utilization of theoretical models and frameworks in the process of

JBI Library of Systematic Reviews JBL000307 2010;8(18):730-751

Godfrey et al. Use of models or frameworks in evidence synthesis © the authors 2010 page 730

Utilisation of theoretical models and frameworks in the process of

evidence synthesis

Christina M. Godfrey RN MSc1

Margaret B. Harrison RN PhD2

Ian D. Graham PhD3

Amanda Ross-White BA MLIS4

1. Queen‟s Joanna Briggs Collaboration, Queen‟s University, Kingston, Ontario, Canada, K7L 3N6

2. School of Nursing, Queen‟s University, Kingston, Ontario, Canada, K7L 3N6

3. Canadian Institutes of Health Research, Ottawa, Ontario, Canada, K1A 0W9

4. Bracken Health Sciences Library, Queen's University, Kingston, Ontario, Canada, K7L 3N6

Corresponding author: Christina M. Godfrey, Queen‟s Joanna Briggs

Collaboration, Queen‟s University, Kingston, Ontario, Canada, K7L 3N6

Tel: 613-533-6000 ext 78760 Email: [email protected]

Executive summary

Background A systematic review is a comprehensive enquiry or study of secondary

data sources. There is a research question, an a priori articulation of methods and a

set of procedures to focus the investigation. Despite these rigorous structures to

guide the review, synthesising evidence is a challenging, resource intense and time

consuming process. Large volumes of information complicate not only the search

functions, but also the conceptualisation of the evidence needed to create the concise

and integrated results. Use of a theoretical model or framework could serve as an

essential element in effectively focusing the review and designing the methods to

respond to the knowledge question.

Objective This scoping review sought to confirm the value of models or frameworks

used by authors working within traditional methodologies for evidence synthesis.

Inclusion criteria

Types of participants The focus of this review was on the context of health care.

Types of intervention(s)/phenomena of interest All studies that discussed models

or frameworks used specifically to address the process of synthesis were included.

Types of studies Discussion, scholarship or methodology papers and reviews were

included.

Types of outcome All theoretical models or frameworks were described, with

specific attention to the purpose of the framework for each study, and the contribution

of the framework to the process of synthesis.

Search strategy The search strategy aimed to find both published and unpublished

studies. A three-step search strategy was utilised. The databases for published

material included CINAHL; Medline; EMBASE; PsycINFO; AMED; Cochrane; Biomed



Central; Scirus; and Mednar. Databases for unpublished material included

Dissertation Abstracts; Sociological Abstracts; Conference proceedings.

Methodological quality The review was a focused scoping review to locate and

describe the contribution of theoretical models or frameworks to the process of

synthesis. The methodological quality of the discussion papers was therefore not

assessed.

Data collection Data was extracted from the discussion papers using an adaptation

of the standardised data extraction tool from the Joanna Briggs Institute Data

Extraction for Narrative, Expert opinion & text (JBI-NOTARI).

Data synthesis Results were discussed in narrative form. The use of frameworks in

each step of the synthesis process was discussed.

Results Eight studies (nine papers) formed the final set included in this review. The

studies targeted the following issues: Child protection; end-of-life care; predictors of

adolescent sexual behaviour and intention; primary care career choice; prognosis of

acute whiplash; reluctance to care; use of Information Technology; young child's

post-divorce adjustment. Frameworks were used in four of the seven steps of

synthesis, and integration of the data indicated that the use of frameworks in the

process of evidence synthesis was valuable and had many advantages.

Conclusion This review illustrates that the addition of structure and guidance

provided by a framework can serve to benefit the process of integration. Studies in

this review indicated that the use of frameworks helped to inform the association

between variables, guide the search strategy, structure and clarify the outcomes,

identify knowledge gaps and indicate areas for future research. Used in this manner,

frameworks could provide a valuable foundation for the process of synthesis.

Implications for practice Evidence from systematic reviews informs practice. The

incorporation of a theoretical model or framework helps to guide the process of

synthesis and clarify the outcomes. This added transparency will facilitate the

assimilation of the evidence by the target audience.

Implications for research Systematic reviews are the highest level of evidence

available at this time. The use of theoretical models or frameworks in the review

process strengthens the rigor and transparency of the integrative method. Further

research into the contribution of theoretical models or conceptual frameworks to the

process of synthesis may be valuable.

Keywords Theoretical model; conceptual framework; theoretical framework;

conceptual model; Systematic review; integrative review; integrative research;

evidence summary

Background

A systematic review is a comprehensive enquiry or study of secondary data sources. There is a

research question, an a priori articulation of methods and a set of procedures to focus the

investigation. Seven formal steps help guide the synthesis process: Stage 1 - Developing the review

protocol; Stage 2 - Developing the review question; Stage 3 - Identifying search criteria;



Stage 4 - Generating the search strategy; Stage 5 - Assessing study quality; Stage 6 - Extracting the

data; and Stage 7 - Synthesising the data. Despite these rigorous structures to guide the review,

synthesising evidence is a challenging, resource intense and time consuming process. Large volumes

of information complicate not only the search functions, but also the conceptualisation of the evidence

needed to create the concise and integrated results.

Formal review protocols, such as those used by Cochrane or the Joanna Briggs Institute, are

procedure driven from methodologies that serve to lead the review group and keep them on-track with

their original goals for synthesis of gathered information. Although such protocols are essential, our

experience is that more is needed to form a basis for the effective conduct of reviews. We believe a

critical and key element is a priori conceptualisation of the review. Use of a theoretical model or

conceptual framework could serve as an essential element in effectively focusing the review and

designing the methods to respond to the knowledge question.

