narrative literature review methods

Methodological Approaches to Literature Review

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• First Online: 09 May 2023
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• Dennis Thomas 2 ,
• Elida Zairina 3 &
• Johnson George 4  

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The literature review can serve various functions in the contexts of education and research. It aids in identifying knowledge gaps, informing research methodology, and developing a theoretical framework during the planning stages of a research study or project, as well as reporting of review findings in the context of the existing literature. This chapter discusses the methodological approaches to conducting a literature review and offers an overview of different types of reviews. There are various types of reviews, including narrative reviews, scoping reviews, and systematic reviews with reporting strategies such as meta-analysis and meta-synthesis. Review authors should consider the scope of the literature review when selecting a type and method. Being focused is essential for a successful review; however, this must be balanced against the relevance of the review to a broad audience.

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Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, Hunter Medical Research Institute Asthma and Breathing Programme, Newcastle, NSW, Australia

Dennis Thomas

Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia

Elida Zairina

Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia

Johnson George

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Correspondence to Johnson George .

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Thomas, D., Zairina, E., George, J. (2023). Methodological Approaches to Literature Review. In: Encyclopedia of Evidence in Pharmaceutical Public Health and Health Services Research in Pharmacy. Springer, Cham. https://doi.org/10.1007/978-3-030-50247-8_57-1

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Planning For Your Expert Literature Review

Narrative literature reviews.

• Types of Expert Literature Reviews

Further Reading

• Standards and Guidelines
• The Systematic Review Process
• Review Tools and Platforms
• Screening Tools and Software This link opens in a new window
• Where to Publish
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Narrative or traditional literature reviews can take many shapes and forms. They do not need to follow any specific guideline or standard. A narrative literature view may be assigned as part of your coursework or capstone.

A narrative literature review can be a first step to building on other research in the field. After all, if it's a topic that you're interested in, you need to know what's already been done, right?

Your Narrative Literature Review Should Have...

• A clearly defined topic
• A search for relevant literature
• A logical organization structure
• An interpretation and discussion of the selected relevant literature

A common structure for narrative literature reviews is IMRaD, or:

• Introduction
• What is your topic?
• What are you interested in finding out?
• Why did you select this topic?
• How did you look for the literature?
• Where did you look?
• What search terms did you use?
• What kind of literature did you find?
• Did the literature you found change your opinion on the topic?
• Did you find out something new?
• What were the key concepts?
• and Discussion
• Evaluate and summarize the major concepts
• Connect the major concepts to future research potential

While the structure above may be sufficient for your topic, you may also consider using the similar but more robust structure IAMRDC, or:

• Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24 (4), 230-235. https://doi.org/10.1179/2047480615Z.000000000329
• Sollaci, L. B., & Pereira, M. G. (2004). The introduction, methods, results, and discussion (IMRAD) structure: a fifty-year survey. Journal of the Medical Library Association 92 (3), 364–367. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC442179/

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Literature Review: Traditional or narrative literature reviews

Traditional or narrative literature reviews.

• Scoping Reviews
• Systematic literature reviews
• Annotated bibliography
• Keeping up to date with literature
• Finding a thesis
• Evaluating sources and critical appraisal of literature
• Managing and analysing your literature
• Further reading and resources

A narrative or traditional literature review is a comprehensive, critical and objective analysis of the current knowledge on a topic. They are an essential part of the research process and help to establish a theoretical framework and focus or context for your research. A literature review will help you to identify patterns and trends in the literature so that you can identify gaps or inconsistencies in a body of knowledge. This should lead you to a sufficiently focused research question that justifies your research.

Onwuegbuzie and Frels (pp 24-25, 2016) define four common types of narrative reviews:

• General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
• Theoretical literature review which examines how theory shapes or frames research
• Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
• Historical literature review which focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

References and additional resources

Baker, J. D. (2016) The purpose, process and methods of writing a literature review: Editorial . Association of Operating Room Nurses. AORN Journal, 103 (3), 265-269. doi:10.1016/j.aorn.2016.01.016

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The Literature Review

• Narrative Review
• Systematic Review
• Scoping Review

Writing your Literature Review

Once you have developed a body of literature to draw from, you can begin writing your literature review. There is no set format for a narrative literature review, and it can vary across fields. However, you will typically see the following elements:

• Sections you might see in a typical research paper including Introduction, background, (possibly) methods, Main/Body, and Conclusion
• Some logical structure of sections (i.e. by time period, by areas of the field, by approach of article etc.)
• Analysis of the relative value of contributions across different sources
• section on areas for further development or further research suggestions

Need writing help? Head to the Graduate Writing Center for help with your literature review!

What is a narrative literature review.

Narrative Literature Reviews are works in which the author reviews a body of literature on a topic and synthesizes the information into a clear narrative that demonstrates the general context of the field . They can also be called a Traditional Literature Review. Compared to Systematic and Scoping reviews, Narrative literature reviews do not use an established method or protocol, but rather take a broad, unspecified approach to what sources are selected to represent the field. Typically narrative literature reviews use peer-reviewed journal articles as their source of scholarship to review, but this might vary based on the individual assignment or review you are conducting. Below are some key elements of a Narrative Lit Review:

• Places the topic within an existing context
• Describes relationships between and around sources cited
• Typically includes critical analysis
• Organizes ideas by theme and/or relevance
• Demonstrates author's knowledge

Staying Organized

Use a reference management software.

Reference Managers are tools that can help you keep track of the scholarly articles you are collecting and reading for your literature review. They can also help you generate citations and bibliographies within your writing. Use the Reference Management Software Guide linked below to learn more about how to get started with one.

Reference Management Research Guide

Keep your search terms in a document or spreadsheet.

Although in Narrative Lit Reviews you are not required to keep detailed reports on your search strategy, it is still important to keep track of the terms you are searching and include information about them to be sure you are casting the widest net possible. Organize your search terms in a way that makes sense to you. As an example, you could keep tabs on:

• Broader terms
• Narrower terms
• Filters that work / filters that don't
• Search strings you can copy and paste directly into search engines and databases

The Research Process

Start with an exploratory/preliminary search.

Use a couple key terms about your topic to try searching without keeping track to see whats out there. This is also a good time to search for already existing reviews on your topic and see if something similar has already been completed. After doing a preliminary search in your general topic, you can begin thinking about your specific research question.

Drafting a Research Question

To start drafting your research question, it may be helpful to consider how your topic fits within a couple of different broad overlapping fields of research. For example, the research question illustrated below asks about identity perspectives from Asian American students in high schools. Each individual topic in this question is its own circle, and the intersection of these circles is the main focus of the literature review. There could be more circles added for each new dimension I would like to add to my research question whether it be a location (i.e. New York City), a clarifying detail (i.e. generational identity), or other form of context.

As you are searching, use the different dimensions of your research question to find individual areas of research, For example, I may want to look at the literature around just the identity of Asian American students, or maybe just look at identity formation in High School. Then, in my literature review, I can synthesize these various fields to explain the different backgrounds and how they all converge around my central topic, the middle of the diagram.

Image from Tips and Strategies for Writing a Dissertation Proposal on Ashe Grads blog.

Conducting your Search

Once you have your research question and key terms from that research question, you can start your formal searching process. In narrative literature reviews it is less important to be comprehensive in checking every possibly relevant result, but more focused on making sure the results you are getting are representative of the fields you are analyzing.

Books in the Libraries to Help with you Narrative Lit Review

Literature Review and Research Design: A Guide to Effective Research Practice

They Say / I Say: The Moves That Matter in Academic Writing, with Readings

The Literature Review: Six Steps to Success

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Composing an Authentic, Academic Narrative Literature Review: How to Evaluate Scholarly Articles and Write a Thorough Narrative Literature Review

Over the course of many years of teaching, I’ve found that both my students and I struggle with our course unit on research writing. It’s boring, it’s difficult, and we all undoubtedly become aggravated with each other throughout the process.

If you’ve ever experienced a lesson burnout, like I have so many times, you know how frustrating it can be for both teacher and students. Unless you’ve written tons of research papers in your lifetime, they can seem like a daunting task. This is especially true for middle school and high school students who are likely just learning how to do so.

If your students are embarking on a research project, one of their first steps in the research process will be completing a comprehensive narrative literature review.

Ironically, I’ve had to do my own narrative literature review of sorts to bring you the resources you’ll find herein. Of note, after you’ve made it to the end of this post, you’ll be able to effectively guide your students in composing a narrative literature review by focusing on these basic tenets:

What is a narrative literature review?

