critical theory in qualitative research

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9 Critical Approaches to Qualitative Research

Kum-Kum Bhavnani, Department of Sociology, University of California at Santa Barbara

Peter Chua, Department of Sociology, San José State University

Dana Collins, Department of Sociology, California State University, Fullerton

• Published: 04 August 2014
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This chapter reflects on critical strategies in qualitative research. It examines the meanings and debates associated with the term “critical,” in particular, contrasting liberal and dialectical notions and practices in relation to social analysis and qualitative research. The chapter also explores how critical social research may be synonymous with critical ethnography in relation to issues of power, positionality, representation, and the production of situated knowledges. It uses Bhavnani’s framework to draw on Dana Collins’ research as a specific case to suggest how the notion of the “critical” relates to ethnographic research practices: ensuring feminist and queer accountability, resisting reinscription, and integrating lived experience.

Qualitative research is now ubiquitous and fairly well-respected throughout the human sciences. That Oxford University Press is producing this much-needed volume is further testament to that notion, and one which we applaud. However, although there are different approaches to conducting qualitative research, what is often not addressed are the philosophical notions underlying such research. And that is where the “critical” enters. Indeed, “critical,” used as an adjective and applied, within the academy, to methods of research is also a familiar phrase. The question is, therefore: what does “critical” mean, and how might it be translated such that present and future researchers could draw on some of its fundamentals as they plan their research studies in relation to progressive political activism?

The popularity of critical research is not predictable. Although the 1960s and early 1970s did offer a number of publications that engaged with critical research traditions (e.g., Gouldner, 1970 ), and the 1990s also led to a resurgence of interest in this area (e.g., Harvey, 1990 ; Thomas, 1993 ), it is now two decades since explicit discussions of critical research have been widely discussed within the social sciences (see Smith, 1999 ; Madison, 2012 , as exceptions).

In this chapter, we first outline meanings associated with “critical.” We then suggest that the narratives of critical ethnography are best suited for an overview chapter such as this. We consider critical ethnography to be virtually synonymous with critical social research as we discuss it in this chapter. In the final section of our chapter, we discuss Dana Collins’ specific research studies to suggest how her approach embraces the notion of “critical” ( Collins, 2005 ; 2007 ; 2009 ).

The “Critical” in Critical Approaches

“Critical” is used in many ways. In everyday use, the term can refer, among other definitions, to an assessment that points out flaws and mistakes (“a critical approach to the design”), or to being close to a crisis (“a critical illness”). On the positive side, it can refer to a close reading (“a critical assessment of Rosa Luxembourg’s writings”) or as being essential (“critical for effective educational strategies”). A final definition is that the word can be used to either denote considerable praise (“the playwright’s work was critically acclaimed”) or to indicate a particular turning point (“this is a critical time to vote”). It is this last definition that is closest to our approach as we reflect on “critical” in the context of qualitative research. That is, drawing from the writings of Marx, the Frankfurt School, and others (see Delanty, 2005 ; Marx, 1845/1976 ; Strydom, 2011 ), we suggest that critical approaches to qualitative methods do not signify only a particular way of thinking about the methods we use in our research studies, but that “critical approaches” also signify a turning point in how we think about the conduct of research across the human sciences, including its dialectical relations to the progressive and systematic transformation of social relations and social institutions.

The most straightforward notion of “critical” in this context is that it refers to (at the least) or insists (at its strongest) that research—and all ways by which knowledge is created—is firmly grounded within an understanding of social structures (social inequalities), power relationships (power inequalities), and the agency of human beings (an engagement with the fact that human beings actively think about their worlds). Critical approaches are most frequently associated with Marxist, feminist, and antiracist, indigenous, and Third World perspectives. At its most succinct, therefore, we argue that “critical” in this context refers to issues of epistemology, power, micropolitics, and resistance.

What does this mean, both theoretically and for how we conduct our research? Most would agree that whereas qualitative research does not, by definition, insist on a nonpositivist way of examining the social world, for critical approaches to be truly critical, an antipositivist approach is the sine qua non of critical research. Furthermore, it is evident as we survey critical empirical research that issues of reflexive and subjective techniques in data collection and the researcher’s relationship with research subjects also frame both the practices and the theories associated with research.

The following section begins by drawing attention to developments and debates involving the more restricted use the term critical as related to Marxism and then explores the ramifications for varying attempts to conduct critical qualitative research.

The Critical Debates

Karl Marx, Friedrich Engels, and their contemporaries (see Engels, 1877/1969 ; Harvey, 1996 ; Lenin, 1915/1977 ; Mao, 1990 ; Ollman, 2003 ) developed dialectical materialist notions of critique and “critical” that were substantively different from prior notions. They incorporated these dialectical materialist notions to develop Marxist theories and politics.

Dialectical materialism refers to an outlook on reality that emphasizes the importance of process and change that are inherent to things (such as objects, phenomena, and situations), as well as of the importance of human practices in making change. Significantly, human struggle over existing conditions and contradictions in things creates not only new conditions, but also new contradictions. This outlook serves as an analytical tool over idealist and old-fashioned materialist worldviews and as a source of strength for exploited peoples in their struggle against ruling elites and classes. It emphasizes that correct ideas, knowledge, and theoretical abstractions are established initially, and perhaps inevitably, through practice.

Dialectical materialism may be used to examine two aspects of the research process and the production of academic knowledge. The first aspect involves the writing process as it is carried out among multiple authors. At the drafting phase, the authors craft their distinct ideas into textual form. Contradictions in ideas are bound to exist in the draft. In doing revisions, some contradictions may become intensified and remain unresolved, yet, most frequently (and hopefully!), many are addressed in the form of clearer, more solid, and coherent arguments, thus resolving the earlier contradictions in the text. Yet, new struggles and contradictions emerge. The synthesis of ideas and argument in the final manuscript may again, however, engage in new struggles with the prevailing arguments being discussed.

The second aspect involves the relationship and interaction between the researcher and the interviewee. As their relationship begins, contradictions and differences usually exist between them, for instance, in terms of their prior experiences and knowledge, their material interests in the research project, and their communication skills in being persuasive and forging consent. The struggle of these initial contradictions could result in new conditions and contradictions. For example, this could lead to

the establishment of quality rapport between them, allowing the interview to be completed while the researcher maintains control over the situation;

the abrupt end of the interview due to the interviewee refusing and asserting her or his right to comply with the interview process; or

an explicit set of negotiations that address the unevenness in power relations between them, along with an invitation for both to be part of the research team and to collaborate in the collection and analysis of data and in the forging of new theories and knowledges.

In the first possibility, the prevailing power relations in interviews remain but shift to beneath the surface of the relationship, under the guise of “rapport.” In the second possibility, power relations in the interview process and initial contradictions are heightened, resulting in new conditions and contradictions that the researcher and research participant have to address, jointly and singly. In the third possibility, the research subject is transformed into a researcher as well, and the relationship between the two is transformed into a more active co-learning and co-teaching relationship. Still, new conflicts and contradictions may emerge as the research process continues to unfold. 1 In short, dialectical materialism stresses the analysis of change in the essence (1), practice (2), and struggle (3). Such analyses are at the root of how change may be imagined within the practices of social research.

Dialectical materialism, which forms the basis of the concept of “critical,” emphasizes the need to engage with power, inequality, and social relations in the arenas of the social, political, economic, cultural, and ideological. Based on this status, it is argued that an analysis of societies and ways of life demands a more comprehensive approach, one that does not view society and social institutions merely as a singular unit of analysis but rather as ones that are replete with history. Dialectical materialism directs its criticism against prevailing views or hegemonies, and, within the context of academic endeavors, engages in debates against positivism and neo-Kantian forms of social inquiry. It is this basis of “critical” that defines it in the context of research as a deep questioning of science, objectivity, and rationality. Thus, the meaning of the term “critical,” based on the idea of “critique,” emerges from the practice and application of dialectical materialism.

Historical materialism emerges from and is based on dialectical materialism. That is, any application of the dialectic to material realities is historical materialism. For example, any study of human society, its history, its development, and its process of change demands a dialectical approach rooted in historical materialism. This involves delving deeper into past and present social phenomena to thereby determine how people change the essence of social phenomena, and, simultaneously, transform their contradictions.

Dialectical materialism regards positivism as a crude and naïve endeavor to seek knowledge and explain phenomena and as one that assumes it is the task of social researchers to determine the laws of social relationships by relying solely on observations (i.e., by assuming there is a primacy of external conditions and actions). In addition, positivism separates the subject (the seemingly unbiased, detached observer) and object (the phenomenon/a under consideration) of study. Dialectical materialism overcomes the shortcomings of positivism by offering a holistic understanding of (a) the essence of phenomena; (b) the processes of internal changes, the handling of contradictions, and the development of knowledge; (c) the unity of the subject and object in the making of correct ideas; and (d) the role of practice and politics in knowledge creation.

Dialectical materialism directs its criticism against dominant standpoints. These standpoints can offer a simplistic form of idealism and philosophical materialism. Within the context of academic endeavors, the methods of dialectical materialism engage in debates against positivism and neo-Kantian forms of social inquiry. This approach challenges assertions that science, objectivity, and rationality are the sine qua non of research and that skepticism and liberalism are the only appropriate analytical positionings by which a research project can be defined as “critical.”

For instance, Auguste Comte and Emile Durkheim, in developing sociological positivism, argued for a new science to study society, one that adopted the methods of the natural sciences, such as skeptical empiricism and the practices of induction. In adopting these methods, approaches relying on early positivism sought to craft knowledge based on seemingly affirmative verification rather than being based on judgmental evaluation and transformative distinctions.

Positivism and dialectical materialism were both developed in response to Kantian and idealist philosophy. In the context of the European Enlightenment, in the late 1700s, Immanuel Kant inaugurated the philosophy of critique. Positivism challenged Kant’s philosophy of critique as the basis for the theory of knowledge.

Kant developed his notion of critique to highlight the workings of human reason and judgment, to illuminate its limitations, and to consolidate its application in order to secure a stable foundation for morality, religion, and metaphysical concerns. Politically, Kantian philosophy provided justification for both a traditionalism derived from earlier periods and a liberalism developed during the ascendance of the Enlightenment.

Kant sought to settle philosophical disputes between a narrow notion of empiricism (that relies on pure observation, perception, and experience as the basis for knowledge) and a narrow notion of rationalism (that relies on pure reason and concepts as the basis for knowledge). He argued that the essence (termed “thing-in-itself”) is unknowable, countering David Hume’s skeptical empiricism, and he was convinced that there is no knowledge outside of innate conceptual categories. For Kant, “concepts without perceptions are empty; perceptions without concepts are blind” (1781/1965, pp. A 51/B 75).

The method of dialectical materialism challenges Kant’s idealism for (what is claimed to be) its faulty assertion that correct ideas and knowing about the “thing-in-itself” can only emerge from innate conceptual categories, ones that are universal and transcendental. In Kantian philosophy, there is no reality (out there) to be known. Rather, it is the experience of reality itself that provides for human reason and consciousness.

Dialectical materialism overcomes Kant’s idealism with its recognition of the existence of concrete phenomena, outside and independent of human reason. Dialectical materialism stresses that social reality and concrete phenomena reflect on and determine the content of human consciousness (and also, we would argue, vice versa). Dialectical materialism also emphasizes the role of practice and politics in knowledge development, instead of merely centering the primacy of ideas and the meanings of objects.

In sum, the core debate against positivism centers on the practices of science. Dialectical materialism regards positivist approaches as crude and naïve endeavors that seek to determine unchangeable laws of nature, rely solely on observations and “sense experience” of phenomena as the basis for knowledge, highlight the primacy of external conditions and actions to explain phenomena, and separate the subject from the object of study. That is, dialectical materialism views positivism as a form of mechanical, as distinct from historical, materialism.

This abridged account of dialectical materialism and the critiques it offers of Kantian idealism and sociological positivism can allow for the formation of a preliminary set of criteria for what may constitute the “critical.” We argue that qualitative research may be critical if it makes clear conceptually and analytically:

The essence and root cause of any social phenomena (e.g., youth and politics);

The relationship between the essence of the social phenomena under consideration to the general social totality (such as how youth and their views of politics are related to wider systems within society, such as education, age, exploitation);

The contradictions within this social phenomenon (such as how young people are expressing their discontent),

and, therefore,

How to conduct more reflexive practices that interrelate data generation, data analysis, and political engagement that challenge existing relations of power.

Contemporary debates between neo-Kantian idealists and dialectical materialists have often been friendly regarding the direction for carving out what is meant by a critical project in qualitative social research. These debates bring to the fore issues of politics, ethics, research design, and the collection and analysis of data. They have also prompted a variety of ways in which “critical” may be used in relation to qualitative research. For the purposes of this chapter, we suggest four substantial ways in which “critical” is used in the context of qualitative research: (a) critical as a form of liberalism, (b) critical as a counterdisciplinary perspective, (c) critical as an expansion of politics, and (d) critical as a professionalized research endeavor and perspective.

Critical as a form of Kantian liberalism is one of the more conventional uses of the term in qualitative research. This use of critical is generally contrasted against the dogmatism of positivist approaches within social scientific research. Yet, to use critical in this way means that we embrace a liberalism that ends up promoting idealism in outlook and pluralism in practice. That is, Kantian liberalism presents itself as a “critical” and novel analysis by combining eclectic ideas and theories while not making known its political stand and its material interests. As a result, it supports prevailing modes of thinking that emphasize abstraction over concrete reality, and it succumbs to relativistist and pragmatist practices in research, such as “anything goes” in collecting data. In terms of methods, this use of “critical” promotes looseness and leniency in ethics and data collection and analysis, often without a structured accountability to the many constituencies that underlie all social research. Furthermore, the use of, for example, phrases such as “critical spaces,” when applied to social research, may be better understood as a celebration of method above theory and meta-theory and an engagement with some (of the often rather) excessive approaches to reflexivity and meta-reflexivity. In sum, this understanding of “critical” lacks appropriate structures of ethics and accountability and often tends to reject dialectic materialism.

The second use of “critical” in regards to qualitative research proposes a more analytical disagreement with conventional scholarly disciplines and, in so doing, seeks to take up counterdisciplinary positions ( Burawoy, 1998 ; 2003 ; Carroll, 2004 ; Smith, 2007 ). There are two main strands in this use of “critical.” One strand argues that “critical” is a means of exposing the weaknesses of conventional academic disciplines such as anthropology, political science, psychology, and sociology. At the same time, this strand maintains the viability of these core social science disciplines. For instance, academic feminists have continually highlighted the masculinist and heterosexist bias in what is considered top-tier scholarship and the need for these disciplines to be more inclusive in terms of perspectives and methodological techniques (e.g., Fonow & Cook, 1991 ; Harding, 1991 ; Ray, 2006 ). Yet such an approach may not inevitably focus on the fundamental problems, such as a neglect of the study of power inequalities (e.g., Boserup 1970 ; and see examples in Reinharz & Davidman, 1992 ). This second strand seeks to carve out interdisciplinary and multidisciplinary fields such as women studies, cultural studies, and area studies to overcome the paradigmatic and fundamental crises within core disciplines ( Bhavnani, Foran, & Kurian, 2003 ; March, 1995 ; Mohanty, 2003 ). Many of these interdisciplinary and multidisciplinary fields have often been more historical and qualitative in their approaches, seeking to go beyond positivist limitations and present a more nuanced and thorough analysis. However, even these multi-, inter-, and antidisciplinary fields have an uneven impact on dominant and conventional knowledge.

Moreover, both strands have not been able to overcome the increasing corporatization and neoliberalization of academic institutions. This issue addresses the increasing restructuring of public education into a private domain, one that relies on privatized practices and funding of both teaching and research. The neoliberalization of the academy is found in the ties of academic research to corporate grants, individualized career advancement, excessive publishing demands and citation indices, and the use of outsourcing for transcription, interviewing, online education, and private research spaces that are “rented” by public institutions, to name a few. These neoliberal conditions of research usually push out those critical researchers who attempt to avoid such exploitative avenues for research, writing, and collaboration. This use of “critical,” however, does expose that critical research is taking shape within contemporary processes of neoliberalism and the increasing privatization of the academy ( Giroux, 2009 ; Greenwood, 2012 ; Pavlidis, 2012 ).

The third and less familiar approach is to view “critical” as invigorating politics through the practices of feminist, antiracist, and participatory action research. This approach, for example, highlights the importance of analyzing power in research, as in terms of the conduct of inquiry, in political usefulness, and in affecting relations of power and material relations. Yet this view of “critical” is dogmatic because this approach demands that every research study meet all criteria of criticality comprehensively and perfectly.

A final use of “critical” emerges from the many scholarly and professionalized approaches that engage with the politics of academic knowledge construction while making visible the limits of positivism. “Critical” is used here as a means to focus primarily on revitalizing scholarship and research endeavors. However, we argue that even this use of “critical” ossifies the separation of the making of specialized knowledge from an active engagement to transform social life. Such a separation is antithetical to dialectical materialism. Often, this fourth form of the term “critical” is based on the logics of the Frankfurt School of critical theory (such as that of Adorno [1973] , Habermas [1985] , and Marcuse [1968] ) and other Western neo-Marxisms (from Lukacs [1971] and Gramsci [1971] to Negri [1999] ). Critical ethnographers and other critical social researchers, drawing from this tradition, often develop public intellectual persona by writing and talking about politics through scholarly and popular forms of publishing and speaking presentations and are even seen to take part in political mobilizations. Yet they can also shy away from infusing their research with a deep engagement in political processes outside the academy.

Later in this chapter, we discuss how to avoid some of the pitfalls of these four types of “critical,” but suffice it to say, in short, that it is the politics and the explicit situatedness of research projects that can permit research to remain “critical.”

Is Critical Ethnography the Same as Critical Research?

George Marcus (1998) argues that the ethnographer is a midwife who, through words, gives birth to what is happening in the lives of the oppressed. Beverley Skeggs (1994) has proposed that ethnography is, in itself, “a theory of the research process,” and Asad (1973) offered the now-classic critique of anthropology as the colonial encounter. However, although many approaches to and definitions of ethnography abound, it is the case that they all agree on one aspect: namely, that ethnographies offer an “insider’s” perspective on the social phenomena under consideration. It is often suggested that the best ethnographies, whether defined as critical or not, offer detailed descriptions of how people see, and inhabit, their social worlds and cultures (e.g., Behar, 1993 ; Ho, 2009 ; Kondo, 1990 ; Zinn, 1979 ).

It is evident from our argument so far that we do not think of ethnographic approaches to knowledge construction as being, in and of themselves, critical. This is because an ethnographic study, although not in opposition to critical ethnography or to critical research in general, has practices rooted in social anthropology. Therefore, its assumptions are often in line with anthropological assumptions (see Harvey [1990] for a recounting of some of these assumptions). Concepts such as “insider” versus “outsider,” “going native,” “gaining access,” and even conceptualizations of a homogenized and/or exoticized “field” that is out there ready to be examined by research remain as significant lenses of methodological conceptualization in much ethnographic research.

Despite, or perhaps because of, the move to reflexivity in ethnographic research, there remain enduring assumptions about best practices. As a result, a certain fetishization of research methods transpires, one that is often epitomized as reflexivity. In this instance, ethnographic and qualitative research become an ideal set of practices for extracting information. In sum, “best research practices,” as ways to extract information, reproduce core power dynamics of racism, gender, class, imperialism, and heteronormativity, which, in turn, reproduce the oppressive dynamics of noncritical qualitative research.

Furthermore, when presenting research merely as reflexive research, it is the case that the researcher can lose sight of the broader social structural and historical materialist context. In addition, a static notion of reflexivity can lead to the researcher not looking outward to assess the wider interconnections among the micropolitics of the research. That is, reflexivity is a dialectic among the researcher, the research process, and the analysis ( Jordan & Yeomans, 1995 ), but it is often presented simply as a series of apparently unchangeable/essential facets of the researcher. Our final point is that for theory to be critical in the development of research paradigms, it has to explicitly engage with lived experiences and cultures for, without that engagement, it remains as formalism (see, e.g., the work of Guenther [2009] and Kang [2010] as examples of critical qualitative research). We are very much in tune with Hesse-Biber and Leavy, who have suggested that (grounded) theory building is a “dynamic dance routine” in which “there is no one right dance, no set routine to follow. One must be open to discovery” (2006, p. 76).

An example of the limitation of conventionally reflexive research is in the area of lesbian and gay research methods that focus on the experiences of gay men and lesbians conducting qualitative research. It also offers a commentary on the role that non-normative sexuality plays in social research. By looking inward (see the earlier comment on “reflexivity”), these methodological frameworks focus on the researcher’s and participants’ lesbian/gay identifications. In so doing, this can fabricate a shared social structural positionality with research participants who have been labeled “gay” or “lesbian.” Such an approach to reflexivity overlooks the fabricated nature of positionalities and ignores the sometimes more significant divisions between researchers and participants that are expressed along the lines of race, class, gender, and nationality. Reflexivity is used only as a way to forge a connection for the exchange of information. A grave mistake is made in this rush to force similarity along the lines of how people practice non-normative sexualities ( Lewin & Leap, 1996 ; for a more successful engagement with queer intersectionality in research, see Browne & Nash, 2010 ).

The point to be made is that critical researchers should not merely ask “how does this knowledge engage with social structure?” Critical researchers, when contemplating the question “What is this?” as they set up and analyze their research, could also ask, “What could this be?” ( Carspecken, 1996 ; Degiuli, 2007 ; Denzin, 2001 ; Noblit, Flores, & Murillo, 2004 , all cited in Degiuli, 2007 ). Perhaps, borrowing from Karen O’Reilly’s thoughts on critical ethnography, one may think of critical research as “an approach that is overtly political and critical, exposing inequalities in an effort to effect change” ( Reilly, 2009 , p. 51). That is, in order for qualitative research to be critical, it must be grounded in the material relationships of history, as may be seen in the work of Carruyo (2011) , Chua (2001 ; 2006 ; 2007 ; 2012 ), Collins (2005 ; 2007 ; 2009 ), Lodhia (2010) , and Talcott (2010) .

Quantz (1992) , in his discussion of critical ethnography, suggests that five aspects are central to the discussion of critical research/ethnography: knowledge, values, society, history, and culture. So far in this chapter, we have discussed knowledge and its production, values/reflexivity and qualitative research/ethnography, society and unequal social relationships, and history as a method of historical and dialectical materialism in order to better understand social and institutional structures. What we have not discussed, however, is the notion of culture, nor, indeed, the predicament of culture ( Clifford, 1998 ): “Culture is an ongoing political struggle around the meaning given to actions of people located within unbounded asymmetrical power relations” ( Quantz, 1992 , p. 483).

Quantz elaborates by stating that culture develops as people struggle together to name their experiences (see Comaroff & Comaroff, 2012 , for a sophisticated and elegant discussion of this thinking). For example, one key task of critical research is to tease out how disempowerment is achieved, undermined, or resisted. That is, the job of the researcher is to see how the disempowerment—economic, political, cultural—of subordinated groups manifests itself within culture, and, indeed, whether the subordinated groups even recognize their disempowerment. For example, “the hand that rocks the cradle rules the world” is one example of how the material disempowerment of many groups of women is presented, in fact, as a strength of women, and yet it takes the gaze away from seeing the subordination of women by ostensibly emphasizing women’s hidden social power.

It is critical qualitative research that has to simultaneously analyze how our research can identify processes and expressions of disempowerment and can then lead to a restructuring of these relationships of disempowerment. At times, critical social researchers engage in long-term projects that involve policy advocacy and community solidarity to link community-driven research with social empowerment and community change (see Bonacich, 1998 ; Bonacich & Wilson, 2008 ; Hondagneu-Sotelo, 2007 ; Stoecker, 2012 ).

The key point is that critical qualitative research parts company with positivistic approaches because it is argued that positivism is only able to offer a superficial set of findings. Critical qualitative research hones research concepts, practices, and analyses into finer points of reference so that societal relationships may be not only understood, but also so that social power inequalities can be undermined. In short, critical social research has a Foucauldian notion of power at its very core and may thus be thought of as offering insights into people’s lived experiences ( Williams, 1976 ) as they negotiate asymmetrical societal power relations (see e.g., Novelli, 2006 ).

The Practices of Critical Qualitative Research

Within our current era of enduring global inequalities, what could constitute a truly critical approach to qualitative research? More than twenty years ago, in “Tracing the Contours” ( Bhavnani, 1993 ), it was argued that if all knowledge is historically contingent and, therefore, that the processes of knowledge production are situated, then this must apply to all research practices as well. 2 This argument was based on Haraway’s (1988) idea that the particularities of knowledge production do not lie in the characteristics of individuals. Rather, knowledge production is “about communities, not about isolated individuals” (p. 590). Building on this, Haraway discussed the significance of partiality and its relationship to objectivity. She suggested that it is the researcher’s knowledge of her own “limited location” that creates objectivity. In other words, knowing the limitations of one’s structural position as a researcher contributes to objective research because there is no objectivity that is omniscient, one from which all can be revealed (Haraway discusses this as the “god trick,” which is like “seeing everything from nowhere,” p. 582).

It is from Haraway’s insights that we develop our argument that situated knowledges are not synonymous with the static reflexivity we describe earlier. This is because, in this latter scenario, the researcher implies that all research knowledge is based on and derives from an individual’s personal historical and biographical perspectives. That is, researchers note their racial/ethnic identity, sex/gender, sexuality, age, class, and ability (i.e., biographical aspects of themselves), which are presented as essential and unchanging factors and that determine the knowledge created by the research. This has also been called “absolute relativism” ( Bhavnani, 1993 ) or “extreme relativism” ( Alcoff & Potter, 1993 ).

We suggest that the three elements central to research being “critical” are partiality, positionality, and accountability. Partiality leads to critical research interrogating prevailing representations as the research is conducted, and this builds on difference. Positionality is not about being reflexive, but about understanding the sociohistorical/political context from which research is created and thus engages with the micropolitics of a research endeavor. Accountability makes it evident that there are many constituencies to which all academic researchers are accountable—for example, their discipline, intellectual integrity, their institution and academic colleagues, the idea of rigorous scientific research, and academic freedom in research—as well as being accountable to the people with whom the research is being conducted. It is accountability that leads to a critical research project interrogating how the lived experiences and cultures of the research participants are inscribed within the research (see Stoecker, 2012 ).