Conceptual frameworks are constructed to identify logical or theoretical relationships among variables

and are often represented diagrammatically. As such they have been referred to in the research

literature as 'conceptual maps'. A conceptual map is "a diagram of the relationship among the

variables linking the independent variable to the dependent variables and serves to clarify the

research problem."1,p.379 A conceptual map is regarded as a theoretical model rather than a model

for statistical analysis, and serves to summarise and integrate the existing state of knowledge about a

phenomenon.1 With systematic reviews, this is a critical element in effectively focusing the review and

designing the methods to respond to the knowledge question.

Since the term 'conceptual frameworks' is frequently used interchangeably with conceptual maps,

models, frameworks, and paradigms, it is important to define these terms. The American Heritage

Dictionary2 defines „conceptual‟ as:

1. The ability to form or understand mental concepts and abstractions

2. Something conceived in the mind; a concept, plan, design, idea, or thought and the word

'framework' as:3

1. A structure for supporting or enclosing something else, especially a skeletal support used as

the basis for something being constructed

2. A fundamental structure, as for a written work

3. A set of assumptions, concepts, values, and practices that constitutes a way of viewing

reality.

Thus the term 'conceptual framework' combines both abstract and form, bringing together thoughts

and ideas and providing a supporting structure with which to contain them. A conceptual framework

facilitates the linkage of concepts with previously constructed reality, thereby promoting the

incorporation of different concepts or new ideas into our existing world view. For example, Kim et al.,4

developed their own conceptual framework in order to identify strategies for constructing teaching

cases for a variety of learning settings. After conducting a review of the literature they developed a

conceptual framework that comprised five attributes: Relevant; Realistic; Engaging; Challenging, and

Instructional, which could serve as a menu of teaching case development options for educators.

Although the term theoretical framework is used interchangeably with conceptual framework, a

theoretical framework generally incorporates at least part of a specific theory as the basis for a study,

and usually guides the development and testing of interventions and hypotheses based on the tenets

of the theory.5 As an example, Mock et al.,

5 describe the use of the Levine Conservation Model to



guide the investigation of an exercise intervention to mitigate cancer-related fatigue. They used this

model because it included principles that help explain cancer-related fatigue and supported exercise

as a potential intervention for the fatigue.

The beginning of an enquiry is considered to be the conceptual phase of research and as such, lays

the foundation by presenting the „state of knowledge‟ about the phenomenon under study.6 This

phase directs the procedures of data production and analysis as well as the interpretation of the

derived findings. Use of a theoretical model or framework at this stage of the review process,

contributes to identifying and accessing needed clinical and policy expertise to hone and focus a

search methodology. However, the usefulness of a model is not limited to establishing the initial focus

and depth of the research project. Once the results of an investigation are known they can be

illustrated and discussed by relating them back to the elements within the model. This process

facilitates the incorporation of new ideas as the model provides the vehicle by which to enter into the

existing knowledge structure. This iterative process of exploration generates questions such as: How

does what is discovered enrich what is known? What new questions have been generated? Do new

areas require exploration as a result of the study's findings?

As the use of theoretical models or conceptual frameworks is not a prescriptive element in the

performance of systematic reviews, this scoping review will determine the value of such models or

frameworks when performing synthesis of evidence.

Systematic reviews versus scoping reviews

The distinction between systematic and scoping reviews is not frequently discussed in the current

literature. Arksey and O‟Malley‟s7 2005 article titled Scoping Studies: Towards a Methodological

Framework differentiates between these two types of reviews and suggests two important differences:

a) systematic reviews typically focus on a well defined question, whereas scoping reviews tend to

address broader topics; and b) systematic reviews assess the methodological quality of included

studies, whereas scoping reviews do not undertake this assessment.

Further to this, Arksey and O‟Malley7 propose two different ways of thinking about scoping reviews: a)

scoping reviews could be considered part of the ongoing process of reviewing in which scoping

reviews precede systematic reviews and help determine the value of undertaking a full systematic

review; or b) scoping reviews are considered a method in their own right and facilitate an examination

of the literature to identify gaps or to summarise and disseminate research findings.

The purpose of this scoping review was to examine the process of evidence synthesis and the

contribution of the use of frameworks to this process. The methodological rigor of the included studies

was not considered an issue that would influence the contribution of the framework or model.

Therefore a scoping review methodology was undertaken to synthesise the existing evidence and is

perceived according to the second category, as a methodology in its own right, producing a stand-

alone study.

Objective

This scoping review sought to confirm the value of models or frameworks used by authors when

performing the synthesis of evidence.



Review question

How does the use of theoretical models or frameworks in the process of synthesis contribute to the

scholarship of integration?

PICO

Problem – complex and challenging process of integrative research and evidence synthesis.

Intervention – use of a model or framework.

Context – conduct of systematic or scoping reviews.

Outcome – description of model(s) or framework(s) currently in use; purpose of framework for the

review; contribution of the framework to the review.

Inclusion criteria

Types of participants

This review did not address a particular set of participants but focused on the context of health care.

Types of intervention(s)/phenomena of interest

This review considered all studies that discussed models or frameworks that were used specifically to

address the process of synthesis. Given the range of terms used to refer to models and frameworks,

the following terms were included:

theoretical models

theoretical frameworks

conceptual models

conceptual frameworks

conceptual maps

Types of studies

This scoping review considered all discussion, scholarship or methodology papers that discussed the

use of models or frameworks to address the process of synthesis.

Types of outcomes

This review described all theoretical models or frameworks used during the process of conducting a

systematic review; discussed the specific purpose of the framework for each study; and the

contribution of the framework to the process of synthesis.



Search strategy

The search strategy aimed to find both published and unpublished studies (Appendix I). A copy of the

Medline search is provided as it represents the most complex and comprehensive of all the strategies.

A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL was

undertaken followed by analysis of the text words contained in the title and abstract, and of the index

terms used to describe the article. A second search using all identified keywords and index terms was

then undertaken across all included databases. Thirdly, the reference list of all identified reports and

articles was searched for additional studies. The databases included: CINAHL; Medline; EMBASE;

PsycINFO; AMED; Cochrane; Biomed Central; Scirus; Mednar.

Studies were limited to English or French language. No date limits were set on the searches and each

search was performed from the beginning date of each database until July 2009. The search for

unpublished studies included the following sources:

Dissertation Abstracts

Sociological Abstracts

Conference proceedings

Electronic searching resulted in lists of articles with details of title, author, source, and sometimes

abstract. All identified articles were assessed on the basis of the abstract (or title if abstract not

available) and full reports were retrieved for all studies that meet the inclusion criteria for the review.

When in doubt, the full article was retrieved.

Initial subject headings and keywords included:

Theoretical model (subject heading); Conceptual framework (subject heading in CINAHL);

Theoretical framework; Conceptual model; Systematic review (subject heading in CINAHL)

Integrative review; Integrative research; Evidence summary.

Method of the review

The citations and articles were reviewed by the lead author. In collaboration with the review panel,

selected studies were checked to verify those accepted into the review and those excluded.

Methodological quality

This study sought to understand the contribution of theoretical models or conceptual frameworks to

the process of synthesis. We therefore focused on each author‟s description of the framework they

used and their assessment of the value of incorporating the framework into evidence synthesis. Given

that our intent was to understand the process, the rigor of the research used to explicate the

frameworks was not considered relevant to this study.

Data extraction

Data was extracted from the discussion papers using an adaptation of the standardised data

extraction tool from the Joanna Briggs Institute Data Extraction for Narrative, Expert opinion & text -

JBI-NOTARI (Appendix II).

The extraction tool was adapted to allow a full description of the model or framework and its

components; if created to address a particular step in the synthesis process; and how the model or



framework contributed to the process of synthesis. The following specific data was extracted:

(modified from Graham8)

1. The origins of the model or framework. Who developed it? Where are they from (institution,

discipline)?

2. The concepts described by the model or framework.

3. The purpose of the framework for the review.

4. The frameworks contribution to the review.

5. The value of the framework for the process of synthesis.

Data synthesis

Results were discussed in narrative form. The contribution of frameworks in each step of the

synthesis process was discussed.

Review results

Description of studies

The search strategy for this review generated 2,795 citations, of which 17 met the inclusion criteria

(Appendix III). An additional six studies were included from hand searching giving a total of 23

studies. Nine papers, comprising eight studies (one companion paper) formed the final set included in

this review (Appendix IV). It is recognised that the numbers in this final set does not reflect the

number of reviews currently using frameworks as part of the process of synthesis. However, the

purpose of this scoping review was to examine the contribution of frameworks to this process of

integration and these nine studies were selected because they specifically addressed this issue and

discussed the value of using models or frameworks as part of their review process. Fourteen studies

were excluded because they did not address the contribution of their framework to the process of

synthesis, or discussed quality assessment models which were used for critical appraisal or statistical

models which were used for meta-analysis (Appendix V). Eight studies9-17

(nine papers) were included

in this review (Appendix VI). Studies ranged in publication date from 1995-2007. Five studies

originated (by location of the lead author) in the United States, one in the United Kingdom, one in

Australia and one in Canada. Disciplines involved included three in public health, two in nursing, one

in medicine, and one in psychology. Six reviews were performed in academic settings and two in

clinical settings, and they targeted the following issues:

Child protection

End-of-life care

Predictors of adolescent sexual behaviour and intention

Primary care career choice

Prognosis of acute whiplash

Reluctance to care

Use of Information Technology

Young child's post-divorce adjustment



Results

Frameworks

Three reviews9;11;16

used frameworks that were researcher developed. Two researchers12;13

based

their frameworks on previously created models that addressed the same issues and three

reviews10;14;15

used other researchers‟ frameworks (Table 1).

Table 1: Author list, purpose of framework and the framework origin

Author

Year

Purpose of Framework Framework Origin

Burridge

2007

To organise the findings into four categories revealing contributing factors of

caregiving reluctance.

Researcher developed

Buhi

2006

To reflect which variables might function as primary determinants for any given

behaviour.

National Institute of Mental Health

Theorists' Workshop

Lorenz

2005

To define outcomes for both patients and caregivers in end-of-life care and to

define the relationship between these outcomes.

Donabedian's Quality of Care

Framework

Taylor

2004

The salutogenic framework was used as a way of clarifying what benefit

particular research findings may have in identifying and using factors which

can be associated with protection, safety and well being of children.

Antonovski's Salutogenesis

Framework

Kukafka

2003

Novel framework intended to guide synthesis of more than one theoretical

perspective for the purpose of planning multi-level interventions to enhance IT

use.

Researcher based on Green and

Kreuter's PRECEDE/ PROCEED

model

Cote

2001

A conceptual framework was designed to classify the literature according to

methodologic quality, target population, and phases of investigation.

Researcher based on work by

Altman and Layman (prognosis of

breast cancer)

Whiteside

2000

Model depicting young child adjustment to divorce - Intent was to determine

what evidence supports the hypothesised connections in the model, as well as

what had not been studied.


