62 ). As Terry in Lawton et al.'s study put it:

“[…] She could see something in me, that, yet although I could see it myself that was the goal I was going for. She could see beyond that, and she was getting me, by the scruff of the neck [gesturing], that's where you want to be across there like…it just gave me enough kick up the pants [laughs] to you know come back and fight” ( 62 ).

Thus, the therapist played a pivotal role, not only in making progress visible, but also in believing in the person, offering them hope for future improvement. It was precisely this kind of progress which was identified by persons with ABI as important in the maintenance and growth of hope ( 59 ). When persons with ABI in the study by Bellon et al. were asked to reflect on times where they felt they had made functional improvements or progress, they were thinking of milestones such as getting rid of a walking stick or being able to read a book in bed. Thus, every day events which showed their improvement and gave hope ( 59 ). Thus, the rehabilitation team was important for the participant's ability to build hope for recovery:

“They (municipal health care team) really came and stayed here and did something. They showed faith in positive development and supported me in that. It's important to convey that recovery can still happen, although the progress is slow” ( 65 ).

3.2.3.2 Sub-theme: goals to make progress visible

Across the included studies, goals were identified as another important theme regarding hope ( 60 – 62 , 64 , 66 ). As expressed by one of the persons with ABI:

“…One aspect that they’ve really got right is focusing on the goal setting. It makes people more positive, and it gives them hope for the future” ( 59 ).

Persons with ABI emphasized the importance of setting goals that were achievable and realistic and warned of the dangers of having unachievable goals: “If I set my goals too high, I fall into a, like my depression goes up, and I get all, it's not worth it. So, I do things little by little” ( 59 ).

In studies including persons with stroke ( 60 , 62 , 64 , 66 ), goals were found to be of importance since hope for recovery reflected the determination to move forward or to meet aspirational goals:

“Keeping myself driven, I am good with that, that is very forward moving, having something to focus on giving me goals, targets, aims and pointers and stuff and that suits me…” ( 66 ).

A strong multidisciplinary approach to rehabilitation using tangible goals to direct recovery seemed important for persons with stroke, as they used goals as a way of being hopeful about the future:

“I want to get rid of the sexy stockings (compression stockings) by the end of this week, you have to walk 10 meters unaided before they go. So they are going this week. I have decided” ( 66 ).

3.2.3.3 Sub-theme: goals based on personal wishes

Professionals could risk undermining the hopes of the persons with ABI, and thereby increasing hopelessness or resignation about their future, by clinging to unrealistic hopes. This made it crucial to support people in imagining future possibilities when lack of progress hit ( 61 ). According to Lawton et al., genuine collaboration was dependent on the therapist's ability to listen carefully to the person with aphasia's narrative if they wanted to generate goals concordant with the person's priorities and needs ( 62 ). Persons who felt that their therapist had attempted to incorporate their personal wishes felt highly engaged with the process, which directly impacted on their engagement in rehabilitation:

“Sometimes she would lead the sessions and sometimes she would … not … … erm … … well … she would let me … have the floor and that, I think that was important as well” ( 62 ).

On the other hand, persons with stroke could feel inadequately understood, if the rehabilitation was not based on their personal wishes:

“They just had a plan of returning me back to work. It was their goal. When they repeated that every time we met, then I started to cry I think, every time” ( 65 ).

Strong et al. also found that the process of co-constructing a personal narrative with persons with aphasia was experienced as being positive, offering an opportunity for the individual to actively contemplate the future and their own goals ( 64 ).

3.2.4 Theme four: the alliance; a balancing act requiring good communication skills

The importance of the therapeutic alliance and rehabilitation professionals' skills is a theme in more than half of the included studies in this review, making it a substantial factor relating to hope in a rehabilitation or recovery process ( 59 – 62 , 64 , 65 ). This theme seemed to be even more decisive when it came to persons with stroke and communication difficulties (aphasia) ( 60 – 62 , 64 ). Three sub-themes were identified in relation to this analytical theme.