What might the necessary elements be for ensuring that our research practices retain the criticality we have discussed earlier? We offer four possibilities that could form a filter through which one could decide if research is critical, using our definition of the term. First, all critical qualitative researchers should interrogate the history of ethnographic research that has led to the systematic domination of the poor; working classes; ethnic, racialized, sexual Others; women; and colonized peoples. That is, critical qualitative researchers must begin research with an understanding of how previous research, including their own, may continue to play a part in the subordination of peoples around the world, for example, by reinscribing them into predictable and stereotypical roles. Second, critical qualitative researchers should work to develop a consciousness of what might constitute critical research practices—without fetishizing methods—that challenge the system of domination often present in social research. Third, researchers who embrace critical qualitative approaches must develop comfort with the notion that they are conducting research with a purpose; that is, researchers grapple with and comprehend that critical research demands that they engage with the idea that they conduct research into research inequalities in order to undo these inequalities. Finally, critical qualitative researchers comprehend that their level of comfort can extend into the idea that research does not simply capture social realities; rather, the critical research approach is generative of narratives and knowledges. Once this last idea is accepted—namely, that knowledge is created in a research project and not merely captured—it is then a comparatively straightforward task to see the need for a researcher’s accountability for the narratives and knowledges he or she ultimately produces. In so doing, it is possible to recognize that all representations have a life of their own outside of any intentions and that representations can contribute to histories of oppression and subordination.

We propose that it is the actual practice of research, and, perhaps, even the idea of researcher as witness ( Fernandes, 2003 ), and not a notion of “best practices,” that keeps the politics of research at the center of the work we do. This includes insights into the redistribution of power, representation, and knowledge production. We suggest that critical research is work that shifts research away from the production of knowledge for knowledge’s sake and edges or nudges it toward a more transformative vision of social justice (see Burawoy, 1998 ; Choudry, 2011 ; D’Souza, 2009 ; Hussey, 2012 ; Hunter, Emerald, & Martin, 2013 ).

Thoughts from the Field

Here, based on Collins’s fieldwork, we highlight a set of critical methodological lessons that became prominent while she was conducting her field research in Malate, in the city of Manila, the Philippines, currently a tourist destination but once famous as a sex district. We define her work as a critical research practice.

Since 1999, Dana Collins has conducted urban ethnographic work in Malate, exploring gay men’s production of urban sexual place. She has been interested in the role of “desire” in urban renewal, and, in particular, how informal sexual laborers (whom she terms “gay hospitality workers,” a nomenclature drawn from their own understandings of their labor and lives) use “desire” to forge their place in a gentrifying district that is also displacing them. This displacement has involved analyzing urban tourism development, city-directed urban renewal, and gay-led gentrification, as well as informal sexual labor.

The research has involved her precarious immersion in an urban sexual field. She undertook participant observation of gay night life in the streets, as well as in private business establishments, and conducted in-depth and in-field interviews with gay business owners, city officials, conservationists, gay tourists, and gay-identified sexual laborers. In addition, she drew on insights from visual sociology and also completed extensive archival work and oral history interviewing. In all of this, she explored the collective memories of Malate as a freeing urban sexual space.

There exist multiple and shifting positionalities of power, knowledge, exchange, and resistance in her research. For one, she points out that she occupies multiple social locations as a white, lesbian-identified feminist ethnographer from a US university, one who forges complicated relationships with urban sexual space, sex workers, and both gay Filipino men and gay tourists.

A critical research practice at heart involves the shifting of epistemological foundations of social science research by addressing core questions of how we know what we know, how power shapes the practices of research, how we can better integrate research participants and communities as central producers of knowledge in our research, and how we can better conceptualize the relationship between the research we do and the social justice we are working toward in this world. 3 Such questions function as a call to action for critical researchers not only to examine the power relations present in research, but to generate new ways of researching that can confront the realities of racism, gender and class oppression, imperialism, and homophobia. This is about not only becoming better researchers, but also about seeking ways to shift the very paradigm of qualitative research and ensuring its service to social change. We have learned to use these questions as a central and ongoing part of the research we do.

Feminist and Queer Accountability to the Micropolitics of the Field

One of the primary tenets of critical qualitative research is that researchers must work with a wider understanding and application of the politics of research. For Kum-Kum Bhavnani (1993) , this means that one needs to be accountable to the micropolitics of research because such accountability destabilizes the tendency to conduct and present research from a transcendent position—the “all knowing” ethnographer, the “outsider” going in to understand the point of view of “insiders,” the attempt to (avoid) “go(ing) native,” and the researcher who aims to “gain access” at all costs and in the interests of furthering research. Micropolitics is not only the axis of inequality that shapes contemporary field relations; it is also the historical materialist relationship that constitutes the field and informs the basis of critical qualitative research. Micropolitics therefore is a critical framework that questions the essentializing and power-laden perceptions of research spaces and people because it encourages both a reflexive inquiry into the limited locations of research, and it involves the more critical practice of the researcher turning outward, to comprehend what Bhavnani calls the “interconnections” among researcher, research participants, and the social structural spaces of “the field.”

Micropolitics illuminates how all research is conducted from the limited locations of gender, race, class, sexual identification, and nationality, as well as illuminating the interconnections among all of these locations. This is not a simplistic reflexive practice of taking a moment in research to account for one’s positionality and then moving on to conduct normative field work; Bhavnani has been critical of such moments of inward inspection that lack substantial accountability to the wider micropolitics of the field. Rather, this move requires an ongoing interrogation of the limited locations of research that show how knowledge is not transcendent. Furthermore, when used reflexively, limited locations offer a more critical framework from which to practice research.

Micropolitics encouraged Collins’ attention to the limited location of a global feminist ethnographer doing research on gay male urban sexual space in Manila. For one, she moved among different positionalities throughout her research—of woman, queer-identified, white, US academic, tourist, ate (Tagalog term for older sister)—and none of these positions was either a transcendent or more authentic standpoint from which to conduct ethnographic work. So, for instance, as a white tourist, she moved easily among the gentrifying gay spaces because these spaces were increasingly designed to encourage her movement around Malate. This limited location showed the increasing establishment of white consumer space, which encouraged the movement of consumers like herself yet dissuaded the movement of the informal sexual laborers with whom she was also spending time—the gay hosts. Her limited location as a white woman researcher from a major US university meant that gay hosts sometimes shared their spaces and meanings of urban gay life with her, yet many times those particular spaces and dialogues were closed—she was not allowed into the many public sexual spaces (parks and avenues for cruising and sex late at night), yet gay hosts treated her as an audience for their many romantic stories about the boyfriends they met in the neighborhood.

Hosts emphasized that they gained much from hosting foreigners in terms of friendship, love, desire, and cultural capital. Yet they monitored the information they shared because she remained to them a US researcher who wielded the power of representation over their lives, despite her closeness with a group of five gay hosts. Hence, gay hosts often chose to remain silent about their difficult memories of sex work or any information that could frame them as one-dimensional “money boys,” as distinct from the “gay”-identified Filipino men who migrated to Malate to take part in a gay urban community.

Micropolitics challenges the authenticity of any one positionality over another; it was Collins’ movement among all of them, as well as her ongoing consideration of their social structural places, that provided her with a more critical orientation to the research. She suggests that she was not essentially a better “positioned” researcher to study “gay” life in Manila because she too is gay. Rather she found that differences of race, class, gender, and nationality tended to serve as more enduring, limited locations that influenced relationships within this research and that required ongoing critical reflexive engagement.

We want to add that a queer micropolitics of the field also offers critical insight into how identities are not stagnant but rather can be fabricated and performative during the research process. This moves researchers away from an essentialist take on their standpoint because an essentialist mind-set can lead to a search for the authentic insider and outsider. It can also lead to an essentialist social positionality that is more conducive for researching. Queer micropolitics show that research is made up of a collection of productive relations and identities. So, for example, her lesbian identification did not create a more authentic connection with gay hosts in Manila; rather, she often fabricated a shared “gay” positionality. This was a performance that served as a point of departure for her many conversations, from which she could proceed to share meanings of what it meant to be “gay” in the Manila and the United States.

Some of the productive relations that arise in research are the continuum of intimacies that develop while doing research. So, like feminists before her, she chose to develop close friendships with hosts where they genuinely loved (in a familial way) as they spoke of love. While learning about gay life in Malate, she stroked egos, offered advice, cried over broken hearts and life struggles, and built and maintained familial relations. Queer micropolitics shows, however, the limitations of such intimacies because intimacy does not equal similarity—the differing social locations of class, race, gender, and nationality meant that the experiences of urban gay life varied immensely. Thus, building such intimacies across these differences requires both the recognition and respect for boundaries that hosts constructed. She had to learn to see and know that when hosts became quiet and pulled away these were acts of self-preservation as well as acts of defiance against the many misrepresentations of their lives that had taken shape in academic research and journalistic renderings of their place in “exotic” sex districts.

A queer micropolitics also shows how research is an embodied practice: researchers are gendered, racialized, classed, and sexualized in the field. This became most apparent as she walked alone at night in the “field” and developed a keen awareness of the deeply gendered aspects of Malate’s urban spaces. For one, her embodiment was a peculiar presence because women in Manila do not walk alone at night. This includes women sex workers who publicly congregate in groups or with clients and escorts; otherwise, they are subject to police harassment. Hence, her very movement in the field as a sole woman felt like a transgression into masculine urban space because her feminine body was treated as “out-of-place” in the public spaces of the streets at night—she was flirted with, name called, followed, and sexually handled as she walked to gay bars for her research. As much as her queer location afforded her an understanding of how gender is a discursive production on the body, replete with the possibility of her being able to transcend and destabilize the gendered body as a biological “reality,” she confronted the discomfort of being read as a real woman in what became predominantly men’s spaces at night.

Yet this gendered embodiment, in part, shaped her knowledge of the district as she developed quick and knowledgeable movement through the streets, a queer micropolitical reading of urban space that arose out of this limited gender location. She was aware of the spacing of blocks, the alleys, the street lighting, and the time of night when crowds spilled out from the bars and onto the streets, allowing her to realize that a socially vibrant street life actually facilitated her movement. This queer micropolitical reading of urban space showed how both researchers and research participants do not simply exist in a neutral way in city space; rather, gender leads to our use and misuse of urban space. She has juxtaposed her experience with those of research participants in her study. The latter spoke at length about their exploratory and liberatory experiences of urban space, replete with their access to masculine sexual spaces—parks for cruising and sex, city blocks for meeting clients or picking up male sex workers, and alleys, movie theaters, and mall bathrooms for anonymous sex.

This queer micropolitical read of Malate’s gentrified space showed how very different was her access to the newly opening bars, restaurants, cafés, and lifestyle stores. Her whiteness signaled assumptions of her class location and positioned her as part of the international presence that this gentrifying space was targeting and whose movement among establishments was encouraged. She received free entry, free drinks, exceptional hospitality, and invitations to private parties, and her movements were closely monitored as she entered and exited establishments for the sake of “protecting a foreign tourist from street harassment” (interview with bar owner).

Overall, she experienced whiteness and class as equally embodied because these locations signaled her power as a “legitimate” consumer, allowing access to urban consumer sites and a privileged movement among gentrified spaces. This embodied experience of gentrified space differed from that of her gay hosts, who were often denied access to these establishments for being Filipino, young, working class, gay, and interested in foreigners. Contrarily, their bodies were constructed as a “threat” to urban renewal in the district.

Resisting Reinscription

Critical qualitative research is also concerned with the politics of representation in research. This requires a hard look at the implicit imperialisms of ethnographic work, including the tendency to go in and get out with abundant factual information, as well as the lasting impact of objectificatory research practices on fields of study. Such practices are evident in the now global rhetoric about the so-called Third World prostitute, who in both academic and journalistic renderings tends to be sensationalized and sexually Othered. This rendering is part of a long history of exoticization that has denied subjectivity and rendered invisible the lived experiences of sexual laborers around the world.

Such failed representations are part of what Kum-Kum Bhavnani (1993) has called “reinscription”—the tendency in research to freeze research participants and sites in time and space, thus rendering them both exotic and silenced. Reinscription denies agency to research participants and renders invisible the dynamic lived experiences of those same research participants. Doing research in both postcolonial and sexual spaces means that researchers must grapple with how our research participates in histories of reinscription—we both enter into and potentially contribute to a field that has been already “examined,” overstudied, and often exoticized. Thus, a critical qualitative approach is one that begins with a thorough understanding of these histories of representation so that we are not entering fields naïvely, as spaces only of exploration. Rather, we enter with knowledge of how the field has already been constituted for us through reinscription. A critical orientation has a core objective of understanding how our representations of research at all levels of the research process could contribute to exoticization by reinscribing participants and sites.

The issue of reinscription became particularly apparent when Dana Collins interviewed gay hosts and grappled with what appeared to be their elaboration of a contradictory picture of their sexual labor, as well as of their lives. In short, hosts tended to “lie,” remain silent, embellish “truths,” and articulate contradictory allusions to their life and labor in Malate. When Collins began her interviewing, she held the implicit objective of obtaining the “truth” about hosts’ lives, which she believed resided in “what they do” in the tourism industry. She was concerned with the “facts” about their lives, even though gay hosts were more likely to express their desire—desire for relations with foreigners, desire to migrate to a “gay” urban district, desire for rewarding work, and desire for community and social change. She struggled with many uncertainties about the discussions: how could they hold a range of “jobs” and attend school, yet spend most of their days and nights in Malate? How could they understand gay tourists as both boyfriends and clients? Why resist the label “sex worker” yet refer to themselves as “working boys” and claim to have “clients?” She struggled to make sense of the meanings that hosts offered even as she simultaneously felt misled concerning the “real” relations of hospitality.

Interviewing hosts about sexualized labor—as a way to produce a representation of sex work—did not facilitate the flow of candid information; hosts later expressed their view that sex work and their lives were already “overstudied.” Many researchers had previously descended on Malate to study sex work, and the district was a prime location for the outreach of HIV/AIDS organizations, some of which had breached the confidence of the gay host community. In short, Dana mistakenly started her research without the knowledge of Malate as a hyperrepresented field, and her research risked reinscribing gay hosts’ lives within that field as static and unchanging.

Importantly, those gay hosts who resisted becoming the “good research subjects” who give accurate and bountiful information, prompted a radical shift in her research framework. They told her stories about their imagined social lives, which encouraged her to rethink her commitment to researching sex work because the transformation of the discourses offered another view of the district, their work, and lives, one that offered a more visionary perspective. She began to focus less on “misinformation” and instead followed how hosts framed their lives. She treated these framings as social imaginings in which Malate features prominently in their understandings of gay identity, community, belonging, and change. In short, their social imaginings functioned as counternarratives to reinscription and offered their lived experience of urban gay place. Such imaginations expressed hope, fear, critique, and desire—in short, they present a utopic vision of identity, community, and urban change.

Integrating Lived Experience

Finally, critical qualitative research is a call to study lived experience, which is a messy, contradictory realm, but a deeply important one if we as critical researchers are truly interested in working against a history of research that has silenced those “under study” (see Weis & Fine, 2012 ). Paying attention to lived experience allows us to better engage with the contradictions mentioned earlier because lived experience is about understanding the meanings that research participants choose to share with researchers, and it is also about respecting their silences. As Kum-Kum Bhavnani (1993) has argued, silences can be as eloquent as words. Finally, integrating lived experience can take a critical qualitative project further because lived experience allows researchers to explore the epistemological relationship of the meanings and imaginings offered by research participants and to be explicit about the project of knowledge production. In other words, a central guiding question of critical qualitative research is how can research participants speak and shape epistemology, rather than solely being spoken about or being the subjects of epistemology?

Collins used hosts’ social imaginings as an epistemological contribution because their imaginings showed how hosts draw from experiences of urban gay community to articulate their desires for change, despite their simultaneous experiences of inequality and exclusion. We read social imaginings as a subjective rendering of urban place—the hosts’ social imaginings expressed their history, identity, subversive uses of urban space, and, ultimately, the symbolic reconstitution of that urban space. In this way, hosts were refiguring transnational urban space by writing themselves and their labor back into the district’s meaning, even as the global forces of tourism and urban renewal threatened to displace them.

In conclusion, we seek to highlight how critical research insists on the interplay of reflexivity, process, and practice. In particular, we encourage critical researchers to be mindful of the multiple meanings and usages of the term “critical” so that we can make more explicit our political interests and stand within our disciplines, the academy, our community, and the world. We offer dialectical materialism as a distinct mode of critical analysis that emphasizes an analysis of change in essence, practice, and struggle. We also suggest that, for researchers to be critical in their research, they should strive to take up research questions and projects that study change, contradictions, struggle, and practice in order to counter dominant interests and advance the well-being of the world’s majority. We should strive to build new research relationships—such as overcoming the faulty divides between researchers and research participants and by promoting systems of community accountability—that dialectically fuse research, political activism, and progressive social change.

Furthermore, we suggest that critical research can agitate against the homogeneity of ethnographic representation, allowing for the realities of people’s lives to come into view. Critical researchers recognize the contested fields of research; yet this requires our critical engagement with the research process, as a reflexive, empathetic, collective, self-altering, socially transformative, and embedded exercise in knowledge production. Therefore, critical research can resist imperialist research practices that are disembodied and that assume a singular social positioning. We use an imperative here to say that we must conduct research as embodied subjects who shift between multiple and limited locations. We also have to find more ways to remain accountable to our communities of research as a way to undo implicit imperialisms in social research. Critical research can work against the remnants of an objectivist and truth-seeking method that supports prevailing interests, classes, and groups while embracing research from social locations that offer situated knowledges and the possibility for greater shared understandings. Finally, critical research can engage the micropolitics of research and foreground the need for the accountability of researchers to resist reproducing epistemic violence.

This last is an idealist imagining of what should happen. However, a number of research projects have approximated closely to these goals.

Parts of our argument have appeared in some of our earlier work (e.g., Bhavnani & Talcott, 2011 ; Collins, 2009 ; 2002 ; Chua, 2001 ).

Although we, as the chapter’s three authors, do not usually use “we” in our writing as a general pronoun, it is the most direct way to offer our insights in this section.

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An Introduction to Critical Approaches

• First Online: 29 September 2022

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• Robert E. White   ORCID: orcid.org/0000-0002-8045-164X 3 &
• Karyn Cooper 4  

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As can be understood from the previous chapter, in qualitative research, words are used as data rather than numerical representations (Miles & Huberman, 1994). All qualitative methods rely on linguistic information rather than on statistical evidence. As such, they tend to employ meaning-based (as opposed to numerical-based) data analysis (Polkinghorne, 1983). Thus, qualitative research utilizes data in the form of text, which, in turn, serves to furnish a detailed analysis of a situation, a case, a subject or an event through original analysis (Creswell, 2013). In qualitative research, data is usually collected and analyzed on fewer participants and situations (Patton, 2014) than is commonly found in quantitative research practices. The previous chapter introduced a short history of qualitative research as it relates to quantitative research endeavours. The current chapter devotes itself to a discussion of a number of approaches to qualitative research, specifically the critical approach.

The reliance on personal experience is the main building block, the main distinction of qualitative research. Not so much feelings, not so much how do we feel about things, but what is the experience as felt, as told, as manifest in the things that we do. Robert Stake, University of Illinois, Urbana-Champaign.

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Transformative Potentials of Critical Educational Inquiry

Emma Simmons

The foundational questions to critical work are: Who/what is helped/privileged/legitimated? Who/what is harmed/oppressed/disqualified?

(Cannella & Lincoln, 2009, p. 54)

Critical inquiry has been criticized for creating illusions of justice and being unable to transform the situations of the oppressed. Critics have voiced concerns for the paradoxical nature of critical inquiry, arguing that by providing alternative understandings of social phenomena, critical inquirers send a message that the oppressed are partly responsible for their situations due to their lack of “ appropriate” knowledge. In this article, we discuss the transformative potentials of critical educational inquiry. We use five contexts of qualitative research, namely, autobiographical, historical, political, postmodern, and philosophical to explore the possibilities of critical inquiry in educational research. We also use an article by Deborah Hicks (2005) to exemplify how critical research may be transformative and empowering by involving the researched in a process of inquiry characterized by negotiation and reciprocity.

critical inquiry, educational research, contexts of qualitative research, empowerment

Introduction

Critical theory generally refers to the theoretical traditions developed by a number of scholars affiliated with the Institute of Social Research at the University of Frankfurt in the mid-twentieth century. This group of scholars, including Max Horkheimer, Theodor Adorno, and Herbert Marcuse, situated this inquiry within German philosophical, social, and political thoughts and traditions. Very soon, the life and work of these scholars were heavily influenced by the devastation of World War I, along with resulting economic crises and political instability. They believed that reinterpretations of society were necessary, during an infamous period in history, when various forms of injustice and subjugation were shaping their world. Unfortunately, only a decade after the establishment of the Frankfurt School, the Nazis overtook Germany in body and mind. The leading scholars of the Frankfurt School decided (or were forced) to move to the United States. However, they were shocked by many aspects of American culture, especially the unquestioned acceptance of empirical practices of American social science research. In 1953, Horkheimer and Adorno decided to return to Germany in order to revitalize the Institute of Social Research, but Marcuse chose to stay in the United States and continue his work in social science research and theorization (Kincheloe & McLaren, 2011).

All members of the Frankfurt School championed a vision of a more just society, in which people have not only an equal access to desirable things but also control over the economic, political and cultural aspects of their lives. They argued that the oppressed and exploited people would be emancipated only if they were empowered to transform their situations by themselves. This theoretical tradition is called “critical” because the promoters of this theory “saw the route to emancipation as being a kind of self-conscious critique which problematizes all social relations, in particular those of and within the discursive practices of power, especially technical rationalism” (Tripp, 1992, p. 13).

Although frequently referenced in social science literature, critical theory has also been misinterpreted, misunderstood and accused of being patriarchal and re-inscribing old power structures. For example, Elizabeth Ellsworth (1989) famously questioned the ability of critical theory to empower the oppressed and transform their situations. To avoid confusion in our discussion, we conceptualize critical theory as a framework to understand “issues of power and justice and the ways that the economy; matters of race, class, and gender; ideologies; discourses; education; religion and other social institutions; and cultural dynamics interact to construct a social system” (Kincheloe & McLaren, 2011, p. 288).

Because of its emancipatory nature, critical theory is different from traditional empiricist theories in three important ways (Schwandt, 2007). First, it is a self-reflective, democratic discourse in the sense that it relinquishes normative and accepted understandings of the social order and adopts a lens of critical reconsideration. Second, unlike the empiricist tradition in which the theorist is disinterested in and detached from the research subjects, critical inquiry is closely related to praxis [i.e., action + reflection = word = work = praxis] (for details, see Freire, 1970). Third, critical inquiry “employs the method of immanent critique, working from within categories of existing thought in order to radicalize those categories, reveal their internal contradictions and shortcomings, and demonstrate their unrecognized possibilities” (Schwandt, 2007, p. 55). Therefore, when research is carried out from the perspectives of critical theory, it aims to identify various forms of power and “seeks in its analyses to plumb the archaeology of taken-for-granted perspectives to understand how unjust and oppressive social conditions came to be reified as historical ‘givens’” (Cannella & Lincoln, 2009, p. 54).

The critical theory tradition has been taken into the field of education by a number of scholars, “but most notably by Paulo Freire in his work with oppressed minorities which gave rise to the term critical pedagogy , meaning teaching-learning from within the principles of critical theory” (Tripp, 1992, p. 13). Other scholars, such as Michael Apple, Henry Giroux, Joe Kincheloe and Peter McLaren have taken up critical theory to unpack politics of education, epistemological violence, control of teachers and learners, commodification of knowledge, and how schools reproduce social, economic, political, and cultural inequalities. In addition to identifying these oppressive roles of education, they have also provided the language of possibility .

In this article, we explore critical inquiry through five contexts, namely, autobiographical, historical, political, postmodern, and philosophical. Karyn Cooper and Robert White (2012) propose these five contexts as “a theoretical framework for conducting, understanding, and interpreting qualitative research” (p. 23). Throughout our exploration, we use Deborah Hicks’ (2005) article “Cultural hauntings: Girlhood fictions from working-poor America” as an example of reflexive, advocacy-centred critical inquiry. In this article, Hicks delineates links between third and fourth-grade girls’ fascination with horror fiction, layered dimensions of their voice and identity, and the complexities of growing up in a predominantly white working-poor community. Using the five contexts of qualitative research (Cooper & White, 2012) as a theoretical framework with reference to Hicks (2005), as an example of critical inquiry, we present our analysis of and insights into the possibilities for and realities for empowerment in critical education research.

Autobiographical Context

One of the over-arching aims of critical inquiry is to include various perspectives in academia and to acknowledge that the stories and voices of particular groups have long been underrepresented in conversation of research. Critical inquiry has paved the way for, and continues to incorporate, the lenses of feminist theory, critical race theory and class analyses, among others, and ultimately seeks to challenge the canonical frames of academia that have allowed for only one reality. The autobiographical context provides a step forward in that challenge, and many practitioners of critical inquiry have used the autobiographical context both to inform their larger critiques and also to situate themselves within the larger discourse. Race and gender theorists such as Gloria Anzaldua (1987), bell hooks (1994), and Beverly Daniel Tatum (1997) weave their autobiographies throughout their critical analyses in order to establish the inextricability between their lived experience and their perspective regarding the world around them.

As described in Cooper and White (2012), the autobiographical context is a way to highlight the researcher’s own perspective in order to better establish a connection between researcher, researched and reader, as well as to contextualize the research produced. Without an autobiographical context, the researcher and, in fact, the research itself would be disembodied and without a human source. As a reader, one would be unable to understand both the insights and the blind spots that the researcher brings to an investigation without an understanding of the author’s preconceived ideologies and experiences: “To use a metaphor, viewing a work of art without contextualizing it in terms of our knowledge about the artist tends to limit our understanding of the painting itself” (Cooper & White, 2012, p. 33). Before theorists in the latter half of the 20 th century began to call into question the positionalities within the academy, the autobiography of the researcher was hidden, leading to an inability to trust the work produced, and an “othering” of the subject.

