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Qualitative Metasynthesis

Qualitative Metasynthesis presents a research method developed for

upcycling and synthesis of qualitative primary studies, aimed at re-
searchers within medicine and health sciences.
This book demonstrates why and how qualitative metasynthesis can
be a method for reuse and expansion of medical knowledge. It pre-
sents the principles of metasynthesis as a qualitative research method,
so that the reader can assess whether this is a research strategy that fits
the aim of their study. The author offers practical advice for conduct-
ing research using this methodology. The presentation is illustrated
by a study carried out by the author and collaborators, reflecting on
real-life challenges and solutions as an example of meta-ethnography,
one of the most frequently used strategies for qualitative metasynthe-
sis. The author also refers to systematic reviews, a methodology devel-
oped within in the tradition of evidence-based medicine, discussing
strengths, weaknesses and pitfalls of this methodology. Rooted in the
interpretative paradigm, qualitative metasynthesis challenges several
of the principles from the evidence-based medicine tradition, offering
reflections on challenges when epistemologically very different meth-
odologies intersect.
This book should be considered essential reading for anyone carry-
ing out qualitative research within the fields of medicine, health and
social care.

Kirsti Malterud, MD PhD, was a general practitioner for 35 years, com-

bined with academic work as a researcher at Uni Research/NORCE
Research Centre and a Professor of General Practice at the University
of Bergen, Norway. Her list of research publications is extensive, with
empirical studies about vulnerable groups of patients as well as meth-
odological contributions on qualitative research methods.
Qualitative Metasynthesis
A Research Method for Medicine
and Health Sciences

Kirsti Malterud
First published in English 2019
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
52 Vanderbilt Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2019 Kirsti Malterud
Translated from Norwegian into English by Kirsti Malterud
The right of Kirsti Malterud to be identified as author of this
work has been asserted by her in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Published in Norwegian by Universitetsforlaget 2017
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book

ISBN: 978-0-367-13418-1 (hbk)

ISBN: 978-0-429-02634-8 (ebk)
Typeset in Times New Roman
by codeMantra
Contents

List of abbreviations ix
Preface xi

1 Utilization and upcycling of existing research

knowledge 1
We do not have to start from scratch 1
Qualitative studies – an open mind, but
no blank slates 1
Research waste or exploiting knowledge capital? 2
Recycling, upcycling and sustainable
management of knowledge resources 3
What will this book offer you? 4
The role of the nursing home doctor in
end-of-life care – a concrete example 5
From chaos and individual research reports
to systematic reviews 6
Comprehensive and critical reading of
the research literature 6
The information deluge 8
Broad mapping 8
Systematic reviews – a specific kind of
research literature summary 9
Evidence from research results 11
Multipurpose knowledge capital 11
Evidence-based medicine 12
Different research questions require
different evidence from relevant
methodologies 13
vi Contents
From summary and renarration to
interpretation and synthesis 15
Descriptive, interpretative or both? 15
Meta-analysis 16
Qualitative metasynthesis 17
Which kinds of research questions can
be studied with qualitative metasynthesis? 19

2 Project planning and literature management 21

Careful preparations are profitable investments 21
Summing up research – a stepwise process 21
A research question that is both flexible
and determined 22
Choosing a strategy 23
The protocol 24
Registration of the project 25
Literature search 25
Overview and steady course 26
Search strategy 27
Search terms in logical combinations 28
Search sources and databases 30
Grey literature 31
Language 32
Before you set off seriously 33
Screening and selection of potentially
relevant primary studies 33
Reference management 33
Systematic screening and rough classification 34
Reading candidate articles in depth
with quality assessment 35
Supplementary search 37
What characterizes your sample? 38
Flowsheet for search and selection 38
Hallmarks of the primary studies 40
Identification of results from the
primary studies 44
Organizing the material from data
extraction 45
 Contents vii
3 Analysis and synthesis 47
Interpretation of the results from the primary studies 47
Synthesis is more than summary and
renarration 47
Levels of interpretation – concepts of
first, second and third orders 48
Different strategies for metasynthesis 50
Meta-ethnography 51
Background 52
Metaphors and translations 52
Analytical perspectives 53
Strategy for analysis – seven steps 54
The matrix as a tool for analysis 54
A specific example of analysis and synthesis 56
Contemporary meta-ethnography 60
Other methods for qualitative metasynthesis 62
Critical interpretive synthesis 62
Thematic synthesis 64
Realist synthesis 65
Reporting your study – writing the article 66
Elements in the article 66
Method, material and analysis 68
Synthesis and results 70
Transparency in reporting qualitative
metasyntheses 74

