Systematic Reviews of Qualitative Literature

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Systematic Reviewsof Qualitative Literature

• Catherine Francis-Baldesari
• UK Cochrane Centre
• Oxford

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Objectives

• Discuss the purpose and characteristics of
  meta-synthesis.
• Become familiar with the concepts and general
  processes to conduct a meta-synthesis.

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What Meta-Synthesis is Not

• Not a systematic literature review.
• Not a collation or codifying of studies.
• Not an aggregation or summing of outcomes.
• Not a concept analysis.

Finfgeld, D.L. (2003). Metasynthesis
The state of the art- so far. Qualitative Health
Research, 13 (7), 893-904
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Purpose

• Meta-analysis aggregating data to reach
  statistical power for detection of cause and
  effect between treatment and outcomes.
• Meta-synthesis integrating data to reach a new
  theoretical or conceptual level of understanding
  and development.
• Thorne, S., Jensen, L., Kearney, M.H., Noblit,
  G., Sandelowski, M. (2004). Qualitative
  metasynthesis
• Reflections on methodological orientation and
  ideological agenda. Qualitative Health Research,
  14 (10), 1342-1365.
• ,

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Concept of Integration

• More than the sum of parts.
• Inferences derived from findings as a whole.
• New higher-order interpretations created.
• Thorne, S., Jensen, L., Kearney, N.H., Noblit,
  G., Sandelowski, M. (2004). Qualitative
  metasynthesis Reflections on methodological
  orientation and ideological agenda. Qualitative
  Health Research, 14 (10), 1342-1365.

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Achieving Integration

• Comprehensive consideration of data
• Inclusion vs. exclusion
• Commonalities and differences
• Sensitivity to patterns
• Intuitive and logical
• Theoretical reconstruction of concepts
• Silverman, D. (2001). Interpreting Qualitative
  Data Methods for Analysing Talk, Text and
  Interaction (2nd ed.). Thousand Oaks, CA Sage
  Publications, Inc.

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Characteristics of Process

• Inductive and interpretive in design.
• Deconstruction and examination of findings from a
  sample of studies.

Mays, N., Pope, C., Popay, J. (2005). Details of
approaches to synthesis A methodological
appendix to the paper. Systematically
reviewing qualitative and quantitative evidence
to inform management and policy making in the
health field. http//www.chsrf.ca/funding_opportun
ities/commissioned_research/ projects/pdf/msynth_a
ppendix_e.pdf - 115.5KB
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• Translation of studies into one another.
• Transformation of parts into whole.
• Development of theory to explain the range of
  findings encountered.

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How Do We Evaluate Outputs of Qualitative
Research?

• Conceptual themes
• Contributory
• Defensible in design
• Rigorous in conduct
• Credible in claim

Spencer, L., Ritchie, J., Lewis, J.,
Dillon, L. (2003). Quality in Qualitative
Evaluation A framework for assessing research
evidence. Government Chief Social Researchers
Office, Cabinet Office, United Kingdom.
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• Contributory
• In advancing wider knowledge or understanding
  about policy, practice, theory or a particular
  substantive field.

• Defensible in design
• By providing a research strategy that can address
  the evaluative questions posed.

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• Credible in claim
• Through offering well-founded and plausible
  arguments about the significance of the evidence
  generated.

• Rigorous in conduct
• Through the systematic and transparent
  collection, analysis and interpretation of
  qualitative data.

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Evaluating Qualitative Studies

• Qualitative
• Credibility
• Confirmability
• Transferability
• Dependability

• Quantitative
• Internal validity
• Objectivity
• Generalisability
• External validity

Malterud, K. 2001. Qualitative research
standards, challenges, and guidelines. The
Lancet, 358, 483-488.
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Theory and Philosophy

• "Application of nursing theory in practice
  depends on nurses having knowledge of the
  theoretical works as well as an understanding of
  how philosophies, models, and theories can relate
  to each other.
• Van Sell, S.L. Kalofissudis, I.A. (2002). The
  Evolving Essence of the Science of Nursing
  Complexity Integration Nursing Theory. E-Book
  retrieved on January 16, 2006 from
  http//www.nursing.gr/Complexitytheory.pdf

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Philosophical Framework

• Determines how reality is explained, the source
  of knowledge, and the perspective taken in
  research and practice.
• Monti, E. J. Tingen, M.S. (1999). Multiple
  Paradigms of Nursing Science Nursing Theory for
  the 21st Century. Advances in Nursing Science,
  21(4), 64-80.

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Theoretical Framework

• Influences how research questions are generated,
  studies are conducted, data are analysed,
  findings are understood, and results are used.
• Alderson, P. (1998). Theories in health care and
  research The importance of theories in health
  care.
• BMJ, 317 1007-1010.

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Conceptual Framework

• Brings theory into practice by organizing themes
  to form models, and operationalizing findings of
  synthesis.
• Enables experience, reflection and wisdom as
  praxis, allowing practice to drive theory.
• Warelow, P.J. (1997). A nursing journey through
  discursive practice. Journal of Advanced Nursing,
  26, 1020-1027.

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Person-Centred Practice with Older People

• Hermeneutic philosophy guided development of
  theoretical and conceptual framework.
• Theoretical framework of authentic consciousness.

• McCormack, B. (2003). Conceptual framework
  for person-centred practice with older people.
  International Journal of Nursing Practice, 9(3)
  202-209.