Referencing William Pinar, Cooper and White (2012) highlight the use of autobiography in research, noting that it need not be a self-indulgent exercise. Pinar demonstrates, through his method of currere, that autobiography is a part of a larger context. His four steps allow researchers to incorporate their lived experiences into their larger research and, in fact, study themselves in order to ask and understand the question, “What do I make of what I have been made?” (Cooper & White, 2012, p. 34). As critical inquiry attempts to inspire new ways of thinking, it simultaneously follows the steps that Pinar lays out—regressive, progressive, analytical, and synthetical. These steps give us the opportunity first to look back on our formative experiences, then forward to where we desire to go. The third step looks at our present, while being informed by our past and future and, fourth, we bring all three pieces together in order to understand our ways of understanding (Pinar, 1975).

Hicks’ (2005) relies heavily on the autobiographical context to perform her critical inquiry. Within her analysis, she interweaves her own autobiography, as well as those of her students. Hicks’ voice as the researcher and author is never lost within her writing; her choices, observations and interactions are always deeply embedded within her work. In fact, the writing/research process and the choices she has made within that are all reflective of her positionality, and she makes no secret of that. In so doing, she avoids the problem of the researcher’s gaze which, gone unmentioned, can affect the ways in which the reader sees the subjects of the research, ultimately skewing the reader’s response and, perhaps in turn, any action taken as a result of her research. As Cooper and White (2012) discuss, by being autobiographically expository, one ensures that both researcher and reader are using the same tools to understand and view the subjects of the research. By revealing our subjectivity, we actually allow more space for our reader to be objective.

In addition to being honest about her own autobiography, we would also argue that Hicks presents what functions almost as an autobiography of the community where she conducted her research. More than simply contextualizing her students’ narratives, the way in which she describes the setting of the classroom leads the reader to feel as if the place is in and of itself. She describes its position on the economic margins of the city by stating that the middle-class “might drive through on the way to something else, noting in passing the ghostly frames of abandoned warehouses or the thick, gray smoke churned out from one of the few working factories” (p. 172).

While this contextualization also has its place in discussions of both the historical and political context, it is raised here as well. Hicks regards the space that her subjects live in with her particular eye and mindset, and gives a specific meaning to both their autobiographies and the very act of contextualization. In doing so, Hicks provides her individual subjects with more of a universality, a way to posit that narrative need not be insular and without academic merit. The research question, as stated by Hicks, is “what was it like to grow up as a girl in contemporary working-poor America?” (p. 172). Thus, her focus on the economic and structural context of her subjects is vital to the larger underpinnings of her research, for which horror novels become merely a vehicle and not the point, in themselves.

The third modality in which we see the autobiographical context at play is, of course, in the narratives of the girls themselves. Hicks uses bell hooks (1994), Myles Horton (1990) and Paulo Freire (1970) as a framework, all three of whom centered both their pedagogies and their scholarship within a context of dialogue so the human aspect of each of the girls’ experiences is vital to the analysis that Hicks is attempting to construct. We learn about these girls through our understanding of their community and through their understandings of and interactions with the books that Hicks posits as “subversive” texts (p. 174). As Hicks describes their reactions to the texts, their previous experience with different genres and the choices that they make, we are able to understand the girls both as individuals, and within their larger contexts.

In Inquiry and Reflection, Diane Dubose Brunner (1994) talks about representations of student experience in various forms of media (pp. 153-186), a topic that is also tackled quite often by both bell hooks and Henry Giroux. By investigating how these girls read different texts, Hicks provides us a new reading of the girls themselves. Brunner talks about the way in which language has been used to describe students, especially along class lines, in television, film and literature, as well as the ways in which students, themselves, have been depicted as using (or conversely, failing to use) language. Hicks’ framing of her larger point of inquiry, the ways in which language and linguistic practices are both reflective and constructive of their material and cultural lives is an investigation into the very way that fictional depictions of youth in educational spaces disembodies them from their contexts, a process described by Brunner (1994). By focusing on the autobiography and narrative experience of herself, her students, and their teacher, Hicks is able to re-contextualize these experiences.

Historical Context

Moving through the five contexts of critical inquiry, we arrive at the historical context. Cooper and White (2012) open their discussion of the historical context with the African proverb, “Until the lion has his own historian, the hunter will always be the hero” (p. 52). This proverb is central to the ideas of a critical, historical analysis. Without questioning, “Whose history is it?” we are unable to look critically at the stories that we have taken as truth (p. 52). Denzin and Lincoln (2005) do just this by going through what they depict as the eight moments of qualitative research. They move from the traditional, through modernist, blurred genres, crisis of representation, and finally, the triple crisis. As they move through these moments, we see the history of qualitative research in varying complexities itself, as it is opened to new voices, new ways of knowing, seeing and understanding.

There are, of course, numerous scholars who aim to illustrate both a critical and historical understanding of their subjects. One such scholar, whose work seems of particular relevance to Hicks’ content and analysis, is David Roediger (1993). By developing a history of American racial construction through the paradigm of whiteness, Roediger takes both a critical and historical look at the ways in which our understanding of self, power, poverty and privilege are informed by the history of racial construction, as well as the history of labour in the United States. As Hicks discusses the working poor character of the town that her work is centered in, Roediger’s (1993) analysis of how labour history and the history of slavery becomes particularly critical to our understandings of the intersections of whiteness and working class identities, as posited by Hicks (2005).

Gloria Ladson-Billings (1995, 1999) also captures a historical context in her analyses of education and race, uniting the contexts of critical race theory and critical pedagogy. By tracing notions of racial segregation and looking at cultural deprivation, Ladson-Billings is able to reclaim the ways that we look at modern schooling and the ways that we talk about racial disparities in education. In so doing, the historical perspective in critical inquiry acts as a counter-argument to sometimes dangerous modes of thinking, such as the “deficit” model of education. Hicks continues this tradition by highlighting the voices of subjects schooled within a working class context, as well as by demonstrating positive examples of engaged learning.

Many of Hicks’ methodological and writing strategies demonstrate a strong connection to the historical context. Firstly, she contextualizes the geographic location based on historical understanding. She discusses its physical make-up, position within the larger urban space and, also, demographic profiles within a historical context. The critical inquiry piece here is that neighborhoods do not simply arise, just as residents are not divorced from their space—neighborhoods themselves do not exist separately from the forces that construct them (Hicks, 2005). She specifically mentions factors such as factory closings that occurred long before her students were born, largely as a means to highlight the ways in which communities live under the economic shadows of what came before. It is clear within a historical context that events do not just happen and dissipate; they continue to have an effect on what comes after them.

Hicks is also able to engage with the historical context by extending her study over a year-long period (She even goes so far as to refer to her data as a “history” (p. 173)). By looking at the girls over a period of time, she engages with notions of change. The other way in which she engages with the historical context is by situating her methodology and theoretical framework within a trajectory of study, wherein she cites the work of Gee (2004) and other practitioners of new literacy studies. In so doing, she draws a historical lens over her specific research, as well as engaging in a larger theoretical conversation.

Political Context

Within critical theory, it is impossible to create barriers between the political, postmodern, and philosophical contexts. Like the postmodern world we live in, they are liquid, and flow into each other at different times of the research and inquiry process. First and foremost, we currently live in the postmodern era and, thus, all contemporary research is firmly rooted within that particular framework. Secondly, if, as Pinar (1978) claims, all intellectual acts are inherently political, then any act of research by an individual or institution is, of course, political as well. Finally, thoughtful considerations of philosophy hold these concepts together and, through the philosophical context, dialogue and discourse are created to enable change. Nonetheless, the political aspect of critical theory is interwoven into all four contexts and must always be present in any research that aims to be called “critical.”

The Frankfurt School, notably Max Horkheimer, is central in exploring the political context of critical theory. Horkheimer (1972) states in his pivotal work, Critical Theory , that there cannot be many defined criteria for critical theory, as it is a product of its political, social, cultural, and economic contexts and is, thus, continually changing; however, he argues that critical theory must always contain the unfaltering “concern for the abolition of social injustice” (p. 242), a sentiment echoed by scholars such as Giroux (2004) and Lather (1986).

Lather (1986), in particular, argues that researchers should employ critical theory in order to avoid the “rape model” of research—namely, objectifying and “othering” one’s research subject. Critical theory can help researchers and institutions build and maintain “a more collaborative approach...to empower the researched, to build emancipatory theory, and to move toward the establishment of data credibility within praxis-oriented, advocacy research” (Lather, 1986, p. 272). Essentially, the goal of critical theory should be to encourage and facilitate emancipatory change for the oppressed, marginalized and misunderstood. For example, in her article, Hicks investigates—and eventually advocates for—the typically “hidden face of poverty” or the hidden “white” face of poverty. Intrigued and surprised by the “predominant Whiteness of the neighbourhood” (p. 171), where she situates her research, Hicks draws attention to an often overlooked area in urban poverty research.

The change called for in critical inquiry can be demonstrated through the realization of agency, which is central to the political context, and to critical inquiry as well: “the political contexts at work within society impact upon one’s sense of agency” (Cooper & White, 2012, p. 72). In Hicks’ article, her goal (though flawed by her own middle-class biases and preconceptions of the working-poor) was to investigate the experience of girlhood in working-poor America, and how the school language practices—mainly reading novels—were “layered within their cultural and material lives” (p. 172). Though her research began with a more observational rather than advocacy focus, Hicks accomplished the praxis-oriented research that is often advocated by Lather (1986) and other critical researchers and theorists. When one student, Brandy, voiced her newfound confidence and proclaimed that “We can start to control this [their situation] by just sitting down and talking” (p. 184), she demonstrated that she had begun to realize her agency—the first step towards the change that critical theory champions.

The students in Hicks’ research also struggled with “juggling the tension and ambiguity of their class differences in a middle-class school culture” (p. 173). This is clearly evident in Hicks’ demonstration of her own middle-class cultural capital, when she attempts to begin the course with a text that the girls simply did not relate to, involving a cultural capital (Bourdieu, 1985) that rested outside of their realm of experience. Instead, the girls chose to focus on a type of text that was familiar to them: horror paperbacks. This shift in the types of literature that the students gravitated towards raises some critical questions: Are students in working-poor, urban neighbourhoods only capable of consuming simple, seemingly “low brow” texts? Should educators push those students beyond their comfortable reading environment into something more literary?

It is here that the true task of critical inquiry begins to take shape: “Literary” for whom, exactly? Why are these texts considered to be “low brow?” Why do we feel the need to teach certain accepted texts within the English classroom? While not specifically stating that these questions entered her research, Hicks displays in her article her engagement with these issues, as she questions her own cultural capital and decides to investigate, instead, the possibilities that lay within the horror paperbacks for unveiling the layered meanings of her students’ identities.

By taking this critical approach, Hicks’ grounds herself in the realm of critical pedagogy for political and social change—after reflecting on and altering her preconceptions of the cultural awareness and capital of her students, she provided them with a forum to be heard and to express their own cultural hauntings. Bauman (1997) claims that “the key to a problem as large as social justice lies in a problem as (ostensibly) small-scale as the primal moral act of taking up responsibility for the other nearby” (p. 70)—while Hicks may not have solved the issue of social justice, her research and willingness to speak and listen to these young girls illustrates her commitment to this group in working-poor America.

Postmodern Context

Critical theory argues that, in our postmodern society, normative assumptions and dominant perspectives of politics, culture and society often remain unquestioned. Horkheimer (1972) proposes that we re-evaluate our interactions and place within society a renewed consciousness that is “dominated at every turn by a concern for reasonable conditions of life” (pp. 198-199). Of course, the critical researcher must question and define what is meant by “reasonable conditions of life;” the researcher must also focus on how that is attainable for each individual. For many theorists, the key lies in the search for individual and collective agency. For example, once the young girls in Hicks’ class developed and discovered their personal stories and voices, they were able to create a larger, collaborative agency that, potentially, could be heard outside of their small, working-poor neighbourhood classroom.

Central to the postmodern context is the move from a producer to a consumer society, and the power dynamics that occur as a result—a concept encountered by many critical theorists and researchers. Foucault (1982) claims that, for society to progress to a more equitable and open society, we are in desperate need of a “new economy of power relations” (p. 779). However, as Giroux (2004) notes, it is important to remember that, within our capitalist, postmodern society, power does not disappear but, rather, becomes reworked, replayed and restaged; perhaps that reworking of power can result from the turn from consumer to producer.

Bauman also voices his concern for our movement from a producer society to a consumer society and notes that, “if unchecked, [it] will spell dire consequences for humanity” (quoted in Cooper & White, 2012, p. 86). He further explains that the concept of choice, and the deceptively simple ability to choose, is yet another crucial component of our postmodern condition, rooted in the dichotomy of producer and consumer. Surrounded by menial daily choices of what espresso drink to purchase, television program to fit into our schedule or Twitter account to follow, it is clear that our postmodern society values choice. Bauman would argue, however, that these are quick, meaningless choices that require little to no responsibility once the choice has been made, but it is these choices that create and shape our identities, only to be “adopted and discarded like a change of costume” (1997, p. 88).

In Hicks’ article, her students began as consumers. They were drawn to the paperback horrors because of their distribution and saturation within the media, from television programs such as Goosebumps , as well as other film interpretations of the genre. However, once they began creating the same horror texts that they originally consumed and became producers, they found their voices and became individuals with their own sense of agency and the awareness of their autobiographical situation within their postmodern, political world.

Even so, Hicks’ students do not have the same choices as many of their middle-class counterparts. Our consumer-driven society emphasizes the constant need for choice, yet so many fail to have the privilege of choice. Indeed, the word “fail” might seem insensitive and severe but, in a consumer-driven society, members of the working-poor have neither the ability nor the means to choose and participate in material culture. In her article, Hicks observes that her students fail to meet the material standards of the dominant, middle-class culture and, therefore, their ability to live within the consumer, postmodern world is gone; there are no jobs left in their area and, so, the “material possibilities” have disappeared for the youth in this working-poor neighbourhood (p. 170). In addition to their attempted participation in the middle-class consumer culture, the young girls also continuously struggle with “juggling the tension and ambiguity of their class differences in a middle-class school culture” (p. 173). If material possibilities are valued in identity construction in a postmodern consumer society, then the students’ inability to obtain them means a negation of individuality and agency and, thus, the potential for collective action and change.

Philosophical Context

The girls in Hicks’ summer school reading group may have juggled tensions and struggled with expression, but they certainly took matters into their own hands when they decided to circulate horror paperbacks amongst themselves. Hicks’ article illustrates a difference between education and schooling, and these young girls in working-poor America used the horror paperbacks as a means of creating their own form of education. Postmodern critical philosopher Maxine Greene (1988) notes the philosophical differences between schooling and education, and argues that “Education...encourages individuals to grow and to become, while schooling constrains students to become servants of a technocratic society” (Cooper & White, 2012, p. 106). This is particularly crucial to coming to an understanding of the dynamic nature of critical theory and, thus, critical pedagogy. Schooling, in Hicks’ situation, relied on a middle-class cultural capital that was not in the same sphere of experience as the education that the girls created for themselves, based on their interests and understandings. They began reading these texts as a self-created peer reading group and it was from this form of education, on the periphery of a middle-class school culture and environment, that the educator, Hicks, noticed the potential in exploring (and further complicating) the layered meanings of the girls’ identities.

Greene (1988) also states that imagination is central to developing one’s particular perspective and realizing one’s individual agency.

It takes imagination to become aware that a search is possible, and there are analogies here to the kind of learning we want to stimulate...it takes imagination on the part of the young people to perceive openings through which they can move. (Cooper & White, 2012, p. 110)

Greene’s (1988) emphasis on imagination paving the path to freedom is central to understanding the philosophical context of critical inquiry and also the philosophical context of Hick’s research. During a discussion of The Wizard of Oz, Hicks asked her students if, given the choice, they would choose to stay in Oz or go back to Kansas. One student, Shannon, imagines her escape from her current situation in a heartbreaking revelation:

I would choose Oz because it’s a beautiful land and up there you don’t hear no gunshots. And you don’t walk on glass and don’t hear people hollering and screaming at you like you do here. (Hicks, 2005, p. 183)

Shannon might not have made a plan of action for escaping her reality, but her imagination in this one instance displays her awareness of her political, social and economic situation, and her desire to escape. Picturing a better place—even one that is imaginary—could have been Shannon’s first step into plucking herself from her reality and escaping into a new one of change and autonomy (Greene, 1988).

Critics often blame critical inquiry for its emphasis on the language of critique, rather than the language of possibility. For example, Elizabeth Ellsworth (1989) expresses her doubt in critical inquiry’s empowering and transformative powers. She argues that “the discourse of critical pedagogy is based on rationalist assumptions that give rise to repressive myths,” and critical pedagogues “perpetuate relations of domination in their classrooms” (p. 297). Like Ellsworth, Viviane Robinson (1992) argues that there is a paradox at the heart of critical inquiry’s endeavours for emancipation. When critical researchers offer alternative understandings of subjects’ situations, their offer has two “arrogant” claims:

a) subjects’ (mis)understandings are at least in part responsible for the situation they find unacceptable; and (b) the alternative understandings offered by the critical social scientist, if acted on, would result in outcomes that are more effective and fulfilling than those currently experienced. (p. 346)

Nonetheless, critical inquiry is, by its nature, self-critical, and critical theorists assert that, while these may be potential issues, true critical inquiry inherently addresses these problems. Rather than criticizing the nature of critical inquiry, Canella and Lincoln (2009) identify three issues that may marginalize and disempower critical inquiry, thus impacting its reception amongst academic and general populations. First, a high level of abstraction and use of difficult language keep the work of critical inquiry away from broader audiences. Second, political forces often attack diversity and discredit critique. Finally, the rise of neoliberalism and hyper-capitalism suppress critical inquiry and privileges evidence-based, positivistic research.

In this article, we have used the five contexts for qualitative research (Cooper & White, 2012) to understand the possibilities for empowerment in critical educational research. In our analysis, Hicks’ (2005) article has provided examples of how teachers can adopt responsive and dialogic pedagogies that “start with close readings of students’ lives and voices” (p. 188). Through her constant reflective, self-critical, and participatory methodology, Hicks avoids the potential pitfalls of critical inquiry and, instead, epitomizes the language of possibility in critical inquiry. Thus, the five contexts of Cooper and White (2012) exemplified through Hicks (2005) illustrate the emancipatory potentials of critical educational research by engaging “the researched in a democratized process of inquiry characterized by negotiation, reciprocity, [and] empowerment” (Lather, 1986, p. 257).

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White, R.E., Cooper, K. (2022). An Introduction to Critical Approaches. In: Qualitative Research in the Post-Modern Era. Springer, Cham. https://doi.org/10.1007/978-3-030-85124-8_2

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Why use theories in qualitative research?

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• Scott Reeves , associate professor 1 ,
• Mathieu Albert , assistant professor 2 ,
• Ayelet Kuper , assistant professor 3 ,
• Brian David Hodges , associate professor and vice-chair (education) 2
• 1 Department of Psychiatry, Li Ka Shing Knowledge Institute, Centre for Faculty Development, and Wilson Centre for Research in Education, University of Toronto, 200 Elizabeth Street, Eaton South 1-565, Toronto, Ontario, Canada M5G 2C4
• 2 Department of Psychiatry and Wilson Centre for Research in Education
• 3 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education
• Correspondence to: S Reeves scott.reeves{at}utoronto.ca

Theories such as interactionism, phenomenology, and critical theory can be used to help design a research question, guide the selection of relevant data, interpret the data, and propose explanations of causes or influences

Previous articles in this series have addressed several methodologies used in qualitative research. Qualitative researchers also rely heavily on theories drawn from the social sciences and humanities to guide their research process and illuminate their findings. This article discusses the role and use of three theoretical approaches commonly used by qualitative researchers in health domains: interactionism, phenomenology, and critical theory. It also explains why such theories are important for clinicians, for health policy, and for patient care.

Why is theory useful?

Theories provide complex and comprehensive conceptual understandings of things that cannot be pinned down: how societies work, how organisations operate, why people interact in certain ways. Theories give researchers different “lenses” through which to look at complicated problems and social issues, focusing their attention on different aspects of the data and providing a framework within which to conduct their analysis.

Just as there is no one way to understand why, for instance, a culture has formed in a certain way, many lenses can be applied to a problem, each focusing on a different aspect of it. For example, to study doctor-nurse interactions on medical wards, various theories can provide insights into different aspects of hospital and ward cultures. Box 1 indicates how each of the theories discussed in this paper could be used to highlight different facets of this research problem.

Box 1 How different theories help illuminate the culture of doctor-nurse interactions on a medical ward

Phenomenology.

A researcher using phenomenology would approach the study of doctor-nurse interprofessional interactions by exploring how individual doctors and nurses made sense of their ward-based interprofessional experiences. Such a study would aim to elicit, through interviews, the meanings each individual attached to their interactions and the classifications they employed to make sense of their working lives within this context. Data would be analysed inductively, focusing on allowing meanings to emerge from the interviews. Specifically, this process would entail examining statements from the interviews and clustering them to form common themes linked to understanding the meanings that doctors and nurses each individually attached to their interactions.

Interactionism

Interactionist theory would be used to explore how the interprofessional relations within a medical ward context were created and modified during the daily interactions of doctors and nurses. Researchers in such a study would observe how doctors and nurses interacted (both verbally and non-verbally) in their shared clinical work; they would also interview both groups to understand the meanings they attached to their differing interprofessional interactions. Data would be analysed inductively by examining observational field notes and interviews to identify and explore the different elements which contributed to the nature of doctor-nurse interactions within a particular context. For example, researchers might examine differences between formal interactions (in front of patients) and informal interactions (in more private hospital settings).

Critical theory

A researcher employing critical theory would approach a study of doctor-nurse interactions by asking how power is related to characteristics of individuals or groups (for example, gender, race, culture). For example, critical scholars such as Anne Witz have shown that professions form hierarchies in which the dominant ones are predominately male (doctors), the first subordinate profession is largely female (nurses) and the most subordinate are often members of ethic minorities (nursing assistants). 14 Data analysis would be informed by the specific critical theoretical lens selected by the researcher. For example, data could be filtered through a feminist lens to help understand how patriarchy operates through doctor-nurse interactions within medical ward settings.

What are examples of theories used by qualitative researchers?

This theory was originally developed by Edmund Husserl to explain how individuals give meanings to social phenomena in their everyday lives. The role of phenomenology was therefore to explore “the essence of consciousness as experienced from the first-person point of view.” 1 Studies that draw upon this theoretical perspective concentrate on exploring how individuals make sense of the world in terms of the meanings and classifications they employ. As such, phenomenology aims to provide accounts that offer an insight into the subjective “lived” experience of individuals. 2 Given the emphasis, phenomenological studies do not attempt to generate wider explanations; rather their focus is on providing research accounts for individuals in a specific setting.

In general, studies that draw upon a phenomenological approach gather data in the form of in-depth semistructured or unstructured interviews and personal documents such as diaries. For example, Porter and colleagues used in-depth individual interviews to understand the meanings people living in residential homes held about their caregivers, 3 whereas Mitchell gathered the meanings of being a senior from narrative stories written by older people about their personal experiences in later life. 4 Theories that privilege understanding of human experience in terms of individual consciousness, such as phenomenology, share links to the work of the German philosopher Georg Wilhelm Friedrich Hegel and French existentialists such as Jean-Paul Sartre. However, phenomenology, as a result of its specific, empirical focus on the individual experience, is an example of a micro level theory within this philosophical orientation.

In contrast to the phenomenological focus on understanding individual perceptions, interactionism concentrates on exploring collective (group or team) behaviours and perceptions. Originally developed by George Mead, this approach aimed to provide an understanding of individuals’ interactions by examining the symbols, especially the language, they use in their daily encounters. In particular, interactionism is an approach that aims to elicit an understanding of how meaning is created and modified by individuals through their social actions, interactions, and reactions. Herbert Blumer outlined interactionism’s three guiding assumptions: that human beings act towards things on the basis of the meanings that these things have for them; that the meaning of such things is derived from, and arises out of, social interaction with one’s fellows; that these meanings are handled in, and modified through, an interpretative process used by the person in dealing with the things he or she encounters. 5

Given the emphasis on understanding the processes of social interactions, interactionist research studies often draw on methods of data collection such as participant observation and interviews to capture these elements of social action. For example, Goffman found that individuals’ interactions are largely dependent on whether they are interacting in a “front stage” (a hospital ward, for example) or a “backstage” (private office, for example) setting. 6 More recent research on the socialisation of medical students has indicated the significance of front and backstage performances in their socialisation. 7

Several theories conceptualise reality as a social or collective construction, and these have roots in the work of European writers such as Émile Durkheim and Lev Vygotsky and of Americans Peter Berger and Thomas Luckman. Interactionism attempts to generalise beyond the individual experience but retains a mid-range focus on local systems and contexts within this broader social constructivist school.

Critical theory is oriented towards critiquing and changing society as a whole. 8 With roots in the work of Marx on production and capitalism, it was further developed at the Institute for Social Research of the University of Frankfurt in the 1930s. More recently, this tradition has been carried on by social scientists such as Pierre Bourdieu and Michel Foucault.

Critical theorists study how the construction of knowledge and the organisation of power in society generally, and in institutions such as schools, hospitals, and governments specifically, can lead to the subjugation or oppression of particular individuals, groups, or perspectives. Critical theorists are concerned with equity and justice in relation to issues such as race, socioeconomic status, religion, and sexuality. 9 For example, Battiste studied how Euro-American dominated health care, pharmaceutical research, and educational institutions marginalise indigenous knowledge, and how both endangered certain populations and marginalised important knowledge about health and the environment. 10 Muzzin used critical theory in her study of how education of health professionals has come to reflect corporate interests, thereby reproducing gender and class inequity, as universities developed “academic capitalism.” 11

Critical theory is not tied to one specific methodology and can be applied at the micro (individual), macro (local systems and contexts), or macro (societal) level.

