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Abstract

Qualitative systematic reviews, or qualitative evidence syntheses (QES), are increasingly used in health settings to guide the development of practice and policy. Thematic synthesis is one of the most well-developed approaches used for QES, however there are limited worked examples describing how to apply the steps of analysis in the literature. This paper describes the processes and decisions undertaken in a qualitative systematic review and thematic synthesis from the perspective of a novice researcher. The described review aimed to explore the shared musical experiences of people living with dementia and their family care partners across a range of settings. We found that shared musical activities fostered experiences of connection and wellbeing for people living with dementia and their family care partners. This was demonstrated with moderate-high confidence through six themes, and our findings informed the development of the Contextual Connection Model of Health Musicking. In presenting a worked example of our review, this paper introduces a systematic approach to coding and discusses the complexities of developing and reporting on analytical themes. We identify the need for a specific thematic synthesis reporting tool, and the need to embed reflexive practices into QES tools more broadly.

Keywords

thematic synthesis qualitative evidence synthesis systematic review worked example

Introduction

Qualitative systematic reviews, also known as qualitative evidence syntheses (QES), combine the findings of primary qualitative studies in a systematic way (Flemming & Noyes, 2021). The terms qualitative systematic review and QES are often used interchangeably, however QES is preferred by the Cochrane Qualitative and Implementation Methods Group as it signifies the unique approaches required for synthesising qualitative evidence (Booth et al., 2016). QES is used to develop a greater understanding of issues addressed in qualitative research and generate insights that extend beyond the findings of individual studies (Carroll, 2017; Flemming & Noyes, 2021). QES is particularly helpful for understanding the experiences and needs of healthcare consumers as it combines perspectives from a range of contexts (Carroll, 2017). As a result, QES is increasingly used in healthcare to guide the development of practice and policy (Flemming & Noyes, 2021). In the study described in this paper, QES was selected to gain insights for developing research into shared musical experiences for people living with dementia and their family care partners.

Thematic synthesis is one of the most well-established approaches to QES alongside framework synthesis and meta-ethnography (Flemming & Noyes, 2021). Thematic synthesis was developed by Thomas and Harden (2008) to address questions about people’s perspectives and experiences. It is recommended by the Cochrane Qualitative and Implementation Methods Group as an accessible and epistemologically flexible approach that is particularly suitable for novice researchers (Booth et al., 2016; Noyes et al., 2018). Correspondingly, thematic synthesis is one of the most commonly used approaches for QES (Flemming & Noyes, 2021).

Despite its popularity, there are few references for conducting thematic synthesis beyond Thomas and Harden’s (2008) foundational paper. In this publication, Thomas and Harden (2008) provide a worked example of a previously published study (Thomas et al., 2003), sharing detailed insights into their coding and development of descriptive themes. In a more recent book chapter, Thomas et al. (2017) use the same example study to outline the thematic synthesis process with added reflections.

Worked examples of QES are a suitable medium for educating novice qualitative researchers (Atkinson et al., 2000). Worked examples illuminate hidden steps and challenges of research methods (Hannes & Lockwood, 2012), serving to “demystify” the numerous challenges and decision-points faced (Soilemezi & Linceviciute, 2018, p. 11). Several worked examples are evident in meta-ethnography (Benoot et al., 2016; Britten et al., 2002; Britten & Pope, 2012) and framework synthesis (Ames et al., 2019; Carroll et al., 2011; Yazdani & Yadollahi, 2019). However, we were only able to locate two worked examples of thematic synthesis in the healthcare-related literature (Lucas et al., 2007; Thomas & Harden, 2008). To address the gap, this paper describes the process and decisions undertaken by a novice researcher (Author 1) conducting a thematic synthesis. To emphasise the subjectivity of these decisions, this article is written from the first-person perspective, where ‘I’ and 'my' refers to Author 1 and ‘we’ refers to the supporting research team (all authors). This aligns with my interpretivist perspective (Wheeler, 2016) and seeks to highlight the unique challenges encountered by novice researchers.

The Example Study

The study described in this paper was a qualitative systematic review and thematic synthesis exploring the research question: How do people living with dementia and their family care partners experience shared musical activities? The rationale and findings of this study are published elsewhere (McMahon et al., 2022). The study described was conducted in the context of my doctoral studies as part of a multinational randomised control trial (Baker et al., 2019). Authors 2 and 7 provided supervision throughout the review process and contributed to reviewing and appraising articles for inclusion. Reflexivity (i.e. critical self-reflection) was applied throughout the coding and analysis process (Finlay, 2002b).

Selecting the Methodology

To determine the best review methodology, I examined a range of QES approaches (Booth et al., 2016) using the RETREAT framework (Review question, Epistemology, Time frame, Resources and Expertise) (Noyes et al., 2019). This process highlighted the suitability of a thematic synthesis approach for my review (see Table 1).

Table 1.

RETREAT Framework Considerations.

