Kate Flemming

The University of York, York, England, United Kingdom

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Publications (32)108.47 Total impact

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    ABSTRACT: Smoking in pregnancy can cause substantial harm and, while many women quit, others continue to smoke throughout pregnancy. The role of partners is an important but relatively under-researched factor in relation to women's smoking in pregnancy; partner's smoking status and attitudes to smoking cessation are important influences in a pregnant women's attempt to quit. Further understanding of how partners perceive the barriers and facilitators to smoking cessation in pregnancy is needed, particularly from qualitative studies where participants describe these issues in their own words. A synthesis of qualitative research of partners' views of smoking in pregnancy and post-partum was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2014 using terms for partner/household, pregnancy, post-partum, smoking, qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement. Nine studies reported in 14 papers were included, detailing the experience of 158 partners; the majority were interviewed during the post-partum period. Partners were all male, with a single exception. Socioeconomic measures indicated that most participants were socially disadvantaged. The synthesis identified recurring smoking-related perceptions and experiences that hindered (barriers) and encouraged (facilitators) partners to consider quitting during the woman's pregnancy and into the post-partum period. These were represented in five lines of argument relating to: smoking being an integral part of everyday life; becoming and being a father; the couple's relationship; perceptions of the risks of smoking; and their harm reduction and quitting strategies. The cluster of identified barriers and facilitators to quitting offers pointers for policy and practice. The workplace emerges as an important space for and influence on partners' smoking habits, suggesting alternative cessation intervention locations for future parents. Conversely, health and community settings are seen to offer little support to fathers. Interventions centred on valued personal traits, like will-power and autonomy, may have particular salience. The review points, too, to the potential for health information that directly addresses perceived weaknesses in official advice, for example, around causal mechanisms and effects and around contrary evidence of healthy babies born to smokers. PROSPERO 2013: CRD42013004170.
    Full-text · Article · Sep 2015 · BMC Public Health
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    ABSTRACT: To ensure that decisions to start and stop dialysis in ESRD are shared, the factors that affect patients and health care professionals in making such decisions must be understood. This systematic review sought to explore how and why different factors mediate the choices about dialysis treatment. MEDLINE, Embase, CINAHL, and PsychINFO were searched for qualitative studies of factors that affect patients' or health care professionals' decisions to commence or withdraw from dialysis. A thematic synthesis was conducted. Of 494 articles screened, 12 studies (conducted from 1985 to 2014) were included. These involved 206 patients (most receiving hemodialysis) and 64 health care professionals (age ranges: patients, 26-93 years; professionals, 26-61 years). For commencing dialysis, patients based their choice on "gut instinct," as well as deliberating over the effect of treatment on quality of life and survival. How individuals coped with decision-making was influential: Some tried to take control of the problem of progressive renal failure, whereas others focused on controlling their emotions. Health care professionals weighed biomedical factors and were led by an instinct to prolong life. Both patients and health care professionals described feeling powerless. With regard to dialysis withdrawal, only after prolonged periods on dialysis were the realities of life on dialysis fully appreciated and past choices questioned. By this stage, however, patients were physically dependent on treatment. As was seen with commencing dialysis, individuals coped with treatment withdrawal in a problem- or emotion-controlling way. Families struggled to differentiate between choosing versus allowing death. Health care teams avoided and queried discussions regarding dialysis withdrawal. Patients, however, missed the dialogue they experienced during predialysis education. Decision-making in ESRD is complex and dynamic and evolves over time and toward death. The factors at work are multifaceted and operate differently for patients and health professionals. More training and research on open communication and shared decision-making are needed. Copyright © 2015 by the American Society of Nephrology.