Aren’t there a lot more theories?

The three theories we have discussed so far in this paper are examples of the possible theories a qualitative researcher might use. Box 2 provides some further examples of other theories that have been used in qualitative research studies in domains related to medicine.

Box 2 More examples of theories used in qualitative research

Professionalisation theory.

Elliot Freidson developed his theory of professionalisation in response to previous explanations that had considered only the range of positive traits of professional groups. 15 Freidson argued that occupational groups, such as medicine, had previously engaged in a process of professionalisation to secure exclusive ownership of specific areas of knowledge and expertise. In obtaining exclusivity, occupational groups secure autonomy of practice, which leads to economic rewards and enhanced status. To protect the gains obtained from professionalisation, occupations guard their areas of knowledge and expertise through strict regulation of entry and the maintenance of professional standards. More recently, this theory has been questioned because of the increasing influence of clinical management on medicine, which Haug argued had resulted in a “deprofessionalisation” process, whereby some of the professional gains described by Freidson have been undermined. 16

Labelling theory

Originating in the sociology of deviance, labelling theory focuses on how society can negatively label a group whose behaviour is deemed as deviating from the norm. The theory was applied in a healthcare context by Scheff to help understand the nature of mental illness. 17 Scheff argued that mental illness is essentially generated as a result of societal influence. To understand deviant actions, individuals often place the label “mental illness” on those who show such actions. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behaviour to fulfil them (a notion termed self fulfilling prophesy). Empirical work by Link et al has shown how influential labelling can be for mentally ill patients: once they are labelled as having this type of illness, people may withdraw from society. 18

Negotiated order theory

This theory was developed by Strauss et al to advance thinking about the way social order is maintained in organisations. 19 Previous explanations of social order within organisations tended to emphasise formal structures and rules and to neglect the influence of negotiations at the micro level. For Strauss and his colleagues, negotiation between individuals (through bargaining, compromising, and mediating) creates and shapes organisational rules and structures. Consequently, micro level negotiation contributes to the development and maintenance of the social order that exists within an organisation. This theory has been used in various organisational settings, including health care, where it indicated that informal negotiation was key in nurse-doctor decisions on patient care. 20

Following work by Merton, such theories can usefully be grouped into a taxonomy to guide novice researchers as to which theories are likely to be helpful in dealing with a particular research problem (table ⇓ ). 12 As shown in the table, grand or “macro” theories are non-specific and constructed from relatively abstract concepts. As a result of their wide ranging nature, these types of theories are difficult to operationalise and verify on an empirical basis. Mid-range theories consider specific phenomena and involve a small number of concepts relating to a restricted range of contexts. “Micro” or practice theories have the narrowest range of interest and are focused on specific phenomena and contexts. Box 3 addresses further frequently asked questions about theories in qualitative research.

Types of theory, with examples from related domains

• View inline

Box 3 Frequently asked questions

How is the term “theory” defined.

A theory is an organised, coherent, and systematic articulation of a set of issues that are communicated as a meaningful whole.

How are theories generated?

Theories are usually generated deductively, from an empirically informed act of creativity, then empirically verified. In this sense, theories result from an ongoing process of deduction and induction.

How can theories be used?

Theories are usually used to help design a research question, guide the selection of relevant data, interpret the data, and propose explanations of the underlying causes or influences of observed phenomena.

Can theories be used to predict research findings and generate hypotheses?

In general, theories in the natural sciences are used to generate predictions about the relation between two or more different variables in order to generate universal laws. In contrast, social scientists assume that social reality is too complex to consider variables in isolation in order to test their causal relationship. In addition, social scientists view universal laws as being unable to explain the complex interrelated functions of societies, thus making it impossible to draw on evidence for prediction. So, for social scientists, a theory is first and foremost a conceptual tool useful in making sense of a complex social reality.

How are theories and methodologies related?

Some theories and methodologies are historically related—that is, they both derive from the same discipline or school, and although they are sometimes used separately they are often taught and used together. The classic example of this is the link between interactionism (theory) and ethnography. Other theories (or families of theories) link well with multiple methodologies. For example, critical theories have been used to varying effect with almost every available methodology (both qualitative and quantitative).

Are these all the possible theories?

No—we have just scratched the surface. Theories have been developed and modified over several hundred years and have dialectically informed each other’s changes over time. The theories we have mentioned in this paper are those that readers are likely to encounter in the health domain. Other important theories used often in the social sciences and humanities, but only occasionally in health related research, include (but are not limited to) marxism and its descendants, feminism, hermeneutics, and the post-modernist family of theories.

Box 4 Further reading

Crotty M. Foundations of social research: meaning and perspective in the research process . London: Sage, 1998.

Denzin NK, Lincoln YS, eds. Handbook of qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 2000.

Layder D. Understanding social theory . London: Sage, 1994.

Ritzer G, Smart B, eds. Handbook of social theory . London: Sage, 2003.

Roberts B. Micro social theory . Basingstoke: Palgrave, 2006.

Scamber G, ed. Sociological theory and medical sociology . London: Tavistock, 1987.

Stones R, ed. Key sociological thinkers . Basingstoke: Macmillan, 1998.

Why is theory important to health policy and patient care?

Theories such as those described above are important to health policy and the delivery of patient care, as the insights they provoke enable research that provides practitioners with a broader understanding of the situations they face in their daily working lives. The use of theory makes it possible for researchers to understand, and to translate for policy makers and healthcare providers, the processes that occur beneath the visible surface and so to develop knowledge of underlying (generating) principles. Importantly, theory can help people move beyond individual insights gained from their professional lives to a situation where they can understand the wider significance and applicability of these phenomena. Good theory based research is immediate, insightful, and applicable in practice; in the words of Kurt Lewin, “there’s nothing so practical as a good theory.” 13

Summary points

Different theories provide different lenses through which to analyse research problems

Various theories are currently used within health related research

Theories can be divided into macro (or grand) theories, mid-range theories, and micro (or practice) theories.

Theories can arise from, or be used within, different research domains (for example, biomedical domain, psychological domain, social domain)

The insights derived from theories are important for guiding health policy and informing the delivery of patient care

Cite this as: BMJ 2008;337:a949

• Related to doi: , 10.1136/bmj.a288
• doi: , 10.1136/bmj.39602.690162.47
• doi: , 10.1136/bmj.a1020
• doi: , 10.1136/bmj.a879
• doi: 10.1136/bmj.a1035

This is the fifth in a series of six articles that aim to help readers to critically appraise the increasing number of qualitative research articles in clinical journals. The series editors are Ayelet Kuper and Scott Reeves.

For a definition of general terms relating to qualitative research, see the first article in this series.

Funding: None.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

• ↵ Smith D. Husserl . London: Routledge, 2007 .
• ↵ Schutz A. The phenomenology of the social world . New York: Northwestern University Press, 1967 .
• ↵ Porter E, Ganong H, Drew N, Lanes T. A new typology of home-care helpers. Gerontologist 2004 ; 44 : 750 -9. OpenUrl Abstract / FREE Full Text
• ↵ Mitchell G. The meaning of being a senior. Nurs Sci Q 1994 ; 7 : 70 -9. OpenUrl Abstract / FREE Full Text
• ↵ Blumer H. Symbolic interactionism: perspective and method . Englewood Cliffs, NJ: Prentice-Hall, 1969 .
• ↵ Goffman E. The presentation of self in everyday life . London: Penguin, 1963 .
• ↵ Sinclair S. Making doctors: an institutional apprenticeship . Oxford: Berg, 1997 .
• ↵ Calhoun C. Critical social theory: culture, history and the challenge of difference . Oxford: Blackwell, 1995 .
• ↵ Kinchloe JL, McLaren P. Rethinking critical theory and qualitative research. In: Denzin NK, Lincoln YS, eds. Handbook of qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 2000 .
• ↵ Battiste M. You can’t be the global doctor if you’re the colonial disease. In: Tripp P, Muzzin L, eds. Teaching as activism: equity meets environmentalism . Montreal and Kingston: McGill-Queen’s University Press, 2005 :121-133
• ↵ Muzzin L. The brave new world of professional education. In: Tripp P, Muzzin L, eds. Teaching as activism: equity meets environmentalism . Montreal and Kingston: McGill-Queen’s University Press, 2005 :149-166
• ↵ Merton R. Social theory and social structure . New York: Free Press, 1968 .
• ↵ Lewin K. Field theory in social science: selected theoretical papers . New York: Harper & Row, 1951 .
• ↵ Witz A. Professions and patriarchy . London: Macmillan, 1992 .
• ↵ Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Harper & Row, 1970 .
• ↵ Haug M. De-professionalisation: an alternative hypothesis for the future. Sociol Rev Monograph 1993 ; 20 : 195 -211. OpenUrl
• ↵ Scheff T. Being mentally ill: a sociological theory . 3rd ed. New York: Transaction, 1999 .
• ↵ Link B, Phelan J. The labelling theory of mental disorder: The consequences of labelling. In: Horwitz A, Scheid T, eds. A handbook for the study of mental health . New York: Cambridge University Press, 1999 :361-76.
• ↵ Strauss A, Schatzman D, Ehrlich R, Bucher M, Sabshin C. The hospital and its negotiated order. In: Freidson E, ed. The hospital in modern society . New York: Free Press, 1963 :147-69.
• ↵ Svensson R. The interplay between doctors and nurses—a negotiated order perspective. Sociol Health Illness 1996 ; 18 : 379 -98. OpenUrl CrossRef Web of Science

Critical Research and Qualitative Methodologies: Theoretical Foundations and Contribution to Nursing Research

Affiliations.

• 1 Assistant Professor, Faculty of Nursing, Université de Montréal, Montréal, Canada [email protected].
• 2 Associate Professor, Department of Nursing, Université du Québec en Outaouais, Saint-Jérome, Québec, Canada.
• PMID: 35584891
• DOI: 10.1891/RTNP-2021-0014

Background: Methodological approaches that draw on critical perspectives (critical ethnography, critical phenomenology, and critical grounded theory) share common concepts, including social justice, reflexivity, positionality, pragmatism and social transformation. These approaches differ from conventional phenomenology, ethnography and grounded theory despite sharing common methodological grounds. Purpose: In this article, we will outline the major contributions of critical theory, as a research paradigm, to the development and evolution of qualitative methodologies. In particular, we will discuss their application to nursing research. The historical and conceptual underpinnings of these critical methodologies will first be described to highlight their paradigmatic characteristics and implications for nursing. Implications for Practice: Although not yet widely employed in nursing research, critical qualitative methodologies are particularly well suited to the discipline as they shed light on issues of power, social control, and marginalization among the vulnerable populations with whom nurses practise on a daily basis. The use of critical approaches can expose the epistemic injustice and social and health inequality that continue to prevail in our society.

Keywords: critical theory; ethnography; grounded theory; phenomenology; qualitative methods.

© Copyright 2022 Springer Publishing Company, LLC.

• Grounded Theory
• Health Status Disparities*
• Nursing Research*
• Qualitative Research

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• Writing Tips

The Four Types of Research Paradigms: A Comprehensive Guide

• 5-minute read
• 22nd January 2023

In this guide, you’ll learn all about the four research paradigms and how to choose the right one for your research.

Introduction to Research Paradigms

A paradigm is a system of beliefs, ideas, values, or habits that form the basis for a way of thinking about the world. Therefore, a research paradigm is an approach, model, or framework from which to conduct research. The research paradigm helps you to form a research philosophy, which in turn informs your research methodology.

Your research methodology is essentially the “how” of your research – how you design your study to not only accomplish your research’s aims and objectives but also to ensure your results are reliable and valid. Choosing the correct research paradigm is crucial because it provides a logical structure for conducting your research and improves the quality of your work, assuming it’s followed correctly.

Three Pillars: Ontology, Epistemology, and Methodology

Before we jump into the four types of research paradigms, we need to consider the three pillars of a research paradigm.

Ontology addresses the question, “What is reality?” It’s the study of being. This pillar is about finding out what you seek to research. What do you aim to examine?

Epistemology is the study of knowledge. It asks, “How is knowledge gathered and from what sources?”

Methodology involves the system in which you choose to investigate, measure, and analyze your research’s aims and objectives. It answers the “how” questions.

Let’s now take a look at the different research paradigms.

1.   Positivist Research Paradigm

The positivist research paradigm assumes that there is one objective reality, and people can know this reality and accurately describe and explain it. Positivists rely on their observations through their senses to gain knowledge of their surroundings.

In this singular objective reality, researchers can compare their claims and ascertain the truth. This means researchers are limited to data collection and interpretations from an objective viewpoint. As a result, positivists usually use quantitative methodologies in their research (e.g., statistics, social surveys, and structured questionnaires).

This research paradigm is mostly used in natural sciences, physical sciences, or whenever large sample sizes are being used.

2.   Interpretivist Research Paradigm

Interpretivists believe that different people in society experience and understand reality in different ways – while there may be only “one” reality, everyone interprets it according to their own view. They also believe that all research is influenced and shaped by researchers’ worldviews and theories.

As a result, interpretivists use qualitative methods and techniques to conduct their research. This includes interviews, focus groups, observations of a phenomenon, or collecting documentation on a phenomenon (e.g., newspaper articles, reports, or information from websites).

3.   Critical Theory Research Paradigm

The critical theory paradigm asserts that social science can never be 100% objective or value-free. This paradigm is focused on enacting social change through scientific investigation. Critical theorists question knowledge and procedures and acknowledge how power is used (or abused) in the phenomena or systems they’re investigating.

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Researchers using this paradigm are more often than not aiming to create a more just, egalitarian society in which individual and collective freedoms are secure. Both quantitative and qualitative methods can be used with this paradigm.

4.   Constructivist Research Paradigm

Constructivism asserts that reality is a construct of our minds ; therefore, reality is subjective. Constructivists believe that all knowledge comes from our experiences and reflections on those experiences and oppose the idea that there is a single methodology to generate knowledge.

This paradigm is mostly associated with qualitative research approaches due to its focus on experiences and subjectivity. The researcher focuses on participants’ experiences as well as their own.

Choosing the Right Research Paradigm for Your Study

Once you have a comprehensive understanding of each paradigm, you’re faced with a big question: which paradigm should you choose? The answer to this will set the course of your research and determine its success, findings, and results.

To start, you need to identify your research problem, research objectives , and hypothesis . This will help you to establish what you want to accomplish or understand from your research and the path you need to take to achieve this.

You can begin this process by asking yourself some questions:

• What is the nature of your research problem (i.e., quantitative or qualitative)?
• How can you acquire the knowledge you need and communicate it to others? For example, is this knowledge already available in other forms (e.g., documents) and do you need to gain it by gathering or observing other people’s experiences or by experiencing it personally?
• What is the nature of the reality that you want to study? Is it objective or subjective?

Depending on the problem and objective, other questions may arise during this process that lead you to a suitable paradigm. Ultimately, you must be able to state, explain, and justify the research paradigm you select for your research and be prepared to include this in your dissertation’s methodology and design section.

Using Two Paradigms

If the nature of your research problem and objectives involves both quantitative and qualitative aspects, then you might consider using two paradigms or a mixed methods approach . In this, one paradigm is used to frame the qualitative aspects of the study and another for the quantitative aspects. This is acceptable, although you will be tasked with explaining your rationale for using both of these paradigms in your research.

Choosing the right research paradigm for your research can seem like an insurmountable task. It requires you to:

●  Have a comprehensive understanding of the paradigms,

●  Identify your research problem, objectives, and hypothesis, and

●  Be able to state, explain, and justify the paradigm you select in your methodology and design section.

Although conducting your research and putting your dissertation together is no easy task, proofreading it can be! Our experts are here to make your writing shine. Your first 500 words are free !

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• Open access
• Published: 26 March 2024

Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review

• Guillaume Fontaine   ORCID: orcid.org/0000-0002-7806-814X 1 , 2 ,
• Marie-Eve Poitras 3 , 4 ,
• Maxime Sasseville 5 , 6 ,
• Marie-Pascale Pomey 7 , 8 ,
• Jérôme Ouellet 9 ,
• Lydia Ould Brahim 1 ,
• Sydney Wasserman 1 ,
• Frédéric Bergeron 10 &
• Sylvie D. Lambert 1 , 11  

Systematic Reviews volume  13 , Article number:  96 ( 2024 ) Cite this article

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Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are evidence-based, standardized questionnaires that can be used to capture patients’ perspectives of their health and health care. While substantial investments have been made in the implementation of PROMs and PREMs, their use remains fragmented and limited in many settings. Analysis of multi-level barriers and enablers to the implementation of PROMs and PREMs has been hampered by the lack of use of state-of-the-art implementation science frameworks. This umbrella review aims to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI). Qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs and/or PREMs in all healthcare settings will be considered for inclusion. Eight bibliographical databases will be searched. All review steps will be conducted by two reviewers independently. Included reviews will be appraised and data will be extracted in four steps: (1) assessing the methodological quality of reviews using the JBI Critical Appraisal Checklist; (2) extracting data from included reviews; (3) theory-based coding of barriers and enablers using the Consolidated Framework for Implementation Research (CFIR) 2.0; and (4) identifying the barriers and enablers best supported by reviews using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Findings will be presented in diagrammatic and tabular forms in a manner that aligns with the objective and scope of this umbrella review, along with a narrative summary.

This umbrella review of quantitative, qualitative, and mixed-methods systematic and scoping reviews will inform policymakers, researchers, managers, and clinicians regarding which factors hamper or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and the level of confidence in the evidence supporting these factors. Findings will orient the selection and adaptation of implementation strategies tailored to the factors identified.

Systematic review registration

PROSPERO CRD42023421845.

Peer Review reports

Capturing patients’ perspectives of their health and healthcare needs using standardized patient-reported outcome and experience measures (referred to herein as PROMs and PREMs, respectively) has been the focus of over 40 years of research [ 1 , 2 ]. PROMs/PREMs are standardized, validated questionnaires (generic or disease-specific); PROMs are completed by patients about their health, functioning, and quality of life, whereas PREMs are focused on patients’ experiences whilst receiving care [ 1 ]. PROMs/PREMs are associated with a robust evidence-base across multiple illnesses; they can increase charting of patients’ needs [ 3 ], and improve patient-clinician communication [ 3 , 4 , 5 ], which in turn can lead to improved symptom management [ 4 , 5 , 6 ], thereby improving patients’ quality of life, reducing health care utilization [ 5 ], and increasing survival rates [ 7 ].

Multipurpose applications of PROMs/PREMs have led to substantial investments in their implementation. In the USA, PROMs are part of payer mandates; in the United Kingdom, they are used for benchmarking and included in a national registry; and Denmark has embedded them across healthcare sectors [ 8 , 9 , 10 , 11 ]. In Canada, the Canadian Institute for Health Information (CIHI) has advocated for a standardized core set of PROMs [ 12 ], and the Canadian Partnership Against Cancer (CPAC) recently spearheaded PROM implementation in oncology in 10 provinces/territories. In 2017, the Organisation for Economic Co-operation and Development (OECD) launched the Patient-Reported Indicators Surveys (PaRIS) to build international capacity for PROMs/PREMs in primary care [ 13 ]. Yet, in many countries across the globe, their use remains fragmented, characterized by broad swaths of pre-implementation, pilots, and full implementation in narrow domains [ 12 , 14 , 15 ]. PROM/PREM implementation remains driven by silos of local healthcare networks [ 16 ].

Barriers and enablers to the implementation of PROMs/PREMs exist at the patient level (e.g., low health literacy), [ 17 ] clinician level (e.g., obtaining PROM/PREM results from external digital platforms) [ 17 , 18 , 19 ], service level (e.g., lack of integration in clinics’ workflow) [ 17 , 20 ] and organizational/system-level (e.g., organizational policies conflicting with PROM implementation goals) [ 21 ]. Foster and colleagues [ 22 ] conducted an umbrella review on the barriers and facilitators to implementing PROMs in healthcare settings. The umbrella review identified a number of bidirectional factors arising at different stages that can impact the implementation of PROMs; these factors were related to the implementation process, the organization, and healthcare providers [ 22 ]. However, the umbrella review focused solely on PROMs, excluding PREMs, and the theory-based analysis of implementation factors was limited. Another ongoing umbrella review is restricted to investigating barriers and enablers at the healthcare provider level, omitting the multilevel changes required for successful PROM/PREM implementation [ 23 ].

State-of-the-art approaches from implementation science can support the identification of multilevel factors influencing the implementation of PROMs and PREMs in different healthcare settings [ 24 , 25 , 26 ]. The second version of the Consolidated Framework for Implementation Research (CFIR 2.0) can guide the exploration of determinants influencing the implementation of PROMs and PREMs [ 27 ]. The CFIR is a meta-theoretical framework providing a repository of standardized implementation-related constructs at the individual, organizational, and external levels that can be applied across the spectrum of implementation research [ 27 ]. CFIR 2.0 includes five domains pertaining to the characteristics of the innovation targeted for implementation, the implementation process, the individuals involved in the implementation, the inner setting, and the outer setting [ 27 ]. Using an implementation framework to identify the multilevel factors influencing the implementation of PROMs/PREMs is critical to select and tailor implementation strategies to address barriers [ 28 , 29 , 30 , 31 ]. Implementation strategies are the “how”, the specific means or methods for promoting the adoption of evidence-based innovations (e.g., role revisions, audit, provide feedback) [ 32 ]. Selecting and adapting implementation strategies to facilitate the implementation of PROMs/PREMs can be time-consuming, as there are more than 73 implementation strategies to choose from [ 33 ]. Thus, a detailed understanding of the barriers to PROM/PREM implementation can inform and streamline the selection and adaptation of implementation strategies, saving financial, human, and material resources [ 24 , 25 , 26 , 32 , 34 ].

Review objective and questions

In this umbrella review, we aim to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

We will address the following questions:

What are the factors that hinder or enable the implementation of PROMs and PREMs in healthcare settings, and what is the level of confidence in the evidence supporting these factors?

What are the similarities and differences in barriers and enablers across settings and geographical regions?

What are the similarities and differences in the perceptions of barriers and enablers between patients, clinicians, managers, and decision-makers?

What are the implementation theories, models, and frameworks that have been used to guide research in this field?

Review design and registration

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI) [ 35 , 36 ]. The umbrella review is a form of evidence synthesis that aims to address the challenge of collating, assessing, and synthesizing evidence from multiple reviews on a specific topic [ 35 ]. This protocol was registered on PROSPERO (CRD42023421845) and is presented according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines (see Supplementary material  1 ) [ 37 ]. We will use the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines [ 38 ] and the PRISMA guidelines [ 39 ] to report results (e.g., flowchart, search process).

Eligibility criteria

The eligibility criteria were developed following discussions among the project team including researchers with experience in the implementation of PROMs and PREMs in different fields (e.g., cancer care, primary care) and implementation science. These criteria were refined after being piloted on a set of studies. The final eligibility criteria for the review are detailed in Table  1 . We will consider for inclusion all qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs or PREMs in any healthcare setting.

Information sources

Searches will be conducted in eight databases: CINAHL, via EBSCOhost (1980 to present); Cochrane Database of Systematic Reviews; Evidence-Based Medicine Reviews; EMBASE, via Ovid SP (1947 to present); ERIC, via Ovid SP (1966 to present); PsycINFO, via APA PsycNet (1967 to present); PubMed (including MEDLINE), via NCBI (1946 to present); Web of Science, via Clarivate Analytics (1900 to present). CINAHL is a leading database for nursing and allied health literature. The Cochrane Database of Systematic Reviews and Evidence-Based Medicine Reviews are essential for accessing high-quality systematic reviews and meta-analyses. EMBASE is a biomedical and pharmacological database offering extensive coverage of drug research, pharmacology, and medical devices, complementing PubMed. ERIC provides valuable insights from educational research that are relevant to our study given the intersection of healthcare and education in PROMs and PREMs. PsycINFO is crucial for accessing research on the psychological aspects of PROMs and PREMs. PubMed, encompassing MEDLINE, is a primary resource for biomedical literature. Web of Science offers a broad and diverse range of scientific literature providing interdisciplinary coverage. We will use additional strategies to complement our exploration including examining references cited in eligible articles, searching for authors who have published extensively in the field, and conducting backward/forward citation searches of related systematic reviews and influential articles.

Search strategy

A comprehensive search strategy was developed iteratively by the review team in collaboration with an experienced librarian with a Master’s of Science in Information (FB). First, an initial limited search of MEDLINE and CINAHL will be undertaken to identify reviews on PROM/PREM implementation. The text words contained in the titles and abstracts, and the index terms used to describe these reviews will be analyzed and applied to a modified search strategy (as needed). We adapted elements from the search strategies of two recent reviews in the field of PROM/PREM implementation [ 22 , 23 ] to fit our objectives. The search strategy for PubMed is presented in Supplementary material 2 . The search strategy will be tailored for each information source. The complete search strategy for each database will be made available for transparency and reproducibility in the final manuscript.

Selection process

All identified citations will be collated and uploaded into the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and duplicates removed. Following training on 50 titles, titles will be screened by two independent reviewers for assessment against the inclusion criteria for the review. Multiple rounds of calibration might be needed. Once titles have been screened, retained abstracts will be reviewed, preferably by the same two reviewers. However, inter-rater reliability will be re-established on 50 abstracts to re-calibrate (as needed). Lastly, the full texts of retained abstracts will be located and assessed in detail against the inclusion criteria by two independent reviewers. Reasons for excluding articles from full-text review onwards will be recorded in the PRIOR flow diagram (PRISMA-like flowchart) [ 38 ]. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer. More specifically, throughout the project, weekly team meetings will be held and will provide the opportunity for the team to discuss and resolve any disagreement that arises during the different stages, from study selection to data extraction.

Quality appraisal and data extraction

As presented in Fig.  1 , included reviews will be appraised and data will be extracted and analyzed in four steps using validated tools and methodologies [ 27 , 36 , 40 ]. All four steps will be conducted by two reviewers independently, and a third will be involved in case of disagreement. More reviewers may be needed depending on the number of reviews included.

