Journal of Nursing Education

EDUCATIONAL INNOVATIONS 

Seeing the Forest for the Trees: A Qualitative Synthesis Project

Cheryl Tatano Beck, DNSc, CNM, FAAN

Abstract

ABSTRACT

Although qualitative studies are increasing in the discipline of nursing, their clinical application and knowledge development will be impeded unless the rich understandings revealed in these individual studies can he synthesized. Meta-synthesis is an invaluable method for accumulating knowledge from individual qualitative studies. This article describes a project focusing on qualitative synthesis that the author required her nursing students in a graduate-level research course to complete. In addition, qualitative meta-synthesis is defined, and its benefits are discussed. Then, Noblit and Hare's approach for synthesizing qualitative studies is described. The remainder of the article is devoted to explaining the actual course project and students' evaluation of the project. The benefits of having graduate students conduct a meta-synthesis are many, and as one student shared, "It was a wonderful, very interesting, and challenging way to teach us."

Abstract

ABSTRACT

Although qualitative studies are increasing in the discipline of nursing, their clinical application and knowledge development will be impeded unless the rich understandings revealed in these individual studies can he synthesized. Meta-synthesis is an invaluable method for accumulating knowledge from individual qualitative studies. This article describes a project focusing on qualitative synthesis that the author required her nursing students in a graduate-level research course to complete. In addition, qualitative meta-synthesis is defined, and its benefits are discussed. Then, Noblit and Hare's approach for synthesizing qualitative studies is described. The remainder of the article is devoted to explaining the actual course project and students' evaluation of the project. The benefits of having graduate students conduct a meta-synthesis are many, and as one student shared, "It was a wonderful, very interesting, and challenging way to teach us."

From the days of their undergraduate research courses, graduate students are familiar with the traditional literature review, in which the research on a topic of interest is critically synthesized and summarized. These narrative literature reviews can have different purposes, such as providing the foundation for a research project, developing innovations for clinical practice, or providing clinicians with state-of-theart research-based information. Although integrative literature reviews written in narrative terms are valuable, they do have some shortcomings. For example, in qualitative research, they do not allow for interpretation and meaningful synthesis of individual studies' findings. Noblit and Hare (1988) warned that integrative literature reviews are unable to make sense of what the group of qualitative studies on a specific topic is saying. Therefore, they believe "literature reviews in practice are more rituals than substantive accomplishments" (Noblit & Hare, 1988, p. 15). Noblit and Hare (1988) called for the work of knowledge synthesis of qualitative studies to be essentially both inductive and interpretive. The goal of meta-syn theses is not aggregative results, but instead interpretive results (Jensen & Allen, 1996).

This article describee a project focusing on qualitative synthesis that the author required her nursing students in a graduate-level research course to complete. In addition, qualitative meta-synthesis is defined, and its benefits are discussed. Then, one approach for synthesizing qualitative studies - meta-ethnography - is described (Noblit & Hare, 1988). The remainder of the article explains the actual course project.

Synthesizing Qualitative Studies

Qualitative meta-synthesis refers to "the theories, grand narratives, generalizations, or interpretative translations produced UOm the integration or comparison of findings from qualitative studies" (Sandelowski, Docherty, & Emden, 1997, p. 366). Although qualitative studies are increasing in the discipline of nursing, their clinical application and knowledge development will be impeded unless the rich understandings revealed in these individual studies can be synthesized. Meta-synthesis is an invaluable method for accumulating knowledge from individual qualitative studies. According to Paterson, Thorne, Canam, and Jillings (2001), "The appeal of meta-synthesis lies in our hunger for more true, more accurate, or more real explanations of phenomena and more coherent ways to make sense of them" (p. 110).

The purpose of meta-synthesis is not just to identify similarities of research on a particular topic but, rather, to dig deep under the surface layer to "emerge with the kernel of a new truth" and increase our understanding (Paterson et al., 2001, p. 111). A meta-synthesis profits from the assortment of methodological and theoretical contexts within the various studies included in it.

For these qualitative findings to have an effect, they need to be placed in a larger interpretative context, which meta- syn thesis can do. Sandelowski et al. (1997) identified three types of qualitative meta-synthesis. The first type involves integrating results from many analytic approaches included in one researcher's research program. The second type is synthesis of results across studies conducted by various researchers on a similar topic. The third kind of meta-synthesis focuses on using qualitative methods to integrate qualitative results from cases across various studies. Use of metasynthesia techniques can transform the results of a generation of qualitative research in nursing and related health care disciplines from a group of individual studies into a powerful body of knowledge that can positively affect health care (Paterson et al., 2001).

