1. Systematic Reviews of Qualitative Literature Catherine Francis-Baldesari UK Cochrane Centre Oxford

2. 2Februrary 2006UK Cochrane Centre Objectives Discuss the purpose and characteristics of meta-synthesis. Become familiar with the concepts and general processes to conduct a meta- synthesis.

3. 3Februrary 2006UK Cochrane Centre 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

4. 4Februrary 2006UK Cochrane Centre 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.,

5. 5Februrary 2006UK Cochrane Centre 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.

6. 6Februrary 2006UK Cochrane Centre Achieving Integration Comprehensive consideration of data Inclusion vs. exclusion Inclusion vs. exclusion Commonalities and differences Commonalities and differences Sensitivity to patterns Sensitivity to patterns Intuitive and logical Intuitive and logical Theoretical reconstruction of concepts 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.

7. 7Februrary 2006UK Cochrane Centre 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_opportunities/commissioned_research/ projects/pdf/msynth_appendix_e.pdf - 115.5KB

8. 8Februrary 2006UK Cochrane Centre Translation of studies into one another. Transformation of parts into whole. Development of theory to explain the range of findings encountered.

9. 9Februrary 2006UK Cochrane Centre How Do We Evaluate Outputs of Qualitative Research? Conceptual themes Conceptual themesContributory Defensible in design Rigorous in conduct 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 Researcher’s Office, Cabinet Office, United Kingdom.

10. 10Februrary 2006UK Cochrane Centre 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.

11. 11Februrary 2006UK Cochrane Centre Rigorous in conduct… Through the systematic and transparent collection, analysis and interpretation of qualitative data. Credible in claim… Through offering well- founded and plausible arguments about the significance of the evidence generated.

12. 12Februrary 2006UK Cochrane Centre 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.

13. 13Februrary 2006UK Cochrane Centre "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 Theory and Philosophy

14. 14Februrary 2006UK Cochrane Centre 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.

15. 15Februrary 2006UK Cochrane Centre 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.

16. 16Februrary 2006UK Cochrane Centre 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.

17. 17Februrary 2006UK Cochrane Centre 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. McCormack, B. (2003). Conceptual framework for person-centred practice with older people. International Journal of Nursing Practice, 9(3); 202-209.

18. 18Februrary 2006UK Cochrane Centre 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.

19. 19Februrary 2006UK Cochrane Centre 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.

20. 20Februrary 2006UK Cochrane Centre Quantitative Viewpoint Determine best practices. Maximize outcomes with minimal expenditures. Achieve best outcomes in the shortest amount of time at the lowest cost possible.

21. 21Februrary 2006UK Cochrane Centre Concept of Compliance: Newton (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.

22. 22Februrary 2006UK Cochrane Centre 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.

23. 23Februrary 2006UK Cochrane Centre 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), 155±163.

24. 24Februrary 2006UK Cochrane Centre 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.

25. 25Februrary 2006UK Cochrane Centre 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.

26. 26Februrary 2006UK Cochrane Centre 3. Reading the studies. Not a one-time event. As the synthesis develops, studies are read and reread to check relevant metaphors and interpretations.

27. 27Februrary 2006UK Cochrane Centre 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.

28. 28Februrary 2006UK Cochrane Centre 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. Compares them to relevant metaphors and concepts from other studies in the form of analogy.

29. 29Februrary 2006UK Cochrane Centre 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.

30. 30Februrary 2006UK Cochrane Centre 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.

31. 31Februrary 2006UK Cochrane Centre 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.

32. 32Februrary 2006UK Cochrane CentreAnalysis 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.

33. 33Februrary 2006UK Cochrane Centre 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.

34. 34Februrary 2006UK Cochrane Centre Types of Meta-Ethnography ReciprocalRefutational Line of argument

35. 35Februrary 2006UK Cochrane Centre Reciprocal Translations directly comparable. Iterative process – studies translated into each other. Metaphors, themes, concepts, and organizers translated across studies.

36. 36Februrary 2006UK Cochrane Centre 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.

37. 37Februrary 2006UK Cochrane Centre Line of Argument Concerned with clinical inference and grounded theorizing. Construction of an interpretation. Involves two steps – translation of studies into one another translation of studies into one another development of grounded theory, putting similarities and differences between studies into an interpretive order development of grounded theory, putting similarities and differences between studies into an interpretive order

38. 38Februrary 2006UK Cochrane Centre 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.

39. 39Februrary 2006UK Cochrane Centre 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.

40. 40Februrary 2006UK Cochrane Centre Questions?