3.2.4.1 Sub-theme: hope promoting relationships

The professionals' ability to provide hope for persons with stroke and aphasia appeared to be influenced by the strength of the therapeutic relationship ( 60 ). At the same time, engagement in the therapeutic process was described as central to the establishment of a partnership between the person with stroke and the health professional. An effective alliance could promote adherence and instill hope whereas an ineffective alliance eroded hope ( 60 , 65 ). If the professionals were perceived to be too distant, maintaining rigid and inflexible boundaries, it could directly affect persons' engagement in rehabilitation as this was incompatible with their needs ( 62 ). This was especially true in the early stages of rehabilitation, during which persons with ABI were highly vulnerable and therefore needed more than professional distance.

On the other hand, being too attached posed a risk to independence and encouraged overreliance ( 62 ). Close alliances were characterized as genuine, friendly, non-judgmental, caring, open and connected. In order to provide the necessary infrastructure for establishing positive therapeutic relationships, the therapist needed to base it on honesty, trust, and respect ( 62 ). The therapeutic alliance was challenged when the person with ABI experienced unmanageable pressure about what to do or manage, as the confidence in the professional then was challenged. Also, professionals’ lack of expertise could challenge the alliance as this constituted a source of frustration for the person with ABI, as could controversies developing between persons with ABI and professionals or among professionals ( 65 ).

3.2.4.2 Sub-theme: keeping hope on a leash

In the study by Bellon et al. the persons with ABI had mixed experiences of how professionals had encouraged or discouraged their hope, some recalling positive and some negative experiences. Negative experiences could involve the professionals being negative about the(ir) future ( 59 ). As a participant in the study by Bellon et al. explained:

“Definitely, it is most positive for them [professionals] to … encourage people to have hope. As I said I’ve seen a lot of people who’ve given up the ghost, and a lot of times they’ve been … given bad advice or no hope by their so-called specialists, and they’ve given up” ( 59 ).

Receiving a bleak prognosis or meeting professionals that were negative about their future had a negative impact on the person with ABI's experiences of hope.

Some persons with ABI felt that the therapists had a responsibility to mask their lack of faith in their progress. However, they also requested a balance between optimism and realism ( 65 ). Some even expressed that hope and encouragement from others were essential for them. Like in the case of Matthew in Bright et al.'s study (2020), who evaluated people for their hope giving qualities considering whether: “… they’re the ones that are offering hope”, or if they should be in his “no hope basket” ( 61 ).

3.2.4.3 Sub-theme: professional competences

The skill set of professionals was of considerable importance across studies as professionals had the potential to discourage or encourage hope in the person with ABI ( 59 , 60 , 62 , 65 ). According to Bellon et al., professionals could beneficially impact upon a person's experience of hope through person-centered and supportive therapeutic relationships ( 59 ). Taule and colleagues identified that successful encounters involving encouragement, empathy and equality seemed to promote the person with stroke's confidence in the professional's ability to help them manage their condition, as well as their sense of empowerment and their hope that they would be able to cope successfully in the future ( 65 ).

Participants appreciated and expressed a desire to cooperate with professionals who displayed essential therapeutic qualities, described as follows:

• Empathetic

• Taking time to listen

• Offering comfort

• Being nice

• Enthusiastic

• Making optimistic statements ( 65 ).

One skill that persons with stroke and aphasia identified as particularly important in helping them to think positive and be hopeful about the future was the professionals’ ability to be supportive. It was also perceived as necessary for the therapist to have highly attuned communication skills in order for the person with aphasia to have a sense of being heard and understood ( 60 , 62 ). Skills like empathetic understanding (not just understanding), giving time and getting to know the human being (not just the diagnosis) were potentially of even greater importance if the persons were to avoid isolation, build trust and maintain hope. As the participant in the study by Lawton expressed it:

“She (professional) helped me because she understood uhh everything really so she umm helped me with me moods and things like that and family and understanding about you know because it's diffi it's diffi it's like a total change from what it was” ( 62 ).

