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Qualitative Health Research

DOI: 10.1177/1049732306295879 2007; 17; 113 Qual Health Res

Terese Bondas and Elisabeth O. C. Hall Challenges in Approaching Metasynthesis Research

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Challenges in Approaching Metasynthesis Research

During the past decades, there has been an impera-tive to further qualitative studies into metasynthe-

sis. Methods for analysis and synthesis of qualitativedata have been developed (Paterson, Thorne, Canam,& Jillings, 2001; Sandelowski & Barroso, 2002a,2002b, 2003a, 2003b), and a growing body of knowl-edge based on metasynthesis of qualitative studies isbeing discussed (Finfgeld, 2003; Kearney, 2001;McCormick, Rodney, & Varcoe, 2003; Paterson &Thorne, 2003; Sherwood, 1999; Thorne, Jensen,Kearney, Noblit, & Sandelowski, 2004). However, dif-ferent views on the application of methods haveemerged in the literature, contributing to confusion andambiguity concerning the challenging questions ofwhat, why, how, and who in metasynthesis research.

The purpose of this article is to discuss metasynthe-sis with the goal of understanding this researchapproach more fully. We will reflect on questions suchas What is metasynthesis? and Why has it developed?Metasynthesis is “research of research” (Paterson et al.,2001, p. 5) in which previous research publications areprimary data and sampling is decided in relation topublications. Thus, metasynthesis research requiressufficient research reports that meet inclusion criteria.Primary researchers are limited in their topic choiceonly by their creativity; research synthesists, however,study topics that are represented in available research

reports. Both the analysis and the syprimary research reports require a thknowledge base on the part of th(Noblit & Hare, 1988; Paterson et al.

Metasynthesis research in nursing in nursing theory and method and evepistemological, and methodological to doing research on research. A grometasynthesis research on nursing cinitiation of this study. Both authorsthe qualitative research network ChNordic Countries (BFiN) (http://wwhave initiated a metasynthesis projec(Aagaard & Hall, in press; Bondas et & Hall, 2006) with the purpose of sacquaintanceship between scattered Nas well as the knowledge base in thbackground factor was our awarenessqualitative studies are well recognizeda substantive body of knowledge,impact for evidence-based practice. to increase evidence-based health carqualitative studies (Evans & PearsoSwanson, & Kuzel, 2001). Furthermoexploring the attributes of metasynthour experiences with phenomenologicpotential of synthesizing studies in ou

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10.1177/1049732306295879

Terese BondasUniversity College, Borås, Sweden

Elisabeth O. C. HallAarhus University, Denmark

The overall aim of this study was to contribute to the development of metasynthesis through an analysis of the chal-lenges involved. The study grew out of the critique of qualitative metaresearch raised by current developers ofmetamethodologies. Different views on the application of methodologies have emerged in the literature, contributingto confusion and ambiguity concerning the challenging questions of what, why, how, and who in metasynthesisresearch, which might increase the risk of misunderstanding. The roots of metasynthesis research are seen as multi-faceted and influencing the development of the methods in different directions. The primary worth of metasynthesisis theoretical and/or methodological development (synthesis) combined with the potential for reflection: goingbeyond and behind the studies (meta). Metasynthesis research has also the potential to raise questions of research col-laboration, culture, and language.

Keywords: metasynthesis; meta-ethnography; metasummary; qualitative methods

nthesis of theseorough scientifice research team, 2001).signals a new eraokes ontological,questions relatedwing interest in

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that even though and have shownthey have littleThere is a call e and the use ofn, 2001; Morse,re, our interest inesis grew out ofal studies and ther research fields

113

114 Qualitative Health Research

(Bondas, 2000, 2005; Hall, 2006). Comparative analy-sis of the findings and theoretical linkages of their con-clusions to other relevant research have rarely beenincluded, but instead, much research seems to havestarted from scratch, and researchers are restudying thesame nursing phenomena again and again (Morse,2001b; Sandelowski, Docherty, & Emden, 1997). Thereare, for example, a multitude of studies about parents’experiences when their small child is critically ill or studies about childbearing, areas that concern the authors of this study, but the theoretical develop-ment is still scarce. Our assumption is that metasynthe-sis research of qualitative studies can help develop evidence-based care.

Given the increased interest in metasynthesisresearch, it is challenging to investigate the ideas inher-ent in the method and explore the facts behind thedoubts and warnings that eminent developers in thefield have put forth. Thorne, Paterson, et al. (2002), forexample, have warned researchers not to underestimatethe complexity of metastudy approaches. The authorsrequire analysis of the theoretical, methodological, andcontextual foundations that are “not to be undertakenby the inexperienced or the faint of the heart” (p. 449),and they raised critical questions about the value ofmetasynthesis, as well as about matters of representa-tion and generalization. The authors accused neophyteresearchers of choosing metastudy approaches on theassumption that they are then free from engaging in”time-consuming and messy” (Thorne et al., 2004,p. 1343) data collection with human participants, andthey worried about studies that claim to be metastudiesbut are, in fact, critical literature reviews. The questionis if we experience a “metamadness” (Sandelowski, inThorne et al., 2004, p. 1357). Metasynthesis research,then, is a challenge that we want to address further.

The “What” of Metasynthesis

We have outlined the roots of metasynthesis andthe development of different modes and terminologyto answer the “what” question in metasynthesis.