    No preview · Article · May 2015 · Clinical Journal of the American Society of Nephrology
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    ABSTRACT: To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies. The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed. A synthesis of qualitative research using meta-ethnography. Five electronic databases (January 1990-May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the review's aims. Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups. Four factors were identified that acted both as barriers and facilitators to women's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking. The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting. © 2014 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
    Full-text · Article · Nov 2014 · Journal of Advanced Nursing
  • Jamilla Hussain · Kate Flemming · Miriam Johnson
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    ABSTRACT: Individuals with chronic advanced diseases such as end stage kidney disease (ESKD) are offered a growing number of choices regarding life-prolonging treatments. Health care teams (HCTs) play an important part in helping patients make decisions about with-holding and withdrawing such treatment. To explore the similarities and differences in the decision-making process for patients with ESKD and their healthcare team (HCT), with regards to dialysis. A systematic review of qualitative studies. The search strategy was peer-reviewed and two independent researchers were involved in screening, data extraction, quality appraisal and synthesis. The Hawker et al (2002) appraisal checklist was used to provide an assessment of quality. The synthesis was conducted using thematic analysis. Eleven studies were eligible for inclusion, including 177 patients and 53 HCT members. With-holding dialysis: Factors weighed up by patients included peer experience, being a burden on family and wider society, and maintaining normal social roles. Some individuals instinctively opted for life-prolonging treatment at all costs, where as others accepted death as a natural course. HCTs on the other hand prioritised biomedical factors and relied on their own objective deliberation rather than patient preference. How individuals coped with their emotions was an important mediating factor. Problem-focussed copers sought various levels of input where as emotion-focussed individuals delegated choice. Problem-focussed individuals viewed the option to withdraw treatment as a 'tremendous control' to stop their suffering. Emotion-focussed copers however passively continued dialysis. HCTs struggled with the dilemma of determining when dialysis was prolonging suffering rather than improving quality-of-life and therefore continued to err on the side of life-prolonging treatment until dialysis was no longer physically possible. Patients and HCTs are influenced by different factors when making decisions about dialysis. Informed shared decision-making requires greater transparency of the impact of such factors on choice.
    No preview · Article · Mar 2014 · Supportive and Palliative Care
  • Hilary Graham · Kate Flemming · David Fox · Morag Heirs · Amanda Sowden
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    ABSTRACT: The adverse effects of smoking in pregnancy are minimised if the mother quits completely in early pregnancy. Smokers are therefore advised to quit abruptly; cutting down is not recommended either as a method of, or alternative to, quitting. However, most pregnant smokers do not quit and cutting down is widely reported. Evidence comes primarily from quantitative studies; qualitative research has contributed little to understandings of cigarette consumption in pregnancy. In consequence, little is known about the place and meaning of cutting down for pregnant smokers. The paper investigates this important dimension of maternal smoking. It explores perceptions and experiences of cutting down among pregnant smokers by examining data from a systematic review of qualitative studies of smoking in pregnancy. The studies were located in high-income countries and published between 1970 and 2012. Twenty-six studies, reported in 29 papers, were included, representing over 640 women. Meta-ethnography guided the analysis and synthesis. Data (participants' accounts and authors' interpretations) were extracted and coded; codes were progressively combined to identify overarching themes ('lines of argument'). Running through the lines of argument was evidence on cutting down; the paper presents and analyses this evidence. The analysis indicates that cutting down figured centrally as both a method of quitting and, for persistent smokers, a method of harm reduction. While pregnant women were aware that official advice was to quit abruptly, cutting down was seen as a positive behaviour change in often-difficult domestic circumstances, and one that health professionals condoned. Our findings suggest that cutting down in pregnancy, as an aid and an alternative to quitting, requires greater recognition if healthcare and tobacco control policies are to be sensitive to the perspectives and circumstances of pregnant smokers.