4 Theoretical and methodological challenges 75

Qualitative methods encounter evidence-based
medicine 75
Scientific paradigms 75
Common features, differences and opposites 76
Social anthropology and metasynthesis 77
A complete and independent literature review? 78
Situated knowledges 79
Cherry picking 80
Finding the needle in the haystack 82
Independent appraisals or bias? 83
viii Contents
Which evidence is the best evidence? 84
The evidence hierarchy 85
A universal gold standard? 86
Grading of evidence 88
New pyramids 89
Diversity or standardization of knowledge 90
Merging apples and oranges – the
synthesis of heterogeneous data 91
Sustainable evidence 92
Three steps forward and two steps back 93
Grading of qualitative metasynthesis 95
Mixed methods and qualitative metasynthesis 97
Qualitative and quantitative methods
in the same study 97
Multi-methodological exploration of
complex research questions 98
Qualitative metasynthesis with mixed methods 98
Synthesis of qualitative primary studies
with different designs 100

5 Final comments 101

Ethics and privacy protection 101
Regulations and approvals 101
Distance as a challenge 102
Contributing something new 103
What do you need to conduct a qualitative
metasynthesis? 104
Competence and experience 104
Relevant primary studies with useful
presentations of results 105
Resources and personal traits 106
Set off! 107
You are not alone 107
Newer and more exciting 107
Wheat or chaff? 108
Sustainable competence – new
opportunities for collaboration 108

References 109
Index 125
Abbreviations

Abbreviation Full concept Explanation

CASP Critical Appraisal Skills Checklist for qualitative studies

Programme
CERQual Confidence in the Method for grading evidence
evidence from reviews quality and strength of
of qualitative research recommendations in
qualitative metasyntheses
CFS/ME Chronic fatigue
syndrome/Myalgic
encephalopathy
CINAHL The Cumulative Index Database of research literature
to Nursing and Allied
Health Literature
CMO Context (C), mechanism Analysis with realist synthesis
(M), outcome (O) focusing on conditions for
intervention
COREQ Consolidated criteria for Checklist for qualitative studies
reporting qualitative
research
EBM Evidence-based medicine
ENTREQ Enhancing Transparency Checklist for reporting
in Reporting qualitative metasyntheses
the Synthesis of
Qualitative Research
EQUATOR Enhancing the quality Flow sheet for reporting
and transparency of literature searches and
health research reviews
GRADE Grading of Method for grading evidence
recommendations quality and strength of
assessment, recommendations in
development and systematic reviews
evaluation
GT Grounded theory A method for qualitative
analysis
(Continued)
x Abbreviations
Abbreviation Full concept Explanation

MEDLINE Medical literature Database of research literature

analysis and retrieval
system online
MM Mixed methods
NHD Nursing home doctor
NOKC Norwegian Knowledge Independent government unit
Centre for the Health
Services
PICO Population-Intervention- Acronym developed for
Comparison-Outcome literature searches of
systematic reviews of
intervention studies
PROSPERO International prospective Database of systematic reviews
register of systematic
reviews
QMARS Qualitative Meta- Reporting standards developed
analysis Article by American Psychological
Reporting Standards Association
QUADAS Quality Assessment of Methodology for systematic
Diagnostic Accuracy reviews of studies of
Studies diagnostic tests
RCT Randomized Controlled
Trial
SPIDER Sample, Phenomenon Acronym developed for
of Interest, Design, literature searches for
Evaluation, Research qualitative metasyntheses
type
SR Systematic review
Preface