Several Roots to Qualitative Metasynthesis

There are several roots of metasynthesis in nursingscience. First, roots can be traced to the social sciences(Zhao, 1991); sociological metatheorizing is defined asthe systematic study of the underlying structure of theory(Ritzer, 1992). Metastudies in sociology have emergedout of the need for careful study of an overwhelm-ing body of classical and contemporary sociological

theories. Metatheorizing is seen as a sign of a paradig-matic crisis and concern for theoretical development,despite the point made by the metatheorists that it is hard to think of a time when theory has not been incrisis (Ritzer, 1992; Zhao, 1991). Postmodernism was followed by a new generation of theorists who were less committed to traditional theoretical perspectives(Ritzer, 1992). This idea is also seen in nursing science,where middle-range theories and studies inspired bypostmodern and poststructural thinking are increasingcompared to the previous grand theories from the 1970sto the 1990s (Hall, 1997).

Another part of the root system is meta-ethnography,developed within anthropology to synthesize the bodyof field research (Noblit & Hare, 1988). However, it hasalso been increasingly adopted in nursing metastudies(Thorne et al., 2004). Currently, meta-ethnography is the most common methodological choice in nursingscience (Bondas & Hall, 2006). Likewise, the systematicreview (Cooper, 1988) can be seen as a predecessor tometasynthesis. Finally, a root extends to quantitativemeta-analysis, which, as a term, has come to represent aresearch strategy in which the results of quantitativestudies using similar instruments, data sets, and analyticmethods can be reanalyzed and aggregated (Glass,McGraw, & Smith, 1981).

Different Modes of Qualitative Metasynthesis

Different modes of metasynthesis have been pre-sented. Initially, the term meta-analysis was used;qualitative meta-analysis was described as the syn-thesis of a group of qualitative findings into a theo-retical model (Schreiber, Crooks, & Stern, 1989).Metastudy differs in many ways from the more tradi-tional literature review. According to van Manen,Manning, and Miller, in their introduction to Noblitand Hare (1988), standard-form reviews usually carrya “whiggish perspective” (p. 7), wherein the past isseen to inform the present such that a tidy accumula-tion of knowledge results. The aims of the reviewshave usually been seen as commonsense knowledgethat does not need to be explained or assessed forquality (Cooper, 1988; Kirkevold, 1997).

Qualitative metasummaries (Sandelowski &Barroso, 2003b) aggregate findings in the form oftopical or thematic summaries or surveys but lack aninterpretive synthesis of data. The techniques involvethe extraction and reduction of data and the calcula-tion of effect sizes. The findings might serve as afoundation for metasynthesis encompassing integra-tions that are more than the sum of parts, in that theyoffer novel interpretations of findings from individual

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studies (Sandelowski, in Thorne et al., 2004).Metasynthesis, then, is more than a summing up ofresearch findings; it involves analyses and theory-generating syntheses that remain faithful to the inter-pretive rendering in each study (Barroso et al., 2003,p. 154). Metasynthesis is defined as interpretive syntheses of data, including phenomenologies, ethno-graphies, grounded theories, and other integrated andcoherent descriptions or explanations of phenomena,events, or cases (Sandelowski & Barroso, 2003a).Recently, the phrase qualitative research integrationhas been introduced to refer to empirical studiesdirected toward the combination of research findingsin reports of qualitative studies. Qualitative researchintegration captures the primary reason researchers inthe health disciplines want to conduct the study; they search for a conclusion about the knowledge in aspecific area of practice (Sandelowski, in Thorne et al.,2004, p. 1357). Sandelowski and Barroso (2003b) alsoadd the term qualitative to “metasynthesis” althoughthe term quantitative metasynthesis has not been foundin the literature.

Paterson et al. (2001) use the term metastudy, andthey differentiated between analysis and synthesis togenerate a thorough understanding of the phenomenonunder study. Their use of metastudy extends the meta-analytic strategies developed in sociology (Zhao, 1991)into the domain of metasynthesis; the analytic sequenceis directly linked to a newly synthesized knowledge, ametasynthesis, based on a tripartite sequence of analy-sis of data, theory, and methodology. Metatheory analy-sis is an examination of theories to determine the linkbetween the theoretical perspective that frames eachprimary study and the methods, findings, and conclu-sions of the research. Metamethod examines themethodological features to determine the way in whichqualitative methods are interpreted, the underlyingmethodological assumptions and trends, and theirmeaning for the research findings. Meta–data analysisis reinterpretation of the actual findings, an analysis of“processed data” from selected qualitative researchstudies in the light of data and findings from other stud-ies. This tripartite systematic interpretive analysis pro-duces a metasynthesis, here called metastudy.

A grounded formal theory inspired by the classicwork of Glaser and Strauss (1967) using groundedtheory findings and applying theoretical sampling andconstant comparison from substantive theories has beendeveloped (Kearney, 1998a, 1998b, 2001; Kearney, inThorne et al., 2004). Kearney (2001) has called the var-ious overlapping approaches a metafamily and haslocated them at a continuum going from tough-minded

theorizing to tender-minded interpretation. In themetafamily, Kearney included the approaches calledaggregated analysis (Estabrooks, Field, & Morse,1994), interpretive metasynthesis (Jensen & Allen,1996), and meta-interpretation (Finfgeld, 1999). Theinfluence of meta-ethnography (Noblit & Hare, 1988)is seen in these variations.

