Focus on qualitative methods. Qualitative metasynthesis: issues and techniques.
ABSTRACT There has been an accumulation of qualitative studies in recent years, but little cumulation of the understandings gained from them. Qualitative research appears endangered both by efforts to synthesize studies and by the failure to do so. Techniques used have included reciprocal translations of key metaphors and concepts and qualitative and quantitative comparative analyses to produce narrative and theoretical integrations. The major problem yet to be resolved is developing usable and communicable systematic approaches to conducting metasynthesis projects that maintain the integrity of individual studies.
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ABSTRACT: La metasíntesis cualitativa es un campo de la investigación emergente con potencial contribución para la práctica basada en evidencias, a pesar de las controversias de carácter conceptual y metodológico. En la última década, innumerables publicaciones han apuntado hacia la relevancia de este tipo de estudio y los diferentes métodos para conducir la síntesis de investigaciones cualitativas. El presente artículo es una sinopsis de estos aspectos, incluyendo las etapas de la metasíntesis.Acta Paulista de Enfermagem 12/2008; 22(SPE1):543-545. · 0.14 Impact Factor
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ABSTRACT: This study is a reflection on the conduction of qualitative meta-synthesis. It addresses the characteristics of systematic bibliographic review as an emerging trend in gathering data for decision-making in health care, comparing diverse review methods, meta-analysis, and meta-synthesis. It discusses qualitative research through its definitions, various disciplines, methods and particularities, highlighting the vast production of qualitative research in nursing and the need create visibility and the impact of results as practical applications. This study presents a definition for qualitative meta-synthesis and its characteristics, discussing the complexity of the methodology and practical aspects of the process. We conclude that qualitative meta-synthesis can be a tool to be researched in nursing, improving and validating the methodology through the inclusion of the large production of qualitative research in nursing, with key points of the profession of providing and receiving care.Texto e Contexto Enfermagem 12/2008; 17(4):771-778. · 0.13 Impact Factor
Focus on Qualitative Methods
Issues and Techniques
Margarete Sandelowski,1* Sharron Docherty,1†Carolyn Emden2‡
1Department of Women’s and Children’s Health, School of Nursing,
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
2Faculty of Nursing, University of South Australia
Received 2 August 1996; accepted 2 December 1996
Abstract: There has been an accumulation of qualitative studies in recent years, but little cu-
mulation of the understandings gained from them. Qualitative research appears endangered both
by efforts to synthesize studies and by the failure to do so. Techniques used have included re-
ciprocal translations of key metaphors and concepts and qualitative and quantitative compara-
tive analyses to produce narrative and theoretical integrations. The major problem yet to be re-
solved is developing usable and communicable systematic approaches to conducting
metasynthesis projects that maintain the integrity of individual studies. ? 1997 John Wiley & Sons,
Inc. Res Nurs Health 20: 365–371, 1997
Keywords: qualitative metasynthesis; qualitative research; integrative reviews of research; research synthesis
Research in Nursing & Health, 1997, 20, 365–371
© 1997 John Wiley & Sons, Inc. CCC 0160-6891/97/040365-07
There has been an unprecedented accumulation
in recent years of qualitative studies in the health
sciences and practice disciplines, but, as yet, little
accumulation of the understandings gained from
these studies. The relative inattention toward inte-
grating qualitative findings stands in sharp con-
trast to the considerable attention given to the de-
velopment of techniques for conducting syntheses
of quantitative research, and the proliferation of
integrative reviews and syntheses of quantitative
research in a variety of substantive fields (Brown
& Hellings, 1988; Chalmers, 1993; Cooper, 1982;
Ganong, 1987; Glass, McGaw, & Smith, 1981;
Jackson, 1980; Light & Pillemer, 1982; Lynn,
The relative lack of effort to “put together”
(Noblit & Hare, 1988, p. 7) the findings from qual-
itative studies has important implications for both
knowledge development and the utilization of
qualitative research in nursing. For these findings
to have impact, they must be situated in a larger in-
terpretive context, and they must be presented in
an accessible and usable form in the real world of
practice and policy making. Knowledge must be
conceptually and/or instrumentally useful (Larsen,
1981) and assimilable into the “personal modes of
knowing, valuing” (Noblit, 1984, p. 95) and/or do-
ing of a variety of potential users, including theo-
rists, researchers, practitioners, policy makers,
and patients. Yet, the goal of creating synthesized
knowledge for utilitarian purposes is an older
modern ideal that contradicts more recent post-
modern challenges to the commodification of
knowledge and the truth value of any grand
knowledge syntheses (Holmes, 1995).