Tools/methodology applied in each phase of the umbrella review. Figure adapted from Boudewijns and colleagues [ 41 ] with permission. CFIR 2.0 = Consolidated Framework for Implementation Research, version 2 [ 27 ]. GRADE–CERQual = Grading of Recommendations Assessment Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative Research [ 42 ]. JBI = Joanna Briggs Institute [ 36 ]

Step 1—assessing the quality of included reviews

In the first step, two reviewers will independently assess the methodological quality of the reviews using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, presented in Supplementary material  3 . We have selected this checklist for its comprehensiveness, applicability to different types of knowledge syntheses, and ease of use, requiring minimal training for reviewers to apply it. The checklist consists of 11 questions. It evaluates whether the review question is clearly and explicitly stated, the inclusion criteria were appropriate for that question, and the search strategy and sources used to determine if they were suitable and adequate for capturing relevant studies. It also assesses the appropriateness of the criteria used for appraising studies, as well as whether the critical appraisal was conducted independently by two or more reviewers. The checklist further examines if there were methods in place to minimize errors during data extraction, if the methods used to combine studies were appropriate, and whether the likelihood of publication bias was assessed. Additionally, it verifies if the recommendations for policy and/or practice are supported by the reported data and if the directives for new research are appropriate. Each question should be answered as “yes”, “no”, or “unclear”. Not applicable “NA” is also provided as an option and may be appropriate in rare instances. The results of the quality appraisal will provide the basis for assessing confidence in the evidence in step four. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer, or at team meetings.

Step 2—extracting data from included reviews

For the second step, we have developed a modified version of the JBI Data Extraction Form for Umbrella Reviews, presented in Supplementary material  3 . We will pilot our data extraction form on two of the included reviews, and it will be revised for clarity, as needed. Subsequently, two independent reviewers will conduct all extraction for each review independently. We will collect the following data: (a) authors and date; (b) country; (c) review aims, objectives; (d) focus of the review; (e) context; (f) population; (g) eligibility criteria; (f) review type and methodology; (g) data sources; (h) dates of search; (i) number of included studies; (j) characteristics of included studies (including study type, critical appraisal score); (k) implementation framework guiding analysis; (l) implementation strategies discussed; (m) results and significance; and (n) conclusions. Barriers and enablers will be extracted separately in step 3. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer, or at team meetings.

Step 3—theory-based coding of barriers and enablers

In the third step, we will use the second version of the Consolidated Framework for Implementation Research (CFIR) [ 27 ] to guide our proposed exploration of determinants influencing the implementation of PROMs and PREMs (see Fig.  2 ). The CFIR is a meta-theoretical framework providing a repository of standardized implementation-related constructs at the individual, organizational, and external levels that can be applied across the spectrum of implementation research. CFIR contains 48 constructs and 19 subconstructs representing determinants of implementation across five domains: Innovation (i.e., PROMs and PREMs), Outer Setting (e.g., national policy context), Inner Setting (e.g., work infrastructure), Individuals (e.g., healthcare professional motivation) and Implementation Process (e.g., assessing context) [ 27 ]. To ensure that coding remains grounded in the chosen theoretical framework, we have developed a codebook based on the second version of the CFIR, presented in Supplementary material 3 . Furthermore, an initial training session and regular touchpoints will be held to discuss coding procedures among the team members involved.

The second version of the Consolidated Framework for Implementation Research and its five domains: innovation, outer setting, inner setting, individuals, and implementation process [ 27 , 43 ]

To code factors influencing the implementation of PROMs and PREMs using the CFIR, we will upload all PDFs of the included reviews and their appendices in the NVivo qualitative data analysis software (QSR International, Burlington, USA). All reviews will be independently coded by two reviewers. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Step 4—identifying the barriers and enablers best supported by the reviews

In the fourth and final step, we will use the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach to assess the level of confidence in the barriers and enablers to PROM/PREM implementation identified in step 3 (see Supplementary material  3 ). This process will identify which barriers and enablers are best supported by the evidence in the included reviews. GRADE-CERQual includes four domains: (a) methodological limitations, (b) coherence and (c) adequacy of data, and (d) relevance (see Table  2 ). For each review finding, we will assign a score per domain from one point (substantial concerns) to four points (no concerns to very minor concerns). The score for the methodological limitations of the review will be assigned based on the JBI Critical Appraisal (step 1). The score for coherence will be assigned based on the presence of contradictory findings as well as ambiguous/incomplete data for that finding in the umbrella review. The score for adequacy of data will be assigned based on the richness of the data supporting the umbrella review finding. Finally, the score for relevance will be assigned based on how well the included reviews supporting a specific barrier or enabler to the implementation of PROMs/PREMs are applicable to the umbrella review context. This will allow us to identify which factors are supported by evidence with the highest level of confidence, and their corresponding level of evidence. A calibration exercise will be conducted on three systematic reviews with team members involved in this stage of the umbrella review, and adjustments to procedures will be discussed in team meetings.

The data synthesis plan for the umbrella review has been meticulously designed to present extracted data in a format that is both informative and accessible, aiding in decision-making and providing a clear overview of the synthesized evidence.

Data extracted from the included systematic reviews will be organized into diagrams and tables, ensuring the presentation is closely aligned with our objectives and scope. These will categorize the distribution of reviews in several ways: by the year or period of publication, country of origin, target population, context, type of review, and various implementation factors. This stratification will allow for an at-a-glance understanding of the breadth and focus of the existing literature. To further assist in the application of the findings, a Summary of Qualitative Findings (SoQF) table will be constructed. This table will list each barrier and enabler identified within the systematic reviews and provide an overall confidence assessment for each finding. The confidence assessment will be based on the methodological soundness and relevance of the evidence supporting each identified barrier or enabler. Importantly, the SoQF table will include explanations for these assessments, making the basis for each judgement transparent [ 42 ]. Additionally, a CERQual Evidence Profile will be prepared, offering a detailed look at the reviewers’ judgements concerning each component of the CERQual approach. These components contribute to the overall confidence in the evidence for each identified barrier or enabler. The CERQual Evidence Profile will serve as a comprehensive record of the quality and applicability of the evidence [ 42 ].

Finally, we will conduct a narrative synthesis accompanying the tabular and diagrammatic presentations, summarizing the findings and discussing their implications concerning the review’s objectives and questions. This narrative will interpret the significance of the barriers and enablers identified, explaining how the synthesized evidence fits into the existing knowledge base and pointing out potential directions for future research or policy formulation.

This protocol outlines an umbrella review aiming to consolidate available evidence on the implementation of PROMs and PREMs in healthcare settings. Through our synthesis of quantitative, qualitative, and mixed-methods systematic and scoping reviews, we will answer two key questions: which factors hinder or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and what is the level of confidence in the evidence supporting these factors? Our findings will indicate which factors can influence the adoption of PROMs and PREMs, including clinician buy-in, patient engagement, and organizational support. Furthermore, our review will provide key insights regarding how barriers and enablers to PROM/PREM implementation differ across settings and how perceptions around their implementation differ between patients, clinicians, managers, and decision-makers. The consideration of different healthcare settings and the inclusion of studies from different geographical regions and healthcare systems will provide a global perspective, essential for understanding how context-specific factors might influence the generalizability of findings.

Strengths of this umbrella review include the use of a state-of-the-art implementation framework (CFIR 2.0) to identify, categorize, and synthesize multilevel factors influencing the implementation of PROMs/PREMS, and the use of the GRADE-CERQual approach to identify the level of confidence in the evidence supporting these factors. Using CFIR 2.0 will address a key limitation of current research in the field, since reviews and primary research are often focused on provider- and patient-level barriers and enablers, omitting organizational- and system-level factors affecting PROM/PREM implementation. This umbrella review will expose knowledge gaps to orient further research to improve our understanding of the complex factors at play in the adoption and sustained use of PROMs and PREMs in healthcare settings. Importantly, using CFIR 2.0 will allow the mapping of barriers and enablers identified to relevant implementation strategy taxonomies, such as the Expert Recommendations for Implementing Change (ERIC) Taxonomy [ 34 ]. This is crucial for designing tailored implementation strategies, as it can ensure that the chosen approaches to support implementation are directly aligned with the specific barriers and enablers to the uptake of PROMs and PREMs.

Umbrella reviews are also associated with some limitations, including being limited to the inclusion of systematic reviews and other knowledge syntheses, while additional primary studies are likely to have since been published. These additional empirical studies will not be captured, but we will minimize this risk by updating the search strategy at least once before the completion of the umbrella review. A second key challenge in umbrella reviews is the overlap between the primary studies, as many studies will have been included in different systematic reviews on the same topic. To address this issue, we will prepare a matrix of primary studies included in systematic reviews to gain insight into double counting of primary studies.

We will maintain an audit trail document amendments to this umbrella review protocol and report these in both the PROSPERO register and subsequent publications. Findings will be disseminated through publications in peer-reviewed journals in the fields of implementation, medicine, as well as health services, and policy research. We will also disseminate results through relevant conferences and social media using different strategies (e.g., graphical abstract). Furthermore, we will leverage existing connections between SDL and decision-makers at a provincial and national level in Canada to disseminate the findings of the review to a wider audience (e.g., the Director of Quebec Cancerology Program, Canadian Association of Psychosocial Oncology).

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed for the purposes of this publication.

Abbreviations

Confidence in the evidence from reviews of qualitative research

Consolidated framework for implementation research

Canadian Institute for Health Information

Canadian Partnership Against Cancer

Expert recommendations for implementing change

Grading of recommendations assessment, development and evaluation

Joanna Briggs Institute

Organisation for economic co-operation and development

Patient-reported indicators surveys

Patient-reported experience measure

Preferred reporting items for overviews of reviews

Preferred reporting items for systematic review and meta-analysis

Preferred reporting items for systematic review and meta-analysis protocols

Patient-reported outcome measure

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Acknowledgements

We wish to acknowledge the involvement of a patient-partner on the RRISIQ grant supporting this project (Lisa Marcovici). LM will provide feedback and guidance on the findings of the umbrella review, orienting the interpretation of findings and the next steps of this project.

We wish to acknowledge funding from the Quebec Network on Nursing Intervention Research/Réseau de recherche en intervention en sciences infirmières du Québec (RRISIQ), a research network funded by the Fonds de recherche du Québec en Santé (FRQ-S). Funders had no role in the development of this protocol.

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GF and SDL conceptualized the study. GF, MEP, MS, MP, and SDL developed the study methods. GF drafted the manuscript, with critical revisions and additions by SDL. All authors provided intellectual content and reviewed and edited the manuscript. GF is the guarantor of this review. All authors read and approved the final manuscript.

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Fontaine, G., Poitras, ME., Sasseville, M. et al. Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review. Syst Rev 13 , 96 (2024). https://doi.org/10.1186/s13643-024-02512-5

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The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

• Faith Boutcher 1 ,
• Whitney Berta 2 ,
• Robin Urquhart 3 &
• Anna R. Gagliardi 4  

BMC Health Services Research volume  22 , Article number:  11 ( 2022 ) Cite this article

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Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Peer Review reports

Contributions to the literature

MMs may play an important KB role in healthcare organizations.

Additional support for the MM KB role may help enhance quality of care in healthcare settings.

An improved understanding of MM KBs will contribute to this nascent area of inquiry in health care.

Health systems are under increasing pressure to improve performance including productivity, quality of care, and efficiency in service delivery. To promote optimal performance, health systems hold healthcare organizations such as hospitals accountable for the quality of care they provide through accountability agreements tied to performance targets [ 1 , 2 ]. Despite such incentives, healthcare organizations face considerable challenges in providing high-quality care and research continues to show that the quality of hospital-based care is less than ideal [ 3 , 4 , 5 ]. Some researchers contend that this is attributed, in part, to the challenges that healthcare organizations face when integrating new knowledge into practice. Some challenges include dedicating sufficient resources to adopt or implement evidence-informed innovations that enhance service delivery and optimize patient health and outcomes [ 6 ].

Healthcare organizations use knowledge translation (KT) approaches to promote the use of evidence-based practices intended to optimize quality of care. The use of knowledge brokers (KBs) is one such approach. KBs are defined as the human component of KT who work collaboratively with stakeholders to facilitate the transfer and exchange of knowledge in diverse settings, [ 7 , 8 , 9 ]. KBs that facilitate the use of knowledge between people or groups have been referred to as opinion leaders, facilitators, champions, linking agents and change agents whose roles can be formal or informal [ 10 , 11 ]. These “influencer” roles are based on the premise that interpersonal contact improves the likelihood of behavioral change associated with use or adoption of new knowledge [ 12 ]. Research shows that KBs have had a positive effect on increasing knowledge and evidence-based practices among clinicians in hospitals, and on advocating for change on behalf of clinicians to executives [ 13 , 14 , 15 ]. However, greater insight is needed on how to equip and support KBs, so they effectively promote and enable clinicians to use evidence-based practices that improve quality of care [ 13 , 16 , 17 ].

Middle managers (MMs) play a pivotal role in facilitating high quality care and may play a brokerage role in the sharing and use of knowledge in healthcare organizations [ 18 , 19 ]. MMs are managers at the mid-level of an organization supervised by senior managers, and who, in turn, supervise frontline clinicians [ 20 ]. MMs facilitate the integration of new knowledge in healthcare organizations by helping clinicians appreciate the rationale for organizational changes and translating adoption decisions into on-the-ground implementation strategies [ 18 , 19 ]. Current research suggests that MMs may play an essential role as internal KBs because of their mid-level positions in healthcare organizations. Some researchers have called for a deeper understanding of the MM role in knowledge brokering, including how MMs enact internal KB roles [ 16 , 17 , 18 , 19 , 21 ].

To this end, further research is needed on who assumes the KB role and what they do. Prior research suggests that KBs may function across five key roles: knowledge manager, linking agent, capacity builder, facilitator, and evaluator, but it is not clear whether these roles are realized in all healthcare settings [ 7 , 21 , 22 ]. KBs are often distinguished as external or internal to the practice community that they seek to influence, and most studies have focused on external KBs with comparatively little research focused on the role of internal KBs [ 7 , 9 , 17 , 23 , 24 ]. To address this gap, we will focus on internal KBs (MMs) who hold a pivotal position because their credibility and detailed knowledge of local context allows them to overcome the barriers common to external KBs. One such barrier is resistance to advice from external sources unfamiliar with the local context [ 25 ].

With respect to what KBs do, two studies explored KB roles and activities, and generated frameworks that describe KB functions, processes, and outcomes in health care [ 7 , 22 ]. However, these frameworks are not specific to MMs and are limited in detail about KB roles and functions. This knowledge is required by healthcare organizations to develop KB capacity among MMs, who can then enhance quality of care. Therefore, the focus of this study was to synthesize published research on factors that influence the KB roles, activities, and impact of MMs in healthcare settings. In doing so, we will identify key concepts, themes, and the relationships among them to generate an organizing framework that categorizes how MMs function as KBs in health care to guide future policy, practice, and research.

We used a critical interpretive synthesis (CIS) to systematically review the complex body of literature on MM KBs. This included qualitative, quantitative, and theoretical papers. CIS offers an iterative, dynamic, recursive, and reflexive approach to qualitative synthesis. CIS was well-suited to review the MM KB literature than traditional systematic review methods because it integrates findings from diverse studies into a single, coherent framework based on new theoretical insights and interpretations [ 26 , 27 ]. A key feature that distinguishes CIS from other approaches to interpretive synthesis is the critical nature of the analysis that questions the way studies conceptualize and construct the topic under study and uses this as the basis for developing synthesizing arguments [ 26 ]. We ensured rigor by complying with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) criteria (Additional file  1 ) and other criteria of trustworthiness [ 28 , 29 ]. We did not register a protocol for this review.

With a medical librarian, we developed a search strategy (Additional file  2 ) that complied with the evidence-based checklist for peer review of electronic search strategies [ 30 ]. We included Medical Subject Headings and keywords that captured the concepts of MMs (e.g., nurse administrator, manager), explicit or non-explicit KB roles (e.g., diffusion of innovation, dissemination, broker, and facilitator), evidence-based practice (e.g., knowledge, evidence) and setting (e.g., hospital, healthcare, or health care). We searched MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC, and the Cochrane Library from January 1, 2001, to August 14, 2020. We searched from 2001 onward because the field of KT did not substantially investigate KBs until 2001 [ 7 , 21 ]. We reviewed the reference lists of eligible articles for additional relevant studies not identified by searches. As is typical of CIS, this was an iterative process allowing search terms to be expanded to optimize search results [ 26 , 31 ].

Eligibility

We generated eligibility criteria based on the PICO framework (population, intervention, comparisons, and outcomes) (Additional file  3 ). Populations refer to MMs functioning as KBs in hospitals or other healthcare settings but did not necessarily use those labels. Because the MM literature is emergent, we included settings other than hospitals (e.g., public health department, Veteran Affairs Medical Centres). We included studies involving clinical and non-clinical administrators, managers, directors, or operational leaders if those studies met all other inclusion criteria. The intervention of interest was how MM KBs operated in practice for the creation, use and sharing of knowledge, implementation of evidence-based practice(s), or innovation implementation. Study comparisons may have evaluated one or more MM KB roles, approaches and associated barriers, enablers and impacts alone or in comparison with other types of approaches for the sharing or implementation of knowledge, evidence, evidence-based practices, or innovations. Outcomes included but were not limited to MM KB effectiveness (change in knowledge, skills, policies and/or practices, care delivery, satisfaction in role), behaviors, and outcomes. Searches were limited to English language quantitative, randomized, or pragmatic controlled trials, case studies, surveys, quasi-experimental, qualitative, or mixed methods studies and conceptual papers. Systematic reviews were not eligible, but we screened references for additional eligible primary studies. Publications in the form of editorials, abstracts, protocols, unpublished theses, conference proceedings were not eligible.

FB and ARG independently screened 50 titles and abstracts according to the eligibility criteria and compared and discussed results. Based on discrepancies, they modified the eligibility criteria and discussed how to apply them. Thereafter, FB screened all remaining titles, and discussed all uncertainties with ARG and the research team. FB retrieved all potentially eligible articles. FB and ARG independently screened a sample of 25 full-text articles, and again discussed selection discrepancies to further standardize how eligibility criteria were applied. Thereafter, FB screened all remaining full-text items.

Quality appraisal

We employed quality appraisal tools relevant to different research designs: Standards for Reporting Qualitative Research (SRQR) [ 32 ], the Good Reporting of a Mixed Methods Study (GRAMMS) tool [ 33 ], Critical Appraisal of a Questionnaire Study [ 34 ], Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) tool [ 35 ], and the Critical Appraisal Checklist for Quasi-Experimental Studies [ 36 ]. FB and ARG independently assessed and compared the quality of a sample of seven studies each. Thereafter, FB assessed the quality of the remaining 24 studies.

Data extraction

We developed a data extraction form to extract information on study characteristics (date of publication, country, purpose, research design) and MM KB characteristics, roles, activities, enablers, barriers, and impacts. To pilot test data extraction, FB and ARG independently extracted data from the same 25 articles, then compared results and discussed how to refine data extraction. Thereafter, FB extracted data from remaining articles, which was independently checked by ARG, and then reviewed by the research team.

Data analysis

FB and ARG conducted an initial reading and coding of a sample of articles independently. Codes were assigned to significant elements of data within the results and conclusions sections of the eligible articles and grouped into relevant categories with shared characteristics and organized into preliminary themes. This was an iterative process that involved ongoing consultation with the research team, who provided feedback on the codes and themes.

We created a matrix of MM KB roles and activities from extant MM and KB theory [ 7 , 18 , 22 , 37 ] and deductively mapped themes from included studies with the matrix to help inform the analysis and interpretation of our findings. As per CIS methodology, we developed an integrative grid (matrix table) where themes pertaining to MM KB roles and activities formed columns, and themes mapped to those roles/activities from individual studies formed rows [ 31 ]. The grid helped us integrate the evidence across studies and explore relationships between concepts and themes to inductively develop synthetic constructs [ 31 , 38 ]. Using a constant comparative approach, we critiqued the synthetic constructs with the full sample of papers to identify conceptual gaps in the available evidence in relation to our aims, and to ensure that the constructs were grounded in the data [ 31 , 38 ]. Our interpretive reflections on MM KB roles, activities, factors, and impacts led us to develop “synthetic arguments” and we used the arguments to structure our findings (attributes, roles, activities, impacts, enablers, barriers) in an organizing framework to capture our interpretation of how MMs function as KBs in healthcare organizations. We used NVivo 12 software to assist with data analysis.

Search results

The initial search yielded 9936 articles. Following removal of duplicates, 9760 titles were not eligible, and 176 items were retrieved as potentially relevant. Of those, 135 were excluded because the study design was ineligible (25), they did not examine MMs (27) or MM KBs (34), were not focused on the evaluation of an MM KB role (39), were editorials (4), or the publication was a duplicate (6). We included 41 articles for review (Fig.  1 PRISMA flow diagram). Additional file  4 includes all data extracted from included studies.

PRISMA flow diagram

Study characteristics

Eligible articles were published between 2003 and 2019. Three (7.3%) were conceptual and 38 (92.7%) were empirical studies. Conceptual articles discussed MM and KB theoretical constructs. Table  1 summarizes study characteristics. Studies examined the impacts of change efforts (47.3%), barriers to practice change (34.2%), and evaluation of KB interventions (18.4%). Most were qualitative (52.6%) and conducted in the United States (36.8%). Of study participants (34.2%) were MMs. In most studies, participants were nurses (63.1%) or allied health (13.2%) and based in hospitals (68.4%). Otherwise, (31.6%) were based in public health or occupational health departments, primary health care centers, Veterans Affairs Medical Centres, community care, and a senior’s care facility.

Quality assessment findings

A critical analysis of the included studies revealed issues related to research design, varying from data collected from heterogeneous healthcare settings and diverse types of MMs to the type of analyses completed (e.g., qualitative, mixed methods), to the strength of conclusions drawn from a few studies’ results (e.g., correlational, or causal). Fifteen (39.5%) studies met the criteria for quality. Twenty-three (60.5%) studies had minor methodological limitations (e.g., no research paradigm identified in qualitative studies, and mixed methods studies did not describe the integration of the two methods) (Additional file  5 ). These methodological flaws did not warrant exclusion of any studies as they provided relevant insights regarding the emerging framework.

MM KB attributes

Seven (18.4%) studies described MM KB attributes (Table  2 ). Of those, 4 (10.5%) identified MM attributes, 2 (5.2%) identified KB attributes, and 1 (2.6%) identified nurse knowledge broker attributes. MM KBs were described as confident, enthusiastic, and experienced with strong research skills [ 41 , 45 ]. They were also responsive and approachable, with an understanding of the complexity of an innovation and the organizational context [ 42 , 43 , 44 ].

MM KB roles and activities

Table  3 summarizes themes pertaining to roles and activities. A total of 63 activities were grouped in the following 12 MM KB roles: (1) gather data, (2) coordinate projects, (3) monitor and evaluate the progress of a project, (4) adjust implementation to organizational context, (5) disseminate information, (6) facilitate networks, (7) bridge the evidence-to-practice gap, (8) engage stakeholders, (9) convince others of the need for, and benefit of a project, (10) coach staff, (11) provide tools and resources and (12) function as a strategic influencer. Roles did not differ among MM KBs in hospital and non-hospital settings.

Table  4 summarizes the frequency of each of the 12 MM KB roles across included studies. The two most common MM KB roles were to monitor and evaluate the progress of a project (14, 36.8%) [ 40 , 41 , 47 , 48 , 49 , 50 , 51 , 54 , 57 , 60 , 63 , 64 , 65 , 66 ] and to convince others of the need for, and benefit of a project (12, 31.6%) [ 46 , 47 , 48 , 50 , 51 , 55 , 58 , 61 , 64 , 65 , 66 , 67 ]. For example, MM KBs played an important role in monitoring the progress of projects to evaluate and reinforce practice change [ 41 , 50 ]. To convince others of the need for, and benefit of a project and to promote staff buy-in, they held ongoing conversations with staff to help them understand the rationale for change, reinforce the message, and encourage staff to consistently maintain the innovations on their units [ 46 , 48 , 66 ]. The least common MM KB role was project coordination (4, 10.5%) [ 39 , 47 , 48 , 56 ].

Several of the identified MM KB roles aligned with five KB roles in prior published frameworks [ 7 , 22 ] and MM role theory [ 18 , 37 ] (Table  5 ). For example, 31 (81.6%) studies described MM KB roles of gather data, project coordination, disseminate information , and adjust implementation to organizational context , which aligned with the roles and activities of a KB knowledge manager. Twenty-nine (76.3%) studies described the MM KB roles of provide tools and resources, convince others of the need for and benefit of a project, and coach staff , which aligned with the roles and activities of a KB capacity builder. We found overlap between the MM KB roles and the four hypothesized roles in MM role theory: (1) disseminate and obtain information, (2) adapt information and the innovations, (3) mediate between strategy and day to day activities, and (4) selling innovation implementation) [ 18 , 37 ]. For example, we found that as capacity builders, MM KBs also mediated between strategy and day-to-day activities such as coaching staff and providing resources, and in the role of knowledge manager, MM KBs obtained, diffused, and synthesized information [ 18 , 37 ].

While MM KB roles identified in included studies aligned with the five previously identified KB roles, the CIS approach we employed identified 12 distinct roles that were further characterized based on corresponding activities associated with each of the 12 roles. Therefore, while this research agrees with prior work on MM KB roles, it represents a robust framework of MM KB roles and activities by elaborating the complexity of MM KB roles and activities.

We fully described two roles compared with prior frameworks: to convince others of the need for and benefit of a project, and function as a strategic influencer. To convince others of the need for and benefit of a project (e.g., a quality improvement, best practice guideline implementation, or innovation), MM KBs used tactics such as role modelling their commitment, providing the rationale for the change, being enthusiastic about its adoption, offering positive reinforcement, and providing emotional support [ 47 , 50 , 58 ]. The role of strategic influencer featured in 7 (18.4%) studies [ 39 , 48 , 52 , 56 , 62 , 65 , 68 ]. For example, MM KBs were influential at the executive level of the hospital, advocating for innovations among less involved team members and administrators, including the hospital board, were members of organizational decision-making groups for strategic planning, and served as an authoritative contact for initiatives.