• Systematic vs. Narrative literature reviews.
• The different types of narrative literature reviews.
• Steps in writing a narrative literature review.

Defining, Differentiating, and Composing a Narrative Literature Review

Essentially, it is a step in the research process that follows selecting a topic and asking a research question. Before developing an engaging thesis, a researcher has to ascertain that scholarly literature exists in support of their proposed thesis.

For students who have grown up with the ability to simply Google a wealth of information and receive desired results in a moment’s time, vetting sources may seem like a foreign concept. Teaching your students how to write this type of work will teach them how to scrutinize sources.

But what is a narrative literature review? According to top researchers, “A literature review is a type of research article published in a professional peer-reviewed journal.” These articles are published in vetted, scholarly journals that you and your students can trust as fact.

In essence, your students select a research topic then hit the databases in search of reputable, trustworthy journal articles that answer their research query and support their anticipated position on that topic. By reviewing the existing literature on the selected topic, students can be sure there is proven data and a body of existing knowledge that supports their thesis.

According to J.D. Baker, a professor at Charles Sturt University, acquiring current and relevant literature on a given topic is, “…an essential part of the research process [that] help[s] to establish a theoretical framework and focus or context for your research.” For this reason, the narrative literature review may very well be one of the most important steps in the research process.

As one of the first few steps in the research process, a step that is likely a foreign task to your students, it’s imperative that the process is broken down into simplified, manageable tasks.

Rebecca Alber, blogger for Edutopia, discusses the importance of scaffolding projects for students. She expounds upon the pedagogy of breaking projects into manageable chunks and “providing concrete structure for each.”

By reading through and analyzing the body of knowledge on a given topic, researchers, like your students, can focus and justify their research. As discussed here , the thesis is the most important part of a research paper, but you can’t arrive at your thesis without a thorough narrative literature review.

In this video, research specialist, Sarah Bronson, explains what a narrative literature review does, how to plan it, and how to write a cohesive and proper review.

Systematic vs. Narrative Literature Reviews: Knowing the Difference

In short, the difference between a narrative literature review and a systematic literature review has to do with the search terms used and the methodology employed when searching databases.

According to those in the know, “A narrative literature review is fairly broad, as it involves gathering, critiquing and summarizing journal articles and textbooks about a particular topic.” In other words, you enter general search terms into a search engine and sift through the yielded articles.

Essentially, a narrative literature review summarizes and synthesizes the body of work on a topic. The review may be generally focused on a broad topic or a specific research question.

A systematic literature review, on the other hand, “tend[s] to use specific search terms and inclusion/exclusion criteria, whereas the criteria for narrative reviews may not be as strict.” This type of work is best employed by writers who have already focused their query and/or thesis. By including or excluding particular terms, a more pointed search return is gleaned.

In essence, the goal of a systematic literature review is to answer a focused objective question. To be clear, in this type of work, the researcher is working with a clearly defined question.

Check out this helpful video that further explicates the point and process of a systematic literature review. Cochrane provides insight into why, in some instances, a systematic review is more useful than its narrative counterpart.

Though both systematic and narrative literature reviews can be useful in producing desired and relevant research documents, knowing which method to use depends on your experience and how far into the research process you’ve gone.

If you are beginning preliminary research, you’ll likely only be able to perform a narrative literature review. You may have a general topic that you’d like to investigate before committing to a topic and a thesis.

However, if you’ve already focused your study and have a better grip on the direction you wish to go, then you may find the systematic review to be useful.

Again, the literature review is just one step in a series of interrelated steps that help students write a focused and cohesive research paper. In this article, you can take a look at later steps in the writing process.

Narrative Literature Reviews: Four Unique Approaches

According to Onwuegbuzie and Frels, there are four common types of narrative literature reviews. Essentially, literature reviews can be broken down into these four categories: general, methodological, theoretical, and historical. Let’s take a look at how they differ from one another.

A general literature review takes a close look at the most important and most current knowledge on a given topic. This type of work will form the basis for your thesis or dissertation; it’s what you’ll do before focusing your query.

Sources cited in a general literature review may include scholarly articles, governmental data, books, interviews, and websites. The general literature includes a summary and assessment of the literature.

A methodological literature review defines the methodology used to apprehend the literature. In other words, this type of paper outlines and explains research methods and parameters.

The methodological literature review analyzes how information was arrived at not necessarily what the literature asserts.

A theoretical literature review analyzes how theories inform research practices. Basically, this type of paper identifies pre-existing theories, the connection between and among them, how well scrutinized the theories are, and the development of new possible theories.

Finally, a historical literature review focuses on the emergence, development, and historical context of a research topic as it presents in a body of knowledge. To be clear, this type of literature review traces the history of a particular issue or theory and how it has evolved since its onset.

In this excellent resource featuring Leigh Hall of teachingacademia.com, Hall further explains the different types of narrative literature reviews. Hall explains the four types of reviews in further detail to help writers determine which is best suited for their research purposes.

Teachers should be clear about their expectations of students concerning which type of narrative literature review is expected of them. A closer look at which type of review is best suited to your students’ projects can help you, the teacher, in guiding your students.

As one of the most important steps in the research process, it’s imperative students can successfully complete a literature review before moving on in the research process.

Lisa L. Munro, Phd., a blogger who examines the importance of creating writing communities among our students, asserts the importance of, “writing a concise literature review just comprehensive enough for the purpose of an academic journal article.”

Narrative Literature Review: A Writer’s Checklist

The writing process is a step-by-step undertaking and some steps are more of a process than others. That’s especially true of composing a narrative literature review.

Essentially, a narrative literature review is a project in and of itself. A proper review adheres to the following steps.

Entitle your review as a “review of…” Titling your work this way lets your reader know exactly what you’re setting out to do in the subsequent paragraphs. However, as a researcher, doing so helps you keep your sources organized and makes it easy to refer back to that source.

Write a brief summary of the article and how it applies to your course of study. This step is where you synthesize the information gleaned from a particular source. It will provide you, the researcher, with an opportunity to decide if it’s useful information that will support your research query.

Your abstract should include a sentence about how the source applies to your own research, your purported thesis, a summary of the literature, and conclusions you’ve made based on your findings.

Introduction

The writer provides his/her rationale and objectives for the literature review. Your introduction should establish your topic of study and an explanation of why your research is important.

Describe the methods used in performing the research. Essentially this is a few sentences explaining the steps and mediums used to acquire your sources. This indicates whether or not your research comes from reputable sources.

Here is where you explain if you used computer databases along with the search terms you employed, scoured physical files at a given office building, read physical texts on a given topic, etc.

Discussion/Summary

The writer discusses his/her discoveries as well as an overall summary of the information. Without repeating what you’ve written in the other parts of your review, in the discussion, you summarize your main findings, interpret those findings, identify the strengths and weaknesses of the given source, compare your findings with other literature on the topic, explain how and if your findings answer your research query, and assert if your thesis is supported by the literature.

In this helpful tutorial, David Taylor, an online writing professor, walks you through the formatting of a literature review. He walks writers through the five-step process of completing a paper in less than 30 minutes.

As in writing any type of composition, students should be reminded to carefully proofread for clarity and correctness. I always suggest that students read their compositions aloud as readers will often hear mistakes before they see them.

A final consideration that students inevitably need to be reminded of is avoiding plagiarism. I find it’s helpful to define plagiarism for students so there’s no question about why copying another’s ideas is problematic.

There are many online plagiarism checkers for teachers and students to use to ensure work is entirely authentic. Check out this article for some tips and tricks for avoiding and identifying plagiarism.

Useful Resources

• What is a research paper?
• How to format a research paper
• 113 great research paper topics
• Writing an educational research paper: research paper sections

One of the most arduous tasks in a research project is gathering the right sources for your purpose. Help students understand how to search in the right places for articles and how to evaluate sources.

One of the questions my students rightfully ask is why they can’t use news media websites. News networks like CNN deliver the facts, don’t they? This article may help you and them to better recognize and evaluate credible source material.

A thorough narrative literature review will get your students off on the right foot. Everything after the literature review falls into place more readily when you have the right sources for your purpose.

What Is a Research Design? | Definition, Types & Guide

Introduction

Parts of a research design, types of research methodology in qualitative research, narrative research designs, phenomenological research designs, grounded theory research designs.

• Ethnographic research designs

Case study research design

Important reminders when designing a research study.