In this article, we consider the appropriateness
and feasibility of attempting qualitative metasyn-
theses, briefly review several efforts to create such
syntheses, and discuss methodological issues in
conducting such projects. We define qualitative
Correspondence to Margarete Sandelowski, University of North Carolina at Chapel Hill, 7460
Carrington Hall, Chapel Hill, NC 27599.
metasynthesis as the theories, grand narratives,
generalizations, or interpretive translations pro-
duced from the integration or comparison of find-
ings from qualitative studies. We do not consider
here qualitative (or narrative) syntheses or reviews
of quantitative studies, or the findings created
from secondary analyses of data pooled from sep-
arate qualitative studies (e.g., West & Oldfather,
CAN YOU SUM UP A POEM?
By its very nature and purposes, qualitative re-
search appears resistant to, and endangered by, ef-
forts to synthesize studies. Just as it goes against
the nature of poetry to attempt to summarize even
one poem about love, so it seems both epistemo-
logically and ethically inappropriate to attempt to
summarize findings from one or more qualitative
studies about human experiences of health and ill-
ness. By virtue of their emphasis on idiographic
knowledge, or the complexities and contradictions
of particulars, qualitative studies resist “summing
up” (Light & Pillemer, 1984).
Turning idiographic knowledge into data for
synthesis seems to represent an unconscionable
loss of the uniqueness of individual projects and a
departure from the larger pedagogic and emanci-
patory aims of qualitative research. Indeed, it is
precisely this knowledge that offsets the recurring
failure of generalizations from quantitative stud-
ies to fit individual cases. To summarize qualita-
tive findings is to destroy the integrity of the indi-
vidual projects on which such summaries are
based, to thin out the desired thickness of particu-
lars, to undermine the “function and provenance”
(Davis, 1991, p. 12) of cases, and, ultimately, to
lose the vitality, viscerality, and vicariism of the
human experiences represented in the original
Moreover, the sheer diversity of practices with-
in the domain of qualitative inquiry seems to work
against efforts to synthesize the findings of quali-
tative studies. Qualitative researchers include in-
quirers with vastly different disciplinary, philo-
sophical, theoretical, social, political, and ethical
commitments, and they often have very different
views of how to execute ostensibly the same kind
of qualitative research. There are postpositivists
and constructivists, feminists and Marxists, and
nurses, educators, and anthropologists conducting
grounded theory, phenomenologic, ethnographic,
and narrative studies. Given the wide variety of
presentation styles for disseminating qualitative
research, and the deliberate blurring of what are
perceived as the artificial lines drawn in research
reports among method, results, and discussion,
even finding the findings can be a challenge.
Furthermore, these diverse inquirers have cor-
respondingly diverse opinions concerning what a
“good” qualitative study is. Although the issue of
whether to include all or only good studies in in-
tegrations of quantitative research has yet to be re-
solved, there appears to be greater consensus con-
cerning what a good correlational or experimental
study is. There can be little consensus, however,
concerning the good in qualitative research, as
there are no “in principle” arguments that can ad-
equately address goodness in the varieties of prac-
tices designated as qualitative research (Engel &
Kuzel, 1992, p. 506). Indeed, even using the term
qualitative research serves to trivialize significant
differences among research practices designated
as qualitative (Atkinson, 1995).