After some decades of engagement with qualitative research methods

in medicine and health sciences, I have become increasingly preoc-
cupied by knowledge as something that is built by communities of
researchers. With previous knowledge as our points of departure,
we want to challenge the old knowledge and develop new. Too often,
though, we start nearly from scratch, as if we were the first ever to
explore a certain problem. To obtain an overview of the research lit-
erature is an important precondition to find out what is missing to
set out on one’s own project. Summing up what we come across in a
systematic way may also evolve into an independent research project.
Qualitative metasynthesis is a specific research method for the system-
atic review, upcycling and synthesis of qualitative primary studies.
With this book, I am addressing researchers from medicine and
health sciences, especially PhD students and postdocs with back-
ground knowledge from qualitative studies. The methodological
traditions in these disciplines are heavily influenced by biomedicine,
epidemiology and quantitative research. Special attention to the pres-
entation of and arguments for the interpretative paradigm underly-
ing qualitative methods is still needed. Evidence-based medicine has
had a particularly powerful impact on the methodology of systematic
reviews within this field, especially regarding literature search and
selection and ideas of standardization and generalization, originally
developed for very different kinds of data and analysis. Important
paradigmatic challenges are raised by this situation and deserve the
specific discussion offered in this book. Still, the book is not about
systematic reviews in general – they are discussed only as far as their
methodology frames qualitative metasynthesis.
The book is intended to contribute to the elaboration of qualita-
tive methodology skills, to demonstrate the use of qualitative meta-
synthesis as a tool for upcycling and expanding the medical field of
xii Preface
knowledge and to offer practical advice for conducting these kinds of
studies. I present principles and procedures specific to metasynthesis
as a qualitative method, giving the reader an opportunity to consider
whether it is a research strategy that is suited to the research aim of a
given study.
This book refers to my selection of empirical studies as well as
texts about methodological and theoretical issues which are reflected
in a comprehensive list of references. My aim is to present principles
and procedures for the most frequently used methods in the con-
text of other available strategies. I selected Noblit and Hare’s meta­-
ethnography as the method to be presented in more detail, but I am
not offering a comprehensive overview of all existing strategies for
qualitative metasynthesis.
My writing process has itself been a kind of qualitative meta-­
metasynthesis, in which I have tried to translate the different contri-
butions into one another in order to develop new connections. I have
emphasized the presentation of practical procedures and issues related
to sustainability of knowledge with qualitative metasynthesis as a tool.
Furthermore, I have taken the opportunity to reflect on and discuss
the scientific strengths, weaknesses and pitfalls related to these strate-
gies. A study in which I participated serves as an example throughout
the book to elucidate specific challenges and solutions.
However, this book is not only meant to be a practical textbook.
Qualitative metasynthesis challenges several of the paradigms in
which the evidence-based medicine tradition and the systematic re-
view methodology are entrenched. Such considerations offer a point
of departure for reflections on the most urgent challenges arising when
two epistemologically very different methodologies intersect.
I am grateful to many people for their support, advice and specific
contributions. My workplace, the Research Unit for General Prac-
tice/NORCE Norwegian Research Centre, Bergen, Norway directed
by Sabine Ruths, offers daily recognition and encouragement. Anette
Fosse, a general practitioner in Mo i Rana, Norway, opened the door
to her own PhD project about the role of the nursing home doctor at
the end of life and agreed to have her project serve as an example in the
book. Signe Flottorp and Lillebeth Larun from the Norwegian Insti-
tute of Public Health have provided valuable comments along the way.
Randi Bolstad and Regina Küfner Lein at the University of B ­ ergen
Library, Department of Medicine and Dentistry, have shared their
professional skills as research librarians. Countless discussions in the
cross-disciplinary “Knowledge, power and health services” research
group with the always optimistic Anne Karen Bjelland and Kari Tove
 Preface xiii
Elvbakken raised many important questions. Sally Thorne and Trish
Greenhalgh encouraged the translation from Norwegian to English
and commented on ethical regulations and approvals.
Fortunately, my supporters do not agree about everything, and as
the author, I take full responsibility for the text and its content. ­Berlin,
Germany, was a wonderful place to find a deeper understanding, con-
centration, inspiration and joy first in writing the book in its origi-
nal Norwegian version and in finishing the translation to English two
years later.
Finally, I wish to thank many researchers I have not met – the au-
thors of the research articles I used as the foundation for writing this
book. Building stone by stone, we may together contribute to progress
and development instead of standing still or walking in circles.
Bergen, May 2019
Kirsti Malterud
1 Utilization and upcycling of
existing research knowledge

We do not have to start from scratch

Research should build on the existing base of knowledge. As r­ esearchers
we acquaint ourselves with, challenge and extend the understanding
and insights mediated by those who have come before us. A thorough
and critical literature review can constitute a point of departure for
new projects and serve as the basis for independent and innovative re-
search that upcycles existing knowledge by finding new uses for and
value in that knowledge. Synopses and syntheses of existing research
knowledge can also offer new insights beyond what we already know,
for what we already know is what we generally notice in the evidence we
­encounter. Systematic reflection is therefore an important precondition
for ­upcycling existing research knowledge to fulfil scientific criteria.