	Thoughts/Notes	Indicated Methodology
Review question	Examples from Matney (2018) highlighted approaches that align with my research question. E.g. “How do clients with Parkinson’s disease perceive their own health after receiving medical music therapy interventions?” (thematic synthesis) and “What are the experiences of caretakers in relation to music interventions in hospice settings?” (meta-synthesis) (p. 102)	Thematic synthesis Meta-synthesis
Epistemology	Framework synthesis, thematic narrative synthesis and thematic synthesis align with ‘critical realism’ which aligns most closely with my theoretical positioning (Barnett-Page & Thomas, 2009)	Thematic synthesis Framework synthesis Thematic narrative synthesis
Time frame	This review is required to inform later stages of my research. Therefore, completing it within a short timeframe is desirable. High time requirement = Meta-syntheses; low time requirement = Framework synthesis, thematic synthesis (Booth et al., 2016)	Thematic synthesis Framework synthesis
Resources	Time resources are somewhat limited as the review is to be largely conducted by one researcher (me) with support from supervisors. I have access to a wide range of interlibrary loans and publications through the University of Melbourne	Low-moderate resource-intensive approaches
Expertise	Thematic synthesis is recommended as an accessible approach for novice researchers (Noyes et al., 2019). Meta-ethnography is contraindicated as it requires an expert team (Noyes et al., 2018)	Thematic synthesis

Thematic synthesis is a flexible approach to qualitative evidence synthesis (QES) designed to explore people’s perspectives and experiences (Thomas & Harden, 2008). It is particularly suitable for exploring participants’ views of interventions and identifying factors that influence an intervention’s success (Matney, 2018). Thematic synthesis involves three steps of analysis: 1) line-by-line coding of text; 2) developing descriptive themes while remaining close to the primary text; and 3) generating analytical themes by adding new interpretative constructs and hypotheses (Thomas & Harden, 2008). Analytical themes are generated by considering how the descriptive themes relate to the original research question (Thomas & Harden, 2008).

Developing a Search Strategy

My search strategy was informed by the aims of the review, discussions with supervisors, previous systematic reviews (Dowlen et al., 2018; Sellars et al., 2018) and the results from SPIDER, a search strategy tool that caters to the needs of QES (Cooke et al., 2012). The workings of my search strategy development are presented in Appendix B. The final search strategy included a Boolean search phrase, a list of databases and journals for searching, and inclusion and exclusion criteria (see Appendix B). This final search strategy and protocol was registered with PROSPERO (CRD42020169360) to reduce the risk of duplication and enable transparency.

Inclusion and Exclusion Criteria

The inclusion and exclusion criteria were informed by the aims of the review, discussions with supervisors, previous thematic syntheses (Dowlen et al., 2018; Sellars et al., 2018) and the SPIDER tool results (see Appendix B). Criteria was translated into a screening checklist and shared with Authors 2 and 7 for masked screening (see Appendix C).

Search and Screening

Through the screening process outlined in Figure 1, we identified 13 articles for inclusion in the review using Rayyan software (Ouzzani et al., 2016). To maintain independence through screening, I assessed 100% of articles, and Authors 2 and 7 shared the role of the second reviewer. This process is outlined in full in McMahon et al. (2022).

Figure 1.

PRISMA flow diagram (adapted from Page et al. (2021)).

Interrater reliability

The interrater reliability of decisions made throughout the screening process (McHugh, 2012) was calculated using Cohen’s kappa (Warrens, 2015) to safeguard transparency in the systematic review process (Belur et al., 2018). The initial screening (κ = 0.54) and full text screening (κ = 0.55) showed moderate agreement between reviewers (Landis & Koch, 1977). While this categorisation of kappa is increasingly acknowledged as arbitrary (Landis & Koch, 1977; Warrens, 2015), it is interesting to consider the level of agreement between raters and the possible contributing factors. Personal factors can impact the assessment process, including assessors’ academic background and experience, methodological preferences, and closeness to the research project (Belur et al., 2018). Several of these factors may have influenced agreement in this review. As a novice researcher, I took a cautious approach and was more hesitant to exclude studies than my experienced supervisors, Authors 2 and 7. These factors may explain our moderate kappa results. The nature of qualitative research may also contribute to differences in interpretation (O’Connor & Joffe, 2020). This was highlighted through our discussions which revealed different interpretations of the inclusion/exclusion criteria. While there are arguments both for and against using interrater reliability tools in qualitative research, in the context of this study it served to promote reflexivity and dialogue about these differences within the team (O’Connor & Joffe, 2020). This ultimately led to greater clarity around the types of articles we wished to include/exclude.

