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A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria

• Oluwaseyi Emiola Ojedoyin 1 &
• Ayodele Samuel Jegede 1  

BMC Medical Ethics volume  23 , Article number:  87 ( 2022 ) Cite this article

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The study evaluated nurses’ perceptions on the benefits, drawbacks, and their roles in initiating and implementing advance directives (AD) at private and public secondary healthcare units.

The study adopted a cross-sectional, comparative-descriptive research design and was anchored on the structural functional theory. A total of 401 nurses (131 private and 270 public) were chosen on purpose. The data was collected between January and March 2018 among nurses at the selected hospitals. Analysis was done via SPSSv28.0.1.0.

Compared to nurses working in private healthcare facilities (72.5%), the majority of nurses at the public healthcare facilities (75.2%) indicated a more favorable opinion of AD’s benefits and (61.9%) felt they had a substantial involvement in the development and execution of AD than their private counterpart (56.5%). Similarly, 60.7% of nurses employed by the government agreed that AD has some disadvantages compared to those employed by the private sector (58.8%). Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; 0.78 times less likely than Muslim to disagree that AD has flaws; and 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, though not significant.

Making decisions at the end-of-life can be challenging, thus AD should be supported across the board in the healthcare industry. Nurses should be trained on their role in developing and implementing AD, as well as on its advantages and how to deal with its challenges.

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Introduction

Humans are born with the fundamental right to life. Due to this, many view death as undesirable, and even healthcare professionals avoid the discussion [ 1 , 2 ]. However, death is an inevitable, natural occurrence that all patients with life limiting illnesses should be prepared for in order to minimize distress at the end stage of life. Advance care planning (APC) is a method of communicating intentions that allows patients to let their loved ones and healthcare providers know in advance how they would like to be treated. One strategy in APC that aid readiness for future illness-related incapacitation, patients’ autonomy and dignity is advance directive (AD). AD is a written document or spoken declaration that enables competent people to make and document their healthcare decisions in advance [ 3 , 4 , 5 , 6 ]. Although patient’s “written directives” is a helpful tool for determining their preferences, tradition still dominates in most Africa countries. AD is yet to be legalised in Nigeria [ 7 ]. However, patients verbally expressed their preferences of care to healthcare professionals, and some even name individuals to make treatment decisions on their behalf when they are incapacitated [ 7 ]. These do not only promote patient participation in EOL discussion but also mitigate the paternalistic aspect of Nigeria’s healthcare system [ 8 , 9 ].

The Nigeria healthcare unit is divided into 3—primary, secondary and tertiary. Healthcare facilities at each unit can be privately owned or publicly owned. The difference between the two hospitals are found in their governance—the former are owned and run by an individual or group of individuals while the later are managed and funded by the government. The secondary healthcare facilities—which was the focus in this study manage advanced medical conditions [ 10 ] and it had been shown that, private hospitals are mostly used by Nigerians [ 11 ]. Nurses at these two facilities play significant roles in patients’ care. They provide medical, emotional, educational, patient-centered care and also serve as mediator between patients and doctors [ 12 , 13 ]. These put them in the best position to help in advance care planning—a procedure for communicating patients’ intentions [ 14 ]. Therefore, comparing the viewpoints of these nurses regarding AD will help to determine how end-of-life care is provided at this healthcare unit. There is a paucity of data on nurses’ perceptions of AD in Nigeria, and no study has described nurses’ perceptions at both private and public secondary healthcare facilities to the best of our knowledge. Previous researches focused on patient perception of AD and advocacy for AD inclusion in the country’s healthcare system [ 5 , 7 , 15 ]. This study therefore compared perceptions of nurses at the private and public secondary healthcare facilities on the advantages, roles and shortcoming of ADs in Ibadan, Oyo state, Nigeria.

Theoretical orientation

Structural–functional model.

A sociological theory known as functionalism views society as an organism of several elements (social institutions) that work together to maintain and reproduce the society [ 16 ]. These social institutions are typical means by which a society can attend to and satisfy both its social and individual needs. For instance, hospital is a social institution with many healthcare professionals collaborating to provide the best possible healthcare services to the community. Social institutions are also examined by functionalists in terms of the roles they played. Hence, to comprehend every part of society (e.g. doctor, nurse, teacher, AD, etc.) and how they affect social cohesion, reproduction, or the effective operation of a larger community, the functions of such institutions, beliefs, or ideologies are taken into considerations.

Merton however proposed that not all structure, custom, religion, ideology etc., serves positive purposes because they may serve both manifest and latent functions [ 17 ]. The latent functions are elements of behaviour or functions that are not openly declared, recognised, desired or intended. While the manifest functions are elements of conduct or functions that are conscious and purposefully [ 17 ]. Both the latent and manifest functions of AD was examined in the present study.

Research design

The study was a cross-sectional comparative-descriptive research design.

Participants

Nurses working in government-owned (public) and privately-owned secondary healthcare institutions as well as nursing students at the chosen hospitals participated in the survey.

Study location

The study was carried out in Ibadan, the Oyo state capital of Nigeria. Ibadan was deliberately chosen because it is Nigeria’s third-most populous city after Lagos and Kano, and because the region has historically had limited access to health care services [ 18 ]. Six out of eleven local government areas (LGAs) in Ibadan were chosen for this study—Ibadan Northeast, Ibadan Southwest, Ibadan Southeast, Ibadan North, and Egbeda. The high number of secondary health care facilities in these LGA coupled with the fact that no study on AD has been carried out among nurses in these locations were a deciding factors.

Sampling technique

A convenient non-probability sampling method was used to select nurses. This was employed due to the low staff strength, heavy workload and burnout on available staff. Five general hospitals and ten private secondary hospitals were included in the study—because of the high proportion of private secondary health facilities to public secondary health care facilities in the location and Nigeria as a whole [ 19 ]. A total of four hundred and one (401) nurses—270 nurses from public and 131 nurses from private hospitals—participated in the study.

Research instrument

Questionnaire was used to elicit information from respondents. Data was gathered in 2018 between January and March. The surveys were distributed to all nurses on-duty at their offices. A total of 430 survey was distributed out of which 401 was returned, making a 93% response rate. A total of 7% of the data was missing because several nurses worked night shifts, took the survey home, went on leave, and neglected to return the questionnaire.

The survey questions were developed after careful examination of literature from various countries [ 20 , 21 , 22 , 23 ]. Additionally, the opinions of three experts on prospective contents that required evaluation were sought. The questions’ ambiguity, relevance, clarity, and comprehensiveness were also evaluated. They assessed the questionnaire’s validity in terms of both face and content. The comments was examined, and the changes were added in the final survey. However, pilot survey was not conducted.

The questionnaire comprises two sections. The first section was on respondents’ socio-demographical characteristics. The second section was on perception and comprises 13 items—4 questions on benefits of AD, 5 questions on nurses’ roles in the initiation and implementation of AD, and 4 questions on shortcomings of AD. A 5-point likert scale was used to grade the responses of the participants ranging from strongly agree (5) to strongly disagree (0).

Data analysis

Data entry, cleaning, and analysis were performed using SPSS 28.0.1.0. Descriptive statistics was calculated for the socio-demographic and perception of nurses to AD. For questions on benefit of and nurses role in AD initiation and implementation, strongly agree and agree responses were merged to form correct perception to AD while, neutral, disagree and strongly disagree was merged as incorrect response. For questions on shortcomings of AD, strongly agree, agree and neutral responses were merged to form incorrect perception to AD while, disagree and strongly disagree was merged as correct response. The score for a correct response was two, while the score for an incorrect response was zero. The mean was calculated and response below the mean was considered as negative perceptions and those above or within the mean as positive perception.

