On the Evolving World of What Constitutes Qualitative Synthesis

In an earlier era, “the literature review” was the rite of passage before one earned the privilege of engaging in a qualitative inquiry. The conventional form of review—borrowed from the world of normal science—tended to be a somewhat tedious litany of descriptions of individual studies on the topic followed by commentary on the shortcomings of each, building toward a conclusion that the thing you intended to study was the most logical and important next step forward. Thankfully, many qualitative researchers took a more comprehensive and holistic approach to the classic literature review, guiding their reader through an exploration of what was known about the topic at hand and how it was known. This style of literature review was decidedly more interesting for the reader, but because these literature reviews were generally also quite purpose-oriented—to justify the study being proposed—they tended not to be easily publishable as distinctive and original contributions to the literature.

In the 1990s, following the earlier lead of educational theorists George Noblit and Dwight Hare in the interpretive ethnographic maneuver they called “meta-ethnography” (Noblit & Hare, 1988), — although, to be fair, a number of others in the social sciences had also experimented with various synthesis approaches over the years — the applied health research world began to take an interest in working out what to do with the volume of qualitative reports that was beginning to accumulate on a wide range of topics within the health research journals. Among the early scholars writing in this space, there was great enthusiasm for the potential value in being able to draw together the insights arising from a multiplicity of studies and to build it into some new form of more comprehensive and integrative level of understanding. However, there were multiple opinions at play with respect to what this kind of work ought to look like and what one ought to call it. An early paper by Estabrooks, Field, and Morse (1994) referred to it as “aggregating qualitative findings,” and one by Schreiber, Crooks, and Stern (1997) called it “qualitative meta-analysis.” Fairly quickly, however, the term “qualitative meta-synthesis” began to emerge as the most common general descriptor of the emergent genre (Jensen & Allen, 1996; Sandelowski, Docherty, & Emden, 1997; Sherwood, 1999).

From those beginning experiments, a methodological tradition evolved in consideration of how one might actually go about conducting such research. Building on approaches that had been explored in sociology (especially George Ritzer, 1990, and Shenyang Zhao, 1991), Paterson, Thorne, Canam, and Jillings (2001) developed “meta-study” as an applied approach to qualitative synthesis in the health world. The approach they envisioned was inherently critically reflective, in that an integrative synthesis of a body of qualitative studies required that one first undertook a thorough unpacking of the implications of method, theory, and the peculiarities of datasets upon what the available corpus of scholarship did and did not contain. Sandelowski and Barroso followed with practical guidance, explaining in considerable detail why all aspects of a meta-synthesis process were highly complex operations, including even such apparently straightforward steps as finding the findings within a qualitative study (Sandelowski & Barroso, 2002) before attempting to classify, interpret, and integrate them (Sandelowski & Barroso, 2006). These techniques progressed as various authors wrestled with the challenges that any such inquiries invariably entailed and worked out various options for thoughtful meta-synthesis scholarship (Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004).

Over time, however, some varienties of meta-synthesis evolved from the kind of complex team process that many of the originators had envisioned into something of a more rapid-fired and streamlined analytic process. For the most part, these qualitative systematic reviews have become the expected alternative to the conventional literature review in the process of socializing new scholars into health research skill sets. Thus, in recent years, we have seen an upsurge of the relatively technical form of the “systematic” form of all research reviews—qualitative included (Greenhalgh, Thorne, & Malterud, 2018). Increasingly, young scholars are being encouraged to formulate their literature reviews into a tightly focused and highly structured process, along the lines advocated by the Cochrane Collaboration (Higgins & Green, 2011; Morton, Berg, Levit, & Eden, 2011) or the Joanna Briggs Institute (JBI) (Lockwood et al., 2017), for which the defining feature is a predetermined searching, screening, and summarizing rubric applied to answering a narrow research question. The frequency with which qualitative meta-synthesis began to appear in the health research literature grew exponentially (Thorne, 2015, 2017), and continues to rise, and as journal editors will attest, an increasing proportion of these qualitative meta-synthesis reports are styled in the Cochrane/JBI manner—in other words, they are “meta-aggregative” in form and explicitly not interpretive (Lockwood et al., 2017).

What this signifies is that increasing numbers of systematic reviewers are counting or tabulating qualitative research results into reports that sum up the major thematic findings extracted from each study and reduce them to the most commonly reported categorizations (Bergdahl, in press)—which would seem, when one thinks about it, to defeat the purpose. As Sandelowski and colleagues warned back in 1997, the meta-synthesis movement poses something of a threat to the fundamental aspirations that underpinned the development of the qualitative health research enterprise in the first place—which were to counter the reductionism of biomedicine by uncovering the complexity of human health phenomena, shedding light on the subjective experiential aspects of various illness conditions and circumstances, engaging a reader with the sights, smells, sounds, thoughts, and feelings of disease and recovery, and so on:

By its very nature and purposes, qualitative research appears resistant to, and endangered by, efforts 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 epistemologically and ethically inappropriate to attempt to summarize findings from one or more qualitative studies about human experiences of health and illness. (Sandelowski, Docherty, & Emden, 1997, p. 366)

Drawing on the work of Light and Pillemer (1984), they went on to propose that, by virtue of “their emphasis on idiographic knowledge” and the “complexities and contradictions” inherent in particularities, qualitative studies themselves “resist summing up” (Sandelowski, Docherty, & Emden, 1997, p. 366).

These twin trends—first, favoring reviews of the systematic variety over those that are narrative, interpretive, or integrative, and second, privileging the more technical “meta-aggregative” style of qualitative meta-synthesis report over one that represents a more interpretive engagement—are leading to the publication of massive volumes of qualitative “meta-synthesis” reports that seem decidedly counter productive to the entire aim of qualitative health research. In mimicking the style of a carefully controlled meta-analysis designed to get us closer to a singular truth (such as about the efficacy of an intervention under explicit circumstances), these kinds of meta products have the look and feel of something that expects to be considered credible, even as it irons out, waters down, spits out, erodes, and erases all of the gorgeous texture, color, and contour that was the essence of the high quality original qualitative research product. One can fully appreciate why, in the world of quantitative science, one might want to believe that truths can be found that are better than competing truths (the anti-vax campaign being a prime example). But that kind of aim cannot and should not be translated into the fabric of qualitative health research scholarship. What we are in the business of is not truths but ideas—ideas that will enlighten, enrich, elaborate, and enhance the understandings with which one approaches real-life problems in the health arena—the suffering child, the strained caregiving family, the person striving for wellness in the context of disabling forces. To assume that there will be one such understanding that surpasses all prior understandings would be pure arrogance. Rather, we should be seeking to add to the existing armament of ideas and insights available to those who engage in care and service, and to be basing those new insights on carefully constructed and grounded, justifiably argued and transparently crafted ways of thinking about, making sense of, and acting on real world health problems.

Given the current situation in which we find the qualitative meta-synthesis universe, I encourage us to take a step back and ask ourselves why we do what we do, and on what basis we believe it matters. If we are guiding our students and colleagues toward systematic rather than narrative or critically integrative reviews in their literature explorations, let’s fully understand what we are suggesting, and what may be the cost (Thorne, 2018). Possibly (until we find a way to stem the current tide) such products have a higher likelihood of getting published somewhere. But, they may also steer our thinking away from the hard work of inductive reasoning and cross-interrogation of lines of argument—the intellectual skill sets from which all of the truly good ideas have arisen. We are in an era in which our scholarly activity runs the risk of seeming a technical machine operation, pumping out increasing numbers of ever more meaningless bits of output.

In this journal, we can play our part in ensuring that qualitative health reseach remains a distinctive genre for getting at complex and various insights, bringing humanity to the human health dilemma, and advancing rather than stifling deep searching and reflective thinking. Rather than using checklists against which we to test the merit of the qualitative products submitted to us, we will continue to draw on the thoughtful peer review community—engaging representatives of the intended audience of a piece of qualitative scholarship in a dialogue with the author about the degree to which the claims are credible and the accounts reveal a strong and thoughtful inquiry process. For qualitative meta-synthesis reports, we will expect that they provide a convincing argument for the value that they add to our understanding—not reducing but expanding upon what we could have known without them. And as one member of the Qualitative Health Research (QHR) associate editor team, I fervently hope we will always have options such as our Pith, Pearls, and Provocation section, in which literature can be interrogated and wrestled with in a manner that informs and delights us, no matter how unsystematically it may have been gathered. QHR has been a major resource in shaping the development of the genre.

As Jan Morse (1991) wrote in an editorial for the first edition of QHR, we will need to continue to monitor the “goodness” of our research in terms of whether it is “good for the patient” (p. 4). She pointed out that we needed to work on identifying and examining the values and assumptions that are important to our research and understanding their relationship to our research methods and findings. It seems that these are still worthy aspirations as we head closer to the journal’s fourth decade. By returning to our roots and reminding ourselves of why we do this qualitative work in the first place, I think we can find a way to overcome the unfortunate consequences of these current trends and ensure that the abiding hopes of the qualitative health movement are not lost in the shuffle, either in the production of new research or in our efforts to synthesize new insights on the basis of working with collections of it. Time to rediscover the beauty and elegance that is the qualitative health researchproduct when it is done well and understands its distinctive contribution to our evolving knowledge.