    No preview · Article · Nov 2013 · Health & Social Care in the Community
  • Kate Flemming · Hilary Graham · Morag Heirs · Dave Fox · Amanda Sowden
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    ABSTRACT: To provide evidence on how women's circumstances and experiences influence their smoking behaviour in pregnancy, including their attempts to quit. Women in disadvantaged circumstances are more likely to smoke prior to pregnancy; they are also less likely to quit in pregnancy and, among those who quit, more likely to resume smoking after birth. Although there is a rich seam of qualitative research on their experiences, it has yet to be bought together and synthesized. The synthesis was conducted using meta-ethnography. A comprehensive search of five electronic databases (inception to May 2012) was completed to identify qualitative research exploring pregnant women's experiences of smoking in pregnancy. Following critical appraisal, 26 studies reported in 29 papers were included in the review. Over 640 pregnant women were represented, the majority drawn from disadvantaged groups. We carried out the synthesis using meta-ethnography. Four dimensions of women's circumstances and experiences of smoking in pregnancy were highlighted: the embeddedness of smoking in women's lives, questioned only because of pregnancy; quitting for pregnancy rather than for good; quitting had significant costs for the woman and cutting down was a positive alternative; the role of partners and the broader dynamics of the couple's relationship in influencing women's smoking habits. Syntheses of qualitative research have an important role to play in producing the evidence base for midwifery, nursing, and public health policy and practice. The four dimensions identified in this review have implications for the design and delivery of interventions to support women to quit smoking in pregnancy.
    No preview · Article · Dec 2012 · Journal of Advanced Nursing
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    ABSTRACT: Background The syntheses of multiple qualitative studies can pull together data across different contexts, generate new theoretical or conceptual models, identify research gaps, and provide evidence for the development, implementation and evaluation of health interventions. This study aims to develop a framework for reporting the synthesis of qualitative health research. Methods We conducted a comprehensive search for guidance and reviews relevant to the synthesis of qualitative research, methodology papers, and published syntheses of qualitative health research in MEDLINE, Embase, CINAHL and relevant organisational websites to May 2011. Initial items were generated inductively from guides to synthesizing qualitative health research. The preliminary checklist was piloted against forty published syntheses of qualitative research, purposively selected to capture a range of year of publication, methods and methodologies, and health topics. We removed items that were duplicated, impractical to assess, and rephrased items for clarity. Results The Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement consists of 21 items grouped into five main domains: introduction, methods and methodology, literature search and selection, appraisal, and synthesis of findings. Conclusions The ENTREQ statement can help researchers to report the stages most commonly associated with the synthesis of qualitative health research: searching and selecting qualitative research, quality appraisal, and methods for synthesising qualitative findings. The synthesis of qualitative research is an expanding and evolving methodological area and we would value feedback from all stakeholders for the continued development and extension of the ENTREQ statement.
    Full-text · Article · Nov 2012 · BMC Medical Research Methodology
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    Kate Flemming · S José Closs · Robbie Foy · Michael I Bennett
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    ABSTRACT: In advanced disease, the management of symptoms and lifestyle are essential for the maintenance of patients' quality of life. Appropriate education by health professionals can help patients to better manage their disease. Although the provision of education by health professionals for patients with advanced cancer is reasonably well documented, much less is known about how health professionals facilitate education with patients with other advanced progressive diseases. The aim of this review was to synthesize qualitative research examining health professionals' knowledge of, attitudes toward, and ability to deliver educational interventions for symptom and disease management to patients with advanced progressive diseases other than cancer. The synthesis was conducted using meta-ethnography. Systematic searching of five electronic databases (CINAHL, Medline, PsycInfo, Web of Science Social Science Citation Index, and EMBASE) was performed. Included studies were data extracted and assessed for quality. Systematic searching of four electronic databases identified 911 records; 17 studies met review inclusion criteria and underwent data extraction and quality appraisal. Three key factors were identified that influenced the delivery of education by health professionals to patients with advanced disease: capacity (to educate and aid decision making), context (of educational delivery), and timing (of education). Health professionals identify and acknowledge a range of factors that influence their ability to deliver education to patients with advanced disease. The types of circumstantial factors identified in this review can influence the successful delivery of educational interventions and need to be considered when such interventions are being developed.
