Using meta-synthesis to support application of qualitative methods findings in practice: A discussion of meta-ethnography, narrative synthesis, and critical interpretive synthesis

Highlights

• Meta-synthesis allows direct clinical applications from findings of qualitative studies.

• Three types of meta-synthesis are presented; meta-ethnography, narrative synthesis, and critical interpretive synthesis.

• Using procedures in this paper will enhance applicability of qualitative findings for service developers and therapists.

Abstract

Meta-synthesis refers to a range of approaches by which existing qualitative studies in healthcare can be reviewed and compared. There is increasing use of meta-synthesis to ensure the clinical applicability of findings from qualitative studies, in healthcare generally, and in the creative arts therapies specifically. Qualitative method research can sometimes lack immediate clinical relevance, as such studies usually focus on the experiences of a small number of participants. Additionally, the results are often presented in great detail; finely elaborated, and described conceptually. Findings reported in this way can be engaging, and even emotionally compelling, however the utility of these outcomes for clinical practice can be limited. Meta-synthesis of multiple studies aims to ensure that findings from qualitative methods studies can be more easily, and effectively, applied in health and social care programs. Three approaches to meta-synthesis are briefly presented here; meta-ethnography, narrative synthesis, and critical interpretive synthesis. A procedure for presentation of meta-synthesis reviews is provided.

Introduction

Greater understanding of the procedures undertaken in meta-synthesis of qualitative studies, will assist in further transferability of qualitative research findings into creative arts therapy practice. Given the growing number of qualitative method studies in the creative arts therapies, the authors perceived value in presenting guidelines for meta-synthesis intended to be of use to journal reviewers, as well as practitioners, students, and researchers.

The brief overview of meta-synthesis methods presented in this paper is intended to support researchers, peer reviewers, research grant evaluators, research students, and practitioners, within the creative arts therapies, and potentially some related fields, to better understand the process of undertaking a meta-synthesis, and the minimum standards required in meta-synthesis reporting. Readers can use the paper to 1. Find out more about the types of meta-synthesis available, and/or 2. Consider how to prepare a report of a meta-synthesis for publication.

The paper briefly introduces three types of meta-synthesis and provides recent examples of these approaches. Minimal comparator information is provided. The reader is directed to Barnett-Page and Thomas (2009) for the most exhaustive comparator review of meta-synthesis methods to date. The information presented here is not intended as a definitive guide to conducting a meta-synthesis, rather it aims to advise how to commence such a study, and supports appropriate reporting of such studies. Researchers new to this approach should familiarize themselves with the procedures of the method chosen through further training and in-depth reading.

Meta is of Greek origin, meaning across or after (Merriam Webster online). Traditionally meta-analysis is a type of systematic review of research used within evidence based medicine to provide an evaluation of the efficacy of a treatment.

Systematic reviews adhere to a strict scientific design based on explicit, pre-specified and reproducible methods. Because of this, when carried out well, they provide reliable estimates about the effects of interventions so that conclusions are defensible. (Centre for Reviews, & Dissemination (CRD), 2009)

Meta-synthesis refers to a range of existing and emerging methods by which qualitative research studies in healthcare are integrated into a larger concept, with the goal of creating findings that are directly relevant to practice (Paterson et al., 2009). Through meta-synthesis, researchers use findings from published studies using qualitative method, to provide further evidence for the effectiveness of an approach within therapeutic work, a service delivery concept, or a specific treatment.

Meta-synthesis is a systematic method, beyond the scope of a literature review, through which the findings of a range of qualitative method studies on a topic can be evaluated, and presented. Additional insights can be gained from viewing the findings across multiple relevant studies. The goal of the meta-synthesis is to elicit novel understandings from comparison and synthesis of the findings of multiple studies. Barnett-Page and Thomas (2009) identified nine existing methods of meta-synthesis, and pointed to further emerging methods. The three methods chosen for this paper are covered in their overview, however the method described here as narrative synthesis they termed meta-narrative. Researchers seeking to use a meta-synthesis method to conduct a review are encouraged to read more widely than this paper, and to confirm terminology and method choice by consulting a wide range of sources.

Meta-synthesis seek to fuse both commonalities and contradictions across relevant studies in order to provide a transformative understanding of a topic or phenomenon of interest (Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004). The researcher provides fresh interpretations of the findings from the studies reviewed. The meta-synthesis goes beyond the traditional literature review in that additional interpretive and inductive analysis is expected. However, there are examples of earlier reflexive and interpretive literature reviews in the creative arts therapies which point to the development of the later meta-synthesis methods (e.g. O’Callaghan, 2009).

The use of meta-synthesis to guide the application of qualitative findings in healthcare has gradually built momentum and applicability (Noyes, Popay, Pearson, Hannes, & Booth, 2008). Service providers and healthcare agencies have sought further information beyond that provided in the meta-analysis of RCT’s. Usually qualitative studies are not intended to be generalizable. They use small sample sizes and are conducted with a view to depth rather than breadth. This is a caution when developing the meta-synthesis. When using small numbers of studies contacting the authors for further information assists credibility of the further findings.

When reporting the outcomes of the meta-synthesis transparency of process is emphasized, especially with regards the procedures followed (Noyes et al., 2008). Arts-based methods are also encouraged to enhance information as to how the research “synthesizer puzzles together an interpretive account of qualitative studies” (Kinn, Holgersen, Ekeland, & Davidson, 2013; p. 1285).