Bland

1995 (a)

Bland

1995 (b)

To reflect the variables that determine medical students’ choice of specialties.

The model presents a theory on how multiple variables work together to

determine specialty choice.


Stages of the review process in which the model or framework was used

All of the studies used their frameworks to assist with the final stage of synthesising the review data

and three studies9;10;13

used their frameworks to help with generating the search strategy. One would

assume that in order to facilitate the synthesis, the data extraction would be performed using the

framework as a guide; however, only two studies9;16

specifically mentioned using their frameworks in

this manner, at this stage (Table 2).



Table 2: Stages of the review process and use of frameworks

Stage of the review process Number of studies using frameworks in this stage

Stage 1 - Developing the review protocol -

Stage 2 - Developing the review question -

Stage 3 - Identifying search criteria 1 ( Kukafka )

Stage 4 - Generating the search strategy 3 (Bland; Buhi; Kukafka)

Stage 5 - Assessing study quality -

Stage 6 - Extracting the data 2 (Bland; Whiteside)

Stage 7 - Synthesising the data 8 (All)

Purpose of the framework for the study

Studies used models or frameworks for one of two reasons:

To organise or classify either the literature or the study findings, in so doing, guide the process of

synthesis. For example, in their review on the prognosis of acute whiplash, Côté et al.,12

designed a

conceptual framework “to classify the literature according to methodologic quality, target population,

and phases of investigation.”12

,p.E445

To illustrate how multiple variables work together, thereby defining or clarifying relationships between

outcomes. In their review on the determinants of primary care specialty choice, Bland et al.,9

generated their model to present “a theory on how multiple variables work together to determine

specialty choice.”9,p.622

Overall five studies10-13;16

used their models or frameworks to augment the organisation of the review

and three studies9;14;15

used frameworks to determine or exemplify the relationships between the study

variables.

Contribution of the framework to the study

Three studies14;15;17

described their framework‟s contribution as serving to inform the association

between variables. Bland and colleagues17

concluded that the benefits of their review were

maximised by using a framework because “the model provided a picture of the whole phenomenon

and how its components related to each other.”17

,p.649 In this capacity the framework could also

highlight parts of the larger phenomenon needing further study, and reveal shortcomings in the

review‟s included studies, gaps in the literature, weak or missing links in the literature, or areas for

further research.

The purpose of framework in the study by Kukafka and colleagues13

was to “facilitate the cross-

theoretical integration of behavioral models to guide multi-level IT implementation plans.”13

,p.219 In

this instance the framework‟s contribution was to organise the disparate theories coherently. “A

planner can then identify those theories that are applicable to each user community and to each

identified barrier to behaviour change. In so doing, the full range of theoretical tools and methods

becomes available to tackle the problem.”13

,p.227

The review by Buhi et al.,10

integrated the literature on the predictors of adolescent sexual behaviour

and identified a „negative contribution‟ of their framework. As a limitation in their review they



recognised that “there are factors not identified in the integrative theoretical framework that may add

to the explanation of adolescent sexual behaviour, ...”10

,p.19

Value of using frameworks in the process of synthesis

The models or frameworks used in the process of integration demonstrated their value at different

stages of the review process and in different ways. Bland et al.17

noted the value of their framework in

several stages of their review.

“A model or theory provides direction and boundaries to guide the search for relevant literature. At the

summary and conclusion stage, a model enables the synthesiser not only to cluster the literature into

themes but also to suggest how these findings work together to explain the larger phenomenon of

interest. … Finally, a review guided by a model reveals the areas that need further study.”17

,p.645-6

A framework‟s value in revealing gaps in knowledge and areas for further investigation were reported

by four studies.9;10;12;16

In their review on the young child‟s post-divorce adjustment, Whiteside et al.,16

stated:

“Many of the pathways in our models had been examined in only one or two studies and thus provide

results that are suggestive, but not definitive. In addition, other variables that may have powerful

impact on the child‟s postdivorce adjustment were not included. Had we focused only on the primary

predictors and their direct relationships to child outcomes, these gaps would not have been evident;

model-driven meta-analysis facilitated our identification of these weak or missing links.”16

,p.22

Buhi and colleagues10

report on the value of frameworks for the conceptualisation of the concepts in

the review, in addition to indicating directions for future research.

“A theoretical framework provides a structure and context for thinking logically about determinants

and their relationships; assists scholars in diagnosing which variables are under-represented in the

research, and reveals both a potentially important gap in knowledge and future directions for

inquiry.”10

,p.5

For some, use of a framework increased the complexity of their enquiry, such as the study by Kukafka

et al.,13

whose model pulled together several behaviour models to guide their decision making

process. For others, use of frameworks served to „unpack‟ or unravel some of the complex issues in

their study. Taylor and colleagues15

integrated the literature on child protection using the salutogenic

framework. They found the addition of a framework to the review process most valuable, and

concluded:

“Application of a salutogenic framework to the results was further illuminating and has utility for both

systematic review methodology and other child protection explorations. The matrix created a warp

and weft effect that identified gaps in current evidence and practice and was able to disentangle some

of the complexities inherent within failure to thrive situations. By beginning to shed understanding on

such processes, the concept of salutogenesis added further depth and rigour to the analysis.”15

,p.633

Discussion

This review illustrates the value of the use of models or frameworks in the process of synthesis.