The impact of the root system can thus be seen in the development of qualitative metasynthesismethodology and the differences in applications. Theanalysis shows various metaconcepts, multiple modesof integrating qualitative studies into new findings,and a proliferation of similar metaconcepts but withdifferent names or related contents. The researchwithin the next years will show what will be devel-oped, but the chaos in the methodological terminol-ogy will continue by proposing new content toexisting concepts. We very much doubt that this trendis furthering the area of metasynthesis research.

The “Why” of Metasynthesis

The questions of the motives for metasyntheses inhuman-oriented disciplines have been described astwofold. Will the findings of the study further knowl-edge that develops the discipline(s), and do the find-ings have the potential to initiate understanding andchanges in the health, suffering, and care of humanbeings? The same questions are asked in the primaryqualitative research, the data in the metasynthesis.

Deepening Knowledge and Understanding

Metasynthesis can complement individual empir-ical studies, but they cannot take their place(Campbell et al., 2003; Ritzer, 1992; Zhao, 1991)because of their dependence on primary qualitativeresearch. Metasynthesis encompasses strategies forboth critique and evaluation of previous research, andstrong incentives for enriching human discourse(Noblit & Hare, 1988), or generating new theory(Paterson et al., 2001). The theory is explicated by aclarification of concepts and patterns in data. The aimis a new, integrated, and more complete interpretationof findings that offers greater understanding in depthand breadth than the findings from individual studies.“Push the level of theory” is a wording that containsthe message of metasynthesis (Schreiber et al., 1989,p. 315). The question of disciplinary development is emphasized by many of the developers (Noblit &Hare, 1988; Paterson et al., 2001; Thorne et al.,2004; Thorne, Joachim, Paterson, & Canam, 2002).

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However, metasynthesizers, like all researchers, runthe risk of finding what they think or wish to seerather than understanding the phenomena.

Metasynthesis allows for organization in a compre-hensive bibliography (Paterson & Thorne, 1998), butthat is not the primary goal, as it is of a review (Cooper,1988; Evans & Pearson, 2001). There is ethical rea-soning for choosing metastudies of, for example, vul-nerable issues in nursing that have gained researchattention, especially when there seem to be conflictingfindings. Metasynthesis shares this feature with sec-ondary analysis. However, in secondary analysis, theresearcher has access to the primary data, which is notthe case in metasynthesis (Heaton, 2004; Thorne,1994, 1998). The studies might also include consider-ations of context, theory, and method from a philo-sophical perspective to further the development of thesubstance and growth of the discipline (Paterson et al.,2001; Ritzer, 1992). Moreover, synthesis includesinterpretation; it gives meaning to a set of studies, andthus it is a true kind of qualitative research (Noblit &Hare, 1988), allowing concepts to be linked across stud-ies (Sherwood, 1999). However, the handicap of themetasynthesist is his or her dependence on the primaryresearch publications and not having been involved inthe research design and the initial data collection. Weargue that the primary value of metasynthesis is theoret-ical and/or methodological development (synthesis)combined with its potential for reflection, going beyondand behind the original qualitative studies (meta).

Development of Research-Based Care

The significance of metasynthesis is its potential topresent comprehensive knowledge, to strengthenresearch-based care, and to facilitate the use of qualita-tive findings in health care (Estabrooks et al., 1994;Paterson et al., 2001). Qualitative research findingsneed to have a stronger impact on decision making inhealth policies (Finfgeld, 2003). Metasynthesis mightlikewise serve as a model to guide the development ofindividualized care interventions with therapeutic out-comes (Sherwood, 1999). Grounded formal theoriescan serve as road maps, as clinicians will use them toconsider possible locations of their patients’ experi-ences in the landscape of experiential variation andidentify an array of routes along which they can guidethem (Kearney, 2001). However, to develop evidence-based practice, there should be discussions about ques-tions such as how are explanations constructed, in whatway are interpretive explanations different, and whatcan reasonably be said about some studies (Noblit &Hare, 1988).

Qualitative studies in evidence-based care havebeen compared to poetics; and this attitude could makethe effort an impossible merger (Sandelowski, inThorne et al., 2004). However, this is due to the defin-ition of evidence either narrowly, as based on empiri-cal and outcome-oriented research, or broadly,including ethical, personal, and aesthetic knowledge(Morse, 2001b). More than having a broad definitionof evidence, we perceive the question of evidence to beabout communicating the findings in a meaningfulway and in relevant media, and to be accessible andimportant to citizens, practitioners, and politicians, aswell as to scholars. Deepening the knowledge andunderstanding is closely related to the meaning of car-ing. In nursing, the interest is knowledge of health, suf-fering, and caring, which primarily has the potential“to minister to the patient” (Bondas, 2003, p. 250).Dialogue between the research and clinical praxis canfurther the emergence of disciplinary knowledge thatbuilds on previous research findings.