On both the total benefits and drawbacks questions, 75% percentile (scoring three or more out of the four questions) was defined as positive perception, while 25% percentile (scored one out of the four questions) was labeled as negative view. The percentiles for the role of nurses in the initiation and implementation of AD were 60% (scoring 3 or more out of the 5 questions) and 40% (scored 2 or fewer out of the 5 questions). Differences between public and private nurses and nurses religion was examine using the odd ratios.

Reliability assessment of the questionnaire was conducted using Cronbach’s alpha coefficient based on Heden scale as cited in Peicus et al. [ 21 ] internal reliability assessment and recommendation. It stated that, a scale is reliable if the Cronbach’s alpha is > 5. The Cronbach alpha for the study is (0.62).

Ethical consideration

The Oyo State Research Ethics Review Committee, with reference number AD13/479/837, as well as administrative officers from each of the chosen hospitals and each participant, gave their approval before the data collection began.

Characteristic and representative of nurses in the study

The complete list of participants characteristics is shown in Table 1 below. The majority of respondents are women (88.9% public and 96.9% private). The majority (56.7%) of staff members at public hospitals hold diploma degrees, with one (0.4%) PhD degree holder. In contrast to the government hospitals, where 44.1% of participants had more than ten years of work experience, more than half (55.7%) of the private participants are within 1–5 years of work experience group. Predominant group are Yoruba (94%), Christians (79.3%) and more respondents from the public hospital (67.3%).

Distribution of nurses perception of benefits of advance directive

As shown in Table 2 below, most of the nurses agreed the AD is helpful when deciding how to treat patients (public-94.5% and private-93.1%); makes decision easier (public-88.2%, private-93.1%), minimize family conflict (public-85.9%, private-80.1%) and majority felt it reduced wasteful spending (public 77%, private 77%);

Perceived nurses role in advance directives

Majority agreed that nurses are crucial in educating about AD (public-78.1%, private-73.3%); in best position to access the appropriate time for end-of-life discussions (public-84.4%; private-78.6%) and are responsible to initiate end-of-life discussion (public-76%, private-57.3%). More participants in the private facilities than those at the public agreed that nurse can transfer a patient to another nurse when not comfortable with the directives.

Perceived shortcomings of advance directive

More participants in public (42.2%) than private (35.9%) disagreed that interpreting AD can be challenging. Two-thirds of private nurses (65.7%) and 55.5% of nurses in the public hospital agreed that AD can lead to requests for care not in the patient’s best interests. The little more than half of the participants felt AD might not accurately reflect patient’s current preferences (public-57.8%; private-52.7%) and uncertain (public-51.8%, private 39.7).

Classification of nurses responses into positive and negative perception

Table 3 shows how nurses generally perceived the benefits of AD, their involvement in its initiation and execution, and its perceived drawbacks. Majority of nurses in the public sector (75.2%) and private sector (72.5%) agreed AD is beneficial to patients, their families, and healthcare providers. More participants in the public sector (61.9%) than private (56.5%) thought they played a critical role in the development and implementation of AD. More nurses (60.7%) in the public sector concurred that AD had drawbacks than its private counterpart (58.8%).

Differences on nurses perception to advance directive

Table 4 below displays how Muslim nurses and Christian nurses perceive AD using odd ratios. Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; are 0.78 times less likely than Muslim to disagree that AD has flaws but are 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, albeit, these differences are not statistically significant.

This study focused on nurses’ perceptions on the benefits, the role of nurses, and the negative aspects of AD at public and private secondary healthcare units in Ibadan, Nigeria. Positive perception regarding AD advantages was found among nurses at both public and private secondary healthcare units. This supported previous reported finding in Australia and Korea. According to these researches, AD guarantee patient autonomy, improve end-of-life care, and give patients a chance to reflect on their own dying stage and demise [ 22 , 23 , 24 ]. The study findings also agreed with prior researches where it was reported that the enforcement of ADs relieved families and patients’ financial, emotional weariness and disagreement [ 24 , 25 ] as we found that, participants agreed that AD can reduced needless stress, excessive spending and prevented or resolved conflict among healthcare practitioners, patients and patients relatives.

Nurses are more available at hospital and are closer to patients than any other healthcare practitioners. As a result, they agreed they are the best resource for patients and their families seeking information about AD. This support earlier researches in Portugal, Korea, New Zealand, and Australia [ 3 , 12 , 22 , 24 , 26 ]. The disparity reported on who is proficient in figuring out the appropriate time to initiate AD among the two group of nurses could be attributed to the quantity and quality of training enjoyed by these nurses. While more trainings are planned for nurses at the public sector, little of such training is available for nurses at the private sector in Nigeria. Davidson et al. also reported that nurses are in the best position to initiate AD [ 12 ]. On who should start the end-of-life conversation with a patient, the nurses at the two healthcare facilities had contrasting opinions. Nurses at private facilities saw it as the doctors’ obligation to begin and record the decision while they made the document readily available when needed, in contrast to nurses at public hospitals who saw it as their role. These was similar to findings in South Africa, Korea and Australia by Bull and Mash, Son et al., and Hobden et al. [ 24 , 27 , 28 ], where nurses saw themselves as the custodians of AD document rather than its initiators and/or implementers. The findings demonstrated that nurses in the private sector are more likely to refer patients whose orders they find objectionable to another nurse or facility. These both supports Siamak’s [ 23 ] findings that nurses have the autonomy to decline participation in the withdrawing or withholding of treatment if such a decision contradicts their personal and/or professional convictions and Hobden’s [ 27 ] findings where 60% of their study participants showed neutrality or disagreement that ADs will still be adhered to even if the medical team does not agree with them. Fear of litigation and the fact that nurses at the public sector enjoyed more autonomy, employment security, and public reputation than those in the private sector are some contributing factors to this [ 26 ]. Making known and reporting violation of patients’ directives were found to be nurses’ responsibilities in the present study. This was in consistent with Hobden et al. [ 27 ] that found nurses play a key role in ensuring that patients’ preferences are honored throughout end-of-life care.

Regarding AD’s shortcomings, the study demonstrates consensus that AD has some degree of negativity, but to various degrees. Over 50% of the study participants in the two sectors agreed and are neutral on the statement that many ambiguous terms are frequently used in AD without enough context or justification thereby making it difficult to interpret. Previous researchers have also noted that unclear instructions and the use of ambiguous language could lead to misreading of patients’ preferences [ 20 , 21 , 27 , 29 ]. The fact that patients’ mostly give their directives verbally when they are critically ill and sometime by their relatives in Nigeria can also contribute to the misapprehension of the directives [ 7 , 30 ]. More public sector nurses thought it was challenging to prove that AD is certain and accurately reflect patients’ current preferences and this made its implementation challenging. Reasons could be because, patients’ decisions regarding their treatment preference evolved over the illness episode due to factors like finance, relative decision, religious beliefs among others. However, these changes may not have reflected in the patient AD or known to the patient proxy. These contributed to the controversy in its implementation. Thus, decisional conflict that results from translating a written order into practice has previously been identified as an obstacle to the application of AD [ 26 , 27 , 28 ]. Ernestina et al. [ 3 ] showed that AD can fail in practice if changes in patient personal value fail to reflect in the directive. Therefore, AD should be periodically addressed and revisited for timely updates [ 21 ]. More than half of the study participants agreed that, there are chances that patients will asked for treatment that is not in their best interests in their AD. This finding supported researches conducted in Queensland, Australia, and Korea where it was reported that AD inhibited medical personnel from providing ethically and medically appropriate treatment to patient [ 20 , 26 , 29 ]. Inadequate knowledge and wrong cultural preconceptions about health, illness and treatment among patients could contributed to this perception. This study has been able to support existing knowledge that religion affiliation influence perception to end-of-life care [ 31 , 32 ]. While more Christian nurses are optimistic on the benefits of AD than Muslim nurses, more Muslim nurses believed they have a role to play in its initiation and execution than their Christians counterpart and thought AD had lesser flaws than the Christians. One of the tenets of Islam is to work for this life as if you were going to live forever and strive for the afterlife as if you were going to die tomorrow [ 33 ]. The Holy Qur’an also instructs Muslims to prepare and strategize their affairs. These may have influenced their perception that they have a greater role to play in the planning and implementation of the patient’s AD and support for AD. The Christian religion also supports AD as useful because it aids patients to avoid unbeneficial treatment [ 34 ].