Incorporating frameworks into the integrative process contributes positively at many stages, and has a

multitude of advantages. In her discussion on the benefits of a model driven meta-analysis, Becker18

proposes that “model-driven syntheses can produce a synergy among studies by suggesting and

addressing questions not examined in any single study.”18

,p.196 Becker‟s article written in 2001



compliments and substantiates the findings of this review. Becker prescribes two objectives for a

model-driven synthesis: a) to determine the extent to which research has investigated all or parts of a

model; and b) to investigate what the current research indicates about paths in the model.18

These

objectives correspond to the purpose of frameworks identified from the review studies: to

organise/classify the literature according to the framework; and to illustrate how framework variables

work together (what Becker calls „the paths in the model‟).

Becker also describes the potential „negative contribution‟ of a model or framework as was reported

by Buhi et al. “Models can limit the generalisations possible from a review if they limit choices of

constructs and variables. Specifically, conclusions can be limited when models do not include an

important construct or operationalisation of that construct.”18

,p.201

Studies in this review indicated that the use of frameworks helped to inform the association between

variables, and identified gaps in the knowledge base as well as areas for further research. The use of

frameworks provided a structure to link constructs and determinants, a guide to the generation of the

search strategy and a mechanism to integrate the review findings. The use of a model or framework

could increase complexity by bringing together several theories under one structure, or assist in the

unravelling of complex issues into their essential determinants.

Conclusion

The use of a model or framework in the process of synthesis is not prescriptive at this time. However,

this review illustrates that the addition of structure and guidance provided by a framework may serve

to benefit the process of integration. The contribution of a framework to inform the association of

variables, guide the search strategy, structure and clarify the outcomes, identify knowledge gaps and

indicate areas for future research could provide a valuable foundation for the process of synthesis.

This obviously has to be balanced with the potential limitations a model or framework could bring to

the research process.

Implications for practice

Evidence from systematic reviews informs practice. The incorporation of theoretical models or

frameworks into the process of synthesis increases the value of this evidence, by providing a solid

underlying structure for the review and by linking outcomes to the theory of a particular model. The

addition of this capacity to guide the process and clarify the outcomes will facilitate the assimilation of

this evidence by the target audience.

Implications for research

Systematic reviews are the highest level of evidence available at this time.19

It is therefore important

to ensure that reviews are undertaken with utmost rigor and transparency. Any opportunity to increase

the strength of integrative research is valuable. The incorporation of theoretical models or frameworks

into this process offers just this enhancement by providing a scaffold on which to anchor the concepts

and processes of the review. Further research into the contribution of theoretical models or

conceptual frameworks to the process of synthesis may be valuable.

Conflict of interest

None.



Acknowledgements

The lead author (CG) would like to acknowledge the Canadian Institutes of Health Research (CIHR)

for funding support provided by a PhD Fellowship Knowledge Translation Award (KPD 85181); and

the instructors from the CIHR-OHRI Knowledge Synthesis Training course for support and guidance

in conducting this review.

References

1. Artinian BM. Conceptual mapping: development of the strategy. Western Journal of Nursing

Research 1982;4(4):379-93.

2. The American Heritage® Dictionary of the English Language FE. Conceptual definition. Answers

com 2004 [cited 2006 Sep 4];Available from: URL: http://www.answers.com

3. The American Heritage® Dictionary of the English Language FE. Framework definition. Answers

com 2004 [cited 2006 Sep 4];Available from: URL: http://www.answers.com

4. Kim S, Phillips WR, Pinsky L, Brock D, Phillips K, Keary J. A conceptual framework for developing

teaching cases: a review and synthesis of the literature across disciplines. Medical Education

2006;40:867-76.

5. Mock V, St.Ours C, Hall S, Bositis A, Tillery M, Belcher A, et al. Using a conceptual model in

nursing research - mitigating fatigue in cancer patients. Journal of Advanced Nursing

2007;58(5):503-12.

6. Batey M. Conceptualisation: Knowledge and Logic Guiding Empirical Research. Nursing

Research 1977;26(5):324-9.

7. Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Social

Research Methodology 2005;8(1):19-32.

8. Graham ID, Tetro J, and the KT Theories Research Group. Some Theoretical Underpinnings of

Knowledge Translation. Academic Emergency Medicine 2007;14:936-41.

9. Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-

statistical meta-analysis of the literature. [Article]. Academic Medicine 1995 Jul;70(7):620-41.

10. Buhi ER, Goodson P. Predictors of adolescent sexual behavior and intention: a theory-guided

systematic review. Journal of Adolescent Health 2007;40(1):4-21.

11. Burridge L, Winch S, Clavarino A. Reluctance to care: a systematic review and development of a

conceptual framework. Cancer Nursing 2007 Mar;30(2):E9-19.

12. Cote P, Cassidy JD, Carroll L, Frank JW, Bombardier C. A systematic review of the prognosis of

acute whiplash and a new conceptual framework to synthesise the literature.[see comment].

[Review] [63 refs]. Spine 2001 Oct 1;26(19):E445-E458.

13. Kukafka R, Johnson SB, Linfante A, Allegrante JP. Grounding a new information technology

implementation framework in behavioral science: a systematic analysis of the literature on IT use.

[Review] [25 refs]. Journal of Biomedical Informatics 2003 Jun;36(3):218-27.

14. Lorenz KA, Lynn J, Morton SC, Dy SM, Shugarman LM, Wilkinson A, et al. Methodological

approaches for a systematic review of end-of-life care. J Palliat Med 2005;8 Supp 1:S4-11.:S4-11.



15. Taylor JS. Salutogenesis as a framework for child protection: literature review. Journal of

Advanced Nursing 2004 Mar 15;45(6):633-43.