4 Discussion

4.1 summary of main findings.

This qualitative synthesis of evidence highlights several key issues for persons with ABI to sustain and instill hope in a time of uncertainty and hopelessness. The four analytical themes and eleven sub-themes identified through thematic synthesis were (1) hope a two folded phenomenon, with the sub-themes “hope as a driving force” and “hope as a source of despair”; (2) time and temporality, with the sub-themes “living one day at a time”, “a fixed future in later stages of the rehabilitation process?” and “self, identity and desirable futures”; (3) progress, goals and visibility, with the sub-themes “progress intwined with hope and facilitated by rehabilitation professionals and peers”, “goals to make progress visible”; and “goals based on personal wishes” and lastly (4) the alliance; a balancing act requiring good communication skills, with the sub-themes “hope promoting relationships”, “keeping hope on a leash” and “professional competences”.

Previous systematic qualitative reviews have primarily explored hope in persons with stroke and left out other subgroups of ABI such as people with traumatic brain injury, hemorrhages in the brain other than stroke etc. ( 36 , 44 , 45 ). Moreover, most of the included studies in these reviews did not give voice to people with communication difficulties following ABI as they were often excluded (ibid).

This review includes all ABI groups and the findings are in line with previous reviews, in that hope is multifaceted (potentially having a positive as well as a negative effect), influenced by several factors (e.g., personal, or social), and crucially related to the establishment of goals ( 36 , 44 , 45 ). All four analytical themes were identified based on experiences that included both persons with TBI, haemorrhage etc. as well as stroke.

Our review highlights several good reasons to pay attention to time and temporality. First, time and temporality serve as a frame within which everything else unfolds, including the rehabilitation or recovery process. Secondly, time and temporality are shown to be of great importance for persons with ABI, especially in the later stages of their rehabilitation or recovery process. The results suggest that hope is to be found elsewhere in the more chronic phases of the rehabilitation, calling for different perspectives and amplifying the importance of the present instead of having a fixed view of the future. For persons with communication difficulties, time and temporality seems to play into their necessity to be rooted in time—specifically, in the present, which serves as an anchor and makes it possible to look at the future with the support of rehabilitation professionals. This leaves us with the question of whether it is easier to maintain or instill hope in earlier stages of rehabilitation compared to later stages? A study by Bright et al. showed that conversations about the future also seems to be constrained and limited in the inpatient setting poststroke ( 68 ). The study explored how clinicians talk about the future with patients and Bright et al. found that these types of conversations were constrained to short-term futures and limited to what aspects of life after stroke were discussed. According to Bright et al. being able to create conversational and relational spaces where people are supported to look into the future with a sense of possibility, hope, and potential is vital for persons to move forward in their lives post stroke. Based on their findings they conclude that, communication must be seen as a core clinical skill and a clinical intervention in its own right ( 68 ).

Our findings suggests that the relationship to professionals can promote adherence and instill hope, especially for persons with aphasia. This is supported by a meta-synthesis from 2020, where relationships were identified as being critical for persons experiencing communication impairment after stroke ( 69 ). In practice, this requires strong communicative competences in rehabilitation professionals ( 70 , 71 ).

Communication partner training is an approach that has shown to be useful in supporting communication skills ( 72 – 76 ). In Denmark the method Supported Conversation for Adult with Aphasia (SCA) is relatively widespread in practice. A review by Christensen et al. shows that also cognitive communication disorders of people with TBI challenge the interaction between rehabilitation professionals and persons with TBI. Their findings demonstrate that the communicative barrier is closely related to the professionals' communicative approach. Moreover, that rehabilitation professionals holding a collaborative and acknowledging approach using supportive strategies are the ones that may facilitate successful communicative interactions ( 77 ). This point to the fact that rehabilitation professionals must be given the opportunity to acquire the necessary competencies in communication strategies.