Data Extraction

Identifying what counts as data within qualitative reviews is a challenge, and decisions vary across studies (Soilemezi & Linceviciute, 2018; Thomas et al., 2017). While some studies choose to include only first order data (e.g. direct participant quotes) others include entire results/findings sections (Soilemezi & Linceviciute, 2018; Thomas et al., 2017). To determine the right approach for this review, I looked to existing thematic syntheses that explored the perspectives of people living with dementia (Dowlen et al., 2018; Hennelly et al., 2019). These studies used first and second order findings. Theoretical perspectives are also relevant to this decision. Some interpretivist researchers argue researcher-selected quotes involve a level of interpretation, so there is little value in distinguishing between first and second order data in a review (Noyes & Lewin, 2011). Based on my interpretivist perspective and the review of previous studies (Dowlen et al., 2018; Hennelly et al., 2019) I decided to extract all data included in the results or findings sections of included publications. This data was imported in PDF format into MAXQDA 2020 (VERBI Software, 2019) for coding and analysis. Details about each study were extracted and entered into a spreadsheet (see Appendix A).

Step One: Coding

In step one, I coded the data inductively and line-by-line according to Thomas and Harden’s (2008) process. Line-by-line coding involves reading each sentence or paragraph carefully and assigning it with one or more codes (Thomas et al., 2017). Linneberg and Korsgaard (2019) argue that line-by-line coding helps to counter any unconscious selectivity that may have occurred in first readings/interaction with data. After sorting included articles alphabetically by author, I began coding the extracted text from the first article in my list (Clark et al., 2021). I took careful notice of specific words as well as sentences and paragraphs as a whole (Linneberg & Korsgaard, 2019). To assist with the coding process I used the research software tool, MAXQDA 2020 (VERBI Software, 2019).

Coding software such as MAXQDA 2020 is recommended by Thomas and Harden (2008) to assist with the coding process. Having previous experience with other software, NVivo (NVivo qualitative data analysis software, 2018), I was drawn to explore MAXQDA 2020 due to its visual appeal and options for colour-coding the data. Coding software has many benefits for the qualitative researcher, including the ability to label and search large quantities of data (Thomas & Harden, 2008). Coding software also allows the coder to organise codes either freely with no linked codes, or in tree-like structures (see Figure 2). These tree-like structures enabled me to create connections between codes with ease. Importantly, these codes were able to be easily moved, edited or adjusted as the coding process progressed.

Figure 2.

Codes organised in tree-like structures.

After the first round of coding my first article, I continued to code each included study in alphabetical order. Coding subsequent studies involved translation (Thomas et al. (2017), where I made judgements about whether a line of text fitted into existing codes or required a new code to be generated. For example, in the first round of coding data from Dowlen’s thesis (2019, p. 125), I allocated text to pre-existing codes: continuity, social belonging and choice and preference. However, in coding a discussion of “Scott’s comedic presence” (Dowlen, 2019, p. 126), I decided the concept of humour was significant enough to warrant its own new code. Each of these decisions was journaled about and discussed within supervision to maintain reflexivity through introspection and mutual collaboration (Finlay, 2002a).

As part of the initial coding, I was careful not to merge codes as I wanted to avoid prematurely ruling out distinctive themes. This is in keeping with reflexive practices where researchers attempt to keep an open mind while exploring data (Finlay & Evans, 2009). For example, in the initial round, several codes were developed on the topic of supportive friendships within groups: social belonging, connecting with group, supportive friendship with peers, friendship, affinity, feeling understood. While there are many similarities and overlapping meanings between these codes, I recognised subtle differences across these. For example, supportive friendship with peers was in essence different to the friendly interactions coded under friendship. This nuanced approach resulted in the generation of a large number of codes (208). To manage these numerous codes, I began to group them with like-named codes in tree-like structures for ease of navigation. For example, I grouped the codes musical connection, dyadic connection and connecting with identity/self under the code connection.

As coding continued, I logged working definitions for codes (see Table 2) which helped clarify my thinking and communicate my thoughts clearly with my supervisors.

Table 2.

Working Definitions of Codes (extract).

Code	Definition/Description
Mutual benefits	Has benefits for both the person living with dementia as well as the family care partner
Reminiscing	Actively remembering (i.e. remembering on purpose or extending/discussing memories by choice)
Evokes meaningful memories	The music evokes memories in participants (can be spontaneous and unintentional)

Once the initial round of coding was completed for each study, I reviewed each study again considering all newly developed codes. This second cycle included re-reading the content and searching the text using keywords. Throughout this cycle, I maintained a log of emerging ideas and questions about the meanings and relationships between codes (see Table 3). These logs supported reflexivity through introspection and, subsequently, mutual collaboration and discursive deconstruction as I dialogued with Author 2 around the nuanced meanings of words and concepts in different contexts (Finlay, 2002a).

Table 3.

Coding Log Excerpts.