The “How” of Metasynthesis

Different qualitative approaches answering the ques-tion of the “how” of metasynthesis have been createdparallel to research projects such as the experiences of health and wellness (Jensen & Allen, 1994, 1996),chronic illness (Paterson, 2001; Paterson, Canam,Joachim, & Thorne, 2003; Paterson et al., 2001; Thorne,Joachim, et al., 2002; Thorne & Paterson, 2002), caring(Sherwood, 1997), and motherhood of HIV-positivewomen (Barroso et al., 2003; Sandelowski & Barroso,2002a, 2002b, 2003a, 2003b, 2003c, 2003d). Noblitand Hare (1988) developed their approach to reconciledifferent ethnographers’ interpretations of the samephenomena in studies of educational institutions; theysuggested that the approach enabled a rigorous proce-dure for deriving substantive interpretations about anyset of ethnographic or interpretive studies. Mainly, ouranalysis of “how” is based on the method of Noblit andHare for several reasons: Their method is a classic inthe area of metasynthesis, it has had implications foradditional metasynthesis studies, and it is the qualita-tive method most commonly cited in metasynthesispublications. However, there is a risk that modificationshave led to misunderstandings of Noblit and Hare’sinherent ideas. Details from three other major methods,qualitative metasynthesis and metasummary, devel-oped by Sandelowski and Barroso, the tripartite metas-tudy developed by Paterson and colleagues, andgrounded formal theory by Kearney (1998a), are alsoincluded. All have been developed during recent years,

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and studies that apply these methods are still scarce. Wehave taken a closer look on the research aims, the selec-tion of studies, the analysis, the synthesis, and thevalidity of a metasynthesis.

The Metasynthesis Question

A metasynthesis project is often created out of aninterest to extend the researchers’ previous area ofinterest (cf. Beck, 2002a, 2002b; Paterson et al., 2003;Paterson & Thorne, 1998, 2003; Paterson et al., 2001).The body of qualitative research in an area is oftendiverse and does not lend itself to easy definition. Thefollowing questions arise: How it is possible to synthe-size these various types of findings? or Will they lendthemselves to deconstruction (Estabrooks et al., 1994;Thorne et al., 2004) or to a philosophical or historicalanalysis (Ritzer, 1992)? The metasynthesist has todecide whether the findings are compatible acrossstudies (Noblit & Hare, 1988). Surface parameters,such as research questions, are suggested to decide thecomparability of the findings (Sandelowski et al.,1997). The researcher is faced with the risk of havingto deal with the same problem as in some primary stud-ies. He or she rushes into data collection and puts toolittle time and effort into asking what the importantquestions really are (Kvale, 1996). There might befindings in the original studies that could be objects ofseparate metasynthesis projects.

Selection of Studies

The criteria for selection, methods for literatureretrieval, and sampling of publications are explicatedfor reasons of validity. It seems far from easy tolocate qualitative research projects, as most biblio-graphic databases do not index articles according toresearch method (Barroso et al., 2003). Accordingly,most metasynthesis studies might use only studiesfrom peer-reviewed journals, and few use unpub-lished studies, so-called “grey literature” (Conn,Valentine, Cooper, & Rantz, 2003, p. 256). Studiessuch as unpublished dissertations, however, mightcontain rich texts, and through inclusion, “publicationbias” might be prevented (Beck, 2002b, p. 454). Inreality, few grounds exist for the exclusion of datadue to lack of methodological quality; studies mightbe mislabeled but still be useful for synthesis purpose(Sandelowski et al., 1997). The assessment of valueand what to label as a “signal” in the studies are impor-tant and have to be considered in relation to the “noise”of the methodological problems (Edwards, Elwyn,Hood, & Rollnick 2000, p. 177). Furthermore, thequestions of language and culture have not yet been

discussed in depth, and non-English research mightthus be overlooked.

The sample size as a question of representation is asdifficult as in the primary qualitative studies and is amatter of narrow or broad research interest. The greaterthe number of substantive studies there are to workwith, the higher the level of formal theory that can beachieved, and the more saturated and transferable is theproduct of analysis (Kearney, 2001). However, largesamples might impede deep analysis in bringingtogether new themes. There is a wealth of informationcontained in each study, and therefore there are recom-mendations of 10 (Sandelowski et al., 1997) to 12 stud-ies (Paterson et al., 2001). We argue for a clearlydefined aim in combination with a purposeful sam-pling strategy and an explicated and systematic searchprocess to create a meaningful and valid synthesis.

Analysis in Metasynthesis

Difficulties in the analysis are usually due to prob-lems in the primary studies, such as varied reportingstyles, misrepresentation of data and analytic proce-dures presented as findings, misuse of quotes andtheory, or lack of clarity (Sandelowski & Barroso,2002a, 2002b). There might also be problems in apply-ing metasynthesis methods that still need to be devel-oped further. As well, disagreement about whichstudies to include exists. Some methods recommendnot combining studies with differing qualitative meth-ods (Estabrooks et al., 1994; Jensen & Allen, 1994,1996; Sherwood, 1999); others consider synthesizingthe findings as the main issue (Sandelowski et al.,1997). The actual research practice shows that differ-ent qualitative studies are seldom separated; they are apart of the metastudy, and the metamethod has thepotential to enrich the findings (Paterson et al., 2001).

Researchers also disagree on what are considereddata. The whole text, even the abstract and the title,might include important messages in the interpretivemeta-ethnography (Noblit & Hare, 1988). The explo-ration of a take-home message is recommended in theapproach of Paterson et al. (2001). In their approach,the analysis is divided in data, theory, and methodanalysis; however, the research team still remainscautious in relation to analysis of the discussion sec-tion because of its subjective, speculative nature.