A research design in qualitative research is a critical framework that guides the methodological approach to studying complex social phenomena. Qualitative research designs determine how data is collected, analyzed, and interpreted, ensuring that the research captures participants' nuanced and subjective perspectives. Research designs also recognize ethical considerations and involve informed consent, ensuring confidentiality, and handling sensitive topics with the utmost respect and care. These considerations are crucial in qualitative research and other contexts where participants may share personal or sensitive information. A research design should convey coherence as it is essential for producing high-quality qualitative research, often following a recursive and evolving process.

Theoretical concepts and research question

The first step in creating a research design is identifying the main theoretical concepts. To identify these concepts, a researcher should ask which theoretical keywords are implicit in the investigation. The next step is to develop a research question using these theoretical concepts. This can be done by identifying the relationship of interest among the concepts that catch the focus of the investigation. The question should address aspects of the topic that need more knowledge, shed light on new information, and specify which aspects should be prioritized before others. This step is essential in identifying which participants to include or which data collection methods to use. Research questions also put into practice the conceptual framework and make the initial theoretical concepts more explicit. Once the research question has been established, the main objectives of the research can be specified. For example, these objectives may involve identifying shared experiences around a phenomenon or evaluating perceptions of a new treatment.

Methodology

After identifying the theoretical concepts, research question, and objectives, the next step is to determine the methodology that will be implemented. This is the lifeline of a research design and should be coherent with the objectives and questions of the study. The methodology will determine how data is collected, analyzed, and presented. Popular qualitative research methodologies include case studies, ethnography , grounded theory , phenomenology, and narrative research . Each methodology is tailored to specific research questions and facilitates the collection of rich, detailed data. For example, a narrative approach may focus on only one individual and their story, while phenomenology seeks to understand participants' lived common experiences. Qualitative research designs differ significantly from quantitative research, which often involves experimental research, correlational designs, or variance analysis to test hypotheses about relationships between two variables, a dependent variable and an independent variable while controlling for confounding variables.

Literature review

After the methodology is identified, conducting a thorough literature review is integral to the research design. This review identifies gaps in knowledge, positioning the new study within the larger academic dialogue and underlining its contribution and relevance. Meta-analysis, a form of secondary research, can be particularly useful in synthesizing findings from multiple studies to provide a clear picture of the research landscape.

Data collection

The sampling method in qualitative research is designed to delve deeply into specific phenomena rather than to generalize findings across a broader population. The data collection methods—whether interviews, focus groups, observations, or document analysis—should align with the chosen methodology, ethical considerations, and other factors such as sample size. In some cases, repeated measures may be collected to observe changes over time.

Data analysis

Analysis in qualitative research typically involves methods such as coding and thematic analysis to distill patterns from the collected data. This process delineates how the research results will be systematically derived from the data. It is recommended that the researcher ensures that the final interpretations are coherent with the observations and analyses, making clear connections between the data and the conclusions drawn. Reporting should be narrative-rich, offering a comprehensive view of the context and findings.

Overall, a coherent qualitative research design that incorporates these elements facilitates a study that not only adds theoretical and practical value to the field but also adheres to high quality. This methodological thoroughness is essential for achieving significant, insightful findings. Examples of well-executed research designs can be valuable references for other researchers conducting qualitative or quantitative investigations. An effective research design is critical for producing robust and impactful research outcomes.

Each qualitative research design is unique, diverse, and meticulously tailored to answer specific research questions, meet distinct objectives, and explore the unique nature of the phenomenon under investigation. The methodology is the wider framework that a research design follows. Each methodology in a research design consists of methods, tools, or techniques that compile data and analyze it following a specific approach.

The methods enable researchers to collect data effectively across individuals, different groups, or observations, ensuring they are aligned with the research design. The following list includes the most commonly used methodologies employed in qualitative research designs, highlighting how they serve different purposes and utilize distinct methods to gather and analyze data.

The narrative approach in research focuses on the collection and detailed examination of life stories, personal experiences, or narratives to gain insights into individuals' lives as told from their perspectives. It involves constructing a cohesive story out of the diverse experiences shared by participants, often using chronological accounts. It seeks to understand human experience and social phenomena through the form and content of the stories. These can include spontaneous narrations such as memoirs or diaries from participants or diaries solicited by the researcher. Narration helps construct the identity of an individual or a group and can rationalize, persuade, argue, entertain, confront, or make sense of an event or tragedy. To conduct a narrative investigation, it is recommended that researchers follow these steps:

Identify if the research question fits the narrative approach. Its methods are best employed when a researcher wants to learn about the lifestyle and life experience of a single participant or a small number of individuals.

Select the best-suited participants for the research design and spend time compiling their stories using different methods such as observations, diaries, interviewing their family members, or compiling related secondary sources.

Compile the information related to the stories. Narrative researchers collect data based on participants' stories concerning their personal experiences, for example about their workplace or homes, their racial or ethnic culture, and the historical context in which the stories occur.

Analyze the participant stories and "restore" them within a coherent framework. This involves collecting the stories, analyzing them based on key elements such as time, place, plot, and scene, and then rewriting them in a chronological sequence (Ollerenshaw & Creswell, 2000). The framework may also include elements such as a predicament, conflict, or struggle; a protagonist; and a sequence with implicit causality, where the predicament is somehow resolved (Carter, 1993).

Collaborate with participants by actively involving them in the research. Both the researcher and the participant negotiate the meaning of their stories, adding a credibility check to the analysis (Creswell & Miller, 2000).

A narrative investigation includes collecting a large amount of data from the participants and the researcher needs to understand the context of the individual's life. A keen eye is needed to collect particular stories that capture the individual experiences. Active collaboration with the participant is necessary, and researchers need to discuss and reflect on their own beliefs and backgrounds. Multiple questions could arise in the collection, analysis, and storytelling of individual stories that need to be addressed, such as: Whose story is it? Who can tell it? Who can change it? Which version is compelling? What happens when narratives compete? In a community, what do the stories do among them? (Pinnegar & Daynes, 2006).

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A research design based on phenomenology aims to understand the essence of the lived experiences of a group of people regarding a particular concept or phenomenon. Researchers gather deep insights from individuals who have experienced the phenomenon, striving to describe "what" they experienced and "how" they experienced it. This approach to a research design typically involves detailed interviews and aims to reach a deep existential understanding. The purpose is to reduce individual experiences to a description of the universal essence or understanding the phenomenon's nature (van Manen, 1990). In phenomenology, the following steps are usually followed:

Identify a phenomenon of interest . For example, the phenomenon might be anger, professionalism in the workplace, or what it means to be a fighter.

Recognize and specify the philosophical assumptions of phenomenology , for example, one could reflect on the nature of objective reality and individual experiences.

Collect data from individuals who have experienced the phenomenon . This typically involves conducting in-depth interviews, including multiple sessions with each participant. Additionally, other forms of data may be collected using several methods, such as observations, diaries, art, poetry, music, recorded conversations, written responses, or other secondary sources.

Ask participants two general questions that encompass the phenomenon and how the participant experienced it (Moustakas, 1994). For example, what have you experienced in this phenomenon? And what contexts or situations have typically influenced your experiences within the phenomenon? Other open-ended questions may also be asked, but these two questions particularly focus on collecting research data that will lead to a textural description and a structural description of the experiences, and ultimately provide an understanding of the common experiences of the participants.

Review data from the questions posed to participants . It is recommended that researchers review the answers and highlight "significant statements," phrases, or quotes that explain how participants experienced the phenomenon. The researcher can then develop meaningful clusters from these significant statements into patterns or key elements shared across participants.

Write a textual description of what the participants experienced based on the answers and themes of the two main questions. The answers are also used to write about the characteristics and describe the context that influenced the way the participants experienced the phenomenon, called imaginative variation or structural description. Researchers should also write about their own experiences and context or situations that influenced them.

Write a composite description from the structural and textural description that presents the "essence" of the phenomenon, called the essential and invariant structure.

A phenomenological approach to a research design includes the strict and careful selection of participants in the study where bracketing personal experiences can be difficult to implement. The researcher decides how and in which way their knowledge will be introduced. It also involves some understanding and identification of the broader philosophical assumptions.