One of the first examples of meta-synthesis relating to creative arts therapies was presented by Meekums and Daniel (2011). They searched databases for research reports in any methodology about the arts for offenders, including creative arts therapy services. They found nine relevant papers that met their criteria. However, they lamented that in view of their rigorous requirements for evaluation they “had to reject many pieces of work that are beautifully-written artistic accounts of artistic and therapeutic work, and of the positive effects of engagement with the arts for the individuals involved” (Meekums & Daniel, 2011). It is suggested that a less exhaustive criteria, and openness to arts-based analysis may have provided a workable solution to their disappointment in being unable to engage a wider body of relevant information. Authors are encouraged to find ways to include a wider range of studies, and authors of qualitative research reports need to ensure the minimum standards of reporting are met (Edwards, 2016).

Meta-synthesis reporting is designed to support service development based on research findings that (1) include service user perspectives, (2) acknowledge the complexity of healthcare service delivery, and (3) honor the often unique nature of the settings in which services are provided (Kinn et al., 2013).

Three methods were selected for review in this paper. The process to decide which methods to include was achieved through discussion between the authors. Our three choices were primarily led by identifying methods relevant to the creative arts therapies. The final decision was to focus on three methods; meta-ethnography, narrative synthesis, and critical interpretative synthesis. They are sufficiently different and have well described processes and research steps which permitted straightforward summary information to be presented. We decided to avoid discussion of the synthesis method relevant to Grounded Theory as it is one of the most common methods for discrete studies in qualitative healthcare research (O’Callaghan, 2012), and its inclusion may have been confusing. We additionally chose to focus on methods that permitted synthesis of findings from multiple studies with heterogeneous methods. The three methods are briefly presented below with reference to an example, followed by a general guide for authors on the information to include when reporting a meta-synthesis of any method for publication.

Meta-ethnography was specifically designed for use in small scale analyses, usually with fewer than 50 studies (Dixon-Woods et al., 2006). It is distinctive from other meta-synthesis procedures in that the qualitative reports used in the analysis are selected by the researchers for their relevance and integrity. Meta-ethnography has therefore been considered less comprehensive than other types of synthesis which rely on wide ranging database searches (Britten et al., 2002, Noblit and Hare, 1988).

In meta-ethnography the researcher synthesizes the findings from related qualitative studies by reflecting them into one another (Noblit & Hare, 1988). The thematic and conceptual material is compared and contrasted across the findings of the studies to generate new insights while at the same time preserving meaning (Kinn et al., 2013; Noblitt & Hare, 1988). Britten et al. (2002) proferred this explanation of the procedures used: “Interpretations and explanations in the original studies are treated as data, and are translated across several studies to produce a synthesis” (Britten et al., 2002, p. 210). Meta-ethnography was originally developed in education research (Noblitt & Hare, 1988). Meta-ethnography in healthcare research seeks to present findings that are directly applicable for practitioners (Britten et al., 2002, France et al., 2014).

In meta-ethnography there are three key steps in conducting the analysis (Noblit & Hare, 1988):

• Reciprocal translational analysis. The key metaphors, themes, or concepts reported in each study report are extracted. These concepts are then translated into each other. Judgements about the ability of the concept of one study to capture relevant concepts from the other studies are based on attributes of the themes. The concept most adequate between the multiple possibilities is identified and included.

• Refutational synthesis. Where contradictions appear between the study reports, these are described, and the synthesizer elaborates and explains incongruities.

• Lines-of-argument synthesis. The research synthesizer builds an elaborated interpretation that reflects the findings of the separate studies. The themes or categories that are most powerful in representing the entire dataset are identified by constant comparisons between individual accounts and the meta-themes or concepts.

The resultant synthesis presents an elaborated framework by which all of the concepts from the original research papers appear, but are unified by greater conceptual integration and practical applicability. Studies using meta-ethnography as the primary method of second order analysis have appeared in a range of healthcare topics including women’s experiences of traumatic birth (Elmir, Schmied, Wilkes, & Jackson, 2010), working with translation services (Brisset, Leanza, & Laforest, 2013), and diabetes care (Vermeire et al., 2007). Kinn et al. (2013) have reported that meta-ethnography was the most commonly used meta-synthesis method in healthcare research.

In a recently completed meta-ethnography accepted for publication pending revisions (O’Callaghan et al., 2016), a research group undertook an analysis of five published reports of research conducted by some of the members of the author team. The method of the five studies was Grounded Theory. Across the five studies, interviews were conducted with 138 participants comprising three groups, 1. People living with a diagnosis of cancer, 2. People caring for these people, and 3. People who had formerly had a carer role who were bereaved.

The meta-ethnography revealed how, when people are affected by cancer’s harsh effects, listening to or playing music can be a lifeline; music can support biopsychosocial and spiritual well-being, or for some people music can be experienced as elusive or difficult to engage. The findings of the meta-synthesis indicated that workers can improve cancer care services by offering music-based services that are responsive to patients and families. Additionally, it is important that workers can understand that when patients and carers alter their music behaviors this may signify additional support needs which workers need to have the capacity to respond to effectively (O’Callaghan et al., 2016).