In addition, criteria of goodness (for any human
endeavor) are historically and culturally context-
dependent. Different communities of knowledge
makers and users have sanctioned different crite-
ria of goodness, and these criteria have changed
over time. For example, nursing standards for con-
ducting qualitative research have tended to em-
phasize methodological rigor and conformity. In
contrast, there are other standards that emphasize
such factors as the real-world significance of the
questions asked and the answers found, the prac-
tical value of the findings, and the extent of in-
volvement with, and personal benefit to, the par-
ticipants of the research (Lincoln & Reason,
1996). Indeed, in the most recent explorations of
quality criteria for qualitative research, scholars
have described them as “emerging” (Lincoln,
1995), and the quest for validity as an obsession
interfering with quality (Kvale, 1995). They have
even suggested moving beyond “criteriology”
In summary, the very emphasis in qualitative re-
search on “N ? 1 experiences” (Eisner, 1991, p.
197) seems to preclude adding up these experi-
ences. Like a poem, a novel, or a painting, even
one qualitative study cannot be summarized.
Yet, qualitative research also appears endangered
by the failure to sum it up. A recurring concern is
that qualitative researchers are engaged in a cot-
tage industry: working in isolation from each oth-
er, producing “one-shot research” (Estabrooks,
Field, & Morse, 1994, p. 510) and, therefore, eter-
nally reinventing the wheel. Qualitative re-
RESEARCH IN NURSING & HEALTH
searchers in nursing too often fail to situate their
work in larger programs of research or fields of
scholarship. The “open-mindedness” of qualita-
tive research is often confused with the “empty-
mindedness” of researchers (Coffey & Atkinson,
1996, p. 157) unprepared to conduct their studies.
Glaser and Strauss (1971, p. 181) warned that the
continued failure to link local grounded theories
into formal theories (a type of qualitative meta-
synthesis) would relegate the findings of individ-
ual studies to “little islands of knowledge,” sepa-
rated from each other and doomed ultimately
never to be visited. Statham, Mauksch, and Miller
(1988, p. 6) used Lofland’s concept of “analytic
interruptus” to refer to the failure of qualitative re-
searchers to go far enough in their work: that is, to
reveal the “subtle, sometimes opaque connec-
tions” among findings and, specifically, among
“apparently disparate findings” (Statham, Miller,
& Mauksch, 1988a, p. 11).
Efforts to synthesize existing qualitative re-
search studies are seen as essential to reaching
higher analytic goals and also to enhancing the
generalizability of qualitative research. Qualita-
tive research is still falsely characterized as un-
generalizable, when generalization is narrowly
conceived in terms of sampling and statistical sig-
nificance. Yet, qualitative research is directed to-
ward naturalistic or idiographic generalizations,
or the kind of generalizations made about particu-
lars (Stake & Trumbull, 1982). As Donmoyer
(1990, p. 176) observed, it is undefensible, dys-
functional, and out of touch with contemporary
views of science not to recognize and value these
kinds of generalizations. Schofield (1990) con-
ceived of qualitative metasyntheses as cross-case
generalizations created from the generalizations
made from, and about, individual cases.
KINDS OF QUALITATIVE
At least three kinds of syntheses of findings from
qualitative studies have been attempted. One kind
of effort involves the integration of findings from
multiple analytic paths taken within a program of
research by the same investigator(s). An example
is Sandelowski’s (1993, 1995) narrative and theo-
retical syntheses describing the transition to par-
enthood of infertile couples. These syntheses were
produced from the results of completed individual
lines of analysis concerning such experiences as
couples’ responses to technological intervention
in conception and childbirth, their strategies for
decision making, and their management of ambi-
Asecond kind of effort involves the synthesis of
findings across studies conducted by different in-
vestigators. Examples of this approach are the
Jensen and Allen (1994) synthesis of qualitative
research findings on wellness–illness, the Field
and Marck (1994) synthesis of studies on uncer-
tain motherhood, the Noblit and Hare (1988)
meta-ethnography of several educational studies,
and the Statham, Miller, and Mauksch (1988b)
synthesis of studies on women’s work. In these
projects, investigators produced narrative or theo-
retical combinations of studies in the same topical
area, using such techniques as reciprocal transla-
tion of key metaphors and concepts and qualitative
Athird strategy involves the use of quantitative
methods to aggregate qualitative findings from
cases across different studies. (These techniques
are used also to create findings from individual
cases in the same study.1) In one quantitative ap-
proach, the case survey method (Lucas, 1974; Yin
& Heald, 1975), researchers use a conceptual
framework to construct a set of highly structured
questions to collect information from individual
case studies in specified topical domains. Answers
to these questions are then transformed into data
amenable to statistical analysis.