Grounded theory is used in a research design when the goal is to inductively develop a theory "grounded" in data that has been systematically gathered and analyzed. Starting from the data collection, researchers identify characteristics, patterns, themes, and relationships, gradually forming a theoretical framework that explains relevant processes, actions, or interactions grounded in the observed reality. A grounded theory study goes beyond descriptions and its objective is to generate a theory, an abstract analytical scheme of a process. Developing a theory doesn't come "out of nothing" but it is constructed and based on clear data collection. We suggest the following steps to follow a grounded theory approach in a research design:

Determine if grounded theory is the best for your research problem . Grounded theory is a good design when a theory is not already available to explain a process.

Develop questions that aim to understand how individuals experienced or enacted the process (e.g., What was the process? How did it unfold?). Data collection and analysis occur in tandem, so that researchers can ask more detailed questions that shape further analysis, such as: What was the focal point of the process (central phenomenon)? What influenced or caused this phenomenon to occur (causal conditions)? What strategies were employed during the process? What effect did it have (consequences)?

Gather relevant data about the topic in question . Data gathering involves questions that are usually asked in interviews, although other forms of data can also be collected, such as observations, documents, and audio-visual materials from different groups.

Carry out the analysis in stages . Grounded theory analysis begins with open coding, where the researcher forms codes that inductively emerge from the data (rather than preconceived categories). Researchers can thus identify specific properties and dimensions relevant to their research question.

Assemble the data in new ways and proceed to axial coding . Axial coding involves using a coding paradigm or logic diagram, such as a visual model, to systematically analyze the data. Begin by identifying a central phenomenon, which is the main category or focus of the research problem. Next, explore the causal conditions, which are the categories of factors that influence the phenomenon. Specify the strategies, which are the actions or interactions associated with the phenomenon. Then, identify the context and intervening conditions—both narrow and broad factors that affect the strategies. Finally, delineate the consequences, which are the outcomes or results of employing the strategies.

Use selective coding to construct a "storyline" that links the categories together. Alternatively, the researcher may formulate propositions or theory-driven questions that specify predicted relationships among these categories.

Develop and visually present a matrix that clarifies the social, historical, and economic conditions influencing the central phenomenon. This optional step encourages viewing the model from the narrowest to the broadest perspective.

Write a substantive-level theory that is closely related to a specific problem or population. This step is optional but provides a focused theoretical framework that can later be tested with quantitative data to explore its generalizability to a broader sample.

Allow theory to emerge through the memo-writing process, where ideas about the theory evolve continuously throughout the stages of open, axial, and selective coding.

The researcher should initially set aside any preconceived theoretical ideas to allow for the emergence of analytical and substantive theories. This is a systematic research approach, particularly when following the methodological steps outlined by Strauss and Corbin (1990). For those seeking more flexibility in their research process, the approach suggested by Charmaz (2006) might be preferable.

One of the challenges when using this method in a research design is determining when categories are sufficiently saturated and when the theory is detailed enough. To achieve saturation, discriminant sampling may be employed, where additional information is gathered from individuals similar to those initially interviewed to verify the applicability of the theory to these new participants. Ultimately, its goal is to develop a theory that comprehensively describes the central phenomenon, causal conditions, strategies, context, and consequences.

Ethnographic research design

An ethnographic approach in research design involves the extended observation and data collection of a group or community. The researcher immerses themselves in the setting, often living within the community for long periods. During this time, they collect data by observing and recording behaviours, conversations, and rituals to understand the group's social dynamics and cultural norms. We suggest following these steps for ethnographic methods in a research design:

Assess whether ethnography is the best approach for the research design and questions. It's suitable if the goal is to describe how a cultural group functions and to delve into their beliefs, language, behaviours, and issues like power, resistance, and domination, particularly if there is limited literature due to the group’s marginal status or unfamiliarity to mainstream society.

Identify and select a cultural group for your research design. Choose one that has a long history together, forming distinct languages, behaviours, and attitudes. This group often might be marginalized within society.

Choose cultural themes or issues to examine within the group. Analyze interactions in everyday settings to identify pervasive patterns such as life cycles, events, and overarching cultural themes. Culture is inferred from the group members' words, actions, and the tension between their actual and expected behaviours, as well as the artifacts they use.

Conduct fieldwork to gather detailed information about the group’s living and working environments. Visit the site, respect the daily lives of the members, and collect a diverse range of materials, considering ethical aspects such as respect and reciprocity.

Compile and analyze cultural data to develop a set of descriptive and thematic insights. Begin with a detailed description of the group based on observations of specific events or activities over time. Then, conduct a thematic analysis to identify patterns or themes that illustrate how the group functions and lives. The final output should be a comprehensive cultural portrait that integrates both the participants (emic) and the researcher’s (etic) perspectives, potentially advocating for the group’s needs or suggesting societal changes to better accommodate them.

Researchers engaging in ethnography need a solid understanding of cultural anthropology and the dynamics of sociocultural systems, which are commonly explored in ethnographic research. The data collection phase is notably extensive, requiring prolonged periods in the field. Ethnographers often employ a literary, quasi-narrative style in their narratives, which can pose challenges for those accustomed to more conventional social science writing methods.

Another potential issue is the risk of researchers "going native," where they become overly assimilated into the community under study, potentially jeopardizing the objectivity and completion of their research. It's crucial for researchers to be aware of their impact on the communities and environments they are studying.

The case study approach in a research design focuses on a detailed examination of a single case or a small number of cases. Cases can be individuals, groups, organizations, or events. Case studies are particularly useful for research designs that aim to understand complex issues in real-life contexts. The aim is to provide a thorough description and contextual analysis of the cases under investigation. We suggest following these steps in a case study design:

Assess if a case study approach suits your research questions . This approach works well when you have distinct cases with defined boundaries and aim to deeply understand these cases or compare multiple cases.

Choose your case or cases. These could involve individuals, groups, programs, events, or activities. Decide whether an individual or collective, multi-site or single-site case study is most appropriate, focusing on specific cases or themes (Stake, 1995; Yin, 2003).

Gather data extensively from diverse sources . Collect information through archival records, interviews, direct and participant observations, and physical artifacts (Yin, 2003).

Analyze the data holistically or in focused segments . Provide a comprehensive overview of the entire case or concentrate on specific aspects. Start with a detailed description including the history of the case and its chronological events then narrow down to key themes. The aim is to delve into the case's complexity rather than generalize findings.

Interpret and report the significance of the case in the final phase . Explain what insights were gained, whether about the subject of the case in an instrumental study or an unusual situation in an intrinsic study (Lincoln & Guba, 1985).

The investigator must carefully select the case or cases to study, recognizing that multiple potential cases could illustrate a chosen topic or issue. This selection process involves deciding whether to focus on a single case for deeper analysis or multiple cases, which may provide broader insights but less depth per case. Each choice requires a well-justified rationale for the selected cases. Researchers face the challenge of defining the boundaries of a case, such as its temporal scope and the events and processes involved. This decision in a research design is crucial as it affects the depth and value of the information presented in the study, and therefore should be planned to ensure a comprehensive portrayal of the case.

Qualitative and quantitative research designs are distinct in their approach to data collection and data analysis. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research prioritizes understanding the depth and richness of human experiences, behaviours, and interactions.

Qualitative methods in a research design have to have internal coherence, meaning that all elements of the research project—research question, data collection, data analysis, findings, and theory—are well-aligned and consistent with each other. This coherence in the research study is especially crucial in inductive qualitative research, where the research process often follows a recursive and evolving path. Ensuring that each component of the research design fits seamlessly with the others enhances the clarity and impact of the study, making the research findings more robust and compelling. Whether it is a descriptive research design, explanatory research design, diagnostic research design, or correlational research design coherence is an important element in both qualitative and quantitative research.

Finally, a good research design ensures that the research is conducted ethically and considers the well-being and rights of participants when managing collected data. The research design guides researchers in providing a clear rationale for their methodologies, which is crucial for justifying the research objectives to the scientific community. A thorough research design also contributes to the body of knowledge, enabling researchers to build upon past research studies and explore new dimensions within their fields. At the core of the design, there is a clear articulation of the research objectives. These objectives should be aligned with the underlying concepts being investigated, offering a concise method to answer the research questions and guiding the direction of the study with proper qualitative methods.

Carter, K. (1993). The place of a story in the study of teaching and teacher education. Educational Researcher, 22(1), 5-12, 18.

Charmaz, K. (2006). Constructing grounded theory. London: Sage.

Creswell, J. W., & Miller, D. L. (2000). Determining validity in qualitative inquiry. Theory Into Practice, 39(3), 124-130.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.

Ollerenshaw, J. A., & Creswell, J. W. (2000, April). Data analysis in narrative research: A comparison of two “restoring” approaches. Paper presented at the annual meeting of the American Educational Research Association, New Orleans, LA.

Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.

van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Ontario, Canada: University of Western Ontario.

Yin, R. K. (2003). Case study research: Design and methods (3rd ed.). Thousand Oaks, CA: Sage

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• Open access
• Published: 04 June 2024

What are medical students taught about persistent physical symptoms? A scoping review of the literature

• Catie Nagel 1 ,
• Chloe Queenan 1 &
• Chris Burton 1  

BMC Medical Education volume  24 , Article number:  618 ( 2024 ) Cite this article

Metrics details

Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management.

The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings.

A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners’ experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS.

Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.

Peer Review reports

Persistent Physical Symptoms (PPS) are symptoms which are disproportionate to currently recognised pathology and are common in all fields of medicine. The term encompasses single symptoms such as pain, dizziness or fatigue, and established syndromes including fibromyalgia and irritable bowel syndrome. It is increasingly understood that PPS arise from complex interactions between the brain and body [ 1 , 2 ]. While historically terms such as “medically unexplained symptoms” have been in common use, most symptoms can actually be explained [ 3 ] and PPS is a more acceptable term to patients [ 4 ].

PPS are common and present to nearly every medical specialty. They represent the primary reason for presentation in around 45% of general practice consultations and between 30 and 70% of presentations to neurology, gynaecology, and rheumatology outpatient clinics [ 5 ]. People with PPS suffer unduly in a medical system that is predisposed to ‘body part medicine,’ [ 6 ] resulting in what Balint referred to as the “collusion of anonymity.” [ 7 ] In other words, patients who pass from specialist to specialist, without any doctor taking full responsibility for holistic care. Patients with PPS consult more frequently [ 8 ] and tend to have a higher rate of referral to secondary care [ 9 ]. This is costly, both in financial terms and in terms of the emotional work for patients and clinicians [ 10 , 11 ]. Patients with PPS often have a poor experience of the health system and can be left feeling marginalised and even stigmatised [ 12 ].

Doctors find it difficult to consult and manage patients with persistent physical symptoms [ 8 ]. The absence of a common language of explanation to reconcile patients’ lived experience with doctors’ biomedical models, is particularly problematic [ 13 ]. It is plausible that difficulties may arise, or be perpetuated by, issues in each of the three domains of learning: cognitive (knowledge), psychomotor (skills) and affective (attitudes) [ 14 ].

The shifting perspectives, particularly around “medically unexplained symptoms” may account for historical uncertainty, however recent adoption of more consistent language and underlying models of symptoms mean that a common curriculum should be possible [ 15 ]. It is the authors’ experience that little teaching and learning at the undergraduate level has previously taken place on this topic. We wanted to find out if this was still the case, by reviewing the current medical education literature.

We carried out a scoping review with narrative synthesis following the approach of Arksey & O’Malley [ 16 ]. The PRISMA-ScR guidelines were used to structure reporting [ 17 ].

Research questions

The aim of the review was to explore the published literature regarding undergraduate medical teaching and learning on persistent physical symptoms. The specific research questions were:

What teaching and learning on persistent physical symptoms has been described for medical undergraduates?

What teaching methods have been used and how have these been evaluated?

Search strategy

We used a Population, Concept, and Context (PCC) framework to structure a systematic search. The population was undergraduate medical students, the concept was persistent physical symptoms, and the context was teaching and learning. A variety of synonyms were used in order to be inclusive, given the constant evolution of terms for persistent physical symptoms. We used adjacency searching and truncation methods in order to broaden the search as widely as possible and to account for different spellings of words or use of phrases across the international context. Search concepts were then combined using Boolean operators. No date range was used, so all studies before 31 March 2023 were included. Inclusion criteria were: studies relating to the teaching and learning of Persistent Physical Symptoms; medical students included in the population; available in the English language. Exclusion criteria were: studies about cancer or terminal pain without the inclusion of other forms of chronic or persistent pain; population not including medical students; letters to the editor, and papers which were not available in the English language. See Table  1 for the full search strategy.

Sources of evidence

Two authors searched for published literature in MEDLINE, PsycINFO, and Web of Science. Additionally, we searched Google and Google Scholar in order to include any grey literature or sources that had not been picked up by the previous search method. We employed citation analysis, by following backward citations from included papers and analysed the citations of any existing literature reviews.

Study selection

We used a two-stage screening process to identify eligible papers: first at title and abstract level and then at full text. This method was undertaken separately by two reviewers.

Literature reviews were excluded to avoid duplicated representation of primary data, but citations in these reviews were analysed to ensure consistent inclusion of studies and to check for any additional sources.

Charting the data: summary and synthesis

Summary findings for each full text article were charted to determine the most relevant items for extraction. This was an iterative process given the high degree of heterogeneity between the studies. Charting was conducted by two reviewers independently. Discrepancies in charting and data extraction were discussed in review meetings and a consensus was reached regarding which data to include for analysis.

Reviewers extracted descriptive data including: country of origin, whether the study was experimental or observational, the characteristics of the study participants, and whether any teaching intervention was evaluated. Other study characteristics were noted, such as the symptom or syndrome represented, as well as the type of study or intervention.

The expectation was that there would be a lack of teaching and learning on the subject of persistent physical symptoms. For this reason, the scoping review aimed to capture the greatest breadth of studies, rather than exclude studies based on quality criteria. If a teaching intervention was used, we did look at whether this was evaluated using a validated tool.

Following the extraction of descriptive data, a narrative synthesis was undertaken to identify other key findings. An inductive, iterative approach was taken in order to identify themes relating back to the research question. Manual coding was undertaken by two authors independently, followed by a discussion with all authors to arrive at an interpretation of the findings.

Search strategy, study selection, and data extraction

Searches identified 1390 unique titles. Studies were limited to English language and human participants, leading to 274 being excluded. First stage screening excluded a further 1080 studies. It was not possible to retrieve one study and six were excluded on full text. Ten further records were identified through a grey literature search using Google and Google Scholar and 18 were found through citation searching, three of which were from a previous literature review [ 15 ]. This resulted in 57 publications for inclusion in the review. See the PRISMA flow diagram in Fig.  1 for a summary of these findings.

PRISMA Diagram

Adapted from Page MJ, et al. [ 17 ]

Descriptive analysis

Study types.

The studies included for review were highly heterogeneous in their nature. 15/57 (26%) studies employed a teaching intervention, with the remaining either being observational or qualitative. 8/57 (14%) studies described or evaluated the teaching curriculum, 13/57 (22%), included an assessment of the current level of learner knowledge. 9/57 (16%) used qualitative methods with learners and 6/57 (11%) with medical educators. One literature review on assessing knowledge, perceptions and attitudes to pain was found [ 15 ]. The citations of this review were checked and the three new sources [ 18 , 19 , 20 ] were included for review. Sources within this literature review that did not meet the eligibility criteria were excluded. The findings of the review itself were noted for congruity, but not formally analysed.

Study characteristics

23/57(40%) of studies took place in USA and 13/57 (23%) in the UK. Six studies took place in Scandinavia and four in Canada, four in Australia and one in New Zealand, India, and Nigeria respectively. Some studies were based in more than one country e.g. Australia and New Zealand [ 21 ]. Publication dates ranged from 1992 to 2022. See Table  2 for a summary of the descriptive data.

Teaching and learning methods

A wide range of teaching and learning methods were discussed in the literature. These are fully described in Table  3 , but included lectures, workshops, reflective practice, and forum theatre.

Evaluation of teaching studies

Four studies used validated tools to assess learner attitudes towards patients with PPS, but only one used such a tool to evaluate a teaching intervention [ 22 ]. Morris, Rankin, and Briggs used the HC-PAIRS attitudinal questionnaire to assess learner attitudes towards patients with chronic low back pain [ 18 , 23 , 24 ]. Whereas Friedberg et al. [ 22 ] used the Chronic Fatigue Syndrome Attitudes Test (CFSAT) and paired t-test to analyse learner attitudes before and after a teaching intervention. The remaining educational interventions either did not use a validated tool for evaluation or were not formally evaluated. See Table  3 for more details.

Thematic synthesis

All studies identified a lack of teaching about persistent physical symptoms (PPS) at undergraduate level. The narrative synthesis identified four themes: An awkward problem, an absence of science, being easily overlooked, and a hidden curriculum.