Rehabilitation strives for a coherent approach, with the bio-psycho-social model forming the basis for rehabilitation ( 32 , 33 ). Danish research in the field of brain injury has nevertheless shown that rehabilitation continues to primarily be aimed at physical and functional rehabilitation and does not adopt a holistic focus where the person's existential and emotional situation is considered ( 32 , 33 ). Rehabilitation of the person's “inner life world” (inside-perspective), understood as dealing and coping with personal, identity-related, and emotional challenges, including hope, is given less focus, although it is an important and central aspect of a bio-psycho-social approach ( 32 , 33 ). Being a professionally skilled occupational therapist or neuropsychologist is therefore not enough. In addition professionals need personal competences ( 70 ). According to Deegan, who has lived experience with disabilities, a decisive step toward understanding the experience of the person with a disability is that rehabilitation professionals embrace and accept their own woundedness and vulnerability because in doing so, “we share a common humanity” ( 78 ).

According to the Mattingly, professionals often focus on what she calls “the medical hope”, a narrow understanding where hope alone is tied to curation and rehabilitation in a more traditional sense. The hope of persons with an illness or disability, however, often involves a much broader understanding of hope as a journey towards healing or recovery, trying to find a positive meaning in what has happened ( 79 – 83 ).

The biomedical model offers no definitive cure when it comes to the physical and psychological consequences of an ABI. However, recovery is not only a pathological matter. Regaining quality of life can happen despite pathological consequences. Thus, there is an imperative need to hope even when everything seems hopeless. Hopelessness can have major consequences for the person, as it has been shown to be associated with depression and suicide across diagnoses ( 84 – 86 ). Hope, on the other hand, has been shown to have a positive impact on rehabilitation outcomes both for persons with mental and physical impairments ( 32 , 33 , 84 , 87 , 88 ). Within neurorehabilitation, it has been seen as good practice to confront persons with ABI with their disabilities since this could lead to greater insight and acceptance of difficulties and thus to a greater motivation to explore their limitations. In practice, however, it appears that confrontations do not necessarily lead to increased motivation. On the contrary, confrontations can lead either to individuals giving up and thus losing motivation and hope, or to mental resistance ( 89 ). This leaves rehabilitation professionals to walk a thin line between encouraging and discouraging hope when it comes to especially persons with ABI lacking insight in their own impairments.

Our analysis furthermore reveals that hope, identity, and social connectedness are closely intertwined as hope gives persons with aphasia the possibility both to dwell in the present but also to move forward. The co-construction of identity change are significant in the person's ability to recalibrate hope, which is often necessary during a rehabilitation or recovery process. For years anthropologists have written about the positive traits of narratives, in that story—told or acted upon—carry a healing potential through their contribution to the transformation of identity, interpretation of the past and even the creation of future scenarios ( 82 , 90 ). When persons acquire a brain injury and are faced with an uncertain future, focusing on life as lived in and over time can therefore make good sense, since such life-changing experiences create a natural focus on both the past and the future. Our review suggests that collaborating with the person on co-constructing a personal narrative holds the potential to support a positive view of identity and to empower persons with aphasia (or other communication difficulties) with new levels of confidence in themselves. This is in line with research within the field of communication disorders, where several studies talk about co-constructed communication as being essential in offering communication partners a way to approach everyday conversation and supporting positive narratives that reaffirm a sense of self ( 91 – 93 ).

Professionals may be afraid of giving false hope, which is why they may end up promoting too little hope to the person with ABI. Being with persons who have wishes, hopes, and dreams for the future, and who at the same time are in a situation that complicates the achievement of these, can be experienced as difficult for professionals. Findings in this review suggest that there is an opposite relationship between professionals playing a vital role, not only in making progress visible, but also in offering persons with ABI hope for future improvement.