In line with the theoretical explanation, the study had demonstrated that although AD has some benefits, such as quick decision-making, conflict resolution, and the prevention of wasteful spending; nurses as members of the healthcare team have a role to play in its initiation and implementation of AD. However, AD does have certain unintended consequences, which are its drawbacks [ 17 ].

This study has added to the corpus of research by identifying the perception of AD at the secondary healthcare facility in Nigeria and the chance that it will be adopted by nurses, who make up the majority of healthcare professionals. The study is limited by the use of the Likert scale to score nurses’ perceptions, which might have inhibited participants from fully expressing their perspectives on the matter. Further research should look into the acceptance of AD among terminally ill patients and their families as well as the amount of abuse or improper inducement of AD among healthcare professionals in secondary and tertiary healthcare facilities in Nigeria.

Making decisions in the final stages of life might be challenging, however AD may make these challenges easier. As a result, AD should be acknowledged in all healthcare sectors as a tool capable of granting patients’ liberty and dignity. Both in the public secondary healthcare unit and the private unit, nurses play a vital role as care providers in the development and execution of patient Ads. However, some of the difficulties in implementing AD that have been identified in this study should be addressed by stakeholders, and nurses at both sectors should be provided with necessary training on how to avoid these difficulties.

Availability of data and materials

Due to confidentiality rules, the datasets created and/or analyzed for the current work are not publically accessible, but they are available from the corresponding author upon justifiable request.

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Acknowledgements

The researchers appreciate the effort and interest of all the nurses who took part in the study, as well as the thoughtful criticism provided by the anonymous reviewers.

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OO made contributions to the concept, literature review, design, data collection, analysis, and findings discussion. AJ oversaw the study, contributed to the concept and design, and critically examined the report for key intellectual content. The final manuscript was read and approved by all writers.

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The Oyo State Research Ethics Review Committee, with reference number AD13/479/837, as well as the administrative head in each of the chosen hospitals and each participant, all approved this study. Every approach used in the study complied with the rules and regulations established by the institutional Research Committee for research involving people. All individuals participated in the study provided their written, informed consent.

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Ojedoyin, O.E., Jegede, A.S. A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria. BMC Med Ethics 23 , 87 (2022). https://doi.org/10.1186/s12910-022-00825-5

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DOI : https://doi.org/10.1186/s12910-022-00825-5

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• Correction: How to appraise quantitative research - April 01, 2019

• Xabi Cathala 1 ,
• Calvin Moorley 2
• 1 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• 2 Nursing Research and Diversity in Care , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Mr Xabi Cathala, Institute of Vocational Learning, School of Health and Social Care, London South Bank University London UK ; cathalax{at}lsbu.ac.uk and Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/eb-2018-102996

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Introduction

Some nurses feel that they lack the necessary skills to read a research paper and to then decide if they should implement the findings into their practice. This is particularly the case when considering the results of quantitative research, which often contains the results of statistical testing. However, nurses have a professional responsibility to critique research to improve their practice, care and patient safety. 1  This article provides a step by step guide on how to critically appraise a quantitative paper.

Title, keywords and the authors

The authors’ names may not mean much, but knowing the following will be helpful:

Their position, for example, academic, researcher or healthcare practitioner.

Their qualification, both professional, for example, a nurse or physiotherapist and academic (eg, degree, masters, doctorate).

This can indicate how the research has been conducted and the authors’ competence on the subject. Basically, do you want to read a paper on quantum physics written by a plumber?

The abstract is a resume of the article and should contain:

Introduction.

Research question/hypothesis.

Methods including sample design, tests used and the statistical analysis (of course! Remember we love numbers).

Main findings.

Conclusion.

The subheadings in the abstract will vary depending on the journal. An abstract should not usually be more than 300 words but this varies depending on specific journal requirements. If the above information is contained in the abstract, it can give you an idea about whether the study is relevant to your area of practice. However, before deciding if the results of a research paper are relevant to your practice, it is important to review the overall quality of the article. This can only be done by reading and critically appraising the entire article.

The introduction

Example: the effect of paracetamol on levels of pain.

My hypothesis is that A has an effect on B, for example, paracetamol has an effect on levels of pain.

My null hypothesis is that A has no effect on B, for example, paracetamol has no effect on pain.

My study will test the null hypothesis and if the null hypothesis is validated then the hypothesis is false (A has no effect on B). This means paracetamol has no effect on the level of pain. If the null hypothesis is rejected then the hypothesis is true (A has an effect on B). This means that paracetamol has an effect on the level of pain.

Background/literature review

The literature review should include reference to recent and relevant research in the area. It should summarise what is already known about the topic and why the research study is needed and state what the study will contribute to new knowledge. 5 The literature review should be up to date, usually 5–8 years, but it will depend on the topic and sometimes it is acceptable to include older (seminal) studies.

Methodology

In quantitative studies, the data analysis varies between studies depending on the type of design used. For example, descriptive, correlative or experimental studies all vary. A descriptive study will describe the pattern of a topic related to one or more variable. 6 A correlational study examines the link (correlation) between two variables 7  and focuses on how a variable will react to a change of another variable. In experimental studies, the researchers manipulate variables looking at outcomes 8  and the sample is commonly assigned into different groups (known as randomisation) to determine the effect (causal) of a condition (independent variable) on a certain outcome. This is a common method used in clinical trials.

There should be sufficient detail provided in the methods section for you to replicate the study (should you want to). To enable you to do this, the following sections are normally included:

Overview and rationale for the methodology.

Participants or sample.

Data collection tools.

Methods of data analysis.

Ethical issues.

Data collection should be clearly explained and the article should discuss how this process was undertaken. Data collection should be systematic, objective, precise, repeatable, valid and reliable. Any tool (eg, a questionnaire) used for data collection should have been piloted (or pretested and/or adjusted) to ensure the quality, validity and reliability of the tool. 9 The participants (the sample) and any randomisation technique used should be identified. The sample size is central in quantitative research, as the findings should be able to be generalised for the wider population. 10 The data analysis can be done manually or more complex analyses performed using computer software sometimes with advice of a statistician. From this analysis, results like mode, mean, median, p value, CI and so on are always presented in a numerical format.

The author(s) should present the results clearly. These may be presented in graphs, charts or tables alongside some text. You should perform your own critique of the data analysis process; just because a paper has been published, it does not mean it is perfect. Your findings may be different from the author’s. Through critical analysis the reader may find an error in the study process that authors have not seen or highlighted. These errors can change the study result or change a study you thought was strong to weak. To help you critique a quantitative research paper, some guidance on understanding statistical terminology is provided in  table 1 .