In a second quantitative approach, the qualita-
tive comparative method (Ragin, 1987), Boolean
algebra is the basis for creating categorical infor-
mation on key variables across individual cases. A
holistic view of individual cases—as distinctive
configurations of associations, causes, and out-
comes—is maintained. Drawing on Ragin’s dis-
tinction between case- and variable-oriented
analyses of cases, Miles and Huberman (1994, pp.
173–174) provided an especially useful illustra-
tion of how case-oriented analyses are directed
first toward ascertaining the distinctive confluence
of variables, or the configuration and flow of
events, within each case, and, then, toward com-
QUALITATIVE METASYNTHESIS / SANDELOWSKI ET AL.
1In social science literature, the word case appears as a refer-
ence to the sampling units within individual studies and/or to
the individual studies themselves. That is, a study with a sam-
ple of 20 women may be conceived as a study of 20 cases
and/or as one case. The results of such a study may be con-
ceived as one local interpretation, which, together with local
interpretations from other studies in a topical area, comprise
the data for a metasynthesis project, and/or as a metasynthesis
of the findings from 20 cases. The view of cases as equal to
sampling units extends the meaning of metasynthesis to in-
clude virtually any effort to bring qualitative data together. In
contrast, the view of cases as equal to studies restricts the mean-
ing of metasynthesis to techniques for larger syntheses across
studies. We emphasize the second meaning in this article.
paring these configurations across cases. In con-
trast, in variable-oriented analyses, the unique
configurations of individual cases are lost as the
analyst’s work is directed toward ascertaining the
mutual influence of a prespecified set of variables
disaggregated from cases.
ISSUES IN CONDUCTING
These efforts are valuable, not only for the findings
produced, but also for illuminating key method-
ological problems that have yet to be resolved.
These problems are, in many respects, comparable
to recurring issues in synthesizing quantitative re-
search (e.g., Jackson, 1980; Lynn, 1989).
Determining Topical Similarity
An initial problem in conducting qualitative meta-
syntheses is deciding which studies are really
about the same substantive phenomenon, event, or
experience. For example, there are many qualita-
tive studies across several disciplines addressing
the illness experience. But, each of them various-
ly emphasizes one or more of the same and differ-
ent facets of that experience in language and style
that may obscure their commonalities and differ-
ences. The idiosyncratic use of language and
method in qualitative research reports alone man-
dates that researchers undertaking qualitative
metasynthesis projects (hereafter called synthe-
sists) be “culturally multilingual” (Noblit & Hare,
1988, p. 7) and expert translators.