An awkward problem

PPS was consistently viewed as an awkward problem. Medical educators and learners found it difficult to understand, particularly when referring to the symptoms as ‘unexplained.’ Some educators described PPS as too complex or too confusing, even ‘dangerous’ to introduce at an undergraduate level and stated the need to focus on the easily ‘explainable.’ [ 25 ] Chronic non-cancer pain was the dominant condition represented in the literature, but despite theoretical concepts of chronic pain being more established, learners found the subject challenging, even ‘unpleasant.’ [ 26 , 27 ].

The absence of science

Four studies highlighted that learners infer patients with PPS have ‘no science’ behind their symptoms. In the study by Vasanthy [ 28 ], clinical role models in Kerala were found to have a ‘nihilistic’ attitude towards people with fibromyalgia and regarded the condition as benign and unimportant. This finding was echoed by UK studies [ 29 , 30 , 31 ] where the impact of a lack of teaching and negative role modelling was evident:

“You can’t really train someone for it because there is no science behind it” [ 30 ].

One final year medical student stated that fibromyalgia was “not a medical issue” intimating that it had no place in the taught curriculum [ 29 ]. Learners understood the need to be supportive and for good communication, but only as a way of achieving relational congruence, not epistemic congruence [ 8 ]. Terminology may be important and in one study learners’ attitudes towards PPS varied depending on the diagnostic label [ 32 ]. As an example, learners thought that people with myalgic encephalopathy were less likely to recover than those with chronic fatigue syndrome [ 32 ].

Easily overlooked

Even without the overt attitudinal barriers described in some studies, PPS as a topic is overlooked in undergraduate medical education. The most common barrier was an already overloaded teaching curriculum [ 25 , 33 ]. PPS was not deemed a priority area by educational leaders and [ 33 ] even when they recognised its importance, they cited a lack of ownership of the topic and a lack of coordination between teaching specialties as a barrier to implementing teaching. This was in contrast to chronic non-cancer pain teaching which usually did have clear ownership by pain specialists and established interdisciplinary relationships [ 34 ]. The experience of learners in the clinical setting was that they were shielded from patients with PPS or directed towards patients with other more easily defined clinical problems [ 28 ].

Stigma and the hidden curriculum

Given the vacuum of formal teaching, learners were taking on stigmatised messages about sufferers of PPS, frequently from role models in the clinical placement setting. Stenhoff and colleagues described a cycle of negativity created by the lack of teaching on the subject of chronic fatigue, which resulted in negative behaviour by clinical role models, in turn perpetuating negative attitudes in the next generation of learners [ 31 ]. Whilst learners recognised the problematic nature of the attitudes towards people with PPS, they lacked the tools to challenge negative stereotypes [ 29 , 30 , 35 ]. Learners experienced a mismatch between formal teaching on the topic and their experience on placement, where these conditions were frequently encountered. They addressed the gap by seeking information about PPS from informal sources, such as their own or their families’ experiences or from the internet [ 36 ]. This lack of explicit teaching and the influence of informal sources has been termed by some authors as the ‘hidden curriculum’ [ 29 , 30 , 31 , 36 ] and this has had a significant impact on learners’ attitudes towards people suffering with PPS.

Suggestions for improvement: relationship to domains of learning

The findings of the narrative synthesis map onto Bloom’s revised three domains of learning [ 14 ].

Knowledge (cognitive)

A number of studies demonstrate success in teaching on the topic of chronic non-cancer pain. Teaching interventions tended to include a foundation of knowledge such as teaching on pain mechanisms, pharmacology, and pain management [ 37 , 38 ]. Such theory-driven interventions led to improved scores on assessment [ 39 ]. Methods of teaching should be considered in the explicitly taught curriculum. Authors recommended an integrated approach [ 40 , 41 ] and one which drew on the skills and knowledge from a variety of disciplines [ 37 , 42 ]. Curriculum mapping was recommended by Howman et al. [ 33 ] in order to identify ways in which this integration could be implemented. The need for an holistic approach which emphasises the importance of empathy [ 41 ] and the biopsychosocial was also widely recognised [ 43 , 44 , 45 , 46 ]. Learners cited a lack of assessment as an indicator that PPS was either unimportant or uncommon [ 29 , 33 ] and therefore any teaching intervention should include assessment in order to drive learning and engagement.

Skills (psychomotor)

Learners valued the addition of skills-based teaching and engaged best with teaching that was experiential [ 47 ] and included either patients with PPS or simulated patients [ 45 , 48 , 49 ]. In one study the focus of the teaching was on interactive, practical teaching for emotionally demanding consultations and the skills taught in such a programme could be transferable to the PPS context [ 49 ]. Approaches to help learners find a common language of explanation [ 13 ] will not only bridge the epistemic gap between clinicians and patients [ 8 ], but should give learners greater confidence and satisfaction in consultations where PPS are the focus.

Attitudes (affective) and the role of reflection

Reflection is a key transferable skill that graduates should acquire as part of their undergraduate training [ 50 ]. Both learners and educators voiced a great deal of anxiety regarding teaching and managing patients with PPS. Some authors utilised reflective logs and visual art as a way of teaching about chronic pain [ 51 ] and learners valued the deep insights provided by this method. Skills in reflection might help to ameliorate the negative emotions felt by learners, especially if combined with a taught framework that helps them understand concepts such as internal bias and cognitive dissonance [ 52 ].

Summary of main findings

This review found that teaching on persistent physical symptoms in undergraduate medical education is inconsistent and incomplete. We identified four important themes: an awkward problem, the absence of science, easily overlooked, and the hidden curriculum. Mapping these to teaching and learning domains provides a coherent framework for undergraduate teaching of these common conditions. Where teaching does take place, this is more frequently on the topic of chronic non-cancer pain. A number of studies have demonstrated improved knowledge [ 39 ], skills [ 49 ], and attitudes [ 51 ] as a result of this teaching [ 34 , 47 ], but high quality evaluation of such teaching and learning is lacking.

Strengths and limitations

This scoping review has addressed a gap in the literature. By undertaking a search of three databases, the grey literature, and citation analysis, a wide range of sources were included for initial screening. Two researchers independently undertook the search strategy before comparing findings which has helped to ensure a robust and systematic approach. Narrative synthesis was undertaken by three researchers, one with expertise in the field of persistent physical symptoms.

The majority of the studies identified were from the USA and UK. Papers that were not accessible in English were excluded, which may explain this finding. Where teaching and learning evaluations had taken place, this was on a small scale usually within one institution. Only one study [ 22 ] used a validated tool to evaluate the efficacy of the teaching intervention.

Implications for practice, policy, and research

There is a lack of teaching on PPS in undergraduate medical education. As a result, medical graduates are ill-equipped to recognise, consult for, and manage this group of conditions. Given the prevalence of PPS across medical specialties this is a priority area that needs to be addressed, whilst acknowledging the barriers that exist to implementation.

The solutions offered up in the literature include the need to consider whole-person care, in order to avoid fragmentation and the “collusion of anonymity” [ 7 ] described above. For this reason, teaching on PPS should be integrated into the core curriculum and draw on a variety of disciplines.

A better understanding of the science behind PPS [ 1 , 2 ] is needed for both educators and learners. There is also a need to move learners beyond reductionist models of communication skills towards more theory-driven approaches of person-centredness, as identified by Bansal [ 53 ]. We need to convey to learners that skilled communication is not about platitudes, but can make a difference to recovery and addresses the current epistemic gap between clinicians and their patients [ 8 , 13 ].

Future educational research should focus on the most effective methods to improve the knowledge base of both educators and students and how best to evaluate the success of future teaching interventions. Skills in person-centred communication and explanation [ 3 ] need to be taught, alongside those in reflection and challenging prejudice.

We identified four important themes which underpin the challenges of teaching medical undergraduates about persistent physical symptoms. Educational faculties need to find ways to integrate teaching into current programmes and work around the existing barriers to successful implementation and evaluation of teaching about these common and limiting conditions. Examples of successful teaching on chronic non-cancer pain were found in the literature. These tended to articulate the science behind symptoms and often included experiential elements. Such examples should be used to inform an approach for teaching about other forms of PPS. Importantly, robust evaluation that accounts for the complexity of the taught environment is needed to ensure our teaching is making a difference, both for our learners and the patients they will go on to encounter.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

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Nagel, C., Queenan, C. & Burton, C. What are medical students taught about persistent physical symptoms? A scoping review of the literature. BMC Med Educ 24 , 618 (2024). https://doi.org/10.1186/s12909-024-05610-z

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How to Conduct a Systematic Review: A Narrative Literature Review

Nusrat jahan.