Note Type	Excerpt from Log
Relationships between codes	Social belonging versus creating supportive group – how are these different? Does belonging require support, and can supportive groups exist without belonging?
	Participate versus contribute. Is there a difference? Contribute implies creating something
	Note: Tease out differences/similarities between facilitation and practical support
Thoughts about code meanings	Musical partnership (Elliott et al., 2020) – is this a way of thinking about togetherness that is different?
Thoughts about code meanings	Facilitation – provision of versus experience/receiving of
Meaning of codes in different contexts	Choice and preference: There is a difference between having choices/preferences honoured in group versus individual sessions. Within a group, familiarity and cultural/biographical relevance was more important than individual preferences, as shared enjoyment of a collective experience seemed to be a powerful factor (Hara, 2013). For dyads in a home setting, however, more individualised choice and preference seems to be more important. Choice and preference is not only about agency, but also about expression of identity
Meaning of codes in different contexts	Facilitation supports experience – applies to indiv. and group

Step Two: Developing Descriptive Themes

In step two, I began grouping codes into descriptive themes. This involved identifying relationships between codes and organising these into conceptual themes (Thomas et al., 2017). In the first part of this process, I used the sets feature in MAXQDA 2020 to organise codes into conceptual groups I had noticed during the coding process (see Figure 3). The sets feature allowed me to explore ideas separately to the tree-like structures created during coding, and acted as a starting point for my brainstorming.

Figure 3.

Creating sets in MAXQDA 2020.

Following these initial groupings, I engaged in mind-mapping and brainstorming with Author 2 to identify and explore key themes and concepts (see Figure 4). This process was informed by groups within the sets, the prominence of individual and grouped codes, and notes from my coding log. The prominence of a code was indicated by the number of times it was allocated across the data.

Figure 4.

Brainstorming and mind-mapping.

Based on the insights gained through brainstorming, I began organising and refining codes to create descriptive themes. I moved codes into more defined categories and checked the coded content against these categories. This systematic process involved bottom-up, top-down and side-to-side processes. During the bottom-up process, I examined less prominent codes in terms of their independence and relationship to other codes. If their meaning was sufficiently similar to another code, these two codes were merged (with the original description included in the merged code (e.g. relaxing/restful)). If they were sufficiently independent in meaning, they were allocated to sit under a relevant parent code. For example, the code something to talk about (8 allocations) was assessed as sufficiently independent to other codes and allocated to sit under the parent code supports dyadic relationship.

Within the top-down process, prominent codes were considered in relationship to other codes, with relevant codes moved to sit under these. For example, all codes were considered for their possible relevance to the prominent theme supports dyadic relationship (55 allocations). Codes identified as relevant to supports dyadic relationship were moved to sit under this code.

MAXQDA 2020s visual tools were also used to explore top-down relationships as shown in Figure 5. This tool allowed the free-form allocation of codes, assisting me to creatively explore the relationships between them.

Figure 5.

MAXQDA 2020s visual tools.

During the side-to-side processes, codes were considered in relation to multiple categories. Where applicable, codes that were relevant to multiple categories were duplicated. For example, shared moments was duplicated to sit under both shared dyadic experiences and over time>the moment, and coded content was re-evaluated under each parent theme.

While many code groups were developed inductively, some groupings were formed deductively as influenced by theoretical frameworks including personhood (Kaufmann & Engel, 2016; Kitwood, 1997) and positive psychology (Clarke et al., 2016). For example, as the codes inclusion, connecting with identity/self, mental/cognitive stimulation, comfortable/safe and control/agency were grouped together under Person with dementia’s experiences of music, I was consciously influenced by theories of personhood and subjective wellbeing posited by Kitwood (1997) and Kaufmann and Engel (2016). This led to the construction of the Parent theme wellbeing (personhood) is supported with underlying categories relating to key aspects of subjective wellbeing: attachment, agency, comfort, inclusion, occupation and identity (Kaufmann & Engel, 2016; Kitwood, 1997). Throughout this process, I continued to consult with my supervisors and engage in reflexive dialogue. The final descriptive themes are shown in Table 4. The number of times a theme is coded is shown in brackets to indicate the theme’s prominence.

Table 4.

Descriptive Themes.

Descriptive Theme	Sub-theme	Underlying Codes
Individual and together (2032)	Person with dementia’s experiences of music (1448)	Wellbeing is supported (1406) Facilitation enhances experiences (90) Challenges with music (35)
	Family care partner’s experiences of music (214)	Supportive (91) ‘They’re still there’ (57): Witnessing (41) and ‘Being together like before’ (15) Cognitive shifts (33) ‘If she feels alright, I feel alright’ (symbiotic) (17) Challenges (13)
	Shared dyadic experiences (370)	Mutually beneficial (38) Supports dyadic relationship (331): Togetherness (135) Dyadic connection (154) Increased/enhanced communication (14)
In group context (1197)	Ecological (478)	Group culture/identity (269) Performative (63) Sense of self in context (35) Something to look forward to/anticipation (28) Individual role in group (23) A musicking space (23) Sustainability (11)
	Facilitation supports/enhances experience (416)	Facilitation style/approach (274) Logistics (129)
	Belonging and connection (286)	Supportive friendships (56) Opportunity for socialising (22) Social belonging (121) Connecting with group (18) Collective experience (33) Levelling (36)
Over time (1033)	Changed over time (80)
	Warming up/tuning in (19)
	Now “the moment” (448)	Enjoyment (121) Embodied response to music (97) Humour (37) Emotional experience (32) Enthusiasm (29) Shared moments (27) Playfulness (24) A ‘special time’ (14) Flow (12) Appreciation of musical aesthetics (11)
	Extending beyond (211)	At home (143): Enhanced personal wellbeing (54), Something to look forward to (33), Replacement for previous activities (24), Increased use of music (18), Something to talk about (9)Community (78): Challenging perceptions/expectations (28), Ongoing connection/community (27), Openness/engagement with other activities (13), Connecting to broader community (10)Creating new meaning (47)
Music as a supportive structure (536)	Connecting (258)	Connecting with memories (90)Musical connection (55)Musical communication (48)Non-verbal communication (36)Connection with present/orientation (20)
	Containing (safety, comfort, boundaries) (116)	A frame (57)Familiar and predictable (43)Internalised haven (11)
	Accessible (58)
	Levelling (38)
	Lifting (34)	Music helps with memory and learning (34)
	Transporting (13)

