- Email: [email protected]
“Meta-Jeopardy”: The crisis of representation in qualitative metasynthesis
“Meta-Jeopardy”: The crisis of representation in qualitative metasynthesis Margarete Sandelowski, PhD, RN, FAAN
The surge of interest in qualitative metasynthesis coincides with qualitative researchers’ growing concern over the “crisis of representation.” Central to this crisis is the challenge to the assumption that any human subjects inquiry can ever authentically represent those subjects. The crisis of representation is intensified in qualitative metasynthesis projects because of the potentially large differences that can exist between lived and narrated lives, and between participants’ accounts and researchers’ accounts of those accounts, and because of the virtual lack of difference thought to characterize the relationship between reality and representation. This crisis can be offset by offering critical/discursive readings of research reports in addition to traditional empirical/analytical readings. Reviewers can thereby preserve both truth and representational humility as regulative ideals. Clinicians can thereby better appraise the utilization value of qualitative metasyntheses.
moving qualitative research to the center of the evidence-based practice movement and as increasing the capacity of qualitative research findings to make a difference in health care: to contribute to the “development of culturally-sensitive theories, culturallyappropriate research tools, and patient-centered, targeted, or tailored interventions that are effective, feasible, and acceptable to users.”3 The recent turn to qualitative research synthesis coincides with a renewed concern over what has come to be known in the qualitative research community as the “crisis of representation.”7 Central to this crisis is the challenge to the assumption that any human subject inquiry can ever faithfully and fairly represent the lives of those subjects. Qualitative researchers have generally found comfort in the belief that qualitative methods permit more intimate, empathetic, and, therefore, more accurate portrayals of the lives of the participants in their studies than quantitative methods. But the crisis of representation has shown this belief to be naive, at best, and hubris, at worst. Instead of giving voice to the voiceless, qualitative researchers have too often engaged in “ventriloquy,”8 controlling the voices of the voiceless and, thereby, maintaining their voicelessness. Accordingly, the crisis of representation continues to engender in qualitative researchers both “discursive” and “disciplinary anxiety.”9 Discursive anxiety arises from the recognition that scientific inquiry is itself composed of competing and often conflicting discourses (eg, about what truth is and how to reach it). Disciplinary anxiety arises from the recognition that the acceptance of studies as credible is dependent on the judgments of the disciplinary communities (eg, nurses, cancer researchers and clinicians) to which researchers belong and want their studies to appeal. To minimize the dangers of misrepresentation, qualitative researchers have increasingly experimented with artistic modes of representing research participants (eg, in poetry, play, and novel) and with participatory models of inquiry that authorize participants to represent themselves. A growing number of qualitative researchers have even gone so far as to abandon efforts to represent others, retreating instead to forms of research, such as auto-ethnography, where the focus is on the researcher.10 The crisis of representation has generated a spate of literature emphasizing the literary, performa-
Truth can be a synthesis, or an impression.1 If I tried to sum them up, they’d fall apart.2
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he proliferation of qualitative studies and renewed emphasis on the utility of all research findings over the last 20 years, and the rise in the 1990s of evidence-based practice as a paradigm, methodology, and pedagogy for the practice disciplines, have led to the current surge of interest in qualitative research synthesis.3 Qualitative research synthesis (most often referred to in the health sciences as qualitative metasynthesis) refers to the family of methods directed toward the systematic review and integration of findings from qualitative studies in target research domains.4 – 6 Typically conceived as the qualitative counterpart and even foil to quantitative meta-analysis, qualitative metasynthesis projects ideally yield novel yet experientially faithful interpretive integrations of qualitative research findings. Champions of qualitative research synthesis in the health sciences see it as Margarete Sandelowski is a Cary C. Boshamer distinguished Professor at the University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. Reprint requests: Dr. Sandelowski, UNC-CH, School of Nursing, #7460 Carrington Hall, Chapel Hill, NC 27599. E-mail: [email protected] Nurs Outlook 2006;54:10-16. 0029-6554/06/$–see front matter Copyright © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2005.05.004
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tive, political, and discursive aspects of inquiry and research dissemination.11–16 If representation remains a crisis in primary qualitative research, it is a potential calamity in qualitative metasynthesis projects. Although intended to be faithful representations of research participants’ experiences, metasyntheses of qualitative research findings are actually far removed from the lives of those persons participating in empirical qualitative research. Qualitative metasyntheses are composed of reviewers’ transformations of primary research findings, which are themselves composed of researchers’ transformations of the data they collected from (or, in a more constructivist vein, generated in concert with) research participants whose words are, in turn, transformations of their experiences in an unrepeatable “remembering moment.”17 (To avoid confusion, I use the word reviewer to refer to researchers conducting qualitative metasynthesis studies and reserve the word researcher to refer to those persons conducting the primary studies that comprise the sample in qualitative metasynthesis studies.) Qualitative metasyntheses are inescapably interpretations at least 3 times removed from the target experiences under investigation; they are themselves reviewers’ representations of researchers’ representations. And it is this distance from, as opposed to the much-celebrated closeness18 to, data and lived experience that makes the qualitative metasynthesis enterprise a potential representational nightmