Rita Pace Parascandalo
Reviewing the literature is the starting point for most research studies.
Since the 1990s the systematic review (SR) has been developed.
The main purpose of a SR is to inform practice and policy and identify gaps in the knowledge.
SR initially focused on quantitative studies, specifically RCTs, and included meta-analysis of data.
Qualitative research could also be reviewed and synthesised, with the aim of providing greater understanding of a phenomenon.
SR have developed in response to a growing need for policy makers, researchers and practitioners to have access to the latest research evidence when making decisions.
More recent advances have led to mixing methods at the review level
Integrating the findings of multiple, already existing studies that are labelled broadly as using either ‘qualitative’ or ‘quantitative’ methods.
SR adopt rigorous methods.
Traditionally, SR have been used most often to answer questions of effectiveness – ‘What works?’
Reviews that go beyond such questions are newer, and often bring together data from both ‘qualitative’ and ‘quantitative’ studies.
Methods for reviewing both qualitative and quantitative studies in a systematic way are still emerging.
‘What are the perspectives of neonatal staff and parents about the transition of preterm infants from the NICU to home?’
Studies designed to focus around NICU discharge preparation and /or transition to home of the preterm infant.
Studies where data has been collected on approaching discharge towards the end of the NICU hospitalisation and /or in the first six months after discharge.
Studies where the infants were discharged home without the requirement of any special care (e.g. apnoea monitors, oxygen therapy, etc)
Studies where the parents are the primary caregivers at home.
Studies where NICU discharge was according to standard procedures.
Studies done in any country, published in any language, using any research design and published from 1990 till present.
Full-text studies are published and accessible.
Studies which are restricted to focus on particular aspects relating to preterm birth e.g. psychological distress.
Abstracts from conferences, books and unpublished dissertations.
Studies published prior to January 1990.
Studies which focus only on the NICU hospitalisation period.
Studies focusing on specialised discharge procedures as in earlier NICU discharge.
An extensive literature search in numerous relevant databases was done.
Ovid Medline, PsycINFO, CINAHL, Cochrane Databases of Systematic Reviews, Academic Search Complete, BMJ Journals, EBSCOhost, BIOMED Collection, JSTOR, Sage Journals Online, Joanna Briggs Institute and Google Scholar.
Studies were also hand-searched.
The search for the literature was done between January and August 2011.
Keywords used included a combination of ‘discharge’ , ‘NICU’, ‘neonatal intensive care’, ‘parent’, ‘staff’, ‘transition’, ‘preterm’.
Synonyms and alternative words / terms to these identified keywords have also been searched.
Using the identified key words and their synonyms or alternative words, two separate literature searches were done; one for neonatal staff and another for the parents.
For each search key words were attributed to four main areas: population, topic, orientation and context.
Boolean searches were then carried out to combine keywords to be searched for each of the four main areas.
Population Topic Orientation Context
Staff
OR
Discharge Planning
OR
Perceptions
OR
Preterm
OR
Nurses
OR
Discharge preparation
OR
Views
OR
Premature
Or
Midwives
OR
Discharge practices
OR
Perspectives
OR
NICU
165 potentially relevant search results
28 were empirical studies which clearly or loosely met the inclusion criteria.
Qualitative studies, n=8, included
Quantitative studies, n= 9, included
Ambiguous studies, n=11, 10 excluded, 1 awaiting english translation
Focus mainly on stress
Unclear when exactly data was collected
Main focus was on the hospitalisation period
Aim of study not reflected in the findings.
Qualitative studies:Qualitative descriptive 5
(US, UK, Korea, Brazil{2})
Phenomenology 3(Sweden, Canada, USA)
Quantitative studies:Descriptive Survey 9(Scotland, England, USA {3}, Canada {2}, Israel
{2})
Quality assessment for qualitative studies utilising the tool developed by Downe et al (2007)
For each study, questions are answered usingY=yes, N=no or UC=unclear Each study is graded using the following grading
system:A: No, or few flaws; quality is highB: Some flaws unlikely to affect qualityC: Some flaws that may affect qualityD: Significant flaws that very likely affect quality
Author, Year & Country
Aims: Clear?
Participants:Appropriate for aims & theoretical perspective?
Design: appropriate for aims & theoretical perspective?
Methods:Appropriate for design?
Sample: size and sampling justified?
Does the data analysis fit with the chosen methodology?
Reflexivity present?
Study ethical?
Do the data presented justify the findings?
Is the context described sufficiently?
Is there sufficient evidence of rigour?
Quality grade
Overall qualitative studies were of average to low quality (2 B, 3C, 3D)
A theoretical perspective and reflexivity were not evident in any of the studies.