Researchers involved in meta-synthesis walk a fine line between analyzing the studies in enough depth to maintain the integrity of specific studies and not becoming so immersed in the details that the end product is not usable. Sandelowski et al. (1997) warned researchers that integrating qualitative studies involves "carefully peeling away the surface layers of studies to find their hearts and souls in a way that does the least damage to them" (p. 370).

Paterson et al. (2001) situated meta-synthesis as the final step in a meta-study. Analysis is the first component of a meta-study, followed by synthesis. There are three parts to the analysis section of the metastudy - meta-data analysis, metamethod, and meta-theory. In metadata analysis, the results of studies in a specific substantive area are examined. Paterson et al. (2001) suggested Noblit and Hare's (1988) metaethnography is an especially useful meta-data-analytic approach. The methodological rigor of these research studies next is assessed in meta-method. Then, in meta-theory, the theoretical perspectives or frameworks underlying these research reports are studied. The second component of a meta-study is the synthesis of the results obtained in the analytic component. This meta-synthesis reassembles the parts of the studies that were deconstructed in the three analytic steps of meta-study and creates a new interpretation of the phenomenon being studied.

Method for Qualitative Synthesis

Noblit and Hare (1988) developed a method for synthesizing qualitative studies. They labeled this method meta-ethnography. A meta-ethnographic approach is "a rigorous procedure for deriving substantive interpretations about any set of ethnographic or interpretive studies" (Noblit & Hare, 1988, p. 9). Noblit and Hare (1988) stressed that interpretive studies include not only ethnographic studies but also all types of interpretive research, such as phenomenology. Their approach consists of the following series of phases that overlap and repeat during the qualitative synthesis:

* The first phase focuses on finding a topic of substantive interest that is worthy of the synthesis work.

* Next, researchers may narrow the focus of the synthesis. Sample criteria are identified to help in the decision of which qualitative studies to include in the synthesis.

* Researchers read and reread the qualitative studies, noting any interpretative metaphors otherwise known as key concepts or themes. Because the meta-ethnographic approach is a synthesis of texts, researchers must pay meticulous attention to the details of each account.

* In this phase, researchers determine the relationship of the studies to one another. Studies can be related to each other in one of three ways - as a reciprocal translation (i.e., studies are essentially similar and can be directly translated), as a refutation (i.e., the accounts are in relative opposition to each other), or in a line of argument (i.e., an inference about a set of parts to some whole). Researchers make a list of key metaphors identified in each account and then juxtapose them.

* The studies then are translated into one another. The kind of translations Noblit and Hare (1988) referred to are not literal but instead are idiomatic, where the meaning of the text is translated. Translations are especially unique syntheses, because they protect the particular, respect holism, and enable comparison" (Noblit & Hare, 1988, p. 28). An adequate translation maintains the central metaphors of each account in their relation to other central metaphors in that same account. In addition, an adequate translation compares the metaphors in one account with those metaphors in the other accounts included in the meta-synthesis.

* In this phase, researchers make a whole, which is something more than what the parts by themselves imply, by synthesizing the translations.

* Lastly, the synthesis is expressed. Depending on the audience, a qualitative synthesis can be expressed in various forms. Although the written form is used most often, Noblit and Hare (1988) suggested other possible forms, such as plays, videos, music, and art.

Noblit and Hare (1988) stressed that the outcome of a meta-ethnography should be viewed as an interpretation, and therefore, it is subject to debate and critique. Evidence of a successful meta-ethnographic synthesis should be the nature of the debate the synthesis brings forth, not the synthesis itself. A meta-ethnographic synthesis is best understood as an ongoing process, rather than as key decision points.

Evaluation of a Qualitative Synthesis

Just as criteria have been developed to assess the rigor of metaanalysis, such as the Meta-Analysis Appraisal Checklist (Beck, 1997), so has this been done for meta-synthesis. Many of the same design criteria for meta-analysis hold for meta-synthesis. These criteria include aspects such as the research question, purpose, theoretical framework, sample criteria, sample, procedure of locating primary studies, and code book.