Being the “holder” of another human being's hope is not an easy task. In fear of giving false hope, professionals may imply and maintain a less hopeful rehabilitation perspective instead ( 66 ). It appears that professionals’ capacity to contain despair and maintain hope prevents the person from giving up and feeling devastated by the brain injury. This require professional skills to tolerate the uncertainty and despair of the person's life. This kind of support is particularly crucial in times when progress is slow.

As we clearly see in this and other reviews, goals are connected to hope. In an ethnographic study by Tonnesen and Nielsen among persons with Parkinson's disease, they found that rehabilitation goals could appear as steppingstones towards hope ( 94 ). The correlation between goals and hope is also emphasized in this review. Progress seems to be paramount for the person's ability to maintain hope over time, thereby making goals a way for professionals to make progress visible. Researchers such as Levack and colleagues have also linked rehabilitation goals and hope. Levack et al. found that rehabilitation goals may keep hope alive by symbolizing possible progress ( 95 ). In a Cochrane review from 2008, Levack and colleagues concluded that there is low quality evidence that goal setting may improve outcomes for adults in rehabilitation with various disabilities, and moreover that the best graded evidence favors positive effects for psychosocial outcomes (such as emotional status, health-related quality of life, etc.) rather than physical outcomes ( 95 ). In this review, persons with ABI and professionals have a clear focus on goal setting in relation to their physical functions, whereas functions in relation to psychosocial conditions are absent. Once again, it is important to stress that goals relating to the psychosocial dimension are equally important when trying to uphold a bio-psycho-social approach in rehabilitation.

Future research should consider looking at experiences of hope in specific stages of the person's rehabilitation or recovery process. This could be of importance for further understanding of the concept of hope as it develops especially over time and in time. Furthermore, future research should consider exploring whether gender, age, social network or pre-injury personality influence the way in which persons with ABI experience hope in their rehabilitation or recovery process. Last, a specific focus on persons with communication difficulties—specifically the subgroup of persons with TBI and cognitive communication disorders, could be of great value as this is often an overlooked group. This group of persons may have unique needs that warrant separate exploration which is why it is important to also include studies that provide persons with communication difficulties with a voice ( 47 ).

4.2 Implications for practice

In light of our results, professionals are advised to consider the impact of giving or taking hope away when it comes to the population of persons with ABI. This review supports the need for practice to acknowledge the deep and fundamental importance of the concept of hope as a major part of the rehabilitation and recovery of persons with ABI, and even more so for persons with communication difficulties such as aphasia.

The literature included in this study provides an insight into why hope is often described as a paradox, having both positive and negative qualities embedded. This paradoxical concept requires professionals to make individual assessments of each person with ABI to find out how hope can best be supported, in the light of the person's personality, social network, etc., as well as where the person is in their rehabilitation or recovery process.

Especially for the subgroup of persons with communication difficulties, there seems to be a need for professionals to acquire skills in how to support conversation and the co-construction of narratives. This entails knowledge on how to work with the personal narratives of the individual, making it crucial that professionals gain qualifications on how to use supportive conversation techniques and tools.

At the same time, this review underlines that professionals play a crucial role when it comes to maintaining supportive relationships and instilling hope throughout the rehabilitation or recovery process. The role requires professionals to value the humanity and personhood of the persons, making them feel heard and understood and keeping a hopeful stance about their potential for recovery. This calls for highly attuned communication skills, along with the ability to contain despair and uncertainty on behalf of the person without losing hope entirely.

If practice therefore wants to offer rehabilitation grounded in a bio-psycho-social approach, then the psychosocial wellbeing of the person needs to be a primary outcome of the rehabilitation on an equal footing with outcomes concerning physical functions. Thus, professionals need to have a raised awareness of the emotional support required if an individual is to recover from a brain injury as a whole person. That is to refer to appropriate health professionals and have cross disciplinary collaborations. This again points to the necessity of setting goals for the physical and more practical part of the person's rehabilitation as well as the psychosocial part of the person's overall recovery.