Synthesists must develop a means for deter-
mining the true topical similarity of studies they
located by using the various techniques available
for information retrieval (Cooper, 1982). This en-
tails the comparison of studies on broad, surface
parameters, including stated research purposes,
research questions asked, and the kinds of findings
produced. Often, research purposes and questions
are so broadly stated, it is only by looking at the
kinds of findings produced that topical similarity
can be determined. In the case of studies all os-
tensibly aimed at exploring the illness experience,
findings may variously emphasize a certain time
period in the illness trajectory, the circumstances
surrounding diagnosis, the management of symp-
toms, the ambiguity of illness, and/or the negotia-
tion of social interactions. Each of these categories
of findings may be the object of separate meta-
Setting Inclusion Criteria
The next problem in conducting qualitative meta-
syntheses is deciding which of the topically simi-
lar studies to include in one project. In topical do-
mains with over 10 studies, the intensive
case-oriented thrust of qualitative analysis pre-
cludes using them all in one project. There is, typ-
ically, a wealth of information contained in a qual-
itative research report and synthesists are obliged
initially to attend to, and account for, all of it. As
in any kind of qualitative research, overly large
sample sizes tend to impede deep analysis and,
therefore, threaten the interpretive validity of find-
Accordingly, synthesists locating more than 10
topically similar studies will have to use a clearly
defined purposeful sampling strategy in order to
set tighter boundaries for the synthesis. Synthe-
sists interested in integrating findings from stud-
ies about the illness experience may locate suffi-
cient findings concerning responses to initial
diagnosis, symptom management, and manage-
ment of ambiguity to warrant each of these topical
areas as foci of separate metasynthesis projects.
The findings from these separate projects may
then be combined to create a grand picture of the
In general, studies should not be excluded for
reasons of quality, because, as we noted previous-
ly, there are wide variations in conceptions of the
good, and in quality criteria. At the very least, syn-
thesists are obliged to explain the conceptions of
good that informed any exclusions. Yet, synthe-
sists should not be misled to discount important
findings for what amount to only surface mistakes.
For example, there are many instances in which
investigators have produced findings worthy of
note, but have used the “wrong” language and
method citations to describe their work. A study
presented as a phenomenology, which is arguably
a qualitative descriptive study, may still be a gen-
erally good study. Using Burns’s (1989) standards
for the critique of qualitative research, such a
study may still have “descriptive vividness”
(p.48), “analytic preciseness” (p.49), and “heuris-
tic relevance” (p. 51). Indeed, even a study mis-
represented as a phenomenology or ethnography
can still have “methodological congruence”
Although quality should not be a criterion used
to exclude studies, it should be included in the
comparative analysis of the design features of
each study. The problem for synthesists here is to
use quality criteria so general that they can be ap-
RESEARCH IN NURSING & HEALTH
plied to any qualitative study, arguably an impos-
sible task given the range of qualitative research
practices. Or, synthesists might use different sets
of criteria for different kinds of studies, an option
that depends on choosing the right set. In the ex-
ample we just gave of the phenomenology that is
arguably a qualitative descriptive study, the set of
criteria used should fit qualitative descriptive
studies. A qualitative content analysis wrongly
presented as a narrative analysis should be evalu-
ated as a content analysis. Synthesists have to be
true “connoisseurs” (Eisner, 1991, p. 63) of qual-
itative research to distinguish between surface er-
rors and mistakes fatal enough to discount find-
After determining which topically similar studies
will be included in a synthesis project, synthesists
are obliged to determine their methodological
comparability, or the similarities and differences
among them. Again, given the varieties of ways in
which grounded theories, phenomenologies, and
ethnographies are created, and the varieties of
practices to which these and other technical words
are attached, synthesists should not rely solely on
the surface uses of method language and citations
to compare studies. Good or bad, one investiga-
tor’s phenomenology may be more like another re-
searcher’s grounded theory than two researchers’
grounded theories. Right or wrong, one investiga-
tor’s rendering of symbolic interactionism may be
more like another investigator’s rendering of crit-
Studies have traditionally been compared on
such features as their conceptual underpinnings,
including the kind of literature reviewed, and their
design features, including techniques used for
sampling, data collection, and analysis (e.g.,
Burns, 1989). This system of comparison is also
very useful in determining the overall structure
and orienting gestalt of studies included in a qual-
itative metasynthesis project. As qualitative stud-
ies bear the personal signatures of researchers (to
a much greater degree than quantitative research),
synthesists have the additional obligation to ac-
count for such signature features. Accordingly, the
coding system used to appraise the methodologi-
cal comparability of studies must include such
researcher related features as disciplinary back-
ground, and personal experiences and commit-
ments, as they are revealed in individual studies.