Factors that influence MMs knowledge brokering

Table  6 summarizes the enablers and barriers of MM KB roles and activities, organized as individual or organizational factors. We identified four enablers at the organizational level: senior management support, availability of resources, engaged staff, and alignment to strategy. The most common was senior management support, featured in 12 (32.0%) studies. We found that senior management support enhanced the commitment of MM KBs to innovation implementation [ 16 , 17 , 19 , 44 , 45 , 52 , 61 , 63 , 66 , 67 , 68 , 69 , 70 ]. For example, senior managers empowered and supported MM KBs to make decisions by ensuring that the necessary structures and resources were in place, and by conveying that the implementation was an organizational priority [ 66 , 68 ]. We identified three individual-level facilitators: training and mentorship, personal attributes, and experience in the MM role. The most common facilitator was training and mentorship, featured in 8 (21.1%) studies. We found that training and mentorship with more experienced managers was important to the success of MM KBs and their projects, especially if they were new to their role [ 16 , 17 , 19 , 41 , 42 , 48 , 54 , 68 ].

Studies reported more barriers ( n  = 8) than enablers ( n  = 7). We found four organizational barriers: a lack of resources, lack of senior management support, staff resistance, and a lack of time. The most common barriers were lack of resources in 12 (32.0%) studies and lack of time in 12 (32.0%) studies. A lack of resources (budget constraints, limited staff) made it challenging for MM KBs to move their projects forward [ 39 , 42 , 44 , 47 , 52 , 55 , 57 , 64 , 68 , 69 , 70 , 71 ]. For example, inadequate funds interfered with obtaining appropriate resources and undermined the feasibility of implementing projects [ 47 , 55 ]. In addition, staffing issues created difficulty in engaging staff in project work and low staffing levels limited capacity to provide desired standards of care [ 42 , 64 ]. Additionally, a lack of protected time for data collection or other project work was identified as a significant barrier to implementing projects [ 17 , 19 , 39 , 42 , 44 , 47 , 52 , 55 , 57 , 64 , 68 , 71 ]. MM KBs also lacked the time to nurture, support and adequately coach staff [ 39 , 55 ].

We identified four individual-level barriers: lack of formal training, dissatisfaction with work life balance, being caught in the middle, and professional boundaries. The most common barriers were lack of formal training (8, 21.1%) and dissatisfaction with work life balance (8, 21.1%). For example, a lack of formal training resulted in MM KBs being unprepared for managerial roles and without the knowledge and skills to promote effective knowledge brokering and knowledge transfer with end users [ 17 , 39 , 41 , 42 , 55 , 57 , 69 , 71 ]. We also found that heavy workloads and conflicting priorities left MM KBs often dissatisfied with their work life balance and hindered their ability to successfully complete projects [ 42 , 44 , 51 , 52 , 57 , 61 , 64 , 71 ]. For example, because of multiple responsibilities and conflicting priorities, MM KBs were often pulled away to address problems or were so absorbed by administrative tasks that they had no time to complete project responsibilities [ 44 , 64 ].

Impact on service delivery and outcomes

Eight (21.1%) studies showed that MM KBs had some impact on organizational and provider outcomes [ 16 , 40 , 43 , 44 , 47 , 56 , 62 , 67 ]. One (2.6%) study reported that practice changes were greater when associated with higher MM leadership scores (OR 1.92 to 6.78) and when MMs worked to help create and sustain practice changes [ 40 ]. One (2.6%) study reported the impact of senior managers’ implementation of an evidence-based Hospital Elder Life Program on administrative outcomes (e.g., reduced length of stay and cost per patient), clinical outcomes (e.g., decreased episodes of delirium and reduced falls), and provider outcomes (e.g., increased knowledge and satisfaction) [ 67 ].

Two (5.3%) studies reported the impact of a Clinical Nurse Leader role on care processes at the service level in American hospitals. Benefits were evident in administrative outcomes such as RN hours per patient day (increased from 3.76 to 4.07) and in reduced surgical cancellation rates from 30 to 14%. There were also significantly improved patient outcomes in dementia care, pressure ulcer prevention, as well as ventilator-assisted pneumonia [ 56 , 62 ]. One (2.6%) study reported financial savings [ 56 ].

Four (10.5%) studies reported the effect of a KB strategy on health professionals’ knowledge, skills, and practices [ 16 , 43 , 44 , 47 ]. For example, Traynor et al. [ 44 ] found that participants who worked closely with a KB showed a statistically significant increase in knowledge and skill (average increase of 2.8 points out of a possible 36 (95% CI 2.0 to 3.6, p  < 0.001) from baseline.

Organizing framework of MM KBs in healthcare organizations

We sought to capture the roles, activities, enablers, barriers and impacts of MM KBs across diverse healthcare settings in an organizing framework (Fig.  2 Organizing framework of MMs who function as knowledge brokers in healthcare organizations). From our interpretation of the published evidence, the findings across studies were categorized into 12 roles and 63 associated activities to represent specific ways in which MM KBs described their roles and activities during project implementation. Influencing factors were categorized into individual and organizational enablers and barriers that influence the efforts of MM KBs in healthcare organizations. While attributes were categorized as enablers, their level of importance as enablers emerged from our synthesis in how they operated in practice. The types of outcomes that we examined also varied between changes in care practice, processes, and competencies which we constructed into provider and organizational outcomes. Our emergent insights were used to construct four synthesizing arguments from the available literature: (1) MM KBs have attributes that equip and motivate them to implement practice change and innovations in healthcare organizations, (2) MMs enact KB roles and activities in healthcare organizations, (3) enablers and barriers influence the knowledge brokering efforts of MMs in healthcare settings; and (4) MM KB efforts impact healthcare service delivery. These synthesizing arguments were used to structure the organizing framework presented in Fig. 2 , which depicts how MM function as KBs in healthcare organizations and their impact on service delivery.

Organizing framework of MMs who function as knowledge brokers in healthcare organizations

We conducted a CIS to synthesize published research on factors that influence the roles, activities, and impacts of MM KBs in healthcare organizations. As per CIS, our output was an organizing framework (Fig. 2 ) that promotes expansive thinking about and extends knowledge of MM KBs in healthcare settings. We identified 63 activities organized within 12 distinct MM KB roles, which is far more comprehensive than any other study [ 7 , 22 ]. We build on prior frameworks and characterize further the roles of strategic influencer and convincing others of the need for, and benefit of an innovation or evidence-based practice. We identified organizational and individual enablers and barriers that may influence the efforts and impact of MM KBs in health care. Of note, a key enabler was senior leadership support while a key barrier for MM KBs was a lack of formal training in project implementation. Such factors should be closely considered when looking at how to strengthen the MM KB role in practice. Furthermore, we found that the MM KB role was associated with enhanced provider knowledge and skills, as well as improved clinical and organizational outcomes.

We offer a novel conceptualization of MM KBs in healthcare organizations that has, thus far, not been considered in the literature. Our theoretical insights (summarized in Fig. 2 ) are an important first step in understanding how individual and organizational factors may influence how MMs enact KB roles, and the impact they have on service delivery and associated outcomes. We found that the many MM KB roles and activities corresponded to the characterization of KB roles in the literature and substantiated MM role theory. Our findings corroborate previous studies and systematic reviews by confirming that MMs function as KBs and build on the MM and KB theoretical constructs previously identified in the literature [ 7 , 18 , 21 , 22 , 37 , 46 , 48 ]. Building on Birken and colleagues’ theory [ 37 ], we found significant overlap between MM and KB roles and activities. Figure  2 helps to define and analyze the intersection of these roles while distinguishing MM KB roles and activities more clearly from other administrative roles.

We contend that Fig. 2 has applicability across a range of healthcare settings and may be used by hospital administrators, policymakers, service providers, and researchers to plan projects and programs. It may be used as a resource in strategic planning, to re-structure clinical programs, build staff capacity, and optimize HR practices. For example, Fig. 2 could be used as a foundation to establish goals, objectives, or key performance indicators for a new or existing clinical program; refine job postings for MM roles to encompass optimal characteristics of candidates to enable KB activities; or identify new evaluation criteria for staff performance and training gaps in existing HR practices. It could also help decision makers take on pilot projects to formalize the KB role in healthcare.

Figure 2 is intended to foster further discussion of the role that MMs play in brokering knowledge in healthcare settings. It can be modified for specific applications, although we encourage retaining the basic structure (reflecting the synthesizing arguments). For example, the factors may change depending on specific localized healthcare contexts (i.e., acute care versus long-term care, or rehabilitation). Although the use of our framework in practice has yet to be evaluated, it may be strengthened with the results of additional mixed methods studies examining MM KBs as well as quasi-experimental studies applying adapted HR practices based upon our framework. As more studies are reported in the literature, the roles, activities, factors, and outcomes can be further refined, organized, and contextualized. Figure 2 can also be used as a guide for future studies examining how MMs enact the KB role across healthcare settings and systems, disciplines, and geographic locations.

Our synthesis provides new insights into the roles of MM KBs in healthcare settings. For example, we further elucidate two MM KB roles: 1) functioning as a strategic influencer; and 2) convincing others of the need for, and benefit of an innovation or evidence-based practice. These are important roles that MM KBs enact when preparing staff for implementation and corroborate Birken et al.’s hypothesized MM role of selling innovation implementation [ 18 , 37 ]. Our findings validate the organizational change literature that emphasizes the important information broker role MMs play in communicating with senior management and helping frontline staff achieve desired changes by bridging information gaps that might otherwise impede innovation implementation [ 37 ]. Our new conceptualization of how MM KBs navigate and enact their roles, and the impact they may have on service delivery and associated outcomes extends the findings of recent studies. These studies found that the role of MMs in organizational change is evolving and elements such as characteristics and context may influence their ability to facilitate organizational adaptation and lead the translation of new ideas [ 53 , 72 , 73 ]. However, further research is required to test and further explicate these relationships in the broader context of practice change.

Our synthesis both confirms and extends previous research by revealing organizational and individual factors that both enabled and hindered MM KBs efforts in healthcare organizations. An important organizational factor in our study was having senior management support. We found that MM KBs who had healthy supportive working relationships with their senior leaders led to project success. This support was critical because without it they experienced significant stress at being “caught in the middle” trying to address the needs of staff while also meeting the demands of senior management. Recent studies confirm our finding that senior management engagement is essential to MM KBs’ ability to implement innovations and underscores the need for senior leaders to be aware of, and acknowledge, the impact that excessive workload, competing demands, and role stress can play in their effectiveness [ 19 , 74 ].

The personal attributes of MM KBs as well as their level of experience were both important factors in how they operated in practice. We identified that key attributes of MM KBs contributed to their ability to drive implementation of initiatives and enhanced staff acceptance and motivation to implement practice change [ 75 , 76 ]. Our findings corroborate recent studies that highlight how the key attributes of effective champions (those that are intrinsic and cannot be taught) [ 77 , 78 , 79 ] may contribute to their ability to lead teams to successful implementation outcomes in healthcare organizations [ 80 , 81 , 82 ]. We also found that experienced MM KBs were well trained, knowledgeable, and better prepared to understand the practice context than novice MM KBs, but a lack of formal training in project implementation was an impediment for both. This emphasizes the importance of providing opportunities for professional development and training to prepare both novice and experienced MM KBs to successfully implement practice change. Our findings contribute to the growing knowledge base regarding what makes an effective MM KB. However, future research should focus on generating evidence, not only on the attributes of MM KBs, but also on how those attributes contribute to their organizational KB roles as well as the relationships among specific “attributes” and specific KB roles. More research is also needed to better understand how and what skills can be taught to boost the professional growth of MM KBs in health care.

Organizational theory and research may provide further insight into our findings and guidance for future research on the role of MM KBs in healthcare organizations. For example, the literature suggests that by increasing MMs’ appreciation of evidence-based practice, context, and implementation strategies may enhance their role in implementing evidence-based practices in healthcare organizations [ 18 , 83 , 84 ]. We found that MM KBs’ commitment to the implementation of an evidence-based project was influenced by the availability of resources, alignment with organizational priorities, a supportive staff and senior leadership. Extending from organizational theory and research, further investigation is needed to explore the nature of the relationship between these factors and the commitment of MM KBs to evidence-based practice implementation and subsequent outcomes.

When assessing the impact of MM KBs in hospitals, we found some evidence of changes in organizational and provider outcomes, suggesting MM KB impact on service delivery. Given that the available outcome data were limited, associational in nature, or poorly evaluated, it was challenging to identify strong thematic areas. Like our study, several systematic reviews also reported the lack of available outcome data [ 7 , 18 , 21 ]. This highlights an important area for research. Future research must include evaluation of the effectiveness of MM KBs and establish rigorous evidence of their impact on service delivery.

Our findings have important implications for policy and practice. MMs are an untapped KB resource who understand the challenges of implementing evidence-based practices in healthcare organizations. Both policy makers and administrators need to consider the preparation and training of MM KBs. As with other studies, our study found that providing MM KBs with opportunities for training and development may yield a substantial return on investment in terms of narrowing evidence-to-practice gaps in health care [ 48 ]. Thus, an argument can be made for recruiting and training MM KBs in health care. However, the lack of guidance on how to identify, determine and develop a curriculum to prepare MM KBs requires more research.

Our synthesis revealed numerous activities associated with 12 MM KB roles providing further insight into the MM role in healthcare settings. Our list of 63 activities (Table 2 ) has implications for practice. We found that MMs enact numerous KB roles and activities, in addition to their day-to day operational responsibilities, highlighting the complexity of the MM KB role. Senior leaders and administrators must acknowledge this complexity. A greater understanding of these KB roles and activities may lead to MM implementation effectiveness, to sustainable MM staffing models, and to organizational structures to support the KB efforts that many MMs are already doing informally. For example, senior leaders and administrators need to take the MM KB role seriously and explicitly include KB activities as a core function of existing MM job descriptions. To date, the KB role and associated activities are not typically or explicitly written into the formal job descriptions for MMs in healthcare settings, as their focus is primarily on operational responsibilities. A formal job description for MM KBs would improve the KB capacity of MMs by giving them the permission and recognition to implement KB-related functions. Our findings inform future research by more clearly articulating the MM KB roles and activities that may be essential to the implementation of evidence-based practice and highlights a much-needed area for future work.

Our study features both strengths and weaknesses. One strength in using CIS methodology was the ability to cast a wide net representing a range of research designs of included studies. This included studies in which MMs were required to be KBs by senior leaders or functioned explicitly as KBs. This enabled us to identify and include diverse studies that made valuable theoretical contributions to the development of an emerging framework, which goes beyond the extant theories summarized in the literature to date [ 18 ]. In contrast to prior systematic reviews of MM roles in implementing innovations [ 18 ], the CIS approach is both systematic and iterative with an interpretive approach to analysis and synthesis that allowed us to capture and critically analyze an in-depth depiction of how MMs may enact the KB role in healthcare organizations. Our synthesis also revealed numerous activities associated with the 12 identified MM KB roles. The resulting theoretical insights were merged into a new organizing framework (Fig. 2 ). These insights are an important first step in understanding how individual and organizational factors may influence how MMs enact KB roles, and the impact they have on service delivery.

Although CIS is an innovative method of synthesizing the literature and continues to evolve, it does have limitations. CIS has yet to be rigorously evaluated [ 85 , 86 ]. While there is some precedent guiding the steps to conduct a CIS, one weakness is that CIS is difficult to operationalize. Another weakness is that the steps to conduct CIS reviews are still being refined and can lack transparency. Therefore, we used standardized, evidence-based checklists and reporting tools to assess transparency and methodological quality, and an established methodology for coding and synthesis. We provided an audit trail of the interpretive process in line with the ENTREQ guidance. Still, there was a risk of methodological bias [ 28 , 85 , 86 ]. Another weakness of qualitative synthesis is its inability to access first order constructs that is the full set of participants’ accounts in each study. As reviewers, we can only work with the data provided in the papers and, therefore, the findings of any review cannot assess primary datasets [ 31 ]. Study retrieval was limited to journals that are indexed in the databases that were searched. We did not search the grey literature, assuming that most empirical research on MM KBs would be found in the indexed databases. Finally, we may have synthesized too small a sample of papers to draw definitive conclusions regarding different aspects of MMs as KBs.

Our study is a first step in advancing the theoretical and conceptual conversation regarding MM KBs by articulating the attributes, roles, activities, and factors influencing their efforts and impact. Through the generation of a novel organizing framework, we identify a potential combination of roles for those in MM positions who may also function as KBs in healthcare organizations. Our study is a timely contribution to the literature and offers an initial understanding of extant evidence of the KB role MMs play in health care. Our framework has utility for policymakers, administrators, and researchers to strengthen the MM role and, ultimately, improve quality of care.

Availability of data and materials

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

Abbreviations

Middle Manager

Knowledge Broker

Middle managers who function as Knowledge brokers

Knowledge Translation

Critical Interpretive Synthesis

Quality Improvement

Enhancing Transparency in Reporting the Synthesis of Qualitative Research

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ENTREQ checklist

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Boutcher, F., Berta, W., Urquhart, R. et al. The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis. BMC Health Serv Res 22 , 11 (2022). https://doi.org/10.1186/s12913-021-07387-z

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The effectiveness of knowledge-sharing techniques and approaches in research funded by the National Institute for Health and Care Research (NIHR): a systematic review

• Helen Baxter   ORCID: orcid.org/0000-0002-3320-2915 1 , 3 ,
• Lindsay Bearne 1 , 2 ,
• Tracey Stone 3 , 6 ,
• Clare Thomas 3 , 4 , 6 ,
• Rachel Denholm 5 , 6 ,
• Sabi Redwood 3 , 6 ,
• Sarah Purdy 6 &
• Alyson Louise Huntley 6 , 7  

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The National Institute of Health and Care Research (NIHR), funds, enables and delivers world-leading health and social care research to improve people’s health and wellbeing. To achieve this aim, effective knowledge sharing (two-way knowledge sharing between researchers and stakeholders to create new knowledge and enable change in policy and practice) is needed. To date, it is not known which knowledge sharing techniques and approaches are used or how effective these are in creating new knowledge that can lead to changes in policy and practice in NIHR funded studies.

In this restricted systematic review, electronic databases [MEDLINE, The Health Management Information Consortium (including the Department of Health’s Library and Information Services and King’s Fund Information and Library Services)] were searched for published NIHR funded studies that described knowledge sharing between researchers and other stakeholders. One researcher performed title and abstract, full paper screening and quality assessment (Critical Appraisal Skills Programme qualitative checklist) with a 20% sample independently screened by a second reviewer. A narrative synthesis was adopted.

In total 9897 records were identified. After screening, 17 studies were included. Five explicit forms of knowledge sharing studies were identified: embedded models, knowledge brokering, stakeholder engagement and involvement of non-researchers in the research or service design process and organisational collaborative partnerships between universities and healthcare organisations. Collectively, the techniques and approaches included five types of stakeholders and worked with them at all stages of the research cycle, except the stage of formation of the research design and preparation of funding application. Seven studies (using four of the approaches) gave examples of new knowledge creation, but only one study (using an embedded model approach) gave an example of a resulting change in practice. The use of a theory, model or framework to explain the knowledge sharing process was identified in six studies.

Conclusions

Five knowledge sharing techniques and approaches were reported in the included NIHR funded studies, and seven studies identified the creation of new knowledge. However, there was little investigation of the effectiveness of these approaches in influencing change in practice or policy.

Peer Review reports

Academic research has little influence on the commissioning, design and delivery of health care services [ 1 , 2 , 3 ]. Stakeholders, including patients, are currently not consulted sufficiently for research to be genuinely informed by their experiences [ 4 , 5 ]. This is of concern to research funders globally, who have a remit to fund health and social care research that improves people’s health and wellbeing [ 6 ]. Knowledge mobilisation is a generic term that refers to making knowledge ready for action and includes activities ranging from dissemination to co-production [ 7 ]. Other similar terms are often used such as knowledge translation, knowledge exchange and integrated knowledge translation (IKT). For the purposes of this review, the key element of knowledge sharing was focused on within the field of knowledge mobilisation to explore knowledge mobilisation as an intervention and an active process, within research studies. Exploration of the lack of integration between researchers and stakeholders within the fields of knowledge mobilisation and implementation has highlighted that knowledge sharing needs to be a two-way process and not, as previously accepted, a linear one [ 8 , 9 , 10 , 11 ]. This shift in understanding has been driven through a recognition of the complexity and messiness inherent in bringing together different communities to develop a common or shared understanding [ 3 , 12 ]. Consequently, activities to improve knowledge sharing and implementation have shifted away from targeting research findings towards patients, practitioners and policy makers and been replaced with techniques to encourage two-way knowledge sharing and co-production [ 9 , 13 , 14 , 15 ]. A variety of theories, models and frameworks have been used to support this two-way process, with varying degrees of success [ 16 , 17 ].

Knowledge mobilisation is defined by the NIHR as ‘sharing knowledge between different communities to create new knowledge to catalyse change’ [ 18 ]. There is consensus that if knowledge is shared between two or more communities, it can result in the creation of new knowledge, which has a greater likelihood of leading to change within practice or research [ 7 , 19 , 20 , 21 ]. Change that can be linked back to original research findings or outcomes is often referred to as research impact [ 22 , 23 , 24 ]. Techniques and approaches that have been developed to follow this mechanism of knowledge sharing include, models of embedded researchers or practitioners, use of knowledge brokers, stakeholder engagement, organisational collaborative partnerships and the involvement of stakeholders in the research or service design process itself. For example, embedded models can facilitate the knowledge sharing process by a researcher or health care practitioner leaving their home organisation to work in a host organisation, thereby increasing the opportunities for sharing knowledge between the two organisations. The underlying premise is that it is through people and their interactions that knowledge is shared and by increasing the proximity of individuals this can facilitate interactional opportunity [ 10 , 25 , 26 ]. They may be hosted by one organisation, but their function is to work between the organisations to facilitate knowledge sharing [ 27 , 28 , 29 ]. Stakeholder engagement, when conducted for two-way knowledge sharing, involves inviting stakeholders to share knowledge at specific meetings, workshops and events [ 30 ]. Involving stakeholders in the research or service design process as equal decision makers, advisers and informed representatives of their community, can also follow two-way knowledge sharing [ 21 , 31 , 32 ]. An additional mechanism is knowledge sharing at an organisational level, where collaborative partnerships are formed [ 33 ].

In the United Kingdom, the National Institute of Health and Care Research (NIHR) awards around £1 billion in research funding per year and, along with other funders, has a strong remit to reduce the research to practice and policy gap [ 34 ]. Yet, to date, there has been limited research that systematically explores and identifies the knowledge sharing techniques and approaches in the NIHR portfolio of research studies. One review examined the mechanisms and pathways to impact of NIHR funded public health research (Boulding, Kamenetzky et al. 2020). It explored the mechanisms and pathways reported on Research fish (a database for researchers to document impact related activities) and triangulated this with qualitative data exploring the researchers’ perspectives of the impact of their research. The authors concluded that the standardised measures were not capturing impact in localised settings or longer-term impact [ 23 ]. A second study explored the public health researchers’ perspectives on impact reporting and highlighted a need for funders to identify their expectations of the impact resulting from the research they fund and to increase their support for knowledge mobilisation activities [ 24 ]. These studies highlighted the need for researchers to have a clearer understanding of the knowledge mobilisation techniques and approaches to inform pathways to impact and focused on NIHR health funding streams [ 23 , 24 ]. To our knowledge, there has been no systematic review that describes the knowledge sharing techniques and approaches that have been applied in NIHR funded research nor synthesises their effectiveness.

This review aimed to answer the following questions: (1) Which knowledge sharing techniques and approaches have been included in NIHR funded health research? (2) How effective are these knowledge sharing techniques and approaches in creating new knowledge that can lead to changes in practice and research?

The protocol for this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO, CRD42020171293; reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [ 35 ]). A restricted systematic methodology was chosen to balance methodological rigour with the resources available [ 36 ].

Search strategy

Electronic databases MEDLINE via OVID and The Health Management Information Consortium, which is a compilation of data from two sources, the Department of Health’s Library and Information Services and King’s Fund Information and Library Services, were searched from inception to 24.4.20 for published studies, which was then updated and rerun on the 1.7.22. The search strategy was based on the terms for the intervention (knowledge sharing techniques and mechanisms, including terms for knowledge transfer, exchange and translation) and population (researchers with patients, clinicians or health services managers) (Additional file 1 : Search Strategy). Additional references were identified from reference lists of included full papers.

Eligibility criteria

This systematic review included studies that described knowledge sharing between researchers with patients, members of the public, clinicians, health service managers (i.e. commissioners, policy makers and hospital managers) or voluntary agencies, that were funded by the NIHR (Table  1 ). Knowledge sharing was defined as ‘any interactional activity through any medium (including in person, email, telephone, etc.) that involves knowledge sharing about healthcare’. For the purposes of this review, knowledge sharing techniques and mechanisms were considered as an intervention, i.e. ‘the act or an instance of intervening’ [ 37 ], where an explicit knowledge-sharing approach had been adopted in contrast to the established process of knowledge remaining within one community. The setting was defined as any healthcare setting, e.g. primary, secondary, tertiary health care services and public health. The outcome was defined as the use of evidence in policy and practice or the involvement of stakeholders in the research process. Where relevant, studies were included irrespective of comparator group. All study designs were included, except protocols and reviews of literature. Only studies published in the English language were included. Studies were excluded if they did not describe knowledge sharing between researchers and a stakeholder group, e.g. describing knowledge sharing between two other stakeholder groups (e.g. clinicians with health service managers, clinicians with patients and patients with health service managers).

Study selection

Records were exported and deduplicated in Endnote and then imported to Covidence for screening [ 38 , 39 ]. The title and abstract screening was conducted by one reviewer (H.B.), with a 20% sample independently screened by one of two reviewers (C.T. and R.D.). Any discrepancies were resolved by discussion. A third reviewer (A.H.) arbitrated if needed. Full text screening was conducted by one reviewer (H.B.) with a 20% sample independently screened by one of two reviewers (T.S. and L.B.); any discrepancies were resolved by discussion. A third reviewer (S.R.) arbitrated if needed.