Table

TABLE 1Metaphors Used to Construct Reciprocal Translations In Mothering Multiples Meta-Ethnographic Synthesis

TABLE 1

Metaphors Used to Construct Reciprocal Translations In Mothering Multiples Meta-Ethnographic Synthesis

In addition to these evaluation criteria, Paterson et al. (2001, p. 125) enumerated four essential questions that must be addressed when judging the quality of a meta-synthesis, including:

* Has the meta-synthesis increased the understanding of the body of research in the field of study?

* Has it illuminated the implications of the contexts, methods, and theories that have influenced the body of research in the field?

* Has it generated a new or expanded a theory?

* Has it articulated an alternative, overarching perspective about the phenomenon?

Paterson et al. (2001) emphasized that one of the measures of the quality of a meta-synthesis is the attention given to explaining the degree to which each primary study is embedded or nested in the results of the meta-synthesis. Both predominant and disparate findings of the primary studies should be identified, as well as how the threads of those studies have built on each other.

Table

TABLE 2Comparison of Metaphors Used in Students' Reciprocal Translations

TABLE 2

Comparison of Metaphors Used in Students' Reciprocal Translations

Qualitative MetaEthnographic Synthesis Project

As one requirement of a graduate nursing research course, 10 students reviewed six qualitative studies on the clinical topic of mothering multiple-birth children (i.e., multiples). Using Noblit and Hare's (1988) method, students conducted a metaethnographic synthesis of six primary studies (Anderson & Anderson, 1990; Garel & Blondel, 1992; GoshenGottstein, 1980; Holditch-Davis, Roberts, & Sandelowski, 1999; Robin, Bydlowski, Cahen, & Josse, 1991; Robin, Josse, & Tourrette, 1988). Students wrote the findings of their qualitative synthesis in a format similar to research reports, including introduction, method, results, and discussion sections using the Publication Manual of the American Psychological Association (2001) format.

The author already had conducted a qualitative synthesis of these studies. The article reporting the findings was "in press" in MCN: The American Journal of Maternal Child Nursing at the time of this course (Beck, 2002). The rationale for selecting the same six studies for the graduate students to synthesize was to allow a comparison of not only each student's findings with other students' findings, but also the students' findings with the author's synthesis.

Figure. Four interrelated, overarching themes of mothering multiples. Reprinted with permission from McGuire (2001).

Figure. Four interrelated, overarching themes of mothering multiples. Reprinted with permission from McGuire (2001).

Each week toward the end of class, time was set aside for the students to share their progress on their qualitative synthesis. It was a time for asking questions and providing guidance for each step of Noblit and Hare's (1988) method.

The last class of the course was devoted to presenting the outcomes of each student's meta-ethnographic synthesis. As emphasized by Noblit and Hare (1988), these outcomes were viewed as interpretations. A discussion of how the students' qualitative syntheses compared and contrasted with one another's, as well as the author's synthesis, was an additional benefit of this assignment. The need to view a meta-ethnographic synthesis as an ongoing process, rather than a final product, became apparent to the students. The number of themes/metaphors students identified in their qualitative syntheses to construct reciprocal translations ranged from three to five. The author's meta-ethnographic synthesis consisted of six themes.

Table

TABLE 3Primary Research Appraisal Tool

TABLE 3

Primary Research Appraisal Tool

At the beginning of the last clase, students were provided with copies of a table, which listed the metaphors the author used to construct the reciprocal translations in her mothering multiples qualitative synthesis (Table 1). The students then were able to compare their own metaphors with those of their professor.

A table similar to Table 2 was constructed on the chalkboard, comparing all 10 students' themes with each other's and the author's. The students and author shared the rationale behind their choices of the central themes/metaphors for their qualitative syntheses. Due to space constraints in this article, only 3 of the 10 students' qualitative syntheses are included in Table 2.

A comparison of these three students' qualitative syntheses with the author's revealed that the students tended to collapse the metaphors into fewer overarching themes than the author. For example, the author separated individualization and problems of differentiation, while the students combined them into one theme. Discussion also centered on the labeling of the major themes and the students' rationale for their choices.

The students were encouraged to design figures or diagrams to visually display the outcomes of their meta-ethnographic syntheses. One example is the Figure (McGuire, 2001).

Another valuable area for discussion with the students was the three types of meta-syntheses described by Sandelowski et al. (1997). Discussion centered on which type students' felt their meta-syntheses were.