The analysis phase requires systematic attention tothe details in the accounts. Techniques such as visualdata display make evident similarities and differencesthat shaped the findings and the convergence or diver-gence of them. Data collection forms have beendeveloped (Paterson et al., 2001; Sandelowski &

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Barroso, 2003a), and they can be modified dependingon the purpose of the metasynthesis. By using dataforms, it is possible to trace the decision making.Moreover, the form serves as a base for recording thedata for the analysis. Another useful technique is theVenn diagram, in which circles and the spaces withincircles are used to represent overlapping and uniqueideas (Sandelowski et al., 1997). The context of the stud-ies is important, and the challenge is to achieve a histor-ical and emic interpretation (Noblit & Hare, 1988).

The analysis of relationships between the studies isa central idea in meta-ethnography (Noblit & Hare,1988), and this, too, might be a challenge. A list of keymetaphors, phrases, ideas, and/or concepts and theirrelationships is created and then juxtaposed. Methodsinclude translation of metaphors, broadly stipulated asthe themes, perspectives, organizers, or conceptsrevealed by the qualitative studies. However, this broadand unusual view of a metaphor might cause problemsin the metasynthesis research. An initial assumptionabout the relationship between the studies can bemade, and three ways to order the studies have beenproposed (Noblit & Hare, 1988). First, studies can becombined such that one study can be presented interms of another. The accounts are then directly com-parable as reciprocal translations and are analogous.Published metastudies most often seem to use thisordering, and we were surprised to discover that thereis no evidence of differences between the findings ofthe studies (Bondas & Hall, 2006). Second, the studiescan be set against one another, such that the groundsfor one study’s refutation of another become visible.The accounts stand in relative opposition to each otherand are essentially oppositional. Synthesizing refuta-tions can show much about the assumptions thatguided various studies by an examination of accounts,debate, and critique. The research into chronic illnessby Paterson et al. (2001) penetrates this question.Third, researchers can tie studies to one another by not-ing just how one study informs and goes beyondanother (Noblit & Hare, 1988). The studies, takentogether, then represent a line of argument that couldbe (a) emic, in allegiance to the studies being synthe-sized; (b) historical, in its use of time to give order;(c) comparative, whereby constructs are an analogy ofthe relationships between the studies; or (d) holistic, inwhich constructs are interpretations of all of the stud-ies, their interrelations, and contexts. Paterson and col-leagues included both metatheory and meta-methodanalysis as specific research endeavors.

Synthesis in Metasynthesis

Synthesis is achieved by maintaining the centralmetaphors and/or concepts of each account and com-paring them to other key metaphors or concepts in that account (Noblit & Hare, 1988). The process is,metaphorically, a sewing together of analysis and syn-thesis (Kearney, 1998a).The language that is used in thesynthesis might contain new metaphors that have moreadequate economy, cogency, range, appearance, andcredibility than those of either study (Noblit & Hare,1988). Using metasynthesis, researchers have thepotential to interpret critically the strengths and limita-tions of the various discrete contributions to the field,propose alternatives, and remap the field (Paterson et al., 2001).

The view of what may be included in the synthesisvaries. A successful synthesis might reveal that the anal-ogy ultimately fails and that the studies are essentiallyincompatible; surface similarities can hide substantivedifferences in what was studied and/or what theaccounts can be taken to mean (Noblit & Hare, 1988).A criterion of fittingness is reached when the metasyn-thesis findings can fit into other contexts as well asreflect typical and atypical elements of life experiences(Jensen & Allen, 1996). Contrary to Noblit and Hare(1988), Paterson and colleagues have resisted proce-dural steps and recommend a nonlinear process ofthinking, interpreting, creating, theorizing, and reflect-ing. However, it seems that the process of theory con-struction in the metasynthesis literature also suffersfrom being overlooked (Morse, 2001b). We argue forthe development of synthesis from an explicit uni- ormultidisciplinary perspective that is systematic as wellas creative and grounded in the data and the competenceof the research team. We concur with Sandelowski et al.(1997) that qualitative studies bear the signature of theresearcher(s) and that synthesists have an obligation toaccount for such individual features.

Validity in Metasynthesis

The criteria of clarity, structure, coherence, scope,generalizability, and pragmatic utility are proposed for all qualitative research (Morse, 1997), but amechanical application of validity techniques shouldbe discouraged (Barbour, 2001; Morse, 1997); the sig-nificance is the “ultimate indicator of the excellence ofthe research” (Morse, 2001a, p. 151). Validity is recog-nized as doing something meaningful that furthersunderstanding and stimulates informed, humane

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thoughts and actions (Angen, 2000). Problems in ametastudy include reliability of data retrieval, missingdata, sampling bias, loss of information, glossing overof details, heterogeneity of quality, differing level ofanalysis, deductive contamination from theories, litera-ture, and serious problems created by exaggeration ofinterpretations—pushing beyond credibility (Jensen &Allen, 1996). Criteria of validity include questions suchas Does the report clarify and resolve rather thanobserve inconsistencies or tensions between materialsynthesized? Does a progressive problem shift result?Is the synthesis consistent, parsimonious, elegant, fruit-ful, and useful (Noblit & Hare, 1988)? Is the purpose ofthe meta-analysis explicit? and Are the research ques-tions clearly stated (Sherwood, 1999)? Furthermore,the inclusion criteria, procedures for data handling andcollection, description of the sample, and rules for dataanalysis and interpretation have to be explicit. We arguefor an explicit validity concept in metasynthesis, whichis in accordance with the views mentioned above.