• View inline

Some basic guidance for understanding statistics

Quantitative studies examine the relationship between variables, and the p value illustrates this objectively.  11  If the p value is less than 0.05, the null hypothesis is rejected and the hypothesis is accepted and the study will say there is a significant difference. If the p value is more than 0.05, the null hypothesis is accepted then the hypothesis is rejected. The study will say there is no significant difference. As a general rule, a p value of less than 0.05 means, the hypothesis is accepted and if it is more than 0.05 the hypothesis is rejected.

The CI is a number between 0 and 1 or is written as a per cent, demonstrating the level of confidence the reader can have in the result. 12  The CI is calculated by subtracting the p value to 1 (1–p). If there is a p value of 0.05, the CI will be 1–0.05=0.95=95%. A CI over 95% means, we can be confident the result is statistically significant. A CI below 95% means, the result is not statistically significant. The p values and CI highlight the confidence and robustness of a result.

Discussion, recommendations and conclusion

The final section of the paper is where the authors discuss their results and link them to other literature in the area (some of which may have been included in the literature review at the start of the paper). This reminds the reader of what is already known, what the study has found and what new information it adds. The discussion should demonstrate how the authors interpreted their results and how they contribute to new knowledge in the area. Implications for practice and future research should also be highlighted in this section of the paper.

A few other areas you may find helpful are:

Limitations of the study.

Conflicts of interest.

Table 2 provides a useful tool to help you apply the learning in this paper to the critiquing of quantitative research papers.

Quantitative paper appraisal checklist

• 1. ↵ Nursing and Midwifery Council , 2015 . The code: standard of conduct, performance and ethics for nurses and midwives https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21.8.18 ).
• Gerrish K ,
• Moorley C ,
• Tunariu A , et al
• Shorten A ,

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Commissioned; internally peer reviewed.

Correction notice This article has been updated since its original publication to update p values from 0.5 to 0.05 throughout.

Linked Articles

• Miscellaneous Correction: How to appraise quantitative research BMJ Publishing Group Ltd and RCN Publishing Company Ltd Evidence-Based Nursing 2019; 22 62-62 Published Online First: 31 Jan 2019. doi: 10.1136/eb-2018-102996corr1

Read the full text or download the PDF:

Nursing Students' Academic Success Factors: A Quantitative Cross-sectional Study

Affiliation.

• 1 Author Affiliations: Instructor III (Ms Brown), Faculty of Nursing, University of Regina; Faculty (Ms McDonald), School of Nursing, Saskatchewan Polytechnic; Assistant Professor (Ms Besse), College of Nursing, University of Saskatchewan, Saskatoon; Faculty (Ms Manson), School of Nursing, Saskatchewan Polytechnic; Black Spruce Analytics Ltd (Mr McDonald); Associate Professor (Dr Rohatinsky), College of Nursing, University of Saskatchewan; Research Assistant (Ms Singh), Faculty of Nursing, University of Regina, Saskatoon, Saskatchewan, Canada.
• PMID: 32530904
• DOI: 10.1097/NNE.0000000000000882

Background: Attrition from nursing programs is an ongoing concern. Capitalizing on nursing students' strengths and supporting areas for remediation will maximize student success.

Purpose: This study explored undergraduate nursing student strengths and areas for remediation at program entry and across all years of nursing education study.

Methods: We used a cross-sectional design and collected data via the Academic Success Inventory for College Students survey tool. Baseline data were collected on first-year students after program start, and data were collected for all years of study at the end of the academic terms.

Results: Compared with other undergraduate students, nursing students exhibited strengths in study skills, in self-organization strategies, in their certainty of progress toward career goals, in recognizing the importance of their studies, and in levels of socializing that did not hinder academic performance. At some data collection points, they had strengths in motivation, confidence, and concentration. Nursing students indicated areas for remediation in studying or test-taking anxiety and their perception of the educator's ability to organize, teach, and assess student progress.

Conclusion: Nurse educators' pedagogical approaches should augment nursing student strengths. Remediation is required to support student success relative to anxiety, and students need orientation to the process of learning.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

• Academic Success*
• Cross-Sectional Studies
• Education, Nursing, Baccalaureate*
• Nursing Education Research
• Nursing Evaluation Research
• Students, Nursing* / psychology

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

See "Examples of Qualitative and Quantitative" page under "Nursing Research" for more information.

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Examples of Qualitative vs Quantitiative

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• v.4(Suppl 1); 2019

Synthesising quantitative and qualitative evidence to inform guidelines on complex interventions: clarifying the purposes, designs and outlining some methods

1 School of Social Sciences, Bangor University, Wales, UK

Andrew Booth

2 School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK

Graham Moore

3 School of Social Sciences, Cardiff University, Wales, UK

Kate Flemming

4 Department of Health Sciences, The University of York, York, UK

Özge Tunçalp

5 Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland

Elham Shakibazadeh

6 Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Associated Data

bmjgh-2018-000893supp001.pdf

bmjgh-2018-000893supp002.pdf

bmjgh-2018-000893supp003.pdf

bmjgh-2018-000893supp005.pdf

bmjgh-2018-000893supp004.pdf

Guideline developers are increasingly dealing with more difficult decisions concerning whether to recommend complex interventions in complex and highly variable health systems. There is greater recognition that both quantitative and qualitative evidence can be combined in a mixed-method synthesis and that this can be helpful in understanding how complexity impacts on interventions in specific contexts. This paper aims to clarify the different purposes, review designs, questions, synthesis methods and opportunities to combine quantitative and qualitative evidence to explore the complexity of complex interventions and health systems. Three case studies of guidelines developed by WHO, which incorporated quantitative and qualitative evidence, are used to illustrate possible uses of mixed-method reviews and evidence. Additional examples of methods that can be used or may have potential for use in a guideline process are outlined. Consideration is given to the opportunities for potential integration of quantitative and qualitative evidence at different stages of the review and guideline process. Encouragement is given to guideline commissioners and developers and review authors to consider including quantitative and qualitative evidence. Recommendations are made concerning the future development of methods to better address questions in systematic reviews and guidelines that adopt a complexity perspective.

Summary box

• When combined in a mixed-method synthesis, quantitative and qualitative evidence can potentially contribute to understanding how complex interventions work and for whom, and how the complex health systems into which they are implemented respond and adapt.
• The different purposes and designs for combining quantitative and qualitative evidence in a mixed-method synthesis for a guideline process are described.
• Questions relevant to gaining an understanding of the complexity of complex interventions and the wider health systems within which they are implemented that can be addressed by mixed-method syntheses are presented.
• The practical methodological guidance in this paper is intended to help guideline producers and review authors commission and conduct mixed-method syntheses where appropriate.
• If more mixed-method syntheses are conducted, guideline developers will have greater opportunities to access this evidence to inform decision-making.

Introduction

Recognition has grown that while quantitative methods remain vital, they are usually insufficient to address complex health systems related research questions. 1 Quantitative methods rely on an ability to anticipate what must be measured in advance. Introducing change into a complex health system gives rise to emergent reactions, which cannot be fully predicted in advance. Emergent reactions can often only be understood through combining quantitative methods with a more flexible qualitative lens. 2 Adopting a more pluralist position enables a diverse range of research options to the researcher depending on the research question being investigated. 3–5 As a consequence, where a research study sits within the multitude of methods available is driven by the question being asked, rather than any particular methodological or philosophical stance. 6

Publication of guidance on designing complex intervention process evaluations and other works advocating mixed-methods approaches to intervention research have stimulated better quality evidence for synthesis. 1 7–13 Methods for synthesising qualitative 14 and mixed-method evidence have been developed or are in development. Mixed-method research and review definitions are outlined in box 1 .