    Full-text · Article · May 2012 · Journal of pain and symptom management
  • K Flemming · S J Closs · R Foy · M I Bennett
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    ABSTRACT: Introduction and aimsThe management of symptoms and lifestyle in advanced disease are essential for the maintenance of patients' quality of life. Health care professionals can facilitate patients to optimise disease management by providing appropriate education. While the provision of education by health professionals for patients with advanced cancer is reasonably well documented, less attention has been paid to other advancing progressive diseases. The aim of this review was to synthesise qualitative research which examined health care professionals' knowledge, attitudes and ability towards delivering educational interventions to patients with the following advanced progressive diseases: heart failure, chronic respiratory disease, end stage renal disease and neuromuscular disorders.Methods The synthesis was conducted using meta-ethnography. Systematic searching of five electronic databases (CINAHL, Medline, PsychInfo, Web of Science Social Science Citation Index and EMBASE) occurred. Included papers were data extracted and assessed for quality.ResultsThe searches identified 911 records, of which 17 met the inclusion criteria for the review. Three key themes influencing the delivery of education to patients with advanced disease were identified: Capacity (to educate and aid decision-making)Context (of educational delivery)Timing (of education).ConclusionA range of enablers and barriers identified by health care professionals influence their ability to deliver education at the end of life. Therefore, any interventions to change practice need to have multiple components, rather than targeting sole aspects such as knowledge or motivation alone. Strategies for improving educational practice should explicitly target factors judged as important and potentially amenable to change.
    No preview · Article · Apr 2011 · Supportive and Palliative Care
  • Zoriah Aziz · Nicky A Cullum · Kate Flemming
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    ABSTRACT: Venous leg ulcers (which appear as open sores) can be caused by a blockage or breakdown in the veins of the legs. Compression of the leg, using bandages or hosiery (stockings), can help heal most of these ulcers. Electromagnetic therapy is also sometimes offered. Electromagnetic therapy is not a form of radiation or heat, but uses an electromagnetic field to try to promote healing. This review of clinical trials concluded that there is no high quality evidence that electromagnetic therapy speeds the healing of venous leg ulcers.
    No preview · Article · Mar 2011 · Cochrane database of systematic reviews (Online)
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    Michael I Bennett · Kate Flemming · S José Closs
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    ABSTRACT: To describe the current position of educational interventions within the context of cancer pain management. Barriers to good cancer pain control exist within patients and professionals and centre on lack of knowledge or poor attitudes towards pain and opioid analgesia. Education provided to healthcare professionals increases knowledge and improves attitudes but this does not necessarily translate into improvements in patient outcomes. However, targeted interventions that modify professional behaviour are effective. Educational interventions directed at patients result in improved patient outcomes, although the mechanisms by which these improvements occur are not yet clear. Overall, educational interventions directed at patients or professionals can result in significant but modest clinical benefit which is similar in magnitude to that achieved by some analgesics. Educational interventions should be part of routine clinical practice alongside optimal oncological and analgesic management. Further work is needed on how best to implement multicomponent interventions within clinical services, including the identification of which combinations are most cost effective.
    Full-text · Article · Mar 2011 · Current opinion in supportive and palliative care
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    ABSTRACT: Pressure ulcers (also called bed sores, decubitus ulcers or pressure sores) are sores on the skin caused by pressure or rubbing. They usually affect immobile people on the bony parts of their bodies such as hips, heels and elbows, and take a long time to heal. Electromagnetic therapy is not a form of radiation or heating, but uses an electromagnetic field with the aim of stimulating healing. However, the review of trials concluded that there is no strong evidence that electromagnetic therapy helps or hinders healing of pressure ulcers.