The “Who” of Metasynthesis

There has also been a debate about the metasynthe-sizers’ competence because of the challenges and the requirements inherent in the methodology(Sandelowski et al., 1997; Thorne et al., 2004).Metastudy has been considered an interestingapproach for research collaboration (Finfgeld, 2003;Noblit & Hare, 1988; Paterson et al., 2001; Sherwood,1999) because of its broad substantial and method-ological nature. Metasynthesis has an inherent poten-tial to generate new questions in a creative andcompetent research team, and especially possibilitiesto create cross-disciplinary research designs (Patersonet al., 2001). Metastudies provide possibilities to learnfrom the collaboration and, at the same time, furtherthe independent interests of each researcher. An impor-tant question is Who should be involved as an activemember of the research team? A cultural multilingualapproach is needed to be able to facilitate understand-ing between culture and language. There is always asocial historical and theoretical context within whichsubstantive findings emerge, which will be of interestin a metastudy (Noblit & Hare, 1988). The transfer ofthe meanings of one culture to another is not a simpleendeavor. It might be wise to include a librarian in themetasynthesis team as specialists in literature retrievalusually find 50% more references than researchers do

(Conn, Isaramalai, et al., 2003). Different meanings ofworldview and perspective, as well as gender, are alsoimportant and are not paid enough attention. Questionsthat need to be solved are the choice of perspective thatcan be brought to the study to give the synthesis coher-ence. However, the research practice as seen in pub-lished metasynthesis articles shows a large amount oflonely research based on interdisciplinary but alsomonoculture data (Bondas & Hall, 2006).

Conclusion

The purpose of this article was to analyze and dis-cuss some challenges, ordered in the what, why, how,and who questions regarding metasynthesis. Ourresearch backpacks contained a growing interest inmetasynthesis based on qualitative research and apply-ing various qualitative methods and many years ofclinical experience as clinical nurses, nurse leaders,and educators. We have tried to lay down our back-packs to be able to rest and reflect, so that we couldunderstand what the metasynthesis literature uncoversand eventually hides. Our metasynthesis project inchildbearing is in its starting phase; the process of cre-ating a research team has involved many negotiations,and consensus on the research design has not yet beenreached. The roots that were found shed light on themultifaceted development of metasynthesis. Theanalysis of the what question shows that the aims aretheoretical and/or methodological development anddevelopment of evidence-based care. Our experiencefrom this analysis is that metasynthesis requires deepcompetence and a strong commitment to the substan-tial as well as to the methodological issues. However,the metasynthesis era could create a metamadness andan ivory tower for qualitative researchers that, in itsnovelty and trendiness, could take energy away fromprimary qualitative research. Taking these pitfalls intoaccount, we find that well-performed metasynthesiscan assist in reflection on the processes involved inprevious qualitative studies in terms of not only wherewe are and where we are going but also where we havenot been and where we could and should go to developthe knowledge and the praxis of nursing and healthcare. Based on our analysis of the what, why, how, andwho in contemporary metasynthesis, we present belowsome questions that researchers might reflect on whenconsidering the fruitfulness and planning of a meta-synthesis design.

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120 Qualitative Health Research

1. The aim of metasynthesis is to interpret and integrate,beyond aggregating, the research in the field of theparticular phenomenon that has been chosen and torecognize variation and alternative perspectives.

2. The aim might direct the formation of an interdis-ciplinary research team that might include transla-tors or multicultural representation, librarians, anduser representatives.

3. The scientific disciplinary perspective(s) is (are)stated and could be constructed as an abductiveexperience and theory-laden model to guide theaim of the study but remain open to the data.

4. The criteria for inclusion and exclusion are con-structed, stated, recorded, and applied.

5. The contexts, methods, and theories that have influ-enced the body of research in the field might beacknowledged and analyzed or might warrantmetastudies of their own.

6. The studies that are included in the metasynthesisare ethically analyzed and referred to.

7. The questions of context, culture, and language areaddressed.

8. The findings of the metasynthesis have the poten-tial to start a debate that will push forward the the-oretical and/or the methodological development ofthe discipline.

9. The research reports are designed and might uselanguage that has the potential to reach variousinterests: citizens, patients and clients, caregivers,policy makers, and scholars.

10. Both meta-analysis and metasynthesis can be pur-sued recognizing the differences in their ontologi-cal, epistemological, and methodological basis.

References

Aagaard, H., & Hall, E. O. C. (in press). Mothers’ experiences of having a preterm infant in the neonatal care unit: A meta-synthesis. Journal of Pediatric Nursing.

Angen, M. J. (2000). Evaluating interpretive inquiry: Reviewingthe validity debate and opening the dialogue. QualitativeHealth Research, 10, 378-395.

Barbour, R. S. (2001). Checklists for improving rigour in qualita-tive research: A case of the tail wagging the dog. BritishMedical Journal, 32, 1115-1117.

Barroso, J., Gollop, C. J., Sandelowski, M., Meynell, J., Pearce,P. F., & Collonis, L. J. (2003). The challenges of searching forand retrieving qualitative studies. Western Journal of NursingResearch, 25, 153-178.

Beck, C. (2002a). Mothering multiples: A metasynthesis of qual-itative research. MCN: American Journal of Maternal ChildNursing, 27, 214-221.