Defining mixed-method research and reviews

Pluye and Hong 52 define mixed-methods research as “a research approach in which a researcher integrates (a) qualitative and quantitative research questions, (b) qualitative research methods* and quantitative research designs, (c) techniques for collecting and analyzing qualitative and quantitative evidence, and (d) qualitative findings and quantitative results”.A mixed-method synthesis can integrate quantitative, qualitative and mixed-method evidence or data from primary studies.† Mixed-method primary studies are usually disaggregated into quantitative and qualitative evidence and data for the purposes of synthesis. Thomas and Harden further define three ways in which reviews are mixed. 53

• The types of studies included and hence the type of findings to be synthesised (ie, qualitative/textual and quantitative/numerical).
• The types of synthesis method used (eg, statistical meta-analysis and qualitative synthesis).
• The mode of analysis: theory testing AND theory building.

*A qualitative study is one that uses qualitative methods of data collection and analysis to produce a narrative understanding of the phenomena of interest. Qualitative methods of data collection may include, for example, interviews, focus groups, observations and analysis of documents.

†The Cochrane Qualitative and Implementation Methods group coined the term ‘qualitative evidence synthesis’ to mean that the synthesis could also include qualitative data. For example, qualitative data from case studies, grey literature reports and open-ended questions from surveys. ‘Evidence’ and ‘data’ are used interchangeably in this paper.

This paper is one of a series that aims to explore the implications of complexity for systematic reviews and guideline development, commissioned by WHO. This paper is concerned with the methodological implications of including quantitative and qualitative evidence in mixed-method systematic reviews and guideline development for complex interventions. The guidance was developed through a process of bringing together experts in the field, literature searching and consensus building with end users (guideline developers, clinicians and reviewers). We clarify the different purposes, review designs, questions and synthesis methods that may be applicable to combine quantitative and qualitative evidence to explore the complexity of complex interventions and health systems. Three case studies of WHO guidelines that incorporated quantitative and qualitative evidence are used to illustrate possible uses of mixed-method reviews and mechanisms of integration ( table 1 , online supplementary files 1–3 ). Additional examples of methods that can be used or may have potential for use in a guideline process are outlined. Opportunities for potential integration of quantitative and qualitative evidence at different stages of the review and guideline process are presented. Specific considerations when using an evidence to decision framework such as the Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence (DECIDE) framework 15 or the new WHO-INTEGRATE evidence to decision framework 16 at the review design and evidence to decision stage are outlined. See online supplementary file 4 for an example of a health systems DECIDE framework and Rehfuess et al 16 for the new WHO-INTEGRATE framework. Encouragement is given to guideline commissioners and developers and review authors to consider including quantitative and qualitative evidence in guidelines of complex interventions that take a complexity perspective and health systems focus.

Designs and methods and their use or applicability in guidelines and systematic reviews taking a complexity perspective

Supplementary data

Taking a complexity perspective.

The first paper in this series 17 outlines aspects of complexity associated with complex interventions and health systems that can potentially be explored by different types of evidence, including synthesis of quantitative and qualitative evidence. Petticrew et al 17 distinguish between a complex interventions perspective and a complex systems perspective. A complex interventions perspective defines interventions as having “implicit conceptual boundaries, representing a flexible, but common set of practices, often linked by an explicit or implicit theory about how they work”. A complex systems perspective differs in that “ complexity arises from the relationships and interactions between a system’s agents (eg, people, or groups that interact with each other and their environment), and its context. A system perspective conceives the intervention as being part of the system, and emphasises changes and interconnections within the system itself”. Aspects of complexity associated with implementation of complex interventions in health systems that could potentially be addressed with a synthesis of quantitative and qualitative evidence are summarised in table 2 . Another paper in the series outlines criteria used in a new evidence to decision framework for making decisions about complex interventions implemented in complex systems, against which the need for quantitative and qualitative evidence can be mapped. 16 A further paper 18 that explores how context is dealt with in guidelines and reviews taking a complexity perspective also recommends using both quantitative and qualitative evidence to better understand context as a source of complexity. Mixed-method syntheses of quantitative and qualitative evidence can also help with understanding of whether there has been theory failure and or implementation failure. The Cochrane Qualitative and Implementation Methods Group provide additional guidance on exploring implementation and theory failure that can be adapted to address aspects of complexity of complex interventions when implemented in health systems. 19

Health-system complexity-related questions that a synthesis of quantitative and qualitative evidence could address (derived from Petticrew et al 17 )

It may not be apparent which aspects of complexity or which elements of the complex intervention or health system can be explored in a guideline process, or whether combining qualitative and quantitative evidence in a mixed-method synthesis will be useful, until the available evidence is scoped and mapped. 17 20 A more extensive lead in phase is typically required to scope the available evidence, engage with stakeholders and to refine the review parameters and questions that can then be mapped against potential review designs and methods of synthesis. 20 At the scoping stage, it is also common to decide on a theoretical perspective 21 or undertake further work to refine a theoretical perspective. 22 This is also the stage to begin articulating the programme theory of the complex intervention that may be further developed to refine an understanding of complexity and show how the intervention is implemented in and impacts on the wider health system. 17 23 24 In practice, this process can be lengthy, iterative and fluid with multiple revisions to the review scope, often developing and adapting a logic model 17 as the available evidence becomes known and the potential to incorporate different types of review designs and syntheses of quantitative and qualitative evidence becomes better understood. 25 Further questions, propositions or hypotheses may emerge as the reviews progress and therefore the protocols generally need to be developed iteratively over time rather than a priori.

Following a scoping exercise and definition of key questions, the next step in the guideline development process is to identify existing or commission new systematic reviews to locate and summarise the best available evidence in relation to each question. For example, case study 2, ‘Optimising health worker roles for maternal and newborn health through task shifting’, included quantitative reviews that did and did not take an additional complexity perspective, and qualitative evidence syntheses that were able to explain how specific elements of complexity impacted on intervention outcomes within the wider health system. Further understanding of health system complexity was facilitated through the conduct of additional country-level case studies that contributed to an overall understanding of what worked and what happened when lay health worker interventions were implemented. See table 1 online supplementary file 2 .

There are a few existing examples, which we draw on in this paper, but integrating quantitative and qualitative evidence in a mixed-method synthesis is relatively uncommon in a guideline process. Box 2 includes a set of key questions that guideline developers and review authors contemplating combining quantitative and qualitative evidence in mixed-methods design might ask. Subsequent sections provide more information and signposting to further reading to help address these key questions.

Key questions that guideline developers and review authors contemplating combining quantitative and qualitative evidence in a mixed-methods design might ask

Compound questions requiring both quantitative and qualitative evidence?

Questions requiring mixed-methods studies?

Separate quantitative and qualitative questions?

Separate quantitative and qualitative research studies?

Related quantitative and qualitative research studies?

Mixed-methods studies?

Quantitative unpublished data and/or qualitative unpublished data, eg, narrative survey data?

Throughout the review?

Following separate reviews?

At the question point?

At the synthesis point?

At the evidence to recommendations stage?

Or a combination?

Narrative synthesis or summary?

Quantitising approach, eg, frequency analysis?

Qualitising approach, eg, thematic synthesis?

Tabulation?

Logic model?

Conceptual model/framework?

Graphical approach?