Step Three: Developing Analytical Themes

Step three is notoriously difficult to describe as it often overlaps with step two (Thomas et al., 2017). As discussed by Thomas et al. (2017), descriptive themes sometimes adequately respond to the research question, while other reviews require an analytical stage. In this study, while some descriptive themes addressed the research question (e.g. Music [is experienced] as a supportive structure), others required a further analytical stage (e.g. in group context). To move from descriptive to analytical (or final) themes (see Table 5), I worked inductively and deductively considering the research question, the prominence of descriptive themes, relevant theoretical frameworks, and my notes from steps one and two. For example, within the descriptive theme detailing people with dementia’s experiences of sharing music, the code wellbeing is supported was highly prominent, with 1406 allocations and detailed underlying codes. This led to the development of the analytical theme, Shared musical activities support wellbeing for people living with dementia. While I was aware of the relevance of Kitwood’s theory of personhood (1997) to this theme’s underlying codes, a closer examination revealed codes aligned with my broader reading around Positive Psychology (Clarke et al., 2020). Positive Psychology theories of wellbeing in dementia expand on Kitwood’s work to include concepts of flourishing and personal growth (Clarke et al., 2016, 2020). These concepts align with the codes creativity, meaning-making and social belonging/citizenship. Based on this congruence, I used Clarke et al. (2020) conceptual framework to structure Theme one’s sub-themes, allocating the codes deductively. The decision to work deductively in this case was discussed and revisited in several cycles with Authors 2 and 7. The other codes and sub-themes within this first descriptive theme were absorbed into other analytical themes (shared musical experiences are experienced by me and as we).

Table 5.

Evolution of Descriptive Themes to Analytical Themes.

Descriptive Theme/sub-theme	Analytical Theme	Overarching Theme
Wellbeing is supported (highly prominent code within the theme Individual and together)	Theme 1. Shared musical activities support wellbeing for people living with dementia	Theme 6. The thread of connection
In group context	Theme 2. Music groups become ecological systems
Ecological
Facilitation supports/enhances experience
Belonging and connection
Over time	Theme 3. Experiences of shared musical activities change over time
Changed over time
Warming up/tuning in
Now “the moment”
Extending beyond
Individual and together	Theme 4. Shared musical activities are experienced by me and as we
Person with dementia’s experiences of music
Family care partner’s experiences of music
Shared dyadic experiences
Music as a supportive structure: Connecting, containing, accessible, levelling, lifting, transporting	Theme 5. Music is a supportive structure

In reviewing the descriptive theme In group settings, I was influenced by previous knowledge of Community Music Therapy (Stige & Aarø, 2012) and ecological theories (Bronfenbrenner, 1992; Bruscia, 2014). For example, as I explored the codes under this theme and engaged in reflexive dialogue with Author 2, the organic development of relationships, culture and rituals in group settings became apparent, leading to the development of the analytical theme, Music groups become ecological systems.

Themes 3 and 5 were largely carried over from the descriptive themes, as these already described aspects of how dyads experienced shared musical activities. Through reflexive discussions and the writing up process, these two themes became more developed. Theme four was derived from the individual and shared experiences highlighted in the descriptive themes. Across all the analytical themes, the writing-up process helped to develop and refine each theme. This is common within qualitative research, as writing is used to process and develop ideas (Mitchell & Clark, 2021). Through this write-up stage, I noticed that the underlying theme of connection appeared repeatedly across themes. As I reviewed the codes, I identified a variety of types of connection throughout. This led to the development of Theme six: The thread of connection. The development of this new theme was discussed with Author 2 and Author 7 to maintain reflexivity.

Reflexive Practices

Throughout the analysis I engaged in regular supervision with Author 2 and Author 7 to discuss my processes and examine emerging codes and themes. This supervision supported the reflexive practice of mutual collaboration, where cycles of dialogue helped to move our understandings beyond initial assumptions, understandings and biases (Finlay, 2002a). As part of these discussions, we reviewed random segments of text and reflected on the accuracy and possible meanings of the codes and themes. We attempted to bring a self-awareness of our own contexts to these discussions (Finlay, 2002b), acknowledging our influences from previous research and theoretical frameworks such as personhood (Kitwood, 1997) and Community Music Therapy (Stige & Aarø, 2011). For example, in my initial coding I created the code performative. At the time of coding, I viewed this as simply the most accurate description for the coded text. On further reflection, I realised I was influenced by my previous knowledge of Community Music Therapy (Stige & Aarø, 2011). With a new awareness of these influences, I re-evaluated my use of this code. After reviewing the data and discussing with Author 2, I decided to retain the original code and embrace these influences while explicitly acknowledging them. I also engaged in regular journaling and note-taking throughout the coding and analysis process. The act of recording and reflecting on my decisions helped me engage in introspection throughout, and these records were a reference and prompt for reflexive dialogue during supervision (Finlay, 2002a).

