Narrative Reviews in Medical Education: Key Steps for Researchers

Background

Narrative review is an umbrella term for a collection of review types in which the review process goes beyond an opinion or commentary. In a narrative review, researchers can pursue an extensive description and interpretation of previously published writing on a chosen topic. Narrative reviews provide a flexible and rigorous approach to analyzing and interpreting the literature. Although there are no consensus reporting guidelines for most narrative review types, researchers conducting narrative reviews usually follow chronological order in their description and organize the manuscript according to introduction, methods, results, and discussion.¹ The types of narrative reviews are diverse, with individual purposes, processes, and best practices for rigor, which will be discussed in subsequent articles in this Journal of Graduate Medical Education series on reviews. Five elements are common across most narrative subtypes, although narrative reviews typically will also reflect the style and subjective interpretations of the author team. These elements include: (1) rationale for a narrative review; (2) clarity of boundaries, scope, and definitions; (3) justification for inclusion and exclusion criteria; (4) reflexivity and a saturation/sufficiency statement; and (5) details on analysis and interpretation.²

Identifying a Research Question

The first step in conducting a narrative review requires researchers to describe the rationale and justification for the review. Narrative reviews are useful for research questions across many different topics. For example, researchers may be seeking clarity on a topic where there is limited knowledge, or to synthesize and analyze an existing topic in a different way. When describing their purpose and audience, researchers are encouraged to frame their review by describing how their chosen research question aligns with existing literature and why their review may offer unique insights for the field.

Searching

When conducting a narrative review, it is important for researchers to name the databases being searched. Although the search terms are not always known at the outset of a narrative review, researchers should provide readers with as much information as possible about how they developed their search strategy and search terms with appropriate rationale for the decisions made along the way; these are often shared via appendices. The search itself may include diverse fields with a wide range of methods. Different subtypes of narrative reviews may involve specific principles or guidelines as part of this search.

Screening

It helps to specify inclusion and exclusion criteria; however, as a narrative review is not designed to be a comprehensive review of the literature, offering the rationale for specific parameters is important. Researchers should be clear and explicit about the choices they made, how they conducted screening, and which team members were involved. Authors should also consider how they assessed the quality of articles included in the review.

Sampling

Narrative reviews include a noncomprehensive and non-exhaustive sample of the literature on a specific topic. Different researchers may take different approaches depending on the purpose of the review. Researchers can limit their sample to peer-reviewed journal articles or may choose to use reference lists and grey literature, such as meeting abstracts and presentations. Although not absolute, explaining the foundational decisions that informed and shaped each part of the review is usually a best practice. To describe the sampling approach, some forms of narrative review provide guidance that can be used by other researchers seeking help with managing sampling.

Reflexivity is another important consideration. Narrative reviewers must be explicit about how the researchers' perspectives and experiences informed decisions, including sampling strategy.

Analysis

Narrative reviews are usually iterative and recursive, while conducting concurrent analysis and interpretation. Review authors must provide examples that justify their interpretations and coherently demonstrate how their interpretations have been used to inform their conclusions.^3,4 In general, all types of narrative reviews must include some form of both descriptive and interpretive analysis. The exact method of analysis may vary; some will rely on thematic or content analysis while others will take a more discursive or critical approach. Some narrative review subtypes are more prescriptive in approach. For example, a meta-narrative review involves narrative synthesis to make sense of different narratives about a chosen topic.⁵ A critical narrative review involves interpretive analysis that compares a field's theoretical understanding of a topic with existing literature on the same topic from a different discipline.^6,7

Strengths and Limitations

Narrative reviews provide a flexible yet rigorous approach for knowledge synthesis, which is useful to many educators and researchers. Yet this approach has limitations; for example, narrative reviews are not often reproducible related to the influence of the authors and setting on screening, sampling, and analysis. Narrative reviews do not include an exhaustive search of all possible evidence on a given topic. A narrative review's approach to inclusion gives rise to another common criticism of narrative reviews: they are selective, which may make them harder to critically appraise against strict criteria. Researchers can address this potential shortcoming by being thoughtful, purposive, and transparent about the choices they make throughout the review process, as well as being explicit in their justifications for these choices. Researchers should also be cautious and avoid overstating conclusions.⁴

Conclusions

Within medical education research, narrative reviews provide scholars with a flexible approach to conduct a rich, meaningful, and practical review of the literature on a topic. Such reviews can be used in a thoughtful and focused way to foster a deeper understanding of a medical education topic. Key considerations for researchers include an explicit and clear rationale for their choice to pursue narrative review methods. Researchers should also be thoughtful, deliberate, and reflexive about their approach to identifying a research question, screening, sampling, and analysis.