• WHICH: Which mixed-method designs, methodologies and methods best fit into a guideline process to inform recommendations?

Complexity-related questions that a synthesis of quantitative and qualitative evidence can potentially address

Petticrew et al 17 define the different aspects of complexity and examples of complexity-related questions that can potentially be explored in guidelines and systematic reviews taking a complexity perspective. Relevant aspects of complexity outlined by Petticrew et al 17 are summarised in table 2 below, together with the corresponding questions that could be addressed in a synthesis combining qualitative and quantitative evidence. Importantly, the aspects of complexity and their associated concepts of interest have however yet to be translated fully in primary health research or systematic reviews. There are few known examples where selected complexity concepts have been used to analyse or reanalyse a primary intervention study. Most notable is Chandler et al 26 who specifically set out to identify and translate a set of relevant complexity theory concepts for application in health systems research. Chandler then reanalysed a trial process evaluation using selected complexity theory concepts to better understand the complex causal pathway in the health system that explains some aspects of complexity in table 2 .

Rehfeuss et al 16 also recommends upfront consideration of the WHO-INTEGRATE evidence to decision criteria when planning a guideline and formulating questions. The criteria reflect WHO norms and values and take account of a complexity perspective. The framework can be used by guideline development groups as a menu to decide which criteria to prioritise, and which study types and synthesis methods can be used to collect evidence for each criterion. Many of the criteria and their related questions can be addressed using a synthesis of quantitative and qualitative evidence: the balance of benefits and harms, human rights and sociocultural acceptability, health equity, societal implications and feasibility (see table 3 ). Similar aspects in the DECIDE framework 15 could also be addressed using synthesis of qualitative and quantitative evidence.

Integrate evidence to decision framework criteria, example questions and types of studies to potentially address these questions (derived from Rehfeuss et al 16 )

GIS, Geographical Information System; RCT, randomised controlled trial.

Questions as anchors or compasses

Questions can serve as an ‘anchor’ by articulating the specific aspects of complexity to be explored (eg, Is successful implementation of the intervention context dependent?). 27 Anchor questions such as “How does intervention x impact on socioeconomic inequalities in health behaviour/outcome x” are the kind of health system question that requires a synthesis of both quantitative and qualitative evidence and hence a mixed-method synthesis. Quantitative evidence can quantify the difference in effect, but does not answer the question of how . The ‘how’ question can be partly answered with quantitative and qualitative evidence. For example, quantitative evidence may reveal where socioeconomic status and inequality emerges in the health system (an emergent property) by exploring questions such as “ Does patterning emerge during uptake because fewer people from certain groups come into contact with an intervention in the first place? ” or “ are people from certain backgrounds more likely to drop out, or to maintain effects beyond an intervention differently? ” Qualitative evidence may help understand the reasons behind all of these mechanisms. Alternatively, questions can act as ‘compasses’ where a question sets out a starting point from which to explore further and to potentially ask further questions or develop propositions or hypotheses to explore through a complexity perspective (eg, What factors enhance or hinder implementation?). 27 Other papers in this series provide further guidance on developing questions for qualitative evidence syntheses and guidance on question formulation. 14 28

For anchor and compass questions, additional application of a theory (eg, complexity theory) can help focus evidence synthesis and presentation to explore and explain complexity issues. 17 21 Development of a review specific logic model(s) can help to further refine an initial understanding of any complexity-related issues of interest associated with a specific intervention, and if appropriate the health system or section of the health system within which to contextualise the review question and analyse data. 17 23–25 Specific tools are available to help clarify context and complex interventions. 17 18

If a complexity perspective, and certain criteria within evidence to decision frameworks, is deemed relevant and desirable by guideline developers, it is only possible to pursue a complexity perspective if the evidence is available. Careful scoping using knowledge maps or scoping reviews will help inform development of questions that are answerable with available evidence. 20 If evidence of effect is not available, then a different approach to develop questions leading to a more general narrative understanding of what happened when complex interventions were implemented in a health system will be required (such as in case study 3—risk communication guideline). This should not mean that the original questions developed for which no evidence was found when scoping the literature were not important. An important function of creating a knowledge map is also to identify gaps to inform a future research agenda.

Table 2 and online supplementary files 1–3 outline examples of questions in the three case studies, which were all ‘COMPASS’ questions for the qualitative evidence syntheses.

Types of integration and synthesis designs in mixed-method reviews

The shift towards integration of qualitative and quantitative evidence in primary research has, in recent years, begun to be mirrored within research synthesis. 29–31 The natural extension to undertaking quantitative or qualitative reviews has been the development of methods for integrating qualitative and quantitative evidence within reviews, and within the guideline process using evidence to decision-frameworks. Advocating the integration of quantitative and qualitative evidence assumes a complementarity between research methodologies, and a need for both types of evidence to inform policy and practice. Below, we briefly outline the current designs for integrating qualitative and quantitative evidence within a mixed-method review or synthesis.

One of the early approaches to integrating qualitative and quantitative evidence detailed by Sandelowski et al 32 advocated three basic review designs: segregated, integrated and contingent designs, which have been further developed by Heyvaert et al 33 ( box 3 ).

Segregated, integrated and contingent designs 32 33

Segregated design.

Conventional separate distinction between quantitative and qualitative approaches based on the assumption they are different entities and should be treated separately; can be distinguished from each other; their findings warrant separate analyses and syntheses. Ultimately, the separate synthesis results can themselves be synthesised.

Integrated design

The methodological differences between qualitative and quantitative studies are minimised as both are viewed as producing findings that can be readily synthesised into one another because they address the same research purposed and questions. Transformation involves either turning qualitative data into quantitative (quantitising) or quantitative findings are turned into qualitative (qualitising) to facilitate their integration.

Contingent design

Takes a cyclical approach to synthesis, with the findings from one synthesis informing the focus of the next synthesis, until all the research objectives have been addressed. Studies are not necessarily grouped and categorised as qualitative or quantitative.

A recent review of more than 400 systematic reviews 34 combining quantitative and qualitative evidence identified two main synthesis designs—convergent and sequential. In a convergent design, qualitative and quantitative evidence is collated and analysed in a parallel or complementary manner, whereas in a sequential synthesis, the collation and analysis of quantitative and qualitative evidence takes place in a sequence with one synthesis informing the other ( box 4 ). 6 These designs can be seen to build on the work of Sandelowski et al , 32 35 particularly in relation to the transformation of data from qualitative to quantitative (and vice versa) and the sequential synthesis design, with a cyclical approach to reviewing that evokes Sandelowski’s contingent design.

Convergent and sequential synthesis designs 34

Convergent synthesis design.

Qualitative and quantitative research is collected and analysed at the same time in a parallel or complementary manner. Integration can occur at three points:

a. Data-based convergent synthesis design

All included studies are analysed using the same methods and results presented together. As only one synthesis method is used, data transformation occurs (qualitised or quantised). Usually addressed one review question.

b. Results-based convergent synthesis design

Qualitative and quantitative data are analysed and presented separately but integrated using a further synthesis method; eg, narratively, tables, matrices or reanalysing evidence. The results of both syntheses are combined in a third synthesis. Usually addresses an overall review question with subquestions.

c. Parallel-results convergent synthesis design

Qualitative and quantitative data are analysed and presented separately with integration occurring in the interpretation of results in the discussion section. Usually addresses two or more complimentary review questions.

Sequential synthesis design

A two-phase approach, data collection and analysis of one type of evidence (eg, qualitative), occurs after and is informed by the collection and analysis of the other type (eg, quantitative). Usually addresses an overall question with subquestions with both syntheses complementing each other.