16. Whiteside MF, Becker BJ. Parental Factors and the Young Child's Postdivorce Adjustment: A

Meta-Analysis With Implications for Parenting Arrangements. Journal of Family Psychology

2000;14(1):5-26.

17. Bland CJ, Meurer LN, Maldonado G. A systematic approach to conducting a non-statistical meta-

analysis of research literature. [Review] [14 refs]. Academic Medicine 1995 Jul;70(7):642-53.

18. Becker BJ. Examining theoretical models through research synthesis: the benefits of model-

driven meta-analysis. Evaluation & the Health Professions 2001;24(2):190-217.

19. Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare .

International Journal of Evidence-Based Health Care 2005;3:207-15.



Appendix I: Search strategy

Medline Search July 20

Search History (27 searches) # ▼ Searches

1 theoretical model.mp. [mp=title, original title, abstract, name of substance word,

subject heading word]

2 theoretical framework.mp. [mp=title, original title, abstract, name of substance word,


3 conceptual model.mp. [mp=title, original title, abstract, name of substance word,


4 conceptual framework.mp. [mp=title, original title, abstract, name of substance word,


5 conceptual map.mp. [mp=title, original title, abstract, name of substance word,


6 or/1-5

7 systematic review$.mp. [mp=title, original title, abstract, name of substance word,


8 integrative research.mp. [mp=title, original title, abstract, name of substance word,


9 integrative review$.mp. [mp=title, original title, abstract, name of substance word,


10 evidence summar$.mp. [mp=title, original title, abstract, name of substance word,


11 narrative summary.mp. [mp=title, original title, abstract, name of substance word,


12 meta-analysis.mp. [mp=title, original title, abstract, name of substance word, subject

heading word]

13 meta?analysis.mp. [mp=title, original title, abstract, name of substance word, subject

heading word]

14 meta-synthesis.mp. [mp=title, original title, abstract, name of substance word, subject

heading word]

15 meta?synthesis.mp. [mp=title, original title, abstract, name of substance word,


16 synthesis.mp. [mp=title, original title, abstract, name of substance word, subject

heading word]

17 or/7-16

18 6 and 17

19 Models, Theoretical/

20 models, nursing/ or models, organisational/

21 19 or 20

22 "Review Literature as Topic"/ 23 meta-analysis as topic/ 24 22 or 23 25 21 and 24 26 18 or 25 27 remove duplicates from 26



Appendix II: Data Extraction Instruments

NOTARI data extraction instrument

Extraction form adapted from JBI NOTARI data extraction instrument

Author ___________Year ______________ Title: ___________________

Author

Full reference

Publication year

Country

Study details :

Context

Institution

Department

Discipline

Setting

Framework description:

Purpose of framework

Framework details

Concept relationships

Framework author

Framework contribution

Stage of the review

Framework value description



Appendix III: Search decision flow diagram

Total # of citations

found 2,795

1950 to July Week 2 2009

Medline 617

1982 –July 28 2009 Cinahl

248

1980 to 2009 Week 29 Embase

278

1985 to July 28 2009 AMED

21

1967 to July Week 3 2009

PsycInfo

1079

2nd Quarter 2009

COCHRANE 94

July 29 2009 Dissertation

24 Socio Abs

4

July 29 2009 Scirus 255

Mednar 175

# of articles

meeting

criteria

10 8 2 0 2 0 0 0

Total number of articles 22 minus 5 duplicates = 17

Hand searching

6

17 plus 6 from hand searching

23

Articles excluded -

models used for critical appraisal or meta-analysis

14

Final number of articles 9



Appendix IV: Included studies

1. Bland CJ, Meurer LN, Maldonado G. A systematic approach to conducting a non-statistical meta-analysis

of research literature. [Review] [14 refs]. Academic Medicine 1995 Jul;70(7):642-53.

2. Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical meta-

analysis of the literature. [Article]. Academic Medicine 1995 Jul;70(7):620-41.

3. Buhi ER, Goodson P. Predictors of adolescent sexual behavior and intention: a theory-guided systematic

review. Journal of Adolescent Health 2007;40(1):4-21.

4. Burridge L, Winch S, Clavarino A. Reluctance to care: a systematic review and development of a

conceptual framework. Cancer Nursing 2007 Mar;30(2):E9-19.

5. Cote P, Cassidy JD, Carroll L, Frank JW, Bombardier C. A systematic review of the prognosis of acute

whiplash and a new conceptual framework to synthesise the literature.[see comment]. [Review] [63 refs].

Spine 2001 Oct 1;26(19):E445-E458.

6. Kukafka R, Johnson SB, Linfante A, Allegrante JP. Grounding a new information technology

implementation framework in behavioral science: a systematic analysis of the literature on IT use. [Review]

[25 refs]. Journal of Biomedical Informatics 2003 Jun;36(3):218-27.

7. Lorenz KA, Lynn J, Morton SC, Dy SM, Shugarman LM, Wilkinson A, et al. Methodological approaches for

a systematic review of end-of-life care. J Palliat Med 2005;8 Supp 1:S4-11.:S4-11. Taylor JS.

Salutogenesis as a framework for child protection: literature review. Journal of Advanced Nursing 2004 Mar

15;45(6):633-43.

8. Whiteside MF, Becker BJ. Parental Factors and the Young Child's Postdivorce Adjustment: A Meta-

Analysis With Implications for Parenting Arrangements. Journal of Family Psychology 2000;14(1):5-26.



Appendix V: Excluded studies

Carlson LE, Feldman-Stewart D, Tishelman C, Brundage MD. Patient-professional communication research in

cancer: an integrative review of research methods in the context of a conceptual framework. Psycho-

Oncology 2005 Oct;14(10):812-28.

Reason for exclusion: Does not address the contribution of the framework to the review process

Classen S, Winter S, Awadzi KD, Garvan CW, Lopez EDS, Sundaram S. Psychometric testing of SPIDER: data

capture tool for systematic literature reviews. American Journal of Occupational Therapy 2008

May;62(3):335-48.

Reason for exclusion: SPIDER is a data capture and quality assessment tool – quality assessment

was outside the scope of this review

Findley TW. Research in physical medicine and rehabilitation. II. The conceptual review of the literature or how

to read more articles than you ever want to see in your entire life.[see comment]. American Journal of

Physical Medicine & Rehabilitation 1989 Apr;68(2):97-102.

Reason for exclusion: Focus of the article was on how to develop a conceptual framework from the

literature

Hersh WR, Hickam DH. How well do physicians use electronic information retrieval systems? A framework for

investigation and systematic review.[see comment]. [Review] [35 refs]. JAMA 1998 Oct

21;280(15):1347-52.

Reason for exclusion: The framework was developed for evaluation and they did not discuss the

contribution of the framework t the review process

Hickam DH, Severance S, Feldstein A, Ray L, Gorman P, Schuldheis S, et al. The effect of health care working

conditions on patient safety. Rockville MD: Prepared by the Oregon Health & Science University

Evidence-based Practice Center Portland, Oregon under contract 290-97-0018 Agency for Healthcare

Research and Quality; 2003. Report No.: Evidence Report/Technology Assessment No. 74. AHRQ

Publication No. 03-E031.

Reason for exclusion: Does not discuss the contribution of models/frameworks to the review process

Kendrick DC, Bu D, Pan E, Middleton B. Crossing the evidence chasm: building evidence bridges from process

changes to clinical outcomes. Journal of the American Medical Informatics Association 2007

May;14(3):329-39.

Reason for exclusion: Mathematical model for analysis

Kim J, Pressler SJ, Jones J, Graves JR. Generating scientific models of knowledge using arcs. Clinical Nurse

Specialist 2008 Nov;22(6):286-92. Godfrey et al Use of models or frameworks in evidence synthesis

page 24

Reason for exclusion: Off topic – arcs is a computer program that builds scientific models

Mayer RE. Models for understanding. Review of Educational Research 1989;59(1):43-64.

Reason for exclusion: Off topic – use of models to increase students‟ understanding

Mulrow C, Langhorne P, Grimshaw J. Integrating heterogeneous pieces of evidence in systematic reviews.

Annals of Internal Medicine 1997 Dec 1;127(11):989-95.



Reason for exclusion: Off topic – does not discuss the contribution of models to the process of

synthesis

Penberthy JK, Cox D, Breton M, Robeva R, Kalbfleisch ML, Loboschefski T, et al. Calibration of ADHD

assessments across studies: A meta-analysis tool. Applied Psychophysiology Biofeedback 2005

Mar;30(1):31-51.

Reason for exclusion: Mathematical model for analysis

Russell CL. An overview of the integrative research review. [Review] [15 refs]. Progress in Transplantation

2005 Mar;15(1):8-13.

Reason for exclusion: Description of the integrative process

Rutledge DN, DePalma JA, Cunningham M. A process model for evidence-based literature syntheses.

Oncology Nursing Forum 2004 May;31(3):543-50.

Reason for exclusion: Process model to structure the interaction of individuals during the conduct of a

review

Smith E, Donovan S, Beresford P, Manthorpe J, Brearley S, Sitzia J, et al. Getting ready for user involvement

in a systematic review. Health Expectations 2009 Jun;12(2):197-208.

Reason for exclusion: Representation framework to categorise users

Smith MC, Stullenbarger E. A prototype for integrative review and meta-analysis of nursing research. Journal of

Advanced Nursing 1991 Nov;16(11):1272-83.

Reason for exclusion: A prototype for integrative research



Author/Year Country Institution

Purpose of Framework Framework Details Framework Contribution Framework Value

Burridge (2007) Australia University of Queensland

To organise the findings into four categories revealing contributing factors of caregiving reluctance

Conceptual framework consisted of the dimensions of caregiving reluctance which were divided into four dimensions: demographic, physical, psychological and social indicators. The outcomes of caregiving reluctance were identified as: deterioration of carer/patient relationship; reduced quality of care; institutionalisation

Classification of the findings according to the framework helped identify three aspects of the consequences of caregiving reluctance, with important implications for carers, patients, and healthcare services.

Framework assisted in analysis of information and classification of studies

Buhi (2006) U.S.A. University of South Florida

To reflect which variables might function as primary determinants for any given behaviour

Eight factors which account for the variance in any given behaviour: A strong intention (or a commitment to performing a behaviour); the absence of environmental constraints (hindering practice); necessary skills; a positive attitude toward performing the behaviour; social normative pressure to act; consistency.

This review’s purpose was to systematically summarise a decade of literature (1996 –2005) regarding these eight model elements’ predictive or explanatory ability when applied to adolescent sexual behaviors or intentions. Contribution positive: the elements of the framework guided the search for empirical studies and were used to classify each reviewed study’s findings. Contribution negative: there are factors not identified in the integrative theoretical framework that may add to the explanation of adolescent sexual behavior.

A theoretical framework provides a structure and context for thinking logically about determinants and their relationships; assists scholars in diagnosing which variables are under-represented in the research, and reveals both a potentially important gap in knowledge and future directions for inquiry.