Research design not justified. Details for recruitment were lacking. Limited aspects of rigour discussed. Lack in other important details; inclusion
criteria and sampling, characteristics of the sample, context of the study.
Utilised a self-designed tool for appraisal of survey studies.
For each study, questions are answered usingY=yes, N=no or UC=unclear Each study is graded using the following
grading system:A: no, or few flaws, quality is highB: some flaws, unlikely to affect qualityC:some flaws, that may affect qualityD:significant flaws, likely to affect quality
Author, Year & country
Aims: clear?
Design: appropriate & justified?
Methods & research tool: clear, appropriate for design?
Participants: appropriate for question?
Sample: size and sampling clear, appropriate & justified?
Methods & tests used for data analysis: clear & justified?
Study ethical?
Do the data presented justify the findings?
Is the context described sufficiently?
Is there sufficient evidence of validity & reliability?
Quality grade
Overall quantitative studies were of average to low quality (4 B, 4 C, 1D)
Majority were small scale studies with non random convenience sampling
Design not justified Recruitment and sampling not clear Limited discussion on issues of validity and
reliability
Study participants:Mothers onlyParents – but results reflect maternal responsesParents – collectively, no distinction between
maternal and paternal responsesParents – responses are distinguised between
mothers and fathers
Sample sizes:6 – 47 mothers and 7 – 10 sets of parents
Sampling methods:Mainly purposiveIn some studies sampling is not clear
Data collection: Methods – semi-structured to unstructured
interviews and focus groups Timing – Range between one time data collection to
longitudinal collection up to five timesStarting from prior discharge, at time of discharge
and up to 6 months after discharge
Data analysis:
Content analysis (Miles & Huberman, 1994)Thematic content analysis (Bardin, 2000)Colaizzi’s (1978) methodGiorgi’s (1985, 2000) method
Study participants:Mothers onlyNeonatal nurses and mothersParents – but results reflect maternal
responsesParents – collectively, no distinction between
maternal and paternal responsesParents – results distinguished between
mothers and fathers
Sample sizes:7 – 34 nurses45 – 56 mothers10 -80 sets of parents867 family-nurse pairs
Sampling methods:Non-random convenience Unclear
Data collection: Methods – self-administered /
face-to-face/telephone questionnaires- Self-designed / standard tools
Timing – from one day before discharge to three months post discharge
Data anlaysis:Descriptive and /or inferential statistics
Findings that contributed to answering the review question were extracted from the studies.
Studies included in this review can be termed ‘descriptive studies’ where perpectives or experiences of participants are elicited from both the quantitative and qualitative paradigms.
These kind of studies are also called ‘views’ studies.
A descriptive thematic analysis was done separately for the qualitative and quantitative studies.
The descriptive themes and their essential features were examined in the light of the review question to infer the perspectives of neonatal staff and parents.
Main Themes Sub-themes Theme components
Parental emotional responses to baby’s discharge home
Changes over time in parental mixed feelings
Positive and negative feelings: upon discharge, at 1 – 4 months post discharge, at 4- 6 months, at 6 months
Preparation and instructions for discharge
Factors predisposing to parental readiness for discharge
Parental reactions to preparations for discharge
Parental participation in infant care during hospitalisation
Various indications of being ready to go home
Negative and positve aspects
Active vs limited involvement in care
Preparation and instructions for discharge (cont)
Professional support and information needs indicated by parents
Factors affecting parental learning on the NICU
Ongoing support and teaching need in various identified areas.
Deficits in information giving
Realities of caring for the preterm baby at home
Maternal and paternal concerns for baby
Difficulties relating to parental roles
Physical and psychological effects of parenting
Adjusting to a lifestyle that included the baby
Maternal ways of coping
Various expressions of mothers and fathers concernsVarious identified difficulties
Maternal and paternal effects
Various changes in lifestyle identified
Self-support, communication & accepting support
Main themes Sub-themes Theme components
Discharge teaching Importance and content
Responsibility for discharge teaching
Unmet parental informational needs
Discharge preparedness perspectives
Importance & content of topics not always agreed by staff and parents
Staff perspectives
Topics lacking adequate information
Staff and parents
Sources of information and support
Prior discharge
Following dischargeDifferent personnel mentioned
Main theme Sub-themes Theme components
Parental feelings (at 2 – 3 months after discharge)
Mothers’ sense of competence and stress/anxiety
Fathers’ sense of competence and stress/anxiety
Different levels of competence and stress/anxiety identified
??????
Possibly a comparative synthesis guided by the following questions:
What are perspectives focused on in the quantitative and qualitative studies?
Which perspectives are similar / different across both types of studies?
What areas have not been addressed in such studies so far?