Qualitative synthesis and the development of clinical guidelines : towards a person-centred approach

Traditionally, clinical guidelines rely on objective evidence from quantitative research, largely derived from Randomized Controlled Trials (RCTs) of specific interventions in a defined healthcare area. Findings from qualitative research tend to be under-represented or overlooked because qualitative studies are more subjective, relatively small in scale and contextually bound. They may, however, contain important information about how a particular intervention works or doesn't work as well as relevant insights concerning the experiences, values and beliefs of key stakeholders with regard to the intervention or healthcare area. In recent years some novel approaches have been developed to address the lack of qualitative data within clinical guidelines. The most popular of these approaches is 'qualitative synthesis', a method that brings together the findings from isolated qualitative studies exploring the same or similar phenomena with a view to eliciting new, more abstract findings such that the whole is greater than the sum of the parts. More recently, techniques derived from qualitative synthesis have been adapted and used to inform global guidelines in the field of maternity care. Recognition that the findings from qualitative synthesis constitute a form of 'evidence' represents a major breakthrough for qualitative research generally but the newly emerging field is a highly contested area. There are internal tensions relating to the nature of qualitative synthesis itself, including the methodological and philosophical basis of the approach, as well as wider tensions relating to the incorporation of interpretive findings into the positivist frameworks associated with clinical guidelines. By referring to eight publications I have either authored or co-authored I will explore the qualitative synthesis landscape from its roots in the interpretive paradigm to its current application in guideline development. I will start by placing qualitative synthesis within the wider context of qualitative research and introduce the most commonly used synthesis technique, meta-ethnography. I will go on to examine some of the methodological, terminological and philosophical tensions that continue to challenge the credibility of this approach and highlight how I have addressed some of these issues by referring to several qualitative syntheses I have published. I will explain how the findings from these syntheses have been incorporated into clinical guidelines in maternity care and highlight some of the compromises that have been made to accommodate this endeavour within the wider context of Evidence Based Medicine (EBM). I will draw on some of the writings of the German philosopher, Jürgen Habermas, and explore how Habermas' concept of colonization might be applied in this context to illuminate some of the areas of contestation. By developing some of Habermas' theoretical discourse I will suggest that the method of qualitative synthesis is evolving in an 'interference zone' where competing claims for integrity strive for priority. I will juxtapose this position with a more utilitarian view of qualitative research and suggest that the findings from qualitative synthesis reflect a wide range of views, beliefs and experiences and represent a collective voice that can be utilized by guideline panels and policy makers. Finally, I will draw on the work of Carl Rogers, psychotherapist and pioneer of the 'person centred care' model, to illustrate how a patient led approach to guideline development, using qualitative-synthesis as a method, might represent a shift in global healthcare strategy towards more authentic and inclusive guidelines.