Lorenz (2005) U.S.A. VA Greater LA Healthcare System, LA, California.

To define outcomes for both patients and caregivers in end-of-life care and to define the relationship between these outcomes

Donabedian described the relationship between outcomes, processes, and structure of care.

Donabedian’s quality-of-care framework structured the examination of the associations among outcomes considered by the project.

The framework informs the association between satisfaction, quality of care, quality of dying, and quality of life, which are various distal outcomes that apply in varying degrees to both patients and caregivers.

Appendix VI: Details of included studies





Taylor (2004) United Kingdom University of Dundee

The salutogenic framework was used as a way of clarifying what benefit particular research findings may have in identifying and using factors which can be associated with protection, safety and well being of children.

Based on an ecological model of health, salutogenesis basically seeks to explore what keeps us healthy, or in the case of child protection, what is protective.

The salutogenesis framework can clarify what benefit particular research findings may have in identifying and using factors which can be associated with protection and safety and well being of children. It is fitting to use frameworks that enhance multidisciplinary understanding and collaboration and that seek to identify those factors that for children are most protective.

Use of a theoretical framework can strengthen research analysis, particularly in application to practice. The matrix created a warp and weft effect that identified gaps in current evidence and practice and was able to disentangle some of the complexities inherent within failure to thrive situations. By beginning to shed understanding on such processes, the concept of salutogenesis added further depth and rigour to the analysis.

Kukafka (2003) U.S.A. Joseph Mailman School of Public Health, Columbia University, New York, NY, USA

Novel framework intended to guide synthesis of more than one theoretical perspective for the purpose of planning multi-level interventions to enhance IT use.

The application of the proposed framework rests on two propositions: (1) IT use is complex, multi-dimensional, and influenced by a variety of factors at individual and organisational levels. The framework is a structure for applying scientific evidence from empirically tested models so that the approaches implemented are built upon links among multiple levels. (2) Success in achieving change is enhanced by the active participation of members from the target user groups. The framework promotes participatory design through a linkage system of critical assessment phases to ensure that the planners have a structure in place to engage system end-users effectively from the start.

The framework serves to focus the scope, to identify the conceptual variables to be extracted, and then to make explicit their relationship to the synthesising question of the analysis. The proposed framework promotes a distinct, problem- driven behavioral science perspective that brings to bear problem definition, application of theory, and empirical evidence in solving a problem. This is beneficial because rather than beginning with a single theory, the framework organises disparate theories coherently. A planner can then identify those theories that are applicable to each user community and to each identified barrier to behavior change. In so doing, the full range of theoretical tools and methods becomes available to tackle the problem. The framework facilitates the move from a single model to explain IT usage to more suitable multi-level interventions.

The proposed IT implementation framework that we have presented draws on several theoretical perspectives on human behavior. Such a framework can be an important element in the effort to improve the implementation and use of IT. This multiple-factor approach can aid in addressing all determinants involved in the implementation and successful adoption of an information system within a healthcare organisation.





Cote (2001) Canada Institute for Work and Health, Toronto, Canada

A conceptual framework was designed to classify the literature according to methodologic quality, target population, and phases of investigation.

The framework meets the needs of clinicians, policy makers, and researchers and integrates three key attributes of prognostic studies: (1) it includes the assessment of the methodologic merit of a study (internal validity); (2) it incorporates the concept of target population and generalisability (external validity); (3) it includes a hierarchy of knowledge that categorises the strength evidence into mutually exclusive categories.

A conceptual framework is proposed that addresses the stakeholders’ needs while emphasising the principles of scientific rigor. The framework will assist clinicians and policy makers to critically appraise the literature and help them identify populations to whom the results may be generalisable. Moreover, it will provide researchers with a tool to systematically identify gaps in the literature and guide future research while mapping a research agenda that avoids the problems of circular epidemiology

The conceptual framework described here clearly shows that despite the recommendations of the Quebec Task Force (QTF), the recent prognostic literature on whiplash remains largely descriptive and demonstrates that large cohort studies investigating a wide range of prognostic factors are necessary to improve the understanding of this problem.

Whiteside (2000) U.S.A. Ann Arbor Center for the Family, Ann Arbor, Michigan

Model depicting young child adjustment to divorce - Intent was to determine what evidence supports the hypothesised connections in the model, as well as what had not been studied

Model illustrates contextual factors, parenting environment, child characteristics, and child outcomes

Model-driven meta-analysis facilitated the identification of weak or missing links in this area of research

The process reveals which pathways in the model have been frequently examined and which relationships have yet to be studied.

Bland (1995)(a) Bland (1995) (b) U.S.A. University of Minnesota Medical School

To reflect the variables that determine medical student's choice of specialties. The model presents a theory on how multiple variables work together to determine specialty choice.

The model depicts the type of school, its mission and faculty composition. The model also depicts the student characteristics with their incoming values and needs. The model illustrates how the type of school influences the student, their needs and values and how this interaction between the school and student influences the student’s choice of specialty.

The literature was sorted according to the components of the model, and the review addressed each of those components and studies. The model provided a picture of the whole phenomenon and how its components related to each other. Use of a model also revealed shortcomings of individual studies, and highlighted parts of the larger phenomenon needing further study.

“A model or theory provides direction and boundaries to guide the search for relevant literature. At the summary and conclusion stage, a model enables the synthesiser not only to cluster the literature into themes but also to suggest how these findings work together to explain the larger phenomenon of interest. … Finally, a review guided by a model reveals the areas that need further study.”

utilization of theoretical models and frameworks in the process of

Documents