Data extraction

Data from included studies were abstracted by one reviewer (T.S.) into a data extraction form, which was piloted a priori on 10% of the included studies (S.P.) and checked for accuracy by a second reviewer (H.B.). Extraction included: study design, author name, author, year, aims, population, intervention/approach and a detailed intervention description. In some instances, studies contained a knowledge sharing element, which was not the primary focus or outcome of the study. In these cases, the detailed description of this element of the study was extracted as the technique or approach. A modified template of the TiDieR checklist was used [ 40 ]. The data were extracted on the design, presence of an evaluation, use of theory or goal, procedures, materials used, context influencing factors, tailoring modifications and assessment of outcome and applicability.

Quality appraisal

Quality appraisal was conducted independently by T.S. with a 20% sample of included studies, which were reviewed by H.B., followed by discussion for any discrepancies. The Critical Appraisal Skills Programme (CASP) qualitative checklist, Critical Appraisal Skills Programme (2018) [ 41 ] was used where appropriate. The CASP qualitative checklist includes two screening question (yes/no) and an additional eight questions (yes/ no/can not tell) if the response to both screening questions were ‘yes’. As outlined by Long and French, the quality of studies was assessed with a focus on the rigour of the data analysis, with consideration of the trustworthiness of the results given [ 41 ]. Using this focus with the overall score from the checklist, the studies were categorised to be of high, moderate or of lower quality.

Data synthesis

A narrative synthesis method was adopted, as it includes a formal analytical process of synthesis to generate new insights [ 42 ]. This narrative synthesis focussed on four key elements: (1) identification of a theory of change. In this review, knowledge sharing as a mechanism to facilitate change was used to explain the anticipated process. (2) Development of a preliminary synthesis of the findings of included studies. A preliminary synthesis was conducted to organise the results of the included studies and identify any factors that influenced the results reported. This was conducted by developing initial descriptions of the results of the included studies, which were then organised to describe patterns, so that the factors impacting on the mechanisms of the intervention could be identified. (3) Exploring relationships in the data. The studies were explored for relationships within and between studies, which involved a process of concept mapping supported by qualitative case descriptions. In particular, the studies were examined for instances where similar mechanisms may be at work even though the overall approach may be described differently. This process was initiated by H.B. in categorising the data under overarching themes based on the mechanism of knowledge sharing, which were refined further through discussion and reflection with L.B. and T.S. into subheadings. (4) Assessing the robustness of the synthesis. An assessment of the robustness of the synthesis was made and only studies that reached a minimum standard of methodological quality assessed by T.S. were included in the final synthesis [ 43 ].

In total, 9897 records were identified after deduplication. A total of 697 full-text studies were screened and 17 studies were included [ 20 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ] (Fig.  1 ).

PRISMA diagram

Study characteristics

The characteristics of the included studies are shown in Table  2 . These were the author, year, aims, population, knowledge sharing technique or approach, mechanism of knowledge sharing and outcome (new knowledge or change in practice or research).

Five of the included studies were descriptive studies and could not be included in the quality appraisal process [ 20 , 49 , 51 , 53 , 57 ]. Of the remaining 10 studies, two were rated of moderate quality [ 47 , 48 ] and eight were rated as high [ 44 , 45 , 46 , 50 , 52 , 54 , 55 , 56 ]. Two studies could not be rated as they provided insufficient detail on the knowledge mobilisation intervention, so these were excluded from the final synthesis (Table  3 ).

Types of knowledge sharing techniques and approaches

Five explicit forms of knowledge sharing studies were described in the included studies (Table  2 ). Three studies applied embedded models of researchers or practitioners [ 20 , 44 , 54 ], and two studies used knowledge brokering. [ 46 , 47 ]. Stakeholder engagement approaches that applied two-way knowledge sharing were used in five studies. These were either priority setting consensus building workshops [ 51 , 55 , 57 ] or facilitated knowledge-sharing events [ 49 , 52 ]. Three studies described approaches where non-researchers were involved in the research or service design process itself. One study did this with patients and members of the public in research projects and another with professionals [ 53 , 56 ]. The approach of involving patient and public members was also used in another study to assist with service design [ 45 ]. Two studies examined organisational collaborative partnerships between universities and healthcare organisations [ 48 , 50 ].

Types of stakeholders

Of the stakeholder groups participating via these approaches, clinicians were involved in nine studies [ 44 , 46 , 49 , 50 , 51 , 53 , 54 , 55 , 57 ], and patients and the public were involved in six studies [ 45 , 49 , 51 , 53 , 56 , 57 ]. Commissioners and policy makers were involved in six studies [ 20 , 48 , 49 , 50 , 51 , 56 ]. Four studies involved health care or service managers [ 51 , 53 , 54 , 56 ]. Four studies also involved members of the voluntary sector [ 47 , 49 , 52 , 56 ], and two studies included local authority staff [ 52 , 56 ].

Timing within research cycle

Six studies applied a knowledge-sharing approach to topic identification [ 44 , 46 , 47 , 49 , 50 , 55 ], and one study extended topic identification to also defining the research question [ 57 ]. Five studies used a knowledge-sharing approach for the conduct of the research [ 20 , 48 , 53 , 54 , 56 ]. One study used knowledge sharing to facilitate the adoption of findings [ 52 ], and two studies used knowledge sharing for the production of service design [ 45 , 51 ]. There were no studies that used a knowledge-sharing approach or technique for designing the research or preparing the funding application.

Sources of NIHR funding

Eight of the studies were funded or supported by a Collaboration for Leadership in Applied Health Research (CLAHRC) [ 44 , 46 , 48 , 50 , 51 , 54 , 55 , 56 ]. One study was funded by a Knowledge Mobilisation Research Fellowship [ 45 ], and one study reported support from both a Knowledge Mobilisation Research Fellowship and a CLAHRC [ 20 ]. Two studies were from the Health Services and Delivery Research funding stream [ 49 , 53 ], one study was from multiple sources, including NIHR funding [ 47 ], one was funded by the Public Health Research Programme [ 52 ] and one was funded by Programme Grants for Applied Research Funding [ 57 ].

Use of theory

Of the 15 studies, 6 studies drew upon or referred to a theory, theoretical basis or used a framework [ 20 , 46 , 47 , 48 , 50 , 56 ], (Table  4 ). The theory most frequently drawn upon was that of Communities of Practice [ 60 , 61 ], which was referred to by three of the studies to explain the process of knowledge sharing [ 20 , 50 , 56 ]. Two studies drew upon other theories to explain knowledge sharing as part of a co-production process. One referred to Ritual Theory [ 62 ] and the concept of Interaction Ritual Chain [ 56 , 63 ], and the other used three theoretical lenses, the co-productionist idiom [ 64 ], interactionist currents within organisation studies [ 65 , 66 ] and communication, argumentation and critique from a pragmatic perspective [ 67 , 68 ], In Ref. [ 48 ]. Another study drew on the sociological theory of dramaturgical perspective [ 47 , 69 ], and one study used the frameworks of why, whose, what and how [ 70 ] and PAHRIS [ 71 ] to explain their approach [ 46 ]. Only one study explicitly referred to a theory of change and outlined a potential process [ 50 ]. Nine studies did not use any theory or frameworks to explain or predict the knowledge sharing process leading to change [ 44 , 45 , 49 , 51 , 52 , 53 , 54 , 55 , 57 ].

Knowledge sharing as a mechanism to facilitate change

The theory of change identified from a preliminary synthesis of the included studies followed the process outlined within the literature, which is shown in Fig.  2 .

Theory of change model developed to inform initial synthesis

All studies confirmed the causal direction of the knowledge sharing mechanism as shown by the arrows in Fig.  2 and were found to be following the process of knowledge sharing across communities with an intention of creating new knowledge (Table  2 ). Seven studies reported that new knowledge had been created through knowledge sharing [ 45 , 50 , 51 , 53 , 54 , 55 , 57 ]. However, only three studies attempted to outline the anticipated change from the knowledge-sharing approach [ 45 , 50 , 53 ], and only one study provided any evidence of change [ 54 ] (Table  2 ).

Evaluation of knowledge sharing technique or approach

Ten studies conducted an evaluation of the knowledge sharing technique or approach to understand its process or effectiveness (perceived or intended) [ 44 , 45 , 46 , 47 , 48 , 50 , 52 , 54 , 55 , 56 ], (Table  4 ). The other five studies gave detailed descriptive accounts of the knowledge sharing process [ 20 , 49 , 51 , 53 , 57 ]. There was no relationship between the knowledge-sharing approaches used and whether an evaluation was conducted. Three studies using stakeholder engagement approaches gave a process description [ 49 , 51 , 57 ], one involvement study [ 53 ] and one study using an embedded model [ 20 ]. Of those studies that conducted an evaluation a range of methodologies were used, which were predominantly qualitative. Six studies used semi-structured interviews [ 44 , 50 , 52 , 54 , 55 , 56 ], three studies used mainly observational methods [ 48 , 52 , 56 ], two studies used document analysis [ 55 ], two studies used reflective diaries [ 44 , 46 ] and two studies analysed field notes and emails or meeting recordings [ 45 , 47 ]. Other methods used were focus groups, surveys and postal questionnaires [ 45 , 48 ]. Five of the studies that conducted an evaluation of the knowledge sharing technique or approach drew upon a theory or framework to understand or explain the process [ 46 , 47 , 48 , 50 , 56 ] (Table  4 ).

Evidence of effectiveness

Of the seven studies that reported the creation of new knowledge [ 45 , 50 , 51 , 53 , 54 , 55 , 57 ], four also evaluated the process and also attempted to outline the anticipated change from the knowledge-sharing approach [ 45 , 50 , 54 , 55 ]. One of these studies used the knowledge-sharing approach of involvement of stakeholders in service design, one explored an organisational collaborative partnership, another used an embedded model and the other a stakeholder engagement approach [ 45 , 50 , 54 , 55 ]. The only study that reported a change in practice or research did not outline the process of change and did not explain the process using a theory or framework [ 54 ]. However, this study of an embedded model was the only report of a change in practice as a result of a knowledge sharing technique or approach (Table  4 ).

This review summarises the knowledge sharing techniques and approaches used in NIHR studies between 2006 and 2022. Five knowledge sharing techniques and approaches have been included in NIHR funded health research: embedded models, knowledge brokers, stakeholder engagement, involved research or service design and organisational collaborative partnerships. In applying a mechanism of knowledge sharing, three studies outlined anticipated change from the process of knowledge sharing using the approach of stakeholder involvement [ 45 , 53 ] and organisational collaborative partnerships [ 50 ], and only one study provided evidence of change, which used an embedded model [ 54 ].

We found that in some studies knowledge sharing techniques and approaches were used but not identified using established terminology and in other studies terminology was used interchangeably, with a lack of consensus on the definition of terms. This may well reflect the developments overtime in how knowledge is mobilised in a non-linear fashion, as this review included papers from 2008 and tracks the gradual establishment of agreed terminology. However, a current lack of clarity of terms has been identified in the literature around co-design, co-production and co-creation, where terms are used interchangeably and clarity around the aims of the approaches are unclear [ 72 ]. This seems also to be the case in what we have referred to as the embedded models, which included researchers in residence and secondment opportunities. It was unclear in synthesising the studies what the different roles were that these terms applied to, as terminology was used differently across the models for example using the term knowledge broker to refer to an embedded researcher working within clinical practice [ 44 ].

Knowledge sharing techniques and approaches were often used without reference to underlying theory or an explanation of the anticipated change process. Although an acknowledgment of the clarity provided by a clear theoretical basis to understand the process of knowledge mobilisation has been accepted, this has been relatively recent [ 73 , 74 ]. Recent studies have highlighted and categorised a large number of theories, models and frameworks available but acknowledged a limited evidence base on their use [ 75 , 76 ]. In this review, only six studies drew on a theoretical base to explain or predict causality, and only four studies used this for evaluating the knowledge sharing technique or approach. A recent systematic scoping review of knowledge transfer and exchange models also noted a lack of evaluation of the processes and outcomes by those engaged in knowledge mobilisation activities [ 77 ]. Evaluation models do exist in the field that construct a framework for assessing impact or change at multiple levels, which also take account of the inherent complexity and uncertainties in assessing change [ 7 ]. To encourage greater use of knowledge mobilisation techniques and approaches amongst non-specialists, more explanation of these is needed to facilitate replication with confidence. Studies describing a knowledge sharing technique or approach without reference to an output, outcome or change mechanism, risk losing the interest of the wider research community, as the benefits of this approach are unclear.

This review included studies where knowledge sharing techniques or approaches could be identified but may not necessarily been acknowledged by the authors. Where knowledge-sharing approaches were not acknowledged, the knowledge sharing component was often not reported in detail. For example, in Batchelor 2013, the knowledge-sharing element of the James Lind Alliance Priority Setting Partnership was given little attention in the reporting and was difficult to untangle from the information gathering element of the study [ 57 ]. As an older study this may reflect less interest at the time in the process of knowledge sharing with stakeholders, although there were clear attempts to extend the remit of the James Lind Alliance to include researchers in the workshops and to involve stakeholders in designing the research questions. Unfortunately, the lack of detail on the procedure reduces the opportunity for replication or wider evaluation when a project is deemed to be successful, reducing the opportunity for future learning. In work involving public contributors, researchers often gave a more detailed account of process and procedures, which may indicate greater maturity in the field for working with this stakeholder group. This may also give an indication as to why so few studies reported on their knowledge sharing activities and intended impact. As the request from funders for the demonstration of research impact is a relatively new requirement, previous work in this area may not have been seen as important or as a core component of a research study. Likewise, prior to the agreement from funders to fund and support impact related activities such as knowledge mobilisation, achieving impact in services or society may have not been seen as within the remit of the research community to deliver.

Promising techniques and approaches that were evaluated, often focused more on acceptability of the approach rather than whether new knowledge was created. This may have been due to an interest in how to maintain ongoing work with stakeholders, or possibly a lack of confidence in the technique or mechanism leading to new knowledge or in the sensitivity of the evaluation to identify it. Although knowledge sharing can be seen as a simple concept, achieving an authentic approach is known to be a complex process [ 7 , 78 ]. It is not to suggest that complexity does not exist, only that current reporting may render the purpose of knowledge sharing techniques and approaches invisible to those outside the specialist field. While the importance of identifying and reporting on impact remains a central issue to funders, identifying techniques and approaches that can lead to changes in practice and research will be of value. Currently the NIHR as a funder, requests engagement and impact plans in applications for funding and advocates the use of knowledge mobilisation strategies from the outset of the study to achieve this [ 18 , 79 ]. Monitoring of the impact from NIHR funded research is then conducted for 5 years after study completion via an online system (Researchfish) [ 80 ].

Strengths and limitations of the review

This systematic review restricted the number of database searches to two and did not explore grey literature, which may have resulted in not identifying all relevant studies. The included studies were also restricted to the English language. However, given that this review is focused on the literature produced by the major UK funder with a requirement for publication in mainstream open access journals, this is less of a concern. A restricted systematic review methodology was used to balance rigour with the resource available [ 36 ]. This requires only a proportion of the screening, full-text review and data extraction to be conducted by two reviewers. Given the difficulties with the terminology, unclear methodologies and complex study designs, studies may not have been identified through the initial searches. As outlined earlier, studies often did not report knowledge mobilisation or knowledge sharing activities in a thorough way and this led to difficulties with data extraction and may have led to an underestimation of use of knowledge-sharing approaches. This review specifically focused on the relationship between knowledge sharing as a key element of knowledge mobilisation activity, leading to the creation of new knowledge with the potential to lead to changes in practice or research (impact). Studies that mobilised knowledge for other outcomes were excluded, which may be a weakness in understanding knowledge mobilisation processes more generally. A key strength of this review was the attempt to apply a robust review framework to an often-confusing field of terms and mixed approaches. An established framework was applied to synthesise the current knowledge in this field with the intention to collate the learning to date and to guide those who are not specialists in knowledge mobilisation towards the techniques and approaches which might be useful for future research.

Key learning

There is a need for clear reporting in the field of knowledge mobilisation that recognises the goals of these techniques and approaches. Theories and models exist that support exploratory work and complex systems, which could be used more widely to explain the knowledge sharing mechanism of knowledge mobilisation approaches. Evaluations of these techniques and approaches could be better linked to the underlying goals or outcomes of change and impact via established theories and explanatory models. This would enable researchers not specialist in the field of knowledge mobilisation to better understand the field and have confidence in introducing these techniques and approaches into their work. Clearer reporting on knowledge sharing processes and outcomes can support the research community and funders alike in identifying where knowledge mobilisation can assist in closing the research to practice gap.

There is little evidence of the effectiveness of knowledge sharing techniques and approaches used in NIHR research studies in influencing change in practice or ongoing research. This does not mean these techniques and approaches are not effective in instigating change or impacting on practice, rather that clear evidence for this has not yet been produced. Although a complex and often messy field, there are theories, models and frameworks that can be used to shed more light on techniques and approaches that currently show promise but lack evidence for their effectiveness.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

National Institute for Health and Care Research

Critical Appraisal Skills Programme

Collaboration for Leadership in Applied Health Research

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This study was funded by the National Institute for Health and Care Research (NIHR) [2021/02]. This study presents independent research funded by the National Institute for Health and Care Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Tracey Stone’s time is supported by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West). Clare Thomas is partly funded by National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) and the National Institute for Health and Care Research, Health Protection Research Unit (NIHR HPRU) in Behavioural Science and Evaluation.

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Baxter, H., Bearne, L., Stone, T. et al. The effectiveness of knowledge-sharing techniques and approaches in research funded by the National Institute for Health and Care Research (NIHR): a systematic review. Health Res Policy Sys 22 , 41 (2024). https://doi.org/10.1186/s12961-024-01127-5

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A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

• Clare Jouanny   ORCID: orcid.org/0000-0002-4959-5901 1 ,
• Purva Abhyankar   ORCID: orcid.org/0000-0002-0779-6588 2 &
• Margaret Maxwell   ORCID: orcid.org/0000-0003-3318-9500 3  

BMC Women's Health volume  24 , Article number:  217 ( 2024 ) Cite this article

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Women’s pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women’s quality of life and wellbeing.

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women’s views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women’s perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

Conclusions

Using the Common-Sense Model to explore women’s help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women’s identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

Systematic Review Registration

PROSPERO CRD42021256956.

Peer Review reports

Women’s health is finally emerging as a globally important subject. United Nations (UN) Sustainable Development Goals (SDG) 3.7 states we should “by 2030 ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes” [ 1 ]. In the United Kingdom (UK), there is growing emphasis on promoting education on women’s health issues, reducing associated stigma, and increasing access to reliable information about women’s health [ 2 , 3 ].

Many women’s health symptoms are considered difficult to talk about, both by women, health care professionals (clinicians) and the public in general [ 4 , 5 ]. Stigma surrounding pelvic symptoms (including urogynaecological and bowel symptoms) matters because it stops women from seeking help. Symptoms such as urinary incontinence (UI) and prolapse can be addressed through early detection and timely receipt of conservative therapies such as pelvic floor muscle training [ 6 , 7 ]. Although not life threatening, these pelvic symptoms are common: pelvic floor dysfunction (PFD) including urinary and faecal incontinence, bladder, bowel, and sexual dysfunction, prolapse and persistent pelvic pain, is prevalent in up to 50% of women [ 8 ], and has a significant impact on women’s quality of life and physical, mental, and social wellbeing [ 9 , 10 ]. The intimate, personal and varied nature of pelvic symptoms, causes significant embarrassment and shame, leading to further psychological distress, reduced functioning, poor body image and social and occupational difficulties [ 9 , 11 , 12 , 13 , 14 ].

Despite the widespread experience of pelvic symptoms, the number of women who seek healthcare is relatively low, as evidenced by most prevalence data on healthcare seeking related to UI. In a large population from the Nurses’ Health Study I and II, of 94,692 middle aged and older women with UI, only 34% reported discussing their symptoms with a clinician [ 15 ]. Similarly, in a web-based survey of 5,861 Danish women experiencing UI, only 29% had sought professional help [ 16 ]. In the UK, a postal evaluation of 2,414 women registered to a general practice found UI prevalent in 40% but only 17% sought professional help [ 14 ]. More stigmatized pelvic symptoms were included in an online survey of 376 Australian women: 99% had bladder, bowel, sexual dysfunction or prolapse, with 51% seeking help [ 5 ], but in the United States (US), only 29% of 938 women aged 45years or more with accidental bowel leakage sought care [ 17 ]. Two recent systematic literature reviews exploring experiences of prolapse, found that despite the availability of effective early treatment options, women lack knowledge and awareness about symptoms and available treatments [ 10 , 18 ].

It is important to understand the barriers and facilitators women experience when seeking healthcare for stigmatized pelvic symptoms to develop approaches to increase knowledge and awareness among the public and clinicians, to encourage women to seek healthcare when necessary and design or redesign services to meet women’s needs. Literature on barriers and facilitators to help seeking with pelvic symptoms does exist but is spread across different conditions or symptom groups, settings, and populations, and has been generated using different methodologies. To our knowledge, this literature on barriers and facilitators has not been brought together systematically to share learning across different conditions, populations, and methodologies.

This systematic review aimed to identify the barriers and facilitators women in high income countries face in seeking help for stigmatised pelvic symptoms. We used the Common-Sense Model of Self-Regulation of Illness and Behaviour (CSM) [ 19 , 20 , 21 ], a model from health psychology, to synthesise and interpret the review’s findings as it helps explain how people behave (e.g. whether to seek help or not) in reponse to potential health threats (e.g. experience of symptoms or receipt of a diagnosis). The model argues that, on being faced with a possible health threat (such as pelvic symptoms), people are triggered to respond, which takes place in three stages. In Stage 1, people interpret or make sense of the threat in relation to previous experiences and their sociocultural environment, to form beliefs about what condition they have, its likely cause, consequences, duration, and cure/controllability (‘interpretation’). These beliefs are also accompanied by emotional responses to the health threat. In Stage 2, they decide how to cope with the threat (‘coping’), which may include going to a doctor, taking medication, self-care (‘approach coping’) or denial, wishful thinking (‘avoidance coping’). In Stage 3 they assess if their way of coping was effective in returning to a normal state of self (‘appraisal’). The model was recently extended to include people’s beliefs about the behaviour and treatment as determinants of coping procedures and illness outcomes, in addition to illness representations [ 22 ].

The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) statement [ 23 ]. PRISMA checklists are available (Additional File 4 ). PROSPERO protocol registration number CRD42021256956.

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) search structure [ 24 ] was chosen as the conceptual framework to specify the review question, develop selection criteria and design search strategy. Although its authors [ 24 ] found that SPIDER was not as sensitive as a traditional PICO [ 25 ], it has been recommended as a systematic and rigorous tool in reviews addressing non-quantitative research questions and offers an optimal balance between sensitivity and specificity in searching [ 26 ] and more easily managed results [ 24 ]. Table  1 shows the framework concepts.

Eligibility criteria

Included pelvic symptoms (Sample) were limited to those likely to affect quality, rather than length, of life. From the literature, pelvic symptoms associated with a degree of stigma in disclosure, and eligible for inclusion in this literature review, were prolapse [ 27 ], urinary and faecal incontinence [ 12 , 28 ], sexual dysfunction, PFD [ 5 ], genital infections such as warts and herpes [ 29 , 30 ], pelvic pain, and abnormal uterine bleeding [ 4 , 31 ]. Some pelvic symptoms arise from issues such as intimate partner violence (IPV), rape, abortion, infertility, female genital mutilation, Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome, Human Papilloma Virus, and urogynaecological cancers. These issues were excluded in favour of including the symptoms that may result from them. Table  2 shows the full list.

The Phenomenon of Interest was help-seeking and its alternative terms. Any study design that captured help-seeking views were included. Evaluation included barriers and facilitators that women expressed about seeking help. The ‘research type’ included peer reviewed, published, qualitative, quantitative, or mixed methods primary studies, set in high-income countries only. A summary of eligibility criteria is in Table  3 .

Information sources

Databases were searched using the platform EBSCOhost: MEDLINE, CINAHL complete, PsycINFO, SocINDEX with Full Text; PubMed, and the Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL); primary studies included in topic relevant systematic reviews; reference list checking of included studies; forward citation searching of included studies in Scopus. Studies were included from year of inception of databases searched, to May 2023.

Search strategy

Scoping searches, MeSH headings used in known relevant studies, thesaurus, and the author’s clinical experience were used to identify subject headings and key words for pelvic symptoms, barriers, and facilitators to seeking healthcare. Peer Review of Electronic Search Strategies (PRESS) checklist [ 32 ] was applied by a medical information specialist. Ethical approval was not sought because this review synthesised results from primary research studies already published. The final search included a combination of terms related to two main concepts: stigmatised pelvic symptoms (Sample) AND help seeking (Phenomenon of Interest). Table  4 shows an example of the search strategy used in MEDLINE. The search strategy was translated by hand for the other databases and registers searched.

Selection process

After removing duplicates, all retrieved studies were screened by title and abstract by two independent reviewers. 10% of full texts were independently dual screened, with substantial agreement (83%; prevalence and bias adjusted kappa [PABAK] 0.66). Study authors were contacted by email where information was unclear or appeared missing, with a response time of three weeks, after which studies were excluded.

Data extraction

A data extraction form designed using Excel, with data items informed by Noyes, Booth [ 33 ] and NICE [ 34 ]. was reviewed and piloted by the research team. Data were extracted by the author, and independently from 33% of included papers by a research assistant. Quantitative data on barriers and facilitators to help-seeking were copied verbatim into the data extraction form and narratively summarised. Qualitative data recording participants’ help seeking views or experiences, found in results or discussion sections, were copied verbatim into NVivo software for analysis.

Quality assessment

The Mixed Methods Appraisal Tool (MMAT) [ 35 ] was used to appraise the methodological quality of each study by the author, and jointly for 33% of studies by a research assistant. The MMAT is pilot tested, interrater reliability tested, and offered five study design categories (one qualitative, three quantitative and one mixed methods) with five core criteria. Information about which areas of a study were problematic are reported, rather than summative scores because this gives more detail.