The three case studies ( table 1 , online supplementary files 1–3 ) illustrate the diverse combination of review designs and synthesis methods that were considered the most appropriate for specific guidelines.

Methods for conducting mixed-method reviews in the context of guidelines for complex interventions

In this section, we draw on examples where specific review designs and methods have been or can be used to explore selected aspects of complexity in guidelines or systematic reviews. We also identify other review methods that could potentially be used to explore aspects of complexity. Of particular note, we could not find any specific examples of systematic methods to synthesise highly diverse research designs as advocated by Petticrew et al 17 and summarised in tables 2 and 3 . For example, we could not find examples of methods to synthesise qualitative studies, case studies, quantitative longitudinal data, possibly historical data, effectiveness studies providing evidence of differential effects across different contexts, and system modelling studies (eg, agent-based modelling) to explore system adaptivity.

There are different ways that quantitative and qualitative evidence can be integrated into a review and then into a guideline development process. In practice, some methods enable integration of different types of evidence in a single synthesis, while in other methods, the single systematic review may include a series of stand-alone reviews or syntheses that are then combined in a cross-study synthesis. Table 1 provides an overview of the characteristics of different review designs and methods and guidance on their applicability for a guideline process. Designs and methods that have already been used in WHO guideline development are described in part A of the table. Part B outlines a design and method that can be used in a guideline process, and part C covers those that have the potential to integrate quantitative, qualitative and mixed-method evidence in a single review design (such as meta-narrative reviews and Bayesian syntheses), but their application in a guideline context has yet to be demonstrated.

Points of integration when integrating quantitative and qualitative evidence in guideline development

Depending on the review design (see boxes 3 and 4 ), integration can potentially take place at a review team and design level, and more commonly at several key points of the review or guideline process. The following sections outline potential points of integration and associated practical considerations when integrating quantitative and qualitative evidence in guideline development.

Review team level

In a guideline process, it is common for syntheses of quantitative and qualitative evidence to be done separately by different teams and then to integrate the evidence. A practical consideration relates to the organisation, composition and expertise of the review teams and ways of working. If the quantitative and qualitative reviews are being conducted separately and then brought together by the same team members, who are equally comfortable operating within both paradigms, then a consistent approach across both paradigms becomes possible. If, however, a team is being split between the quantitative and qualitative reviews, then the strengths of specialisation can be harnessed, for example, in quality assessment or synthesis. Optimally, at least one, if not more, of the team members should be involved in both quantitative and qualitative reviews to offer the possibility of making connexions throughout the review and not simply at re-agreed junctures. This mirrors O’Cathain’s conclusion that mixed-methods primary research tends to work only when there is a principal investigator who values and is able to oversee integration. 9 10 While the above decisions have been articulated in the context of two types of evidence, variously quantitative and qualitative, they equally apply when considering how to handle studies reporting a mixed-method study design, where data are usually disaggregated into quantitative and qualitative for the purposes of synthesis (see case study 3—risk communication in humanitarian disasters).

Question formulation

Clearly specified key question(s), derived from a scoping or consultation exercise, will make it clear if quantitative and qualitative evidence is required in a guideline development process and which aspects will be addressed by which types of evidence. For the remaining stages of the process, as documented below, a review team faces challenges as to whether to handle each type of evidence separately, regardless of whether sequentially or in parallel, with a view to joining the two products on completion or to attempt integration throughout the review process. In each case, the underlying choice is of efficiencies and potential comparability vs sensitivity to the underlying paradigm.

Once key questions are clearly defined, the guideline development group typically needs to consider whether to conduct a single sensitive search to address all potential subtopics (lumping) or whether to conduct specific searches for each subtopic (splitting). 36 A related consideration is whether to search separately for qualitative, quantitative and mixed-method evidence ‘streams’ or whether to conduct a single search and then identify specific study types at the subsequent sifting stage. These two considerations often mean a trade-off between a single search process involving very large numbers of records or a more protracted search process retrieving smaller numbers of records. Both approaches have advantages and choice may depend on the respective availability of resources for searching and sifting.

Screening and selecting studies

Closely related to decisions around searching are considerations relating to screening and selecting studies for inclusion in a systematic review. An important consideration here is whether the review team will screen records for all review types, regardless of their subsequent involvement (‘altruistic sifting’), or specialise in screening for the study type with which they are most familiar. The risk of missing relevant reports might be minimised by whole team screening for empirical reports in the first instance and then coding them for a specific quantitative, qualitative or mixed-methods report at a subsequent stage.

Assessment of methodological limitations in primary studies

Within a guideline process, review teams may be more limited in their choice of instruments to assess methodological limitations of primary studies as there are mandatory requirements to use the Cochrane risk of bias tool 37 to feed into Grading of Recommendations Assessment, Development and Evaluation (GRADE) 38 or to select from a small pool of qualitative appraisal instruments in order to apply GRADE; Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) 39 to assess the overall certainty or confidence in findings. The Cochrane Qualitative and Implementation Methods Group has recently issued guidance on the selection of appraisal instruments and core assessment criteria. 40 The Mixed-Methods Appraisal Tool, which is currently undergoing further development, offers a single quality assessment instrument for quantitative, qualitative and mixed-methods studies. 41 Other options include using corresponding instruments from within the same ‘stable’, for example, using different Critical Appraisal Skills Programme instruments. 42 While using instruments developed by the same team or organisation may achieve a degree of epistemological consonance, benefits may come more from consistency of approach and reporting rather than from a shared view of quality. Alternatively, a more paradigm-sensitive approach would involve selecting the best instrument for each respective review while deferring challenges from later heterogeneity of reporting.

Data extraction

The way in which data and evidence are extracted from primary research studies for review will be influenced by the type of integrated synthesis being undertaken and the review purpose. Initially, decisions need to be made regarding the nature and type of data and evidence that are to be extracted from the included studies. Method-specific reporting guidelines 43 44 provide a good template as to what quantitative and qualitative data it is potentially possible to extract from different types of method-specific study reports, although in practice reporting quality varies. Online supplementary file 5 provides a hypothetical example of the different types of studies from which quantitative and qualitative evidence could potentially be extracted for synthesis.

The decisions around what data or evidence to extract will be guided by how ‘integrated’ the mixed-method review will be. For those reviews where the quantitative and qualitative findings of studies are synthesised separately and integrated at the point of findings (eg, segregated or contingent approaches or sequential synthesis design), separate data extraction approaches will likely be used.

Where integration occurs during the process of the review (eg, integrated approach or convergent synthesis design), an integrated approach to data extraction may be considered, depending on the purpose of the review. This may involve the use of a data extraction framework, the choice of which needs to be congruent with the approach to synthesis chosen for the review. 40 45 The integrative or theoretical framework may be decided on a priori if a pre-developed theoretical or conceptual framework is available in the literature. 27 The development of a framework may alternatively arise from the reading of the included studies, in relation to the purpose of the review, early in the process. The Cochrane Qualitative and Implementation Methods Group provide further guidance on extraction of qualitative data, including use of software. 40

Synthesis and integration

Relatively few synthesis methods start off being integrated from the beginning, and these methods have generally been subject to less testing and evaluation particularly in a guideline context (see table 1 ). A review design that started off being integrated from the beginning may be suitable for some guideline contexts (such as in case study 3—risk communication in humanitarian disasters—where there was little evidence of effect), but in general if there are sufficient trials then a separate systematic review and meta-analysis will be required for a guideline. Other papers in this series offer guidance on methods for synthesising quantitative 46 and qualitative evidence 14 in reviews that take a complexity perspective. Further guidance on integrating quantitative and qualitative evidence in a systematic review is provided by the Cochrane Qualitative and Implementation Methods Group. 19 27 29 40 47

Types of findings produced by specific methods

It is highly likely (unless there are well-designed process evaluations) that the primary studies may not themselves seek to address the complexity-related questions required for a guideline process. In which case, review authors will need to configure the available evidence and transform the evidence through the synthesis process to produce explanations, propositions and hypotheses (ie, findings) that were not obvious at primary study level. It is important that guideline commissioners, developers and review authors are aware that specific methods are intended to produce a type of finding with a specific purpose (such as developing new theory in the case of meta-ethnography). 48 Case study 1 (antenatal care guideline) provides an example of how a meta-ethnography was used to develop a new theory as an end product, 48 49 as well as framework synthesis which produced descriptive and explanatory findings that were more easily incorporated into the guideline process. 27 The definitions ( box 5 ) may be helpful when defining the different types of findings.

