Rediscovering the “Narrative” review

In recent years, the iconic literature review that was once the hallmark of all nursing and health care studies is starting to disappear. It has increasingly been supplanted by a new species of literature review exercise that positions itself as “systematic,” thereby signaling that it considers itself a distinct kind of product within the evidentiary hierarchy. In the qualitative research world, the increase in publications based on metasynthesis methodology, for example, has been exponential. In a paper published in early 2017, I observed that a Google Scholar search limited by year of publication for the keyword “qualitative meta synthesis” had accelerated from 10 in 1995 to 245 in 2005 and 3,250 in 2015 (Thorne, 2017). As I write, only halfway through 2018, the year has already yielded 9,620. So as a form of scholarly product, the systematic review—even in the qualitative world—is undoubtedly gaining popularity. It is not difficult to understand what motivates scholars in fields such as clinical medicine or population health to be increasingly enthusiastic about the opportunities systematic review provides to access larger and more diverse samples toward answering precise questions (Mulrow, Thacker, & Pugh, 1988). However, in the qualitative world, for the questions of interest to nursing scholars, what motivates a systematic review is somewhat more difficult to untangle. When I first began working with metasynthesis methodologies, I know I had high aspirations to get to the bottom of some of the complex problems that intrigue our discipline (how can we best support persons in their experience with chronic illness, or how does one learn the art of delicate communication in a humanly complex context such as cancer). I quickly learned, however, that the business of being systematic tended to orient the scholar in one of two directions—to aggregate and summarize the commonalities between what was inevitably a highly diverse collection of studies, or to deconstruct the ideas that the different scholars had brought to their qualitative work and that explained so many of the nuances of their various interpretations. In that same 2017 editorial, I decried the increasing prevalence of the kind of qualitative metasynthesis that seemed a mere technical exercise (reaffirming what those in the field already knew about a phenomenon, and—even more dangerous perhaps—ignoring the nuances of depth and difference in favor of reinscribing only that which was common and relatively superficial). In the former kind of work, I could see that which makes a truly beautiful qualitative study the elegant and evocative product that can touch our hearts and inspire our clinical wisdom evaporating into becoming one more superficial tickbox in a table of common themes (Thorne, 2015). And yet I firmly believe that our discipline has been so attracted to qualitative inquiry precisely because it is hungry for the intricate complexities that make human health experience so incredibly fascinating. Thus, the enthusiasm for the systematic in this particular context seems highly counterproductive to the core disciplinary epistemology that has inspired the scholarly work in the first place. Concurrent with the rise of the synthesis movement, we have also seen an increasing disregard for the more critically reflective or integrative kind of literature review product. Graduate students and junior scholars are being steered in the direction of systematic (which is understood to constitute a potentially publishable stand-alone scholarly product) rather than the more narrative or interpretive kind of review that could have engaged them more thoughtfully within the depth and breadth of possible literature (and is increasingly assumed to be unpublishable). In a recent paper published in BMC Medical Research Methodology, Faggion, Bakas, and Wasiak (2017) compared the proportion of “narrative” versus “systematic” reviews in five leading medical journals. While their observation of quite significant differences was interesting, what was even more intriguing was their evident assumption in conducting and publishing this comparison that it was relevant by virtue of the systematic reviews signifying superior scholarship. A lively conversation about that assumption ensued on social media, following which I joined forces with two colleagues—both physicians with established track records in methodological writing—to write a discussion paper on what we referred to as the “spurious hierarchy” of systematic over narrative reviews (Greenhalgh, Thorne, & Malterud, 2018). The point of that paper was to reinvigorate the discussion about why one does a review, and to try to turn the tide against the alarming trend to try to render all review products systematic. We argued that systematic reviews of any kind, including qualitative metasynthesis, were appropriate when the purpose was to address narrowly focused questions (“puzzles or problems that require data”) for which a summary of the findings of studies that had asked that specific question might be helpful. In contrast, where the purpose of a review was to deepen understanding with respect to a broad or complex issue (“those that require clarification and insight”), the interpretation and critique that a more narrative form of review could provide was preferable (p. 2). So often what nurses seek when they set out to study something qualitatively is indeed better captured by intellectual mechanisms that steer us toward “clarification and insight” than by amalgamations of additional data. It seems quite important, then that we challenge the creeping conflation of being “systematic” with the idea of higher quality. I sincerely hope that there is always a secure place within the nursing literature for papers that are descriptive, thoughtful, critically reflective, integrative, and that use the interpretive processes of narrative review to extend our understanding of how and why a body of knowledge has evolved in the manner it has, and what sense we ought to make of it in relation to our current challenges. Nursing Inquiry takes pride in being a journal that not only publishes formal research papers, including systematic reviews, when they demonstrably critically advance our thinking in some manner, but also discussion papers, perspectival reflections, and well done narrative literature reviews. When authors have been willing to dig deep and engage intimately with a body of published work, to engage the scholars who have previously reflected on a topic in conversation with one another, and to offer us a journey through the logic that has brought them to new insights about a field, we the readers appreciate that we have had the privilege of enjoying a truly meaningful experience with “the literature.”