Beck, C. (2002b). Postpartum depression: A metasynthesis.Qualitative Health Research, 12, 453-472.

Bondas, T. (2000). Att vara med barn: En vårdvetenskaplig studieav kvinnors upplevelser under perinatal tid [To be with child:A study of women’s lived experiences from a caring science

athttp://qhr.sagepub.comDownloaded from

perspective]. Åbo, Sweden: Åbo Akademi. (In Swedish,English summary)

Bondas, T. (2003). Caritative leadership: Ministering to thepatients. Nursing Administration Quarterly, 27, 249-255.

Bondas, T. (2005). To be with child: A heuristic synthesis inmaternal care. In R. E. Balin (Ed.), Trends in midwiferyresearch (pp. 119-136). New York: Nova Science.

Bondas, T., Berg, M., Hall, E. O. C., Lundgren, I., Brinchmann, B. S.,& Vehviläinen-Julkunen, K. (2004). Metasynthesis as anapproach in a Nordic collaboratory research program in child-bearing. Paper presented at the Third Nordic InterdisciplinaryConference on Qualitative Methods in the Service of Health,Aarhus University, Denmark (Abstracts p. 28).

Bondas, T., & Hall, E. O. C. (2006). Meta questions in metasyn-thesis research: Paper presented at the Fourth NordicInterdisciplinary Conference on Qualitative Methods in theService of Health, Växjö University, Sweden. InternationalJournal of Qualitative Studies on Health and Well-Being,1(Suppl. 1), 13-32.

Campbell, R., Pound, P., Pope, C., Britten, N., Pill, R., & Morgan, M.(2003). Evaluating: Meta-ethnography: A synthesis of qualitativeresearch on lay experiences of diabetes and diabetes care. SocialScience and Medicine, 56, 671-684.

Conn,V. S., Isaramalai, S.-A., Rath, S., Jantarakupt, P., Wadhawan, R.,& Dash, Y. (2003). Beyond MEDLINE for literature searches.Image: Journal of Nursing Scholarship, 35, 177-182.

Conn, V. S., Valentine, J. C., Cooper, H. M., & Rantz, M. (2003).Grey literature in meta-analyses. Nursing Research, 52,256-261.

Cooper, H. (1988). Synthesizing research. Thousand Oaks, CA:Sage.

Edwards, A., Elwyn, G., Hood, K., & Rollnick, S. (2000). Judgingthe “weight of evidence” in systematic reviews: Introducingrigour into the qualitative overview stage by assessing Signal andNoise. Journal of Evaluation in Clinical Practice, 6, 177-184.

Estabrooks, C. A., Field, P. A., & Morse, J. M. (1994).Aggregating qualitative findings: An approach to theorydevelopment. Qualitative Health Research, 4, 503-511.

Evans, D., & Pearson, A. (2001). Systematic reviews:Gatekeepers of nursing knowledge. Journal of ClinicalNursing, 10, 593-599.

Finfgeld, D. L. (1999). Courage as a process of pushing beyondthe struggle. Qualitative Health Research, 9, 803-814.

Finfgeld, D. L. (2003). Metasynthesis: The state of the art-so far.Qualitative Health Research, 13, 893-904.

Glaser, B. G., & Strauss, A. S. (1967). The discovery of groundedtheory. Chicago: Aldine.

Glass, G. V., McGraw, B., & Smith, M. L. (1981). Meta-analysisin social research. Beverly Hills, CA: Sage.

Hall, E. O. C. (1997). Four generations of nurse theorists in theU.S. An overview of their questions and answers. Vård iNorden, 17(2), 15-23.

Hall, E. O. C. (2006). When a newborn or small child is criticallyill: Nurses’, parents’and grandparents’experiences and dynam-ics in family-centred care. Aarhus: Aarhus University, Instituteof Public Health, Department of Nursing Science, Faculty ofHealth Sciences, Denmark.

Heaton, J. (2004). Reworking qualitative data. London: Sage.Jensen, L. A., & Allen, M. N. (1994). A synthesis of qualitative

research on wellness-illness. Qualitative Health Research, 4,349-369.

Orebro Universitet on September 12, 2008

Bondas, Hall / Challenges in Metasynthesis 121

Jensen, L. A., & Allen, M. N. (1996). Meta-synthesis of qualita-tive findings. Qualitative Health Research, 6, 553-560.

Kearney, M. H. (1998a). Ready-to-wear: Discovering groundedformal theory. Research in Nursing and Health, 21, 179-186.

Kearney, M. H. (1998b). Truthful self-nurturing: A grounded for-mal theory of women’s addiction recovery. Qualitative HealthResearch, 8, 495-512.

Kearney, M. H. (2001). New directions in grounded formaltheory. In R. Schreiber & P. N. Stern (Eds.), Using groundedtheory in nursing (pp. 227-246). New York: Springer.

Kirkevold, M. (1997). Integrative nursing research—An impor-tant strategy to further development of nursing science andnursing practice. Journal of Advanced Nursing, 25, 977-984.

Kvale, S. (1996). InterViews: An introduction to qualitativeresearch interviewing. Thousand Oaks, CA: Sage.

McCormick, J., Rodney, P., & Varcoe, C. (2003). Reinterpretationsacross studies: An approach to meta-analysis. Qualitative HealthResearch, 13, 933-944.