Professionals should be knowledgeable about the emotional dimensions of rehabilitation during their training and education. The current professional training sequence includes limited information about the relational impact professionals can have on persons in rehabilitation and the psychosocial dimensions of this process. If we are to pay greater attention to social and psychological factors in the lives of people with disabilities and chronic health conditions, there need to be opportunities for cross-disciplinary professionals in general to have continuing education in psychosocial rehabilitation and to work with and develop their own personal skills at various levels of training.

4.3 Limitations

We have used an aggregative review form, namely a systematic review of qualitative research, as we wanted to accumulate knowledge relevant to the phenomenon of hope and show relationships among the pieces of knowledge across the included studies ( 96 ). In doing so we have tried to guide the selection of studies by clear eligibility criteria just as a systematic approach has been applied in the different steps of the review process. A review protocol was outlined and adapted along with the search process but only used as a working tool for the authors and therefore not registered at e.g., PROSPERO.

With this review we wanted to explore hope as experienced by the broad ABI population in a rehabilitation or recovery setting. This resulted in studies that cut across diagnostic groups covering many different impairments and taking place in a mixture of in- and outpatient services at several different stages of the rehabilitation or recovery process. In our thematic synthesis we have tried to be transparent about the different contexts of the included studies, but nevertheless the broad scope of this review is both a strength and a weakness. There is a limitation upon transferability of the findings in relation to the contextual data presented in the studies that could have been followed more closely throughout the review if the context of the studies had been more alike.

Although some of the included studies in this review only had few participants the data from these qualitative studies were of great importance as they gave valuable insight into an often-excluded group: People with ABI and communication difficulties (aphasia). So even though some would argue it to be a limitation (small sample size), it proved to be necessary in this qualitative review in order to represent the broad group of people with ABI.

Most of the included studies were gathered in high or middle-income countries which probably has a significance in that other perspectives could be imagined to be present in low-income countries, which possibly do not have the same infrastructure around healthcare.

The thematic synthesis methodology applied to this review offers a transparent approach to the synthesis of the primary studies; however, future research should consider whether other approaches used to analyse data could help bring other aspects of hope to the surface.

4.4 Conclusions

According to the findings of this review, rehabilitation professionals should embrace the ambiguity of hope, as a driving force as well as a source of despair. Attention must be paid to time and temporality and how to make progress visible as well as tangible for persons with ABI during their rehabilitation or recovery process. Finally, rehabilitation professionals must acknowledge the relationship with the individual with ABI as a core component of the rehabilitation in general. This requires a focus on professionals' personal competences, as a hope-promoting relationship between the professional and the person with ABI seems to be needed in order to accommodate to the psycho-social part of the bio-psycho-social approach.

Author contributions

CH: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. CG: Conceptualization, Data curation, Formal Analysis, Methodology, Supervision, Validation, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This review is part of a full PhD scholarship funded by the rehabilitation center “Neurorehabilitation Copenhagen”, Municipality of Copenhagen, Denmark (DK).

Conflict of interest

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

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fresc.2024.1376895/full#supplementary-material

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Keywords: hope, acquired brain injury, rehabilitation, recovery, literature review, qualitative studies, thematic synthesis

Citation: Højgaard Nejst C and Glintborg C (2024) Hope as experienced by people with acquired brain injury in a rehabilitation—or recovery process: a qualitative systematic review and thematic synthesis. Front. Rehabil. Sci. 5:1376895. doi: 10.3389/fresc.2024.1376895

Received: 26 January 2024; Accepted: 26 April 2024; Published: 14 May 2024.

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© 2024 Højgaard Nejst and Glintborg. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Camilla Højgaard Nejst, [email protected]

This article is part of the Research Topic

Vol II: Person-Centred Rehabilitation – Theory, Practice and Research