Quality and Accountability

To assess the quality of these findings, I completed a CASP assessment (Critical Appraisal Skills Programme, 2018) for each included article, and a GRADE-CERQual assessment for each analytical theme and sub-theme (Lewin et al., 2018). A summary of these is provided in Appendix D, and the full results are published alongside the study’s results (McMahon et al., 2022). The GRADE-CERQual assessments found moderate-high confidence in this study’s findings based on methodology, coherence, adequacy and relevance (Lewin et al., 2018; McMahon et al., 2022). In reporting the findings of this systematic review, I used the PRISMA 2020 checklist (published in McMahon et al. (2022)) and the ENTREQ reporting guidelines (Tong et al., 2012).

Discussion

In this worked example, we aimed to explore how people living with dementia and their family care partners experienced shared musical activities across a range of settings. While the comprehensive search increased our chance of capturing all relevant articles, the subjective nature of inclusion/exclusion criteria became clear as we embarked on the reviewing process, thereby highlighting the importance of transparency. I used the updated PRISMA checklist (Page et al., 2021) and the ENTREQ reporting guidelines (Tong et al., 2012) to promote transparency. While there is considerable overlap between these tools, they both have unique benefits. PRISMA’s online tools provide a convenient and comprehensive approach for reporting on any type of systematic review (McGregor, 2021; Page et al., 2021). ENTREQ includes items specific to qualitative reviews, prompting the reporting of coding processes, theme development, and clear presentation of quotations. Therefore, we recommend the use of both PRISMA (Page et al., 2021) and ENTREQ (Tong et al., 2012) for transparency in future QES.

Despite using these tools, I found it challenging to report steps two and three transparently due to the lack of distinction between stages. This is common within thematic syntheses (Thomas et al., 2017). To counter this, we recommend reviewers keep detailed notes in every step. While I attempted to do this through journaling and recording decisions, a checklist or reporting tool may have supported this further. Since the development of ENTREQ, specific reporting guidelines have been developed for meta-ethnography, realist reviews and meta-narrative reviews (Flemming & Noyes, 2021). There are, however, no specific reporting tools for thematic synthesis despite its popularity (Flemming & Noyes, 2021). In light of the above challenges, there is a demonstrated need for a specific reporting tool for thematic synthesis.

In keeping with the Cochrane group’s recommendations, I found thematic synthesis to be an accessible approach to QES as a novice researcher (Noyes et al., 2018). The lack of distinction between stages two and three, however, may be challenging for novice researchers. Therefore, guidance across these stages from experienced researchers is highly recommended. Worked examples of thematic syntheses from experienced researchers would further benefit this field.

According to its proponents, QES makes economical use of existing data to gain insights into complex interventions (Booth et al., 2016; Flemming et al., 2019). This thematic synthesis confirms this view, making use of existing data with vulnerable populations to gain insights into complex processes within shared musical activities.

The discussed review was potentially limited by the exclusion of mixed methods studies, and the lack of diverse populations in the primary studies. Future studies may benefit from using broader inclusion criteria. Additionally, the review may have benefited from deeper reflexive practices to promote integrity and transparency (Finlay, 2002b). While I attempted to incorporate reflexive practices throughout, these were largely limited to introspection and mutual collaboration (Finlay, 2002a). While reflexivity is acknowledged as an important aspect of QES (Downe et al., 2019; Flemming & Noyes, 2021), it is not widely embedded in reporting processes. This could be improved by including reflexive practices in future QES tools.

A strength of this study was the detailed reporting of step one: coding. In this worked example, I provide a systematic approach to coding including top-down, bottom-up and side-to-side processes. This example adds to the existing literature around coding (Chenail, 2012; Linneberg & Korsgaard, 2019; Thomas et al., 2017), providing a unique perspective from a novice researcher. The use of ‘I’ in my first-person discussion also supported critical reflection on my theoretical influences and decision-making. Within a qualitative paradigm, this reflexivity increases the transparency and trustworthiness of research (Finlay, 2002b).

Conclusion

In conclusion, this worked example may provide guidance for novice researchers conducting a qualitative thematic synthesis. This paper provides an example of the key decisions and processes undertaken, and explored the challenges and benefits of conducting QES and thematic syntheses. We highlight the need for meticulous note-taking and reflexivity during analysis to facilitate transparent reporting, and the need to develop a specific thematic synthesis reporting tool that incorporates reflexive processes. We also identify the need to embed reflexive practices into general QES tools. More broadly, this worked example demonstrates how primary qualitative research may be utilised to gain insights into complex processes like music therapy (Carroll, 2017; Flemming & Noyes, 2021). These rich understandings are a valuable guide for healthcare providers and policy developers in community music, music therapy and dementia care spaces (Barbour, 2008; Booth et al., 2016; Flemming & Noyes, 2021).