1 Psychiatry, Mount Sinai Chicago

Sadiq Naveed

2 Psychiatry, KVC Prairie Ridge Hospital

Muhammad Zeshan

3 Department of Psychiatry, Bronx Lebanon Hospital Icahn School of Medicine at Mount Sinai, Bronx, NY

Muhammad A Tahir

4 Psychiatry, Suny Upstate Medical University, Syracuse, NY

Systematic reviews are ranked very high in research and are considered the most valid form of medical evidence. They provide a complete summary of the current literature relevant to a research question and can be of immense use to medical professionals. Our goal with this paper is to conduct a narrative review of the literature about systematic reviews and outline the essential elements of a systematic review along with the limitations of such a review.

Introduction and background

A literature review provides an important insight into a particular scholarly topic. It compiles published research on a topic, surveys different sources of research, and critically examines these sources [ 1 ]. A literature review may be argumentative, integrative, historical, methodological, systematic, or theoretical, and these approaches may be adopted depending upon the types of analysis in a particular study [ 2 ].

Our topic of interest in this article is to understand the different steps of conducting a systematic review. Systematic reviews, according to Wright, et al., are defined as a “review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research, and to extract and analyze data from the studies that are included in the review” [ 3 ]. A systematic review provides an unbiased assessment of these studies [ 4 ]. Such reviews emerged in the 1970s in the field of social sciences. Systematic reviews, as well as the meta-analyses of the appropriate studies, can be the best form of evidence available to clinicians [ 3 ]. The unsystematic narrative review is more likely to include only research selected by the authors, which introduces bias and, therefore, frequently lags behind and contradicts the available evidence [ 5 ].

Epidemiologist Archie Cochrane played a vital role in formulating the methodology of the systematic review [ 6 ]. Dr. Cochrane loved to study patterns of disease and how these related to the environment. In the early 1970s, he found that many decisions in health care were made without reliable, up-to-date evidence about the treatments used [ 6 ].

A systematic review may or may not include meta-analysis, depending on whether results from different studies can be combined to provide a meaningful conclusion. David Sackett defined meta-analysis as a “specific statistical strategy for assembling the results of several studies into a single estimate” [ 7 - 8 ].

While the systematic review has several advantages, it has several limitations which can affect the conclusion. Inadequate literature searches and heterogeneous studies can lead to false conclusions. Similarly, the quality of assessment is an important step in systematic reviews, and it can lead to adverse consequences if not done properly.

The purpose of this article is to understand the important steps involved in conducting a systematic review of all kinds of clinical studies. We conducted a narrative review of the literature about systematic reviews with a special focus on articles that discuss conducting reviews of randomized controlled trials. We discuss key guidelines and important terminologies and present the advantages and limitations of systematic reviews.

Narrative reviews are a discussion of important topics on a theoretical point of view, and they are considered an important educational tool in continuing medical education [ 9 ]. Narrative reviews take a less formal approach than systematic reviews in that narrative reviews do not require the presentation of the more rigorous aspects characteristic of a systematic review such as reporting methodology, search terms, databases used, and inclusion and exclusion criteria [ 9 ]. With this in mind, our narrative review will give a detailed explanation of the important steps of a systematic review.

Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) checklist

Systematic reviews are conducted based on predefined criteria and protocol. The PRISMA-P checklist, developed by Moher, et al., contains 17 items (26 including sub-items) comprising the important steps of a systematic review, including information about authors, co-authors, their mailing and email addresses, affiliations, and any new or updated version of a previous systematic review [ 9 ]. It also identifies a plan for documenting important protocol amendments, registry names, registration numbers, financial disclosures, and other support services [ 10 ]. Moher, et al. also state that methods of systematic reviews involve developing eligibility criteria and describing information sources, search strategies, study selection processes, outcomes, assessment of bias in individual studies, and data synthesis [ 10 ].

Research question

Writing a research question is the first step in conducting a systematic review and is of paramount importance as it outlines both the need and validity of systematic reviews (Nguyen, et al., unpublished data). It also increases the efficiency of the review by limiting the time and cost of identifying and obtaining relevant literature [ 11 ]. The research question should summarize the main objective of a systematic review.

An example research question might read, “How does attention-deficit/hyperactivity disorder (ADHD) affect the academic performance of middle school children in North America?” The question focuses on the type of data, analysis, and topic to be discussed (i.e., ADHD among North American middle school students). Try to avoid research questions that are too narrow or broad—they can lead to the selection of only a few studies and the ability to generalize results to any other populations may be limited. An example of a research question that is too narrow would be, “What is the prevalence of ADHD in children and adolescents in Chicago, IL?” Alternately, if the research question is too broad, it can be difficult to reach a conclusion due to poor methodology. An example of a research question that is too broad in scope would be, “What are the effects of ADHD on the functioning of children and adolescents in North America?”

Different tools that can be used to help devise a research question, depending on the type of question, are: population, intervention, comparator, and outcomes (PICO); sample, phenomenon of interest, design, evaluation, and research type (SPIDER); setting, perspective, intervention, comparison, and evaluation (SPICE); and expectation, client group, location, impact, professionals, and service (ECLIPSE).

The PICO approach is mostly used to compare different interventions with each other. It helps to formulate a research question related to prognosis, diagnosis, and therapies [ 12 ].

Scenario: A 50-year-old white woman visited her psychiatrist with a diagnosis of major depressive disorder. She was prescribed fluoxetine, which she feels has been helpful. However, she experienced some unpleasant side effects of nausea and abdominal discomfort. She has recently been told by a friend about the use of St. John’s wort in treating depression and would like to try this in treating her current depression. (Formulating research questions, unpublished data).

In the above-mentioned scenario, the sample population is a 50-year-old female with major depressive disorder; the intervention is St. John’s wort; the comparison is fluoxetine; and the outcome would be efficacy and safety. In order to see the outcome of both efficacy and safety, we will compare the efficacy and safety of both St. John’s wort and fluoxetine in a sample population for treating depression. This scenario represents an example where we can apply the PICO approach to compare two interventions.

In contrast, the SPIDER approach is focused more on study design and samples rather than populations [ 13 ]. The SPIDER approach can be used in this research question: “What is the experience of psychiatry residents attending a transgender education?” The sample is psychiatry residents; the phenomenon of interest is transgender education; the design is a survey; the evaluation looks at the experience; and the research type is qualitative. 

The SPICE approach can be used to evaluate the outcome of a service, intervention, or project [ 14 ]. The SPICE approach applies to the following research question: “In psychiatry clinics, does the combined use of selective serotonin reuptake inhibitor (SSRI) and psychotherapy reduce depression in an outpatient clinic versus SSRI therapy alone?” The setting is the psychiatry clinic; the perspective/population is the outpatient; the intervention is combined psychotherapy and SSRI; the comparison is SSRI alone; and the evaluation is reduced depression. 

The ECLIPSE approach is useful for evaluating the outcome of a policy or service (Nguyen, et al., unpublished data). ECLIPSE can apply in the following research question: “How can a resident get access to medical records of patients admitted to inpatient from other hospitals?” The expectation is: “What are you looking to improve/change to increase access to medical records for patients admitted to inpatient?” The client group is the residents; the location is the inpatient setting; the impact would be the residents having easy access to medical records from other hospitals; and the professionals in this scenario would be those involved in improving the service experiences such as hospital administrators and IT staff.

Inclusion and exclusion criteria

Establishing inclusion and exclusion criteria come after formulating research questions. The concept of inclusion and exclusion of data in a systematic review provides a basis on which the reviewer draws valid and reliable conclusions regarding the effect of the intervention for the disorder under consideration [ 11 ]. Inclusions and exclusion are based on preset criteria for specific systematic review. It should be done before starting the literature search in order to minimize the possibility of bias.

Eligibility criteria provide the boundaries of the systematic review [ 15 ]. Participants, interventions, and comparison of a research question provide the basis for eligibility criteria [ 15 ]. The inclusion criteria should be able to identify the studies of interest and, if the inclusion criteria are too broad or too narrow, it can lead to an ineffective screening process.