This phase of analysis helps synthesists under-
stand each study on its own terms before attempt-
ing any cross-case comparisons or integrations. As
in most kinds of qualitative analysis, any a priori
coding systems used are developed to the point
where they adequately capture the salient features
of every study included. That is, coding systems
must help the synthesist understand the particular
structure and configuration of elements character-
izing each study, or what makes that study unique-
ly what it is.
Explicating Methods and Techniques
The most complex problem synthesists face is de-
veloping and communicating the techniques used
to compare the findings of each study. Indeed,
putting findings together is the raison d’être of
qualitative metasynthesis and of the preliminary
analyses we just described. The major methods that
have been used, including reciprocal translation of
metaphors and concepts and qualitative and quan-
titative comparative analyses, remain either rela-
tively untried and undeveloped, and/or difficult to
codify or understand. Researchers conducting
qualitative syntheses are conducting a highly so-
phisticated kind of qualitative analysis and inter-
pretation and, like all such work, its “magic” (May,
1994) may resist attempts at disenchantment.
No matter what method is used, the aim of qual-
itative metasynthesis is to account for all impor-
tant similarities and differences in language, con-
cepts, images, and other ideas around a target
experience. In contrast to quantitative metaanaly-
sis, qualitative metasynthesis is not about averag-
ing or reducing findings to a “common metric”
(Wolf, 1986, p. 33), but rather enlarging the inter-
pretive possibilities of findings and constructing
larger narratives or general theories. Miles and
Huberman (1994) have described a variety of
analysis techniques, including visual data dis-
plays, which permit synthesists to recognize sim-
ilarities and differences that shaped findings
among studies, and the convergence or divergence
of the findings themselves. A useful technique to
capture similarity and difference is the Venn dia-
gram, in which circles and the spaces within cir-
cles are used to represent overlapping and unique
ideas (Cieutat, Krimerman, & Elder, 1969).
As they are engaged in the interpretation of cul-
turally diverse texts in different languages (or texts
created in different disciplinary and philosophical
contexts), synthesists will also have to develop
QUALITATIVE METASYNTHESIS / SANDELOWSKI ET AL.
skills in analyzing studies for such features as con-
trolling images and metaphors, key rhetorical de-
vices, and plot lines (Martin, 1990; Riessman,
1993). For example, the key to understanding sev-
eral studies of the illness experience in relation to
each other may lie in recognizing how they all
reprise familiar cultural stories, such as the hero on
a quest or the warrior battling an enemy. In addi-
tion, synthesists must be skilled in semantic (liter-
al) and idiomatic (meaning) translation (Noblit &
Hare, 1988, p. 31) of key ideas in studies.
Qualitative metasynthesis is one response to con-
cerns about the relevance and utility of qualitative
research, and much work remains to be done to de-
velop strategies for creating them. Qualitative
metasynthesis is not a trivial pursuit, but rather a
complex exercise in interpretation: carefully peel-
ing away the surface layers of studies to find their
hearts and souls in a way that does the least dam-
age to them. Synthesists must analyze studies in
sufficient detail to preserve the integrity of each
study and yet not become so immersed in detail
that no usable synthesis is produced.
The rightness of efforts to sum up qualitative
studies is debatable, as this kind of work seems to
contradict the postmodern rejection of “totalizing
thought” and “metanarratives” of any kind
(Holmes, 1995, p. 358). Arguably, though, the
time has come to make the most of the qualitative
findings we have, which will likely entail some in-
terpretive resolution “beyond postmodernism”
(e.g., Owens, 1995) designed to reconcile appar-
ently irreconcilable projects. The time also has
come to recognize that calls for yet more re-
search—to gain better understandings of events or
to resolve patient and practice problems—do not
necessarily entail the collection of yet more new
data from already overburdened people. Indeed,
synthesis projects should be recognized as an im-
portant avenue toward the development of nursing
knowledge and as exemplars of clinical scholar-
ship (Diers, 1995) that deserve the same rewards
and tangible supports available for so-called pri-
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