Data analysis and synthesis

Quantitative data were narratively synthesised, with content analysis of barriers and facilitators, and discussed and agreed with co-authors. Primary qualitative data were extracted and imported into NVivo software, before coding into pre-existing concepts from the analysis of quantitative data, with new concepts added as necessary. Reflecting on patterns and meaning in the data, themes were generated, developed, and reviewed at length through reflective thematic analysis [ 36 ], sense-checked with co-authors, and refined before naming and definition. Quotations from participants were used to illustrate themes. Synthesis of quantitative, qualitative, and mixed methods results drew together themes about barriers and facilitators to healthcare seeking with stigmatised pelvic symptoms, which were mapped to the CSM. Mapping the data to theory helped to explain the relationship of identified themes to help-seeking behaviours and identify potential targets for intervention.

Assessment of confidence in cumulative evidence

Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual) [ 37 ], was used to assess confidence in the findings in terms of methodological limitations, relevance to the review aim, coherence of the review findings in relation to the primary data, and the adequacy of data presented in the primary studies. The Data Richness Scale [ 38 ] was used to assess adequacy of qualitative data.

Reflexivity. The authors have backgrounds in pelvic health physiotherapy, with lived experience (CJ), applied health research (PA, MM), health psychology (PA) and sociology (MM). Before conducting the review, the authors considered their own philosophical positions, context, and life experiences in discussion with each other, to facilitate transparency of relevant preconceptions and beliefs.

Results of search

The electronic search generated 4,527 papers, and reference list checking and forward citation searching found 572 papers. After removal of duplicates, 3,963 titles and abstracts were screened, of which 3,569 were excluded, leaving 394 studies. It was not possible to access 20 papers, and eligibility criteria were not met by 215 papers after full text screening, leaving 159 papers that met all inclusion criteria (53 quantitative, 101 qualitative, 5 mixed methods). Initially, studies were not excluded based on publication year. However, it became apparent that the publication year of included studies ranged from 1988 to 2023, with 48.3% published between 1988 and 2010. This range encompassed a period of significant technological and cultural change, that occurred following the turn of the millennium (e.g., emergence of world wide web). It was speculated whether women’s experiences of barriers and facilitators were the same or had changed due to developments and cultural changes over this period. To test this speculation, data from all quantitative studies were extracted, and content analysis used to code healthcare seeking barriers and facilitators. These were compared across five decades from the 1980s to the present and were found to be similar. This suggested that excluding papers before 2010 was unlikely to miss barriers to healthcare seeking that are currently important to women. Exclusion of 73 studies prior to 2010 led to a total of 86 studies included in this review (33 quantitative, 48 qualitative, and 5 mixed methods). Figure  1 . shows the search results displayed in a PRISMA flow diagram.

Prisma flow diagram

Overview of studies

The main characteristics of quantitative, qualitative, and mixed methods studies are available (Additional File 1 ). Broadly, 36.05% of papers were from Europe, 31.40% from North America, 20.93% from East Asia and Pacific, 6.98% from Middle East and North Africa, 2.33% Worldwide, and 1.16% from Latin America. The geographical representation of all included studies is shown in Table  5 . Participants in all studies were described as ‘women’ or ‘female’: whilst recognising that not everyone with female anatomy identifies as a woman, or female, we have used these terms throughout this paper.

Quantitative studies ( n  = 33) represented 19,185 female participants from nineteen high income countries. All but one study used cross sectional survey design with questionnaires, mostly using unvalidated, bespoke questions on healthcare seeking. Due to heterogeneity of methods, meta-analysis was not possible. One study used a discrete choice experiment to investigate if cost of care and appointment wait time affected healthcare seeking intentions with urinary tract infection (UTI) symptoms [ 76 ]. Stigmatised pelvic symptoms studied included urinary incontinence (18 papers), PFD (five papers), sexual dysfunction (three papers), prolapse (two papers), pelvic pain, urinary tract infection, uro-genital atrophy, constipation, and menstrual dysfunction (one paper each).

Qualitative ( n  = 48) and mixed methods ( n  = 5) studies represented views and experiences of 2,653 women collected through interviews, focus groups, and 216 blog posts, from fifteen high income countries. Only eight papers stated the theoretical framework on which their study was based. Stigmatised pelvic symptoms studied included urinary incontinence (19 papers), PFD (nine papers), prolapse, and pelvic pain (eight papers each), urinary dysfunction, and sexual dysfunction (six papers each), anal incontinence (two papers), and mixed urinary and anal incontinence (two papers).

Quality Assessment

Using the MMAT indicated that 19 of 33 quantitative papers lacked information about representativeness of the sample. Authors were contacted for clarification, with few responses. Ten quantitative papers lacked appropriateness of measures for the healthcare seeking element, possibly because healthcare seeking was often a secondary theme. 28 quantitative papers did not provide any, or enough information on reasons for non-participation, resulting in an uncertain risk of non-response bias. All MMAT criteria were met in 37 of the 48 qualitative papers. In five papers it could not be established if the findings were adequately derived from the data, and in nine papers there was not enough information to determine coherence between data sources, collection, analysis, and interpretation. The interpretation of results was not substantially derived from data in five papers. Data Richness Scale assessments showed 40 qualitative papers had reasonable to good amounts and depth of data. No papers were excluded based on their data richness score. Each theme was assessed for data ‘adequacy’. Most had only minor concerns meaning that there were many studies within a theme, some with only little or superficial data, but some more detailed and specific. Mixed methods papers met all the qualitative methodological quality criteria but there were limitations in quantitative methodological quality in all five studies, and in mixed methods methodological quality in all but one paper. Most frequently this was uncertainty about different components of the study adhering to the quality criteria of each tradition of the methods involved. Quality assessment of all studies using the MMAT is accessible (Additional File 2 ). The CERQual assessment of confidence in the evidence across the key themes was high, with no, or minor concerns about methodological limitations, coherence, relevance, and data adequacy. The results of quality assessment suggest the need for higher quality research in quantitative descriptive studies in this field, particularly to facilitate the assessment of risk of nonresponse bias.

Quantitative studies

The most cited barriers were coded as embarrassment, shame, and taboo, (18 papers) closely followed by participants expressing a lack of knowledge about where to seek healthcare, and about treatment options, with a low expectation of benefit (18 papers). Some participants indicated that they did not recognise their symptoms as a significant medical problem, or thought their symptoms were not troublesome enough to seek healthcare and deprioritised them (19 papers). Many thought their symptoms were normal, especially after childbirth, or with ageing (15 papers). Participants frequently reported that if their clinician asked at all, they were embarrassed, were not interested in, or would not take their pelvic symptoms seriously (14 papers). Others perceived their clinician was too busy and did not want to bother them about pelvic symptoms (5 papers). Fear of being examined, and of required investigations and treatment, were barriers (17 papers), with a few participants being fearful that their symptoms indicated more serious disease (3 papers). Waiting times, inconvenience, being too busy to attend, transport issues, religious, and cultural factors, language difficulties and service issues such as appointment delays, and cost, were all obstacles (21 papers). A less common barrier to seeking healthcare was a desire to cope or self-help (5 papers).

Facilitators for seeking healthcare most often included increased bother from pelvic symptoms (9 papers). Support from family and friends to seek healthcare (4 papers), and knowledge and learning about new treatments encouraged some participants (3 papers), whilst others only sought help due to stigma, embarrassment, self-blame, guilt, or depression about their pelvic symptoms (3 papers) or feared that their symptoms were indicative of serious disease (2 papers). Papers containing the key barriers and facilitators are referenced (Additional File 3 ).

Qualitative and mixed methods studies

Four themes encompassed women’s barriers to healthcare-seeking: (1) Stigma, (2) Women’s lack of knowledge (with three sub-themes of normalising, deprioritising, and fear), (3) Trivialising by clinicians, and (4) Inconvenience and cost of seeking healthcare.

Stigma this theme was a key barrier to help-seeking, encapsulating the frequently used codes, “embarrassing’, “ashamed’, and less often, ‘taboo” (30 papers).

“For me, I was embarrassed to speak to anybody, really, about it, for a long time. But now, I regret that I did that, because I left myself to a bad stage.” [prolapse]; [ 27 ] “You don’t know why, you feel sort of ashamed, you feel embarrassed to talk about it, as if you are somehow a failure, with guilt, you know?” [47 years with UI]; [ 57 ] “Yes. You can talk about almost anything else I think, all kinds of matters considering your genitals and. but not this, this I think is very taboo” [SUI] [ 59 ].

Embarrassment is the emotional impact from stigma, with shame also associated with stigma [ 120 ]. Stigma may be categorised as enacted or felt. Felt stigma may be internalised, perceived, and anticipated [ 121 ]. Internalised stigma was most often described by women seeking help with stigmatised pelvic symptoms, in the way they internalised negative beliefs and perceptions around their symptoms, expressed psychological distress, reduced self-worth, shame, and self-loathing [ 122 ]. Some participants expressed greater embarrassment to talk to a male clinician: “ …My GP is a handsome 40-year-old man, and I would not dream of [laughs] talking to him about anything like that!” [sexual dysfunction] [ 51 ], while others blamed themselves for their symptoms: “ When I was younger, I took a lot of laxatives, so I did this to myself ” [bowel leakage] [ 78 ], or felt self-disgust: “… I feel dirty and disgusted in myself already ” [bowel leakage] [ 115 ].

Lack of knowledge about symptoms in general caused many participants uncertainty over whether to seek healthcare (23 papers):

“You feel disoriented, you don’t know if it is normal or not, whether you should worry or not” [45 years with UI] [ 57 ]. “I did not know that happened to women. I did not know anything about it. I was scared because I didn’t know what it was.” [prolapse] [ 98 ]. “ How can you talk about something [when] you don’t even know what it is?” [bowel leakage] [ 78 ].

Three sub-themes related to ‘lack of knowledge’: normalising, deprioritising, and fear. ‘ Normalising ’: participants normalised pelvic symptoms as women, following childbirth, and with ageing, as something they should not seek medical help for (22 papers):

“I simply thought: the urinary incontinence is just part of it. Your whole body is turned inside out after delivery anyway. So I thought it’s just part of the game.’ ” [PFD] [ 12 ]. “I have some good friends, and my daughter. Well, they have the same problem. It’s age. That’s all we boil it down to is the age. Nothing you can do about it.” [urinary dysfunction] [ 85 ].

‘ Deprioritising ’ was developed from new codes in qualitative data relating to prioritising other things, avoiding, or denying pelvic symptoms, and low bother from symptoms, which was found across all data (19 papers):

“ We forget about ourselves a little. Everybody else comes first, and then later, me.” [PFD] [ 84 ]. Participants across a wide range of pelvic symptoms felt low symptom bother did not justify seeking help: “… it’s only a little bit, not like oh I’ve wet my pants” [urinary dysfunction] [ 47 ] and “ I just forget about it, because it’s not an every week thing.” [bowel leakage] [ 78 ].

‘ Fear ’ related to women’s lack of knowledge and information and included codes about fear of examinations, investigations, and treatments, and inappropriate fear of serious disease, all of which delayed seeking help (8 papers):

“To be exposed, that is something you don’t want to risk, so every time [examination] it is like a mental procedure, the sense of exposure. Well, it’s almost like an abuse, it is something you don’t want to do but you must.” [pelvic pain -endometriosis] [ 61 ]. “ I didn’t want to be put on some pill that would make me more constipated. Sometimes the cure is worse than the disease…” [bowel leakage] [ 78 ]. “ When your uterus or bladder falls, it is very dangerous. You can get cancer ” [PFD] [ 86 ].

‘ Trivialising ’ was a significant theme that grew around codes involving women’s relationship difficulties with their clinician (25 papers). A new code from qualitative data included in this theme was women feeling judged by clinicians if they mentioned pelvic symptoms. Women felt they were not being taken seriously, not being asked about symptoms, and perceived their clinician was embarrassed to discuss symptoms:

“ I told my doctor, I had urine loss all the time…you know what he said? Honestly, I will tell you…”wear a kotex”” [PFD] [ 86 ]. “ You’ve got a rectocele.’ ‘What is it?’ ‘Oh, you don’t need to know.’ Well, hey, if it’s to do with you, you’re the one person who needs to know about it. You shouldn’t be sort of kept like, ‘Oh, you’re a child being a nuisance. Go away. You don’t need to know.” [prolapse] [ 87 ]. “And then she also said that maybe I should learn to live with it, I thought that was a bit crazy. And ehm, that also made me think I did not feel taken seriously. Because I really thought, well, hello, I’m 20!” (22 yrs) [pelvic pain – vulvodynia] [ 52 ]. “The lack of urgency is real with OBGYNs. Maybe younger doctors are more open, but the attitude of older gynaecologists is to do what they did to me. He just gave me a pat on the butt and told me I could live with it.” [prolapse] [ 90 ].

‘Trivialising’ also included women expressing their perception that their clinicians lacked knowledge or training about pelvic symptoms, found in two quantitative and 12 qualitative and mixed methods studies:

“ The GP took me seriously, but in retrospect I think he didn’t have the knowledge…” [pelvic pain – vulvodynia] [ 52 ].

‘Inconvenience and cost of seeking healthcare ’ developed as a theme from overlapping codes in which women described a variety of cultural, gender or religious factors, as well as communication issues with their clinician, long waiting times at appointments making them difficult to fit in to everyday life, and for some, the cost of having to take time away from paid work, or childcare to attend, as barriers to help-seeking (15 papers). Codes around service issues were incorporated: the inconvenience women experienced to physically attend appointments or have treatment, delays in receiving an appointment for a particular service, and the cost of care, especially if they did not have health insurance (12 papers).

Facilitator codes only found in qualitative and mixed methods studies included clinicians taking women seriously, being open to uncertainty, asking about symptoms, and offering support, developing the new theme of ‘supportive clinician attitude’(18 papers), which was added to the themes of worsening symptoms, increasing women’s knowledge, and social support already found in quantitative studies.

Synthesis of all results

Table  6 shows how themes were developed from codes across the data. There was high certainty from the data that barriers and facilitators to healthcare seeking were similar across different stigmatised pelvic symptoms, countries, and research designs.

The extended CSM was applied to better explain these results by describing how women’s perceptions about, and interpretation of their symptoms influence their behaviours in relation to coping with those symptoms. Women’s interpretation of symptoms is influenced by the cognitive and emotional representations triggered by their symptoms, which may be influenced by previous experiences, and sociocultural factors. Accurate cognitive representation of the potential threat from pelvic symptoms requires women to know the identity, cause, consequences, cure/controllability, and likely timeline of their symptoms. Findings from this review suggest that women’s lack of knowledge, reported in 44 studies, and normalising of symptoms, reported in 37 studies, threaten identification of pelvic symptoms. Attribution of cause is threatened by women believing their symptoms are normal. In the early stages, the full consequences of pelvic symptoms may not be appreciated because initially symptoms cause low bother and are deprioritised and normalised. Conversely, some women delay healthcare seeking because they (usually incorrectly) fear serious disease because of their symptoms. Lack of knowledge of treatment options threatens appropriate representation of the timeline and cure/controllability of pelvic symptoms, with some women hoping for spontaneous resolution, whilst others believe their symptoms are incurable. Women’s ability to make sense of their perceptions (coherence) of symptoms is affected by a lack of knowledge, that disrupts women’s cognitive representation of their symptoms.

Women’s main emotional representation of the potential threat from pelvic symptoms is stigma (embarrassment, shame, and taboo). Cited in 52 studies, stigma was the most reported barrier to healthcare seeking, and to a lesser extent, fear: of examination, investigations, treatment, and serious disease.

Women’s treatment beliefs are affected by a lack of knowledge about treatment options, where to seek healthcare, and low expectations of treatment benefit, all delaying healthcare seeking. Women’s beliefs about seeking healthcare are influenced by sociocultural factors (subjective norms, perceived behavioural control), their own, and others’ attitudes. Attitudes of women seen in the data from this literature review indicated that women believed that seeking help for pelvic symptoms would cause them to feel stigmatised, that they would be judged, and their symptoms trivialised by their clinician, and that clinicians would normalise their symptoms, possibly due to a perception that clinicians lacked knowledge and training about pelvic symptoms. Subjective norms define what women believe others would do if they had pelvic symptoms: our data suggest the subjective norms are to normalise and deprioritise their own symptoms, cope, and feel stigmatised. Women’s perceived behavioural control over pelvic symptoms is reduced by lack of knowledge, service issues, and is affected by inappropriate self-help and coping. The key themes from help seeking barriers mapped to the CSM are shown in Fig.  2 .

Using the extended CSM to explain barriers to healthcare seeking with stigmatised pelvic symptoms

In summary, women’s cognitive and emotional representations, treatment beliefs, and beliefs about help-seeking affect their ability to manage their pelvic symptoms. The data show how coping (Stage 2. CSM) is affected by women’s lack of knowledge, causing (mis-)interpretation of their symptoms, and leading them to display either ‘approach-oriented coping’ through inappropriate self-help, such as relying on sanitary pads for incontinence, or ‘avoidant-oriented coping’ procedures such as normalising, and deprioritising symptoms, instead of seeking help. Women appear to become stuck in a maladaptive, distressed loop between the interpretation and coping stages of the CSM, because iterative interpretation of their symptom perceptions, and the social messages they gather about seeking help with pelvic symptoms, reinforce the stigma of, and their lack of knowledge about symptoms. For many women, it was only worsening impact from symptoms and fear of more serious disease that pushed them to seek healthcare. There were a small number of voices (six papers), who believed they should assert themselves to take responsibility to ask for professional help, but the majority of women suggested that a supportive attitude from their clinician, especially to ask women about pelvic symptoms, would facilitate seeking healthcare for stigmatised pelvic symptoms.

This is the first review which covers such a wide range of stigmatised pelvic symptoms, to our knowledge. The principal findings of this mixed methods systematic literature review are that stigma (embarrassment, shame, and taboo), lack of knowledge, and women feeling ‘trivialised’ by clinicians, are definitive barriers to seeking help. Using a health psychology model (CSM) contributed to understanding how the emotional representations (stigma) and cognitive representations (lack of knowledge) particularly affect identification of pelvic symptoms, and clinician behaviour. Referring again to theory, Dixon-Woods, Cavers [ 123 ] described the construct of Candidacy, to explain how, influenced by their context, other people, and sociocultural issues, individuals negotiate their eligibility for healthcare between themselves and healthcare services, in an iterative cycle. When someone seeks healthcare, they assert their candidacy, which is then judged by clinicians (‘Adjudication’), either helping, or hindering their healthcare journey. In the case of seeking help with pelvic symptoms, stigma, women’s lack of knowledge, and their experiences leading to an expectation of their symptoms being trivialised, combine to make women’s candidacy for healthcare unclear. If clinicians lack knowledge and training about pelvic symptoms, they may trivialise, normalise, or judge symptoms, and so adjudicate against women’s healthcare seeking attempts.

‘Unclear candidacy’ is proposed as the overarching theme for this synthesis. The connection between the Candidacy model and the CSM’s illness representations was demonstrated in a paper exploring access to, and experiences of healthcare services [ 124 ]. This connection helps to understand the voices of women seeking help in this analysis: Stigma, lack of knowledge, and feeling trivialised by clinicians were the key factors affecting women’s identification of themselves as candidates for healthcare. Women both judge their own symptoms and feel judged by clinicians as unsuitable, or unworthy, to seek help for stigmatised pelvic symptoms. Women’s beliefs that if they seek healthcare they will not be taken seriously by clinicians, collude to frustrate their candidacy for healthcare. Our data show that women experience felt stigma, and enacted stigma from negative judgements by clinicians, further discriminating against women’s candidacy for healthcare with stigmatised pelvic symptoms. The facilitators that most often prompted women to seek healthcare were more knowledge about pelvic symptoms, worsening symptoms, and feeling that their clinician was supportive, especially in asking specifically about pelvic symptoms. This suggests that women who believe their clinician will have a supportive attitude are more likely to develop a positive emotional representation of their symptoms and will more likely seek healthcare. Increasing women’s knowledge would help them to appropriately identify the cognitive representation of threat posed by their symptoms, to decide if they can appropriately self-manage their symptoms or need to seek professional help.

The strengths of our review are the inclusion of a wide range of carefully considered, stigmatised pelvic symptoms, explored across many high-income countries, with rigorous application of eligibility criteria, and the use of theoretical models to explain the link between barriers and facilitators and help-seeking behaviours, allowing suggestion of possible targets for intervention. Selection bias was reduced by the ability to include studies published in English, German, French, Spanish, and Swedish. Ethnic representation where reported, was mostly white and also included Black, Hispanic and Asian women. The overall CERQual assessments of confidence [ 37 ] were high for the barriers to healthcare seeking found in our review, signifying issues common to women across stigmatised pelvic symptoms. Help-seeking barriers concur with those found in recent systematic literature reviews investigating experiences of individual, stigmatised pelvic symptoms: abnormal uterine bleeding [ 4 ], prolapse [ 10 , 125 ], and a recently published study exploring women’s experiences of PFD [ 93 , 126 ], and urogynaecological care for racial and ethnic minority women [ 127 ]. Stigma, and lack of knowledge were likewise barriers for those with urinary incontinence [ 128 , 129 ]. In a public survey, which was part of a call for evidence to inform the Women’s Health Strategy for England [ 130 ], published after commencement of this review, 84% of respondents said they had not been listened to by healthcare clinicians, which concurs with our findings, although not specific to pelvic health. Our finding that women perceived clinicians lacked knowledge and training (cited in 12 qualitative and mixed methods studies) was only found in one recent review relating to prolapse [ 10 ]. Our finding of women’s perception that clinicians normalise their pelvic symptoms (cited in seven qualitative and mixed methods studies), was only found in one review about abnormal uterine bleeding [ 4 ]. Few facilitators to healthcare seeking were reported in other reviews. Increased knowledge, social support and worsening symptoms were similarly found to encourage women to seek healthcare with PFD [ 10 , 127 , 131 ]. In contrast to others’ results, we found a large volume of qualitative data expressing the importance of a supportive clinician to facilitate women’s healthcare-seeking for pelvic symptoms. This may be due to the large number of women’s voices represented over a wide range of pelvic symptoms. It is likely to be an important consideration in developing future interventions.

We recognise limitations in this review. Although our search included many stigmatised pelvic symptoms, some relevant publications may have been missed, and not all symptoms were represented in the included literature. Grey literature was not investigated because we chose to include only peer reviewed studies to ensure a degree of rigour, and due to resource restrictions. Only women living in high income countries were included, to allow better understanding of barriers and facilitators in countries with similar economies to the UK, whilst recognising that the UK National Health Service is unique. Excluding studies published before 2010 is mitigated by thorough content analysis of the data in all quantitative studies concerning barriers and facilitators prior to exclusion, confirming that issues that currently concern women were unlikely to be missed. Quality appraisal using the MMAT was challenging because non-response bias was unclear in many quantitative studies, there was insufficient focus on healthcare seeking in ten papers, and few contacted authors responded to requests for clarification. Most included studies only captured the voices of women already seeking healthcare with symptoms: taking a public health approach to seek the concerns of all women may uncover further barriers and facilitators to seeking help for stigmatised pelvic symptoms not found in this review.

The findings of this review mean that efforts to encourage women to seek healthcare with pelvic symptoms need to target the barriers by reducing stigma, increasing knowledge, and supporting primary care clinicians to routinely discuss stigmatised pelvic symptoms with women. Changing the social norm so women believe they will be taken seriously if they seek healthcare is likely to empower them to appropriately manage their symptoms. Since this review began, there has been an explosion of interest and information about menopause, with celebrity endorsement in the UK [ 132 ], which along with the first ever UK Government Women’s Health Strategy [ 130 ], may help to normalise discussion of stigmatised pelvic health symptoms, reducing stigma. Clinicians at all levels, particularly in primary care, need to legitimise women’s candidacy for pelvic healthcare. This may require clinician education and training to better understand the significant effects of pelvic symptoms on women’s quality of life and wellbeing, to confidently educate women about their anatomy, their symptoms, and how to negotiate the healthcare system. Evidence informed, local pathways of care should be available and widely recognised to enable women to self-manage symptoms, when possible, to know when and where to seek help, and to expect to be supported by clinicians throughout their journey, with timely referral to specialist multidisciplinary services when required.

There are unanswered questions about facilitating early help-seeking in women with stigmatised pelvic symptoms: A few interventions have successfully increased pelvic health knowledge for a short duration [ 133 , 134 , 135 , 136 ], probably by improving cognitive representations of illness identity, but there is a lack of research targeting emotional representations to reduce the stigma of pelvic symptoms. Results from this systematic, mixed methods literature review suggest that changing stigma, knowledge, and beliefs about seeking help for pelvic symptoms will support women to identify their candidacy for healthcare, reduce normalising and deprioritising of symptoms, inappropriate self-help, and incorrect adjudication by clinicians who normalise and trivialise women’s pelvic symptoms. Future research needs to explore whether targeting both cognitive and emotional representations towards stigmatised pelvic symptoms, and the attitudes and norms women encounter, can encourage women to seek healthcare sooner. A successful intervention to raise awareness, reduce stigma and encourage women with stigmatised pelvic symptoms to seek timely healthcare could be used to better inform public health policy, reduce unnecessary surgical costs, and work towards meeting the United Nations Sustainable Development Goals core target 3.7 by 2030 [ 1 ].

Abbreviations

Cochrane Database of Systematic Reviews

Cochrane Central Register of Controlled Trials

Common-Sense Model of Self-Regulation of Illness and Behaviour

Female Genital Mutilation

Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research

Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome

Human Papilloma Virus

Mixed Methods Appraisal Tool

Prevalence And Bias Adjusted Kappa

Pelvic Floor Dysfunction

Peer Review of Electronic Search Strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Sustainable Development Goals

Sample, Phenomenon of Interest, Design, Evaluation, Research type, search structure

Urinary Incontinence

United Kingdom

United Nations

United States

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Jouanny, C., Abhyankar, P. & Maxwell, M. A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms. BMC Women's Health 24 , 217 (2024). https://doi.org/10.1186/s12905-024-03063-6

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