Different levels of findings

Descriptive findings —qualitative evidence-driven translated descriptive themes that do not move beyond the primary studies.

Explanatory findings —may either be at a descriptive or theoretical level. At the descriptive level, qualitative evidence is used to explain phenomena observed in quantitative results, such as why implementation failed in specific circumstances. At the theoretical level, the transformed and interpreted findings that go beyond the primary studies can be used to explain the descriptive findings. The latter description is generally the accepted definition in the wider qualitative community.

Hypothetical or theoretical finding —qualitative evidence-driven transformed themes (or lines of argument) that go beyond the primary studies. Although similar, Thomas and Harden 56 make a distinction in the purposes between two types of theoretical findings: analytical themes and the product of meta-ethnographies, third-order interpretations. 48

Analytical themes are a product of interrogating descriptive themes by placing the synthesis within an external theoretical framework (such as the review question and subquestions) and are considered more appropriate when a specific review question is being addressed (eg, in a guideline or to inform policy). 56

Third-order interpretations come from translating studies into one another while preserving the original context and are more appropriate when a body of literature is being explored in and of itself with broader or emergent review questions. 48

Bringing mixed-method evidence together in evidence to decision (EtD) frameworks

A critical element of guideline development is the formulation of recommendations by the Guideline Development Group, and EtD frameworks help to facilitate this process. 16 The EtD framework can also be used as a mechanism to integrate and display quantitative and qualitative evidence and findings mapped against the EtD framework domains with hyperlinks to more detailed evidence summaries from contributing reviews (see table 1 ). It is commonly the EtD framework that enables the findings of the separate quantitative and qualitative reviews to be brought together in a guideline process. Specific challenges when populating the DECIDE evidence to decision framework 15 were noted in case study 3 (risk communication in humanitarian disasters) as there was an absence of intervention effect data and the interventions to communicate public health risks were context specific and varied. These problems would not, however, have been addressed by substitution of the DECIDE framework with the new INTEGRATE 16 evidence to decision framework. A d ifferent type of EtD framework needs to be developed for reviews that do not include sufficient evidence of intervention effect.

Mixed-method review and synthesis methods are generally the least developed of all systematic review methods. It is acknowledged that methods for combining quantitative and qualitative evidence are generally poorly articulated. 29 50 There are however some fairly well-established methods for using qualitative evidence to explore aspects of complexity (such as contextual, implementation and outcome complexity), which can be combined with evidence of effect (see sections A and B of table 1 ). 14 There are good examples of systematic reviews that use these methods to combine quantitative and qualitative evidence, and examples of guideline recommendations that were informed by evidence from both quantitative and qualitative reviews (eg, case studies 1–3). With the exception of case study 3 (risk communication), the quantitative and qualitative reviews for these specific guidelines have been conducted separately, and the findings subsequently brought together in an EtD framework to inform recommendations.

Other mixed-method review designs have potential to contribute to understanding of complex interventions and to explore aspects of wider health systems complexity but have not been sufficiently developed and tested for this specific purpose, or used in a guideline process (section C of table 1 ). Some methods such as meta-narrative reviews also explore different questions to those usually asked in a guideline process. Methods for processing (eg, quality appraisal) and synthesising the highly diverse evidence suggested in tables 2 and 3 that are required to explore specific aspects of health systems complexity (such as system adaptivity) and to populate some sections of the INTEGRATE EtD framework remain underdeveloped or in need of development.

In addition to the required methodological development mentioned above, there is no GRADE approach 38 for assessing confidence in findings developed from combined quantitative and qualitative evidence. Another paper in this series outlines how to deal with complexity and grading different types of quantitative evidence, 51 and the GRADE CERQual approach for qualitative findings is described elsewhere, 39 but both these approaches are applied to method-specific and not mixed-method findings. An unofficial adaptation of GRADE was used in the risk communication guideline that reported mixed-method findings. Nor is there a reporting guideline for mixed-method reviews, 47 and for now reports will need to conform to the relevant reporting requirements of the respective method-specific guideline. There is a need to further adapt and test DECIDE, 15 WHO-INTEGRATE 16 and other types of evidence to decision frameworks to accommodate evidence from mixed-method syntheses which do not set out to determine the statistical effects of interventions and in circumstances where there are no trials.

When conducting quantitative and qualitative reviews that will subsequently be combined, there are specific considerations for managing and integrating the different types of evidence throughout the review process. We have summarised different options for combining qualitative and quantitative evidence in mixed-method syntheses that guideline developers and systematic reviewers can choose from, as well as outlining the opportunities to integrate evidence at different stages of the review and guideline development process.

Review commissioners, authors and guideline developers generally have less experience of combining qualitative and evidence in mixed-methods reviews. In particular, there is a relatively small group of reviewers who are skilled at undertaking fully integrated mixed-method reviews. Commissioning additional qualitative and mixed-method reviews creates an additional cost. Large complex mixed-method reviews generally take more time to complete. Careful consideration needs to be given as to which guidelines would benefit most from additional qualitative and mixed-method syntheses. More training is required to develop capacity and there is a need to develop processes for preparing the guideline panel to consider and use mixed-method evidence in their decision-making.

This paper has presented how qualitative and quantitative evidence, combined in mixed-method reviews, can help understand aspects of complex interventions and the systems within which they are implemented. There are further opportunities to use these methods, and to further develop the methods, to look more widely at additional aspects of complexity. There is a range of review designs and synthesis methods to choose from depending on the question being asked or the questions that may emerge during the conduct of the synthesis. Additional methods need to be developed (or existing methods further adapted) in order to synthesise the full range of diverse evidence that is desirable to explore the complexity-related questions when complex interventions are implemented into health systems. We encourage review commissioners and authors, and guideline developers to consider using mixed-methods reviews and synthesis in guidelines and to report on their usefulness in the guideline development process.

Handling editor: Soumyadeep Bhaumik

Contributors: JN, AB, GM, KF, ÖT and ES drafted the manuscript. All authors contributed to paper development and writing and agreed the final manuscript. Anayda Portela and Susan Norris from WHO managed the series. Helen Smith was series Editor. We thank all those who provided feedback on various iterations.

Funding: Funding provided by the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health through grants received from the United States Agency for International Development and the Norwegian Agency for Development Cooperation.

Disclaimer: ÖT is a staff member of WHO. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO.

Competing interests: No financial interests declared. JN, AB and ÖT have an intellectual interest in GRADE CERQual; and JN has an intellectual interest in the iCAT_SR tool.

Patient consent: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: No additional data are available.

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