Footnotes

Author Contributions

Kate McMahon: Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Writing – Original Draft, Review and Editing, Project Administration; Imogen Clark and Felicity Baker: Conceptualisation, Methodology, Investigation, Formal Analysis, Writing – Review and Editing, Supervision; Karette Stensæth: Conceptualisation, Writing – Review and Editing; Helen Odell-Miller: Conceptualisation, Writing - Review and Editing; Anna Bukowska and Thomas Wosch: Conceptualisation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of Melbourne, National Health and Medical Research Council (NHMRC; NH&MRC GNT1169867) and the EU Joint Programme – Neurodegenerative Disease Research (JPND; HESOCARE-329-005). The HOMESIDE team and HOMESIDE International PhD (HIP) group provided feedback and dialogue that supported this study’s development.

ORCID iD

Kate McMahon

: Study Information

Table A1.

Details of Final Included Articles.

Author	Year	Title	Research Methodology	Data Collection	Country	Intervention Type	Intervention Setting	Participant Details	Professional/ Theoretical Framework
Clark et al.	2018	Community-dwelling people living with dementia and their family care partners experience enhanced relationships and feelings of well-being following therapeutic group singing: A qualitative thematic analysis	Thematic analysis	Semi-structured interviews with dyads	Australia	Therapeutic group singing	Public health facility	8 × spousal/partner dyads; 1 × parent/daughter dyad	Music therapy; Person-centred
Clark et al.	2021	“Doing things together is what it’s about”: An interpretative phenomenological analysis of the experience of group therapeutic songwriting from the perspectives of people with dementia and their family care partners	Interpretative Phenomenological Analysis (IPA)	Semi-structured interviews with dyads	Australia	Therapeutic group songwriting	Community-based	10 dyads total – 5 × spousal dyads living together, 3 × spousal dyads living separately, 2 × family dyads (parent-adult child) living separately	Music therapy; person-centred; family-centred, community music therapy
Dowlen	2019	The ‘in the moment’ musical experiences of people with dementia: A multiple-case study approach	Multiple case study design	Video-observation, video-elicitation interviews, participant diaries, and observational notes by participant/observer	UK	Group music therapy	Community-based group setting	4 × spousal dyads; Four of the six people living with dementia attended the group with a family carer; (Scott, Phillip, Carol and Henry) (Dowlen, 2019, P. 96: 880)	Music therapy; community music therapy
Elliott et al.	2020	Music lessons: Exploring the role and meaning of music for older adults with dementia	Multiple case study design – developed own qualitative analysis to analyse text and video	Semi-structured interviews, observation, and self-recorded videos from dyads	Canada	Home-based music	Home-based	3 × spousal dyads	Community health
Garabedian and Kelly	2020	Haven: Sharing receptive music listening to foster connections and wellbeing for people with dementia who are nearing the end of life, and those who care for them	Thematic analysis	Semi-structured interviews with carers, key staff and managers; video recordings of intervention	UK	Live and recorded music listening	Residential aged care	12 × dyads: A person living with dementia and “someone closely connected to them” (p. 1)	Social sciences; personhood
Gardner	1999	Music therapy: Enhancing communication between family care partners and their loved ones with dementia (Alzheimer’s disease)	Inductive qualitative analysis	Video/audio recordings of sessions plus interviews with family members and staff	USA	Joint music therapy sessions with the person living with dementia and their family care partner	Residential aged care	2 × mother/daughter dyads	Music therapy; family-centred music therapy
Hara	2011	Expanding a care network for people with dementia and their carers through musicking: Participant observation with Singing for the Brain	Ethnography and grounded theory	Participant observation and interviews, photographs and audiovisual recordings of sessions. 30 × interviews with care partners, care-receivers, volunteers, facilitators and charity reps	UK	“Singing for the Brain”, a community-based music activity	Community group setting	10 care-receivers, 10 carers and 15 volunteers	Music sociology, community music therapy
Hara	2013	We’ll meet again: Music in dementia care	Ethnography and grounded theory	Participant observation and interviews, photographs and audiovisual recordings of sessions. Interviews with care partners, care-receivers and volunteers	UK	Community music groups	Community group	Approximately 30 participants including care-receivers, family care partners, group leaders and volunteers	Music sociology, community music therapy
Lee et al.	2020	Promoting well-being among people with early-stage dementia and their family carers through community-based group singing: a Phenomenological study	IPA	Semi-structured interviews with individual participants (separately)	UK (Ireland)	Community singing group facilitated by a music therapist	Community setting	6 × dyads	Music therapy; person-centred
Macgregor	2016	Music therapy: A bridge to communication for familial care partners of persons with dementia	Thematic analysis	Audio recordings of pre and post interviews, care partner respondents’ journal logs, and the researcher’s observational field notes and journal log. Researcher took notes by hand after sessions	USA	Home-based therapeutic music supported by a music therapist	Home-based	4 × dyads	Music therapy; personhood
Osman et al.	2016	‘Singing for the Brain’: A qualitative study exploring the health and well-being benefits of singing for people with dementia and their carers	Thematic analysis	Semi-structured interviews with dyads	UK	Community group music program ‘Singing for the Brain’	Community group setting	3 × mother/daughter dyads, 7 × spousal dyads	Music psychology
Shibazaki and Marshall	2017	Exploring the impact of music concerts in promoting well-being in dementia care	General qualitative analysis	Semi-structured interviews	UK/Japan	Music concerts in care homes for people living with dementia and their families	Residential aged care	53 participants: 27 people living with dementia, 13 family members, 9 nursing/volunteer staff, 4 care/activities managers	Clinical psychology
Unadkat	2015	Theorising group singing for couples in dementia care	Grounded theory	Semi-structured interviews	UK	Group singing	Various community group settings	17 dyads

