Background
The range of different methods for synthesising qualitative research has grown in recent years [
1]. There are now a number of different qualitative synthesis methods including qualitative meta-synthesis, narrative synthesis, thematic synthesis, interpretative synthesis, grounded theory and meta-ethnography. A qualitative synthesis is defined as
‘any methodology whereby study findings are systematically interpreted through a series of expert judgements to represent the meaning of the collected work’ [
2]
.. In a qualitative synthesis the findings of qualitative studies are pooled [
2]
. The use of some types of qualitative syntheses allow for the inclusion of mixed-methods and quantitative research studies alongside qualitative studies. A qualitative synthesis approach can be used to examine the available literature, and review and integrate the primary research studies related to a specific question or phenomenon, to reveal deeper insights or explanations that would not be possible from a single study [
3]. The various qualitative synthesis approaches mentioned above differ in their purposes, philosophical traditions and whether they primarily aggregate or re-interpret the study findings [
4,
5]. Meta-ethnography is an inductive, interpretative approach upon which most interpretative qualitative synthesis methods are based [
6] and is the most commonly utilised qualitative synthesis approach in healthcare research [
7].
Meta-ethnography is particularly suited to developing conceptual models and theories [
8]. This method of qualitative synthesis is often chosen over alternative approaches as it is more suitable for the development of analytical rather than descriptive findings [
9]. A meta-ethnography differs from other qualitative synthesis approaches as the reviewer re-interprets the conceptual data (themes, concepts or metaphors) created by the authors of the primary study whilst taking into account the primary data (participant quotes) using a unique translation synthesis method in order to transcend the findings of individual study accounts and create higher order themes [
10,
11]. Meta-ethnographic reviews offer greater description of methods and higher order interpretation compared to conventional narrative literature reviews [
12]. In health sciences, meta-ethnographies can be used to generate evidence for healthcare and policy [
13]. A meta-ethnographic synthesis approach is suitable when researchers are interested in conceptual or theoretical understandings of a particular phenomenon. Unlike some qualitative synthesis approaches which allow the inclusion of mixed-methods design studies (such as thematic synthesis and interpretative synthesis), a meta-ethnographic approach enables only the inclusion of qualitative studies. A meta-ethnography can include multiple study designs, whereas other approaches such as grounded theory require only the inclusion of similar study approaches [
14].
Although meta-ethnography is a widely used qualitative literature synthesis method within healthcare research, it is poorly demarcated and there is a lack of clarity surrounding the description of the data analysis process. A number of reviews have used this approach [
15‐
20] but do not provide a fully rigorous description of the stages involved in the analysis process. Given the value of qualitative meta-synthesis in integrating the findings from multiple studies into a higher conceptual level, it is important to provide detailed guidance on each of the steps involved in conducting a meta-ethnography. This paper aims to fill this gap by outlining a step-by-step method for conducting meta-ethnography. We describe our interpretation of each of the seven steps outlined by Noblit & Hare [
10] who first proposed this approach. We also incorporate adaptations and developments by recent researchers [
21] and provide annotations where applicable to assist in describing the stages involved.
The worked example we are using is a published meta-ethnography (reference and author names omitted for author anonymity during peer review). Where applicable, illustrative examples from this review are provided alongside the each phase to demonstrate the process.
Within a meta-ethnographic synthesis, the process of translation is key and unique. It is defined as ‘comparing the metaphors and concepts in one account with the metaphors and concepts in others’ [
10]. A meta-ethnography should involve a reciprocal and refutational translation, where possible combined with a line of argument synthesis [
22,
23]. Reciprocal translation occurs when concepts in one study can incorporate those of another [
22], whereas a refutational translation explains and explores differences, exceptions, incongruities and inconsistencies [
1,
22,
24]. Reviewers often overlook refutational translation [
24,
25]; however studies may refute each other [
26,
27] or concepts within studies may refute one another [
27,
28]. Therefore it may be possible to conduct both a reciprocal and refutational translation [
22]. A line of argument synthesis is not an alternative to conducting a translation but is viewed as the next stage of analysis [
23]. A line of argument synthesis is the translation of accounts that interpret different aspects of the same phenomenon under study, which results in producing a whole that is greater than the sum of its individual parts [
10,
15]. Although Noblit & Hare [
10] describe meta-ethnography as a seven step process, it is important to acknowledge that this process is iterative and the phases are not discrete but may overlap and run in parallel [
10]. A meta-ethnography reporting tool, eMERGE has very recently been developed, and provides a framework for reviewers to follow when reporting the important aspects of a meta-ethnography [
22].
Discussion
Meta-ethnography is an evolving approach to synthesising qualitative research and is being increasingly used in healthcare research [
29]. A meta-ethnographic approach offers a greater description of methods and higher-order interpretation (an overarching explanation of a phenomenon that goes beyond what the study parts alone imply), compared to a conventional narrative literature review [
12]. The use of this approach can assist in generating evidence for healthcare staff, researchers and policy-makers. Although this approach is being used by numerous reviewers, transparency on how each of the stages should be conducted is still poor and there is a lack of clarity surrounding the exact stages reviewers utilise to reach their final synthesis [
23]. The ultimate aim of qualitative research synthesis in healthcare is to contribute towards improvements in patient care and experience, as well as improving the processes for healthcare professionals involved [
39]. In order for a meta-ethnography syntheses to be considered to be of high quality and useful, the meta-ethnographic approach needs to be rigorous and consistent. Therefore, a clear understanding of the steps included in a meta-ethnography is vital to produce a synthesis which is rigorous and comprehensive. Poorly reported methods of meta-ethnography can also make it challenging, particularly for early career qualitative researchers to conduct this synthesis. Therefore, we have provided a practical step-by-step guide to assist reviewers with conducting a meta-ethnographic synthesis of qualitative research. High quality qualitative research synthesis should not end with the final write up and further research needs to focus on how the impact of qualitative research can be maximised to improve healthcare.
Like any other method, the meta-ethnographic approach is not without its limitations. Within a meta-ethnography, although reviewers provide a synthesis, this is only one interpretation and as qualitative synthesis is subjective, several alternative interpretations are likely to be possible [
66]. The subjective nature of a meta-ethnography may also affect the representativeness of the synthesis findings. To develop this guide, we searched for articles in a number of ways which is described in detail in the methods section. However, as a systematic literature search was not conducted to identify articles for the development of this guide, there is the potential that this may have resulted in the exclusion of some articles. Whilst we have provided guidance on how to conduct a meta-ethnographic synthesis, it is important to note that this is a flexible guide, which researchers can utilise and adapt the stages, according to their own research questions and the phenomenon under study. Some of the steps and challenges described in this guide hold true for systematic reviews in general. However, this guide aimed to offer practical step-by-step guidance on how to conduct meta-ethnography for even those researchers who may not be experienced in conducting systematic reviews as well as being unfamiliar with a meta-ethnographic approach. This guide was developed to assist with conducting a meta-ethnography within healthcare research. Although this guide would be potentially useful beyond healthcare research, there might be additional challenges and considerations in other research fields which may not be fully captured in this guide.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.