Using qualitative research in systematic reviews: Older people’s views of hospital discharge: SCIE Report 9

Systematic reviews have become a cornerstone of evidence-based policy and practice in modern welfare democracies. The UK has developed major review centres, such as the Centre for Reviews and Dissemination at the University of York and the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, University of London. The Social Care Institute for Excellence (SCIE) is currently developing systematic reviews in social care. The Cochrane and Campbell Collaborations coordinate international work in health and social welfare. However, current methods of systematic review are focused almost exclusively on how to synthesise effectiveness studies – addressing the question of whether a method of social intervention works. Little work has been developed on synthesising the messages from other kinds of studies that might tell us additionally why interventions do or do not work, and whether they produce outcomes that matter to people who use services. The term ‘narrative synthesis’ refers to a descriptive account using words rather than numbers to describe the combined effects of different studies. This report produces a descriptive synthesis from qualitative studies, so could be referred to as ‘qualitative narrative synthesis’. We have shortened this cumbersome term to ‘qualitative synthesis’. Because this approach has not been widely used in social care, SCIE decided to develop a worked example of applying qualitative synthesis to a social care topic. The chosen topic is older people’s views of hospital discharge. This is a policy area in the UK that has been subject to a conventional, high-quality systematic review, but which lacks attention to the views of older people about what they value in terms of both process and outcomes. The general research question was framed as ‘What are older people’s experiences of hospital discharge, and how are they influenced by staff views and behaviour?’ This question raised a number of related sub-questions: What are older people’s explanations for their level of participation in discharge processes? What are staff views (within the same hospital) about older people’s level of participation and the factors influencing this? What are older people’s experiences and priorities immediately after hospital discharge? What characterises non-medical services or interventions that older people value in assisting them to achieve their aims after discharge? We defined older people as those aged 60 or over and stipulated that the studies must explore their experience of hospital discharge rather than, for example, that of hospital or community care more generally. The qualitative synthesis is based on a selective search that identified 104 relevant studies, of which 28 were selected for detailed evaluation and 15 for synthesis. Most studies in the synthesis focused primarily on hospital discharge of those older people without cognitive or communicative impairment, who required some assistance on returning home. Therefore, the synthesis may be of limited relevance to those admitted for minor conditions who return home without the need for assistance, or to people with severe cognitive impairments or communication difficulties who were not interviewed.
The work was guided by an advisory group of older people with experience of hospital discharge, who made important contributions to this study about inclusion criteria, study quality and analytic themes. This approach added the kind of sensitivity to key issues that stems from direct experience; and this influenced the literature searches, the definition of outcomes that were considered important, and the definition of criteria for inclusion and quality appraisal. It also provided an opportunity to test the relevance of key conceptual categories during synthesis. This report shows that qualitative synthesis of older people’s views on hospital discharge is feasible and productive. It helps to explain other review findings about interventions that were found to help older people to deal with being discharged, and, in particular, it highlights the importance of the information and education ingredients in effective interventions and why an intervention that begins prior to discharge from hospital and continues when the older person returns home is more effective. However, it also reveals a significant new dimension – the need to locate the experience of hospital discharge within a life-planning perspective for older people. This report also notes limitations in the reporting of primary studies of people’s experiences and views. If research studies are to be subject to qualitative synthesis, improvements are required in the depth of description and the reporting of socio-demographic detail. Within these limitations, this report offers a detailed example of how qualitative synthesis can enhance systematic reviews in the field of social care