Appendix B: Search Strategy Development

Appendix C: Inclusion/Exclusion Criteria Checklist

Title. Shared musical experiences for people living with dementia and their family care partners: A thematic synthesis

Research Question. How do people living with dementia and their family care partners experience shared musical activities?

Definitions. People living with dementia are defined as people with a diagnosis of any type of dementia. Family care partners include family members or friends who provide informal care for the person living with dementia (i.e. not a paid employee). These pairs of people may be referred to collectively as a dyad. Shared musical activities are defined as a musical experience (active or receptive) where both members of the dyad are involved.

Framework. People living with dementia and their family care partners’ experiences will be explored both individually and through a family-centred lens as a dyad, which recognises the interconnected nature of these relationships (Hao & Ruggiano, 2020). For this reason, proxy accounts of people with dementia’s experiences will be included when provided by the family care partner.

Table C1.

Inclusion/Exclusion Criteria.

	Include	Exclude	Justification
Methodology	Primary research reporting first-person expressions of subjective experiences and perspectives (or proxy reports by family care partners)	Literature reviews of primary research studies	Aim is to extract voice/perspective of participants
Methods	Qualitative studies; first-person accounts (e.g. interview, self-completed scales/questionnaires and other forms of self-expression); proxy accounts by family care partners	Quantitative studies, mixed methods studies	As noted by Zeilig et al. (2019), quantitative measures alone may be a somewhat reductive approach to measuring complex concepts such as experiences of music. As this study aims to explore the complexity of participants’ experiences, a decision has been made to limit the scope to include qualitative studies only, as this will ensure a focus on participants’ individual experiences rather than limited pre-defined categories
Participants	Studies where people living with dementia and their family care partners are involved in shared musical activities	Studies that do not include both people living with dementia and family care partners; studies with mixed participant populations (e.g. people with dementia + older adults without dementia) that do not present results of each group separately	Aim to clearly identify voices/experiences of people living with dementia and their family care partners
Intervention Settings	All settings	No exclusion	Dyads may have valuable experiences to share across a range of settings
Sample size	Any	None	Rich qualitative data may be found in all sample sizes
Music interventions	Studies with a primary focus on the use of music for people living with dementia and their family care partners. This may include formal and informal musical experiences, as well as both active and receptive music experiences	Studies that do not focus on the use of music; Studies with mixed-modality interventions (e.g. music with art, music with exercise etc.)	Aim to identify impact of music only
Topic	Studies that report on people living with dementia and family care partners’ first person experiences and/or perspectives of shared musical activities (active or receptive)	Studies that do not report on dyads’ experiences and/or perspectives of music	Aim to explore participants’ experiences of shared musical activities
Publication type	Peer-reviewed journal articles, Masters and PhD theses and dissertations, peer-reviewed book chapters	Editorials, conference abstracts and proceedings, blogs, reports, reviews	Aim to identify the representation of dyads’ experiences within peer-reviewed research specifically
Language	Studies in English	Studies in languages other than English	Non-English studies may complicate attempts to define concepts/experiences due to issues around language and translation

Appendix D: CASP and GRADE-CERQual

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Exploring Shared Musical Experiences in Dementia Care: A Worked Example of a Qualitative Systematic Review and Thematic Synthesis

Abstract

Keywords

Introduction

The Example Study

Selecting the Methodology

Developing a Search Strategy

Inclusion and Exclusion Criteria

Search and Screening

Interrater reliability

Data Extraction

Step One: Coding

Step Two: Developing Descriptive Themes

Step Three: Developing Analytical Themes

Reflexive Practices

Quality and Accountability

Discussion

Conclusion

Footnotes

Author Contributions

Declaration of Conflicting Interests

Funding

ORCID iD

: Study Information

Appendix B: Search Strategy Development

Appendix C: Inclusion/Exclusion Criteria Checklist

Appendix D: CASP and GRADE-CERQual

References