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• Conceptual framework of person-centredness
  addressed patient's and nurse's values within the
  context of a care environment.
• Integration of conversation analysis and
  reflective conversation for data collection and
  analysis.
• Findings suggest nurses need to perceive the
  patient as an individual and articulate the
  mutual understanding and expectations in the
  relationship.

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Why Do Meta-Synthesis?

• Theory building
• Theory explication
• Theoretical development

Schreiber, R., Crooks, D.,Stern, P. N. (1997).
Qualitative meta-analysis. In J. M. Morse (Ed.),
Completing a qualitative project (pp 311-326).
Thousand Oaks, CA Sage.
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Quantitative Viewpoint

• Determine best practices.
• Maximize outcomes with minimal expenditures.
• Achieve best outcomes in the shortest amount of
  time at the lowest cost possible.

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Concept of ComplianceNewton (2004)

• At risk populations for low rates of
  breastfeeding include poorly educated,
  poverty-stricken, young African-American women.
  Unfortunately, the understanding of why these
  populations are noncompliant is rudimentary.

Newton, E.R. (2004). The Epidemiology of
Breastfeeding. Clinical Obstetrics Gynecology,
47(3)613-23.
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Qualitative Viewpoint

• Strengthen the role of qualitative studies in
  health sciences research.
• Improve applicability of qualitative research
  findings in clinical practice.
• Build on a qualitative body of knowledge to
  inform theory, practice, research, and policy.

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Concept of Self-Regulation Conrad (1985)

• Re-frames the medically defined problem of
  noncompliance.
• Allows the modification of medication practice
  for asserting some clinical control over
  epilepsy.

Barbour, R.S. (2000). The role of
qualitative research in broadening the evidence
base' for clinical practice. Journal of
Evaluation in Clinical Practice, 6 (2), 155163.
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• Theoretically generalizable understanding of
  apparently illogical behaviour in a wide range of
  clinical and non-clinical contexts.
• Childhood immunizations, observance of safer sex,
  and daily management of asthma and diabetes.

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Steps in Meta-Synthesis

• 1. Getting started. Identification of
  intellectual interest that qualitative research
  might inform.
• 2. Deciding what is relevant to initial interests
  and inclusion criteria for studies.

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• 3. Reading the studies. Not a one-time event. As
  the synthesis develops, studies are read and
  reread to check relevant metaphors and
  interpretations.

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• 4. Determining how the studies are related. Lists
  of key metaphors, phrases, ideas, or concepts and
  their relationships from each study and
  juxtaposed with those of other studies.
• This phase is complete when an initial
  assumption about the relationship between studies
  can be made.

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• 5. Translation. Treating accounts in studies as
  analogies.
• Translation maintains central metaphors and
  concepts in each study related to other metaphors
  or concepts in the same study.
• Compares them to relevant metaphors and
  concepts from other studies in the form of
  analogy.

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• 6. Synthesizing translations.
• Translations compared to determine if some
  metaphors and concepts encompass those from other
  studies.
• If so, another level of synthesis is possible
  analyzing competing interpretations and
  translating them into each other.

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• 7. Expressing the synthesis.
• Meta ethnography must be translated into the
  language of intended audiences.
• Clarity and transparency.
• Concise and straightforward.

Noblit, G.W. Hare, R.D. (1988).
Meta-Ethnography Synthesizing Qualitative
Studies. Newbury Park, CA Sage Publications,
Inc.
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Metasummary

• Extraction of findings from all studies in
  review.
• Generation of comprehensive inventory of findings
  across studies.
• Findings reduced to parsimonious list.
• Frequency effect sizes calculated.

Sandelowski, M. Barroso, J. (2003). Creating
Metasummaries of Qualitative Findings. Nursing
Research, 52(4), 226-233.
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Analysis

• Content analysis from meta findings used to
  identify patterns and themes common across
  studies.
• Constant comparison analysis clarifies distinct,
  shared meanings.
• Empirical results become foundation for
  metasynthesis.

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Meta-Ethnography

• Critical thinking and conceptual analysis occur
  simultaneously with insight, creativity and
  intuition.
• Analogies and metaphors formed during
  interpretation become new knowledge and
  understanding.
• Dynamic and real time self-awareness of the
  synthesis process is essential.

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Types of Meta-Ethnography

• Reciprocal
• Refutational
• Line of argument

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Reciprocal

• Translations directly comparable.
• Iterative process studies translated into each
  other.
• Metaphors, themes, concepts, and organizers
  translated across studies.

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Refutational

• Interpretation designed to argue against another
  interpretation.
• Explanation not of findings but significance of
  findings.
• Exhibits beliefs and ways of arguing.
• Promotes individual reflexivity.
• Enriches critical discourse.

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Line of Argument

• Concerned with clinical inference and grounded
  theorizing.
• Construction of an interpretation.
• Involves two steps
• translation of studies into one another
• development of grounded theory, putting
  similarities and differences between studies into
  an interpretive order

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Summary

• Meta-synthesis is needed to build on the
  qualitative body of literature in healthcare.
• Different philosophical and theoretical
  approaches result in different designs, analysis,
  and results.
• Diversity in approaches to meta-synthesis is
  important for enlarging discourse.

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• Generalization of theory across clinical
  situations and relationships is critical.
• Bringing theory to practice, and practice to
  theory is possible.
• Nursing is uniquely situated to pursue this
  methodological paradigm.

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Questions?