Morse, J. M. (1997). Considering theory derived from qualitativeresearch. In J. M. Morse (Ed.), Completing a qualitative project:Details and dialogue (pp. 163-188). Thousand Oaks, CA: Sage.

Morse, J. M. (2001a). Qualitative significance [Editorial].Qualitative Health Research, 14, 151-152.

Morse, J. M. (2001b). Qualitative verification: Building evidence byextending basic findings. In J. Morse, J. Swanson, & A. Kuzel(Eds.), The nature of qualitative evidence (pp. 203-220).Thousand Oaks, CA: Sage.

Morse, J., Swanson, J., & Kuzel, A. (Eds.). (2001). The nature ofqualitative evidence. Thousand Oaks, CA: Sage.

Noblit, G. W., & Hare, R. D. (1988). Meta ethnography:Synthesizing qualitative studies. Newbury Park, CA: Sage.

Paterson, B. L. (2001). The shifting perspectives model of chronicillness. Image: Journal of Nursing Scholarship, 33, 21-26.

Paterson, B. L., Canam, C., Joachim, G., & Thorne, S. (2003).Embedded assumptions in qualitative studies of fatigue.Western Journal of Nursing Research, 25, 119-133.

Paterson, B. L., & Thorne, S. (1998). An innovative approach toqualitative research synthesis (Abstract 107). Workshop pre-sented at the Fourth Qualitative Health Research Conference,Vancouver, Canada.

Paterson, B. L., & Thorne, S. (2003). The potential of meta-synthesis for nursing care effectiveness research. CanadianJournal of Nursing Research, 35, 39-43.

Paterson, B. L., Thorne, S. E., Canam, C., & Jillings, C. (2001).Meta-study of qualitative health research. A practical guide tometa-analysis and meta-synthesis. Thousand Oaks, CA: Sage.

Ritzer, G. (1992). Metatheorizing in sociology: Explaining thecoming of age. In G. Ritzer (Ed.), Metatheorizing (pp. 7-26).Newbury Park, CA: Sage.

Sandelowski, M., & Barroso, J. (2002a). Finding the findings inqualitative studies. Image: Journal of Nursing Scholarship,34, 213-220.

Sandelowski, M., & Barroso, J. (2002b). Reading qualitative studies.International Journal of Qualitative Methods, 1(1), Article 5.

ahttp://qhr.sagepub.comDownloaded from

Retrieved September 1, 2006, from http://www.ualberta.ca /~ijqm/

Sandelowski, M., & Barroso, J. (2003a). Classifying the findings inqualitative studies. Qualitative Health Research, 7, 905-923.

Sandelowski, M., & Barroso, J. (2003b). Creating meta-summariesof qualitative findings. Nursing Research, 52, 226-231.

Sandelowski, M., & Barroso, J. (2003c). Motherhood in the con-text of maternal HIV infection. Research in Nursing andHealth, 26, 470-482.

Sandelowski, M., & Barroso, J. (2003d). Toward a metasynthesisof qualitative findings on motherhood in HIV-positive women.Research in Nursing and Health, 26, 153-170.

Sandelowski, M., Docherty, S., & Emden, C. (1997). Qualitativemetasynthesis: Issues and techniques. Research in Nursingand Health, 20, 365-371.

Schreiber, R., Crooks, D., & Stern, P. N. (1989). Qualitative meta-analysis. In J. M. Morse (Ed.), Qualitative nursing research: Acontemporary dialogue (pp. 311-327). London: Sage.

Sherwood, G. D. (1997). Metasynthesis of qualitative analysis ofcaring. Advances in Nursing Science, 3(1), 32-42.

Sherwood, G. D. (1999). Meta-synthesis: Merging qualitativestudies to develop nursing knowledge. International Journalfor Human Caring, 3, 37-42.

Thorne, S. (1994). Secondary analysis in qualitative research:Issues and implications. In J. M. Morse (Ed.), Critical issuesin qualitative research methods (pp. 263-279). London:Sage.

Thorne, S. (1998). Ethical and representational issues in qualitativesecondary analysis. Qualitative Health Research, 8, 547-555.

Thorne, S., Jensen, L., Kearney, M. H., Noblit, G., & Sandelowski, M.(2004). Qualitative metasynthesis: Reflections on methodologicalorientation and ideological agenda. Qualitative Health Research,14, 1342-1365.

Thorne, S., Joachim, G., Paterson, B., & Canam, C. (2002). Influenceof the research frame on qualitatively derived health scienceknowledge. International Journal of Qualitative Methods,1(1), Article 1. Retrieved September 1, 2006, from http://www.ualberta.ca/~iiqm/backissues/1_1Final/html/thorneeng.html

Thorne, S., & Paterson, B. (2002). Two decades of insiderresearch: What we know and don’t know about chronic illnessexperience. Annual Review of Nursing Research, 18, 3-25.

Thorne, S., Paterson, B., Acorn, S., Canam, C., Joachim, G., &Jillings, C. (2002). Chronic illness experience: Insights from ametastudy. Qualitative Health Research, 12, 437-452.

Zhao, S. (1991). Metatheory, metamethod, meta-data-analysis:What, why, and how? Sociological Perspectives, 34, 377-390.

Terese Bondas, PhD, RN Docent, is a professor and researchleader at the University College of Borås, Sweden.

Elisabeth O. C. Hall, PhD, RN, is an associate professor atAarhus University, Denmark.

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