The meta-ethnography has been registered with the International Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42020184343. Protocol development was informed by recent advances in meta-ethnographic theory and practice [33, 34, 36, 38–42]; and with reference to the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist (see Additional File 1). Data from eligible papers will be synthesised following the seven phases (see Fig. 1) outlined by Noblit and Hare (1988); however, meta-ethnography is not a linear process and these phases will likely overlap and repeat as the synthesis proceeds [36]. Findings will be evaluated using the Confidence in Evidence from Reviews of Qualitative Research (CERQual) approach [43]; and reported in accordance with the eMERGe reporting guidelines [44]. Ethical approval is not required for a synthesis of published peer-reviewed studies (http://www.hra-decisiontools.org.uk/ethics/).
Theoretical perspective
We (HP, KM and NB) collaborated to prepare a National Institute for Health Research funding application with the intention to build on previous work [45, 46] and this has now been funded. HP has worked as a National Health Service Hospital Pharmacist for the past 15 years, specialising in the field of antimicrobials since 2009, and is now a National Institute for Health Research (NIHR) Clinical Doctoral Research Fellow. JF and NB are Medical Sociologists with extensive qualitative research and meta-ethnography experience. KM is a Professor of Medical Education and has broad research experience including qualitative methods and analysis. SR is an experienced information specialist.
Meta-ethnography is an inductive, highly interpretive approach [36, 40]. We will be endeavouring to develop new interpretations from first order data (primary study participant interpretations); and second order data (author interpretations of participant interpretations) presented in the primary studies. To broaden perspective and to support the development of insightful, practical theory we have formed a stakeholder group who will contribute to the synthesis. Stakeholders will include: a Consultant Surgeon, Anaesthetist and Microbiologist; a Hospital Pharmacist; and several patient representatives. Additionally, technical support will be provided by an Information Specialist (SR) and a Research Fellow (EC) from the NIHR Applied Research Collaboration South West Peninsula Patient and Public Involvement team.
Phase one: getting started
Quality assessment
No studies will be excluded based on quality alone [52]. However, all studies will be assessed by HP using the qualitative Critical Appraisal Skills Programme (CASP) tool [53] to support careful and systematic reading [40] with consideration of a range of aspects [41]. Lower quality assessment scores – for example, due to poor reporting or abridged methods sections (often the case in medical journals) – does not always reflect the quality of the research; however, it can draw the reviewer’s attention to shortcomings in the interpretation of study findings that may have an impact on the results of the synthesis [38].
Three reviewers (HP, KM and JF) will then use a pragmatic approach, first described by Dixon-Woods et al. (2007) [54], to classify studies based on their perceived utility to the meta-ethnography (see Table 2). Those studies deemed ‘irrelevant’ or ‘fatally flawed’ will be excluded. Remaining papers – key papers; satisfactory papers; and questionable papers – will be included in the synthesis. Any disagreement regarding categorisation of a study will be resolved by consensus between three reviewers (HP, KM and JF). Additionally, synthesis messages derived from the included studies will be examined against ‘key’ papers (only) to test their contributions and promote further discussion and insight, consistent with previous work [41]. HP will maintain a Microsoft Excel spreadsheet of study demographics; appraisal scores; and inclusion/exclusion decisions.
Table 2: Study classifications [54]
Category
|
Study characteristics
|
Key papers
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Conceptually rich with the potential to make an important contribution to the synthesis
|
Satisfactory papers
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Less valuable than key papers but still relevant
|
Questionable papers
|
Uncertain contribution
|
Irrelevant
|
Not relevant to the review question
|
Fatally flawed
|
Study data not presented in a usable format
|
Phase three: reading the studies
This stage of the meta-ethnography involves repeated careful reading of the studies to gain familiarity and to identify the main concepts described i.e. what is each study telling us. HP will record contextual information, such as study setting; participants (e.g. sub-speciality, grade and number included); research design; and aim, in a Microsoft Excel spreadsheet. Following repeated close reading (HP, KM and JF), the studies will be imported into NVivo qualitative data analysis software. Key concepts (potentially explanatory ideas) from each study’s results and/or discussion section will then be independently coded by two reviewers (HP and JF or KM). The coded data will include quotations from participants (first-order data); and quotations from the original study’s authors (second-order data). Reviewers (HP, JF and KM) will then discuss and agree the key concepts, recording them in a Microsoft Excel spreadsheet.
Phase four: determining how the studies are related
The next phase requires us to identify the relationship between the primary studies, and their key concepts, through a process of close comparison. We will begin to determine whether the synthesis is ‘reciprocal’ (primary studies’ concepts are directly complementary), ‘refutational’ (primary studies’ concepts oppose each other) or ‘lines-of-argument’. In the latter case, primary studies identify different aspects of a larger phenomenon which when taken together offer a new interpretation; a ‘whole’ is discovered from a set of parts [36]. We are aware that meta-ethnographies frequently produce reciprocal or lines-of-argument translations [55]. Lines of argument syntheses often bring together interrelated concepts, but may also represent lack of attention to conflicting findings. We will actively seek disconfirming or contradictory findings and concepts.
Phase five: translating the studies into one another
Translation involves sorting the key concepts (from primary studies) into conceptual categories or ‘piles’ [42]. HP, KM and JF will independently compare key concepts across the primary studies, grouping them all into conceptual categories (third order data) with a definition of what each conceptual category encompasses. The conceptual categories will be developed inductively, through a process of constant comparison (of key concepts), rather than according to any a priori theory, although we recognise each reviewer’s interpretations will be influenced by their backgrounds. The reviewers (HP, KM and JF) will then compare interpretations and, with input from stakeholders, collaboratively develop a final list of conceptual categories which will be tested against the primary studies to ensure a good fit. The multi-disciplinary input will enable us to challenge our own understandings and will support the identification of a range of possible analytic interpretations.
Phase six: synthesising translations
Synthesising translations is the on-going process whereby findings are further abstracted to form a conceptual framework [42] which explains the phenomena of interest. It cannot be reduced to a set of mechanistic tasks [39] but will involve three reviewers (HP, KM and JF) working collaboratively to ‘make sense’ of the conceptual categories, with the aim of developing a new theory that explains how and why contextual factors act and interact to influence APB among surgical teams. If appropriate, a visual way of representing the findings will be developed iteratively, to convey the theory.
Emerging interpretations will be discussed with: (1) the authors of the primary studies (where possible) to test the validity of our third-order interpretations; (2) academic and surgical/stewardship audiences to receive feedback, for example at departmental seminars, conferences and methodological discussion fora; and (3) our wider stakeholder group to ensure that the knowledge is applicable and meaningful. Additionally, we will assess the synthesis findings using the CERQual approach [43] to transparently determine how much confidence can be placed in them.
Phase seven: expressing the synthesis
Findings from the meta-ethnography will be published in a peer-reviewed journal; presented at suitable fora (including surgical and infection conferences and relevant teaching); and made available to patients and members of the public. HP will lead on the development of project outputs. However, we will work with key stakeholders and patient representatives to ensure that the media are acceptable to their target audience and disseminated via the most effective channels.
HP, KM and JF will approve final versions prior to publication.