Protocol registration

Developing and registering research protocol is another important step of conducting a systematic review. The research protocol ensures that a systematic review is carefully planned and explicitly documented before the review starts, thus promoting consistency in conduct for the review team and supporting the accountability, research integrity, and transparency of the eventually completed review [ 10 ]. PROSPERO and the Cochrane Database of Systematic Reviews are utilized for registering research protocols and research questions, and they check for prior existing duplicate protocols or research questions. PROSPERO is an international database of prospectively registered systematic reviews related to health care and social sciences (PRISMA, 2016). It is funded by the National Institute for Health Research. The Cochrane Collaboration concentrates on producing systematic reviews of interventions and diagnostic test accuracy but does not currently produce reviews on questions of prognosis or etiology [ 16 ].

A detailed and extensive search strategy is important for the systematic review since it minimizes bias in the review process [ 17 ].

Selecting and searching appropriate electronic databases is determined by the topic of interest. Important databases are: MEDLARS Online (MEDLINE), which is the online counterpart to the Medical Literature Analysis and Retrieval System (MEDLARS); Excerpta Medica Database (EMBASE); and Google Scholar. There are multiple electronic databases available based on the area of interest. Other important databases include: PsycINFO for psychology and psychiatry; Allied and Complementary Medicine Database (AMED) for complementary medicine; Manual, Alternative, and Natural Therapy Index System (MANTIS) for alternative medical literature; and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for nursing and allied health [ 15 ].

Additional studies relevant for the review may be found by looking at the references of studies identified by different databases [ 15 ]. Non-indexed articles may be found by searching the content of journals, conferences proceedings, and abstracts. It will also help with letters and commentaries which may not get indexed [ 15 ]. Reviewing clinical trial registries can provide information about any ongoing trials or unpublished research [ 15 ]. A gray literature search can access unpublished papers, reports, and conference reports, and it generally covers studies that are published in an informal fashion, rather than in an indexed journal [ 15 ]. Further search can be performed by selecting important key articles and going through in-text citations [ 15 ].

Using Boolean operators, truncation, and wildcards

Boolean operators use the relationship between different search words to help with the search strategy. These are simple words (i.e., AND, OR, and NOT) which can help with more focused and productive results (poster, Jahan, et al.: How to conduct a systematic review. APPNA 39th Summer Convention. Washington, DC. 2016). The Boolean operator AND finds articles with all the search words. The use of OR broadens the focus of the search, and it will include articles with at least one search term. The researchers can also ignore certain results from the records by using NOT in the search strategy.

An example of AND would be using “depression” AND “children” in the search strategy with the goal of studying depression in children. This search strategy will include all the articles about both depression and children. The researchers may use OR if the emphasis of the study is mood disorders or affective disorders in adolescents. In that case, the search strategy will be “mood disorders” OR “affective disorders” AND “adolescents.” This search will find all the articles about mood disorders or affective disorders in adolescents. The researchers can use NOT if they only want to study depression in children and want to ignore bipolar disorder from the search. An example search in this scenario would be “depression” NOT “bipolar disorder” AND “children.” This will help ignore studies related to bipolar disorder in children.

Truncation and wildcards are other tools to make search strategy more comprehensive and focused. While the researchers search a database for certain articles, they frequently face terminologies that have the same initial root of a word but different endings. An example would be "autism," "autistic," and "autism spectrum disorder." These words have a similar initial root derived from “autis” but they end differently in each case. The truncation symbol (*) retrieves articles that contain words beginning with “autis” plus any additional characters. Wildcards are used for words with the same meanings but different spellings due to various reasons. For the words with spelling variations of a single letter, wildcard symbols can be used. When the researcher inputs “M+N” in the search bar, this returns results containing both “man” or “men” as the wildcard accounts for the spelling variations between the letters M and N.

Study selection

Study selection should be performed in a systematic manner, so reviewers deal with fewer errors and a lower risk of bias (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #). Study selection should involve two independent reviewers who select studies using inclusion and exclusion criteria. Any disagreements during this process should be resolved by discussion or by a third reviewer [ 10 ]. Specific study types can be selected depending on the research question. For example, questions on incidence and prevalence can be answered by surveys and cohort studies. Clinical trials can provide answers to questions related to therapy and screening. Queries regarding diagnostic accuracy can be answered by clinical trials and cross-sectional studies (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #). Prognosis and harm-related questions should use cohort studies and clinical trials, and etiology questions should use case-control and cohort studies (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #).

Data screening and data extractions are two of the major steps in conducting a systematic review [ 18 ]. Data screening involves searching for relevant articles in different databases using keywords. The next step of data screening is manuscript selection by reviewing each manuscript in the search results to compare that manuscript against the inclusion criteria [ 18 ]. The researchers should also review the references of the papers selected before selecting the final paper, which is the last step of data screening [ 18 ].

The next stage is extracting and appraising the data of the included articles [ 18 ]. A data extraction form should be used to help reduce the number of errors, and more than one person should record the data [ 17 ]. Data should be collected on specific points like population type, study authors, agency, study design, humanitarian crisis, target age groups, research strengths from the literature, setting, study country, type(s) of public health intervention, and health outcome(s) addressed by the public health intervention. All this information should then be put into an electronic database [ 18 ].

Assessing bias

Bias is a systematic error (or deviation from the truth) in results or inferences. Biases can change the results of any study and lead to an underestimation or overestimation of the true intervention effect [ 19 ]. Biases can impact any aspect of a review, including selecting studies, collecting and extracting data, and making a conclusion. Biases can vary in magnitude; some are small, with negligible effect, but some are substantial to a degree where an apparent finding may be entirely due to bias [ 19 ]. There are different types of bias, including, but not limited to, selection, detection, attrition, reporting, and performance.

Selection bias occurs when a sample selected is not representative of the whole general population. If randomization of the sample is done correctly, then chances of selection bias can be minimized [ 20 ].

Detection bias refers to systematic differences between groups in how outcomes are determined. This type of bias is based on knowledge of the intervention provided and its outcome [ 19 ].

Attrition bias refers to systematic differences between groups in withdrawals from a study [ 19 ]. The data will be considered incomplete if some subjects are withdrawn or have irregular visits during data collection.

Reporting bias refers to systematic differences between reported and unreported findings, and it is commonly seen during article reviews. Reporting bias is based on reviewer judgment about the outcome of selected articles [ 20 ].

Performance bias develops due to the knowledge of the allocated interventions by participants and personnel during the study [ 20 ]. Using a double-blind study design helps prevent performance bias, where neither the experimenter nor the subjects know which group contains controls and which group contains the test article [ 14 ].

Last step of systematic review: discussion

The discussion of a systematic review is where a summary of the available evidence for different outcomes is written and discussed [ 10 ]. The limitations of a systematic review are also discussed in detail. Finally, a conclusion is drawn after evaluating the results and considering limitations [ 10 ].

Discussion of the current article

Systematic reviews with or without a meta-analysis are currently ranked to be the best available evidence in the hierarchy of evidence-based practice [ 21 ]. We have discussed the methodology of a systematic review. A systematic review is classified in the category of filtered information because it appraises the quality of the study and its application in the field of medicine [ 21 ]. However, there are some limitations of the systematic review, as we mentioned earlier in our article. A large randomized controlled trial may provide a better conclusion than a systematic review of many smaller trials due to their larger sample sizes [ 22 ], which help the researchers generalize their conclusions for a bigger population. Other important factors to consider include higher dropout rates in large studies, co-interventions, and heterogeneity among studies included in the review.

As we discussed the limitations of the systematic review and its effect on quality of evidence, there are several tools to rate the evidence, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [ 22 ]. GRADE provides a structured approach to evaluating the risk of bias, serious inconsistency between studies, indirectness, imprecision of the results, and publication bias [ 22 ]. Another approach used to rate the quality of evidence is a measurement tool to assess systematic reviews (AMSTAR) [ 23 ]. It is also available in several languages [ 23 ].

Conclusions

Despite its limitations, a systematic review can add to the knowledge of the scientific community especially when there are gaps in the existing knowledge. However, conducting a systematic review requires different steps that involve different tools and strategies. It can be difficult at times to access and utilize these resources. A researcher can understand and strategize a systematic review following the different steps outlined in this literature review. However, conducting a systematic review requires a thorough understanding of all the concepts and tools involved, which is an extensive endeavor to be summed up in one article.

The Cochrane Handbook for Systematic Reviews of Interventions and the Center for Reviews and Dissemination (CRD) provide excellent guidance through their insightful and detailed guidelines. We recommend consulting these resources for further guidance.

Given that our article is a narrative review of the scholarly literature, it contains the same limitations as noted for any narrative review. We hope that our review of the means and methods for conducting a systematic review will be helpful in providing basic knowledge to utilize the resources available to the scientific community.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

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