The class's attention next was directed to the degree to which each of the six primary studies was embedded in the final outcome of students' meta-ethnographic syntheses. Students' descriptions of the results of their qualitative syntheses were scanned to determine whether they had included not only the predominant, hut also disparate, views revealed in the six primary studies.

Evaluation of the methodological - rigor of each study included in the meta-ethnographic synthesis was another focus of class discussion. Students gained additional experience in critiquing qualitative studies as a result of this assignment. The Primary Research Appraisal Tool developed by Paterson et al. (2001) (Table 3) is an example of a format that can be used by students to assess the rigor of the individual studies included in their qualitative syntheses.

At the end of the course, students evaluated the meta-ethnographic synthesis assignment. On a Likert scale from 1 = unacceptable to 10 = outstanding, 9 of the 10 students evaluated the assignment as outstanding (10), and the remaining student rated the assignment a 9.

Some student responses to an open-ended question regarding the qualitative synthesis project included:

* "The project made the course more interesting and stimulated the students' interest in research."

* The most positive aspect of the course was the variety of learning projects."

* "The meta-synthesis was a wonderful, very interesting, and challenging way to teach us."

Conclusion

As evidenced in this article, the benefits of having graduate students conduct a meta-ethnographic synthesis are many. Faculty are encouraged to use the course project described in this article as a beginning template. Modifications, such as organizing the qualitative synthesis as a small group project, rather than individual projects, can be made easily. Regardless, the meta-ethnographic synthesis project will help graduate students see the forest for the trees of qualitative studies.

References

  • American Psychological Association. (2001). Publication manual of the American Psychological Association (5th ed.). Washington, DC: Author.
  • Anderson, A., & Anderson, B. (1990). Toward a substantive theory of mother-twin attachment. MCN: The American Journal of Maternal Child Nursing, 15, 373-377.
  • Beck, C.T. (1997). Use of meta-analysis as a teaching strategy in nursing research courses. Journal of Nursing Education, 36, 87-90.
  • Beck, C.T. (2002). Mothering multiples: A meta-synthesis of qualitative research. MCN: The American Journal of Maternal Child Nursing, 27, 214-221.
  • Clancy, S. (2001). Mothering multiples: A meta-synthesis of qualitative studies. Unpublished manuscript, University of Connecticut.
  • Garel, M., & Blonde!. B. (1992). Assessment at 1 year of the psychological consequences of having triplets. Human Reproduction, 7, 729-732.
  • Goshen-Gottstein, E.R. (1980). The mothering of twins, triplets, and quadruplets. Psychiatry, 43, 189-204.
  • Holditch-Davis, D., Roberts, D., & Sandelowski, M. (1999). Early parental interactions with and perceptions of multiple birth infante. Journal of Advanced Nursing, 30, 200-210.
  • Jensen, L.A., & Alien, M.N. (1996). Metasyntheses of qualitative findings. Qualitative Health Research, 6, 553560.
  • McGuire, KE. (2001). The experience of mothering multiples: A meta-synthesis of six qualitative studies. Unpublished manuscript, University of Connecticut.
  • Noblit, G.W., & Hare, R.D. (1988). Metaethnography: Synthesizing qualitative studies. Newbury Park, CA: Sage.
  • Paterson, B.L., Thorne, S.E., Canam, C., & Jillings, C. (2001). Meta-study of qualitative health research. Thousand Oaks, CA: Sage.
  • Pazdrak, C. (2001). Mothering multiples: A meta-synthesis of qualitative research. Unpublished manuscript, University of Connecticut.
  • Robin, M., Bydlowski, M., Cahen, F., & Josse, D. (1991). Maternal reactions to the birth of triplets. Acta Geneticae Medicae et Gemellologiae, 40, 41-51.
  • Robin, M., Josse, D., & Tourrette, C. (1988). Mother-twin interaction during early childhood. Acta Geneticae Medicae et Gemellologiae, 37, 151-159.
  • Sandelowski, M., Docherty, S., & Emden, C. (1997). Qualitative meta-synthesis: Issues and techniques. Research in Nursing & Health, 20, 365-371.

TABLE 1

Metaphors Used to Construct Reciprocal Translations In Mothering Multiples Meta-Ethnographic Synthesis

TABLE 2

Comparison of Metaphors Used in Students' Reciprocal Translations

TABLE 3

Primary Research Appraisal Tool

10.3928/0148-4834-20030701-09

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