    No preview · Article · Nov 2010 · Cochrane database of systematic reviews (Online)
  • Kate Flemming
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    ABSTRACT: This paper is a report of a Critical Interpretive Synthesis to synthesize quantitative research, in the form of an effectiveness review and a guideline, with qualitative research to examine the use of morphine to treat cancer-related pain. Critical Interpretive Synthesis is a new method of reviewing, developed from meta-ethnography, which integrates systematic review methodology with a qualitative tradition of enquiry. It has not previously been used specifically to synthesize effectiveness and qualitative literature. Data sources. An existing systematic review of quantitative research and a guideline examining the effectiveness of oral morphine to treat cancer pain were identified. Electronic searches of Medline, CINAHL, Embase, PsychINFO, Health Management Information Consortium database and the Social Science Citation Index to identify qualitative research were carried out in May 2008. Qualitative research papers reporting on the use of morphine to treat cancer pain were identified. The findings of the effectiveness research were used as a framework to guide the translation of findings from qualitative research using an integrative grid. A secondary translation of findings from the qualitative research, not specifically mapped to the effectiveness literature, was guided by the framework. Nineteen qualitative papers were synthesized with the quantitative effectiveness literature, producing 14 synthetic constructs. These were developed into four synthesizing arguments which drew on patients', carers' and healthcare professionals' interpretations of the meaning and context of the use of morphine to treat cancer pain. Critical Interpretive Synthesis can be adapted to synthesize reviews of quantitative research into effectiveness with qualitative research and fits into an existing typology of approaches to synthesizing qualitative and quantitative research.
    No preview · Article · Jan 2010 · Journal of Advanced Nursing
  • Kate Flemming
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    ABSTRACT: Morphine is the most commonly used opioid for severe cancer-related pain. Despite its established effectiveness, it is often used cautiously in clinical practice, particularly outside specialist palliative care. This review identifies the key social, contextual, and physical concerns held by patients, carers, and health care professionals when using morphine, which might explain the caution taken in its use. The review used an approach called critical interpretive synthesis (CIS), which combines conventional systematic review techniques with methods for interpretative synthesis of qualitative research. An existing review examining the effectiveness of morphine and a guideline on its use were synthesized with 19 qualitative articles to establish understanding of how context of use can affect the established effectiveness of morphine. The article argues for the appropriateness of CIS for answering questions of this type. The results demonstrate that using morphine is a balancing act and a trade-off between pain relief and adverse effects. Deep-seated concerns regarding the symbolism of morphine, addiction, and tolerance are held by patients, carers, and clinicians, which influence prescription and use. Cancer pain is a referent for disease status and has existential meaning, with the introduction of morphine becoming a metaphor for impending death. Cancer pain is intersubjective, with its perception and reporting influenced by those with whom the patient interacts. By understanding the context and social meaning surrounding the use of morphine to treat cancer pain, health care professionals can begin to anticipate, acknowledge, and address some of the barriers to its use, thereby enhancing pain control.
    No preview · Article · Sep 2009 · Journal of pain and symptom management
  • Kate Flemming · Joy Adamson · Karl Atkin
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    ABSTRACT: Evaluating interventions in palliative care using randomized controlled trials (RCTs) has helped advance the specialty and create an evidence base for the delivery of care. RCTs, however, are notoriously difficult to conduct in palliative care, raising a variety of practical, ethical and moral dilemmas. Mixed-methods research, which combines qualitative research and RCTs, offers a potential solution to these problems. This paper begins by examining the theoretical basis for combining the two approaches, before reviewing the specific role qualitative research could play in planning, conducting and implementing trials. The paper then goes on to explore how palliative care research currently uses the mixed-methods approach, by searching the trials included in six Cochrane Systematic Reviews (n = 146) on the incorporation of qualitative research. Only one trial undertook qualitative research. These findings reflect some of the challenges facing mixed-methods research, which include lack of experience in a research team, the problems of obtaining funding and difficulties in publishing. The paper concludes that while combining qualitative and quantitative research is not a panacea for methodological problems in palliative care research, with careful planning and integration, the approach may enhance the clinical and ethical utility of trial findings, which in turn will improve patient care.
    No preview · Article · Apr 2008 · Palliative Medicine
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    Deyaa Al-Kurdi · S E M Bell-Syer · Kate Flemming
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    ABSTRACT: Venous leg ulcers are common, especially in the elderly. They are caused by damage or blockage in the veins of the legs, which in turn lead to pooling of blood and increased pressure in these veins. These changes can eventually damage the skin and lead to ulcer formation. Compression, using stockings or bandages is the most widely used and acceptable treatment. However, ultrasound has been used as an additional intervention especially in difficult, longstanding ulcers to hasten healing and improve symptoms. The mechanisms by which ultrasound waves interact with healing tissues are not fully understood. There is weak evidence that ultrasound increases the healing of venous (varicose) leg ulcers.
    Full-text · Article · Feb 2008 · Cochrane database of systematic reviews (Online)
  • Michelle Briggs · Kate Flemming
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    ABSTRACT: This paper is a report of a study to identify and synthesize all published qualitative research studies exploring patients' experiences of living with a leg ulcer. Leg ulceration is a common chronic condition with over 40% of patients having open ulceration for over a year. Leg ulceration can have a significant and detrimental effect on a persons' life. Electronic searches of Ovid MEDLINE (R) (1966-2005), CINAHL (1982-2005), EMBASE (1980-2005), British Nursing Index (1985-2005), ASSIA, Social Science Citation Index (SSCI) and PsychINFO (1985-2005) were carried out in June 2005. Studies were included if: they described experience of living with a leg ulcer, e.g. phenomenological studies, grounded theory, descriptive, focus groups or interview studies; included adults with chronic leg ulceration (venous, mixed or arterial); published in English. Analysis was undertaken using the Qualitative Assessment and Review Instrument software for synthesis of qualitative research. Twelve studies met the inclusion criteria. There were eight phenomenological studies, two using grounded theory and two 'descriptive studies'. The location of the research was United Kingdom (7), United States of America (2), Sweden (1), Australia (1). Five common themes related to the experience of living with leg ulceration were identified: Physical effects of leg ulceration; Describing the leg ulcer journey; Patient-professional relationships; Cost of a leg ulcer; Psychological impact. Leg ulceration should be viewed as a chronic, debilitating condition. The clinical focus of care should be symptom management through the 'leg ulcer journey'.
    No preview · Article · Sep 2007 · Journal of Advanced Nursing
  • Kate Flemming

    No preview · Article · Aug 2007 · Evidence-Based Nursing
  • Kate Flemming · Michelle Briggs
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    ABSTRACT: This paper presents an evaluation of the effectiveness of three search strategies to identify research for a qualitative synthesis of patient experiences of living with a leg ulcer. Systematic reviews of research are increasingly the form of evidence used for evaluation of health care. There are well-established methods for conducting systematic reviews of effectiveness incorporating randomized controlled trials. Methods have been developed for the synthesis of qualitative research, but these are not widely used or evaluated. Searching for qualitative research is one of the least developed and tested areas in systematic reviewing of qualitative research. The replication of three search strategies (free text, thesaurus and broad-based terms) developed for identification of qualitative research papers within electronic databases is described. Each strategy was run in seven electronic databases: MEDLINE, CINAHL, EMBASE, British Nursing Index, Social Science Citation Index, Applied Social Sciences Index and Abstracts, PsychInfo. The effectiveness of these strategies for identifying qualitative research for a synthesis of patients' experiences of living with a leg ulcer is discussed. Each of the three search strategies produced similar numbers of potentially and actually relevant papers from each of the seven databases. These results were most striking for CINAHL, when all of the papers ultimately included in the review were identified by each search strategy. No other database identified all included papers. A simple search strategy using broad-based terms was as effective as a complex one (free text) in locating qualitative research examining patients' experiences of living with a leg ulcer. For a question with a clear nursing focus, it may be sufficient to search only CINAHL in order to locate qualitative research. This result needs replicating with other nursing topics.
    No preview · Article · Feb 2007 · Journal of Advanced Nursing
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    Kate Flemming
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    ABSTRACT: Evidence-based nursing is central to the knowledge base for nursing practice. Critics of evidence-based nursing dislike the central role that randomized controlled trials (RCTs) take in providing evidence for nursing, claiming that the context and experience of nursing care are removed from evaluation. Many nursing decisions involve questions regarding the effectiveness of interventions, best evaluated by RCTs. This article explores the epistemological and practical feasibility of combining qualitative research with RCTs (mixed methods research) in evaluations of nursing practice. Through theoretical and practical examples, it proposes that mixed methods research has the potential to enhance the evidence base for nursing.
    Preview · Article · Jan 2007 · ANS. Advances in nursing science