Qualitative studies – an open mind, but no blank slates

Qualitative research methods are often used to explore themes with
limited research evidence. We draw conclusions by moving from the
particular to the general, focusing on subjectivity during data collec-
tion and interpretation and analysis (Malterud, 2001b, 2017b). The field
of epistemology focuses on knowledge about knowledge. The episte-
mological preconditions for qualitative research methods are rooted
in the interpretative paradigm (see Chapter 4), but our interpretations
are not arbitrary. They must be reached with professional reflexivity
in order to become research knowledge (Alvesson & Sköldberg, 2009).
Qualitative methods are better suited to developing new questions
than to repeating previous answers. As the explicit aim is to develop
original and relevant knowledge, the qualitative researcher often takes
up the position of explorer or traveller (Kvale, 1996), with a feeling of
entering a jungle in which nobody has previously tread. This researcher
2 Upcycling of existing knowledge
identity is supported by using inductive approaches with qualitative
research methods. Being researchers, however, we do not have blank
slates when we enter the field and encounter empirical data.
To be sure, some qualitative methodology traditions argue that the
best point of departure is to start the research project with an open
mind and enter the field without any preconceptions. I disagree with this
position. We certainly do not start with answers decided on in advance,
but it is not possible to wipe the slate entirely clean and reset human
imagination and experience (Morse, 1994). As human beings, we always
take along inner images of how the world looks as to the questions we
want to answer or elucidate. We always belong to some context or other
of existing knowledge and understanding. The qualitative researcher
might therefore need an extra reminder that we do not need to start
from scratch every time we set off on a new research project.

Research waste or exploiting knowledge capital?

The concept of research waste has appeared on the academic agenda
in recent years (Chalmers et al., 2014). We are wasting research if we
do not sensibly use what is already there. Knowledge is power and
should be shared. Within the academic community, research evi-
dence is regarded as a joint asset, and we can contribute to the fur-
ther ­development of knowledge capital by the best possible utilization
of knowledge provided by other researchers. Instead of starting from
scratch, we should therefore establish an overview of existing evi-
dence, taking a qualified and critical perspective (Britten et al., 2017).
Independent of a research aim or method, the project will benefit from
a comprehensive literature search as a point of departure to identify
the foundation and establish an appropriate starting point.
In this way, I can first pay due respect to my colleagues and prevent
arrogance. Otherwise, my enthusiastic starting mood might seduce
me into thinking that I am the first or the only or the best researcher
to explore the topic in question. A reality orientation can support a
calming, sobering counterbalance when I find my own research ques-
tion to be amazingly original, and I will often discover that somebody
already has been close to the issue I want to explore. Perhaps an ex-
cellent study has recently been published, illuminating my aim bet-
ter than I could. Instead of seeing this as having lost a competition,
I can rather imagine that I am participating in a relay race in which
I ­recognize the teammate who passes me the baton as a great point of
departure for my own leg.
 Upcycling of existing knowledge 3
Second, I am spared much unnecessary extra work by finding out
what research has already been done about the issue. When I can stand
on the shoulders of others, I do not have to start from zero myself
(­Moher et al., 2016). By means of a comprehensive literature search,
it is likely that I will meet hitherto unknown like-minded ­colleagues –
researchers from different parts of the world who share my interest and
have already explored parts of the topic that are perhaps not exactly
what I want to pursue myself. Hence, I can obtain good raw materials
that help me to mould my research aim without simply repeating what
is already known. I can also use my recently acquired insights to make
connections for further collaboration. In this way, the potential for
developing more original knowledge is enhanced, which will provide a
bonus from the editors and reviewers who will assess the contributions
as to readability and originality.
Third, a literature review can always give access to learning and new
insights, even in a subject that I think I already know well. New pub-
lications may appear, presenting questions, perspectives, methods or
results that push me forward with new ideas about my field of research
or my plans. Such inspirations are more easily put into practice when
they appear early in the research process. Closer to the end, more is
needed to substantially change my mind or direction.

Recycling, upcycling and sustainable management

of knowledge resources
Recycling, a concept developed and promoted by the environmental
movement, means that items that have apparently become redundant
or unnecessary are used again instead of simply being thrown away
(Rosvold, 2012). Recycling is a logical response to waste and a meas-
ure to counteract the preventable destruction of valuable commodities
and environmental contamination. Two students furnish their home
with a couch and a dining table set aside by a middle-aged couple.
Dresses from the 1980s become popular retro clothing among hipsters
in 2018. Useful objects are being utilized in a new context, and instead
of becoming garbage or contamination, old items are given new op-
portunities in new frames. Upcycling means “to upcycle (something)
in such a way that the resulting product is of a higher value than the
original item” (Merriam Webster Dictionary). This is something other
than the transformation of garbage, where objects are dissolved into
raw materials and reused in something completely different, as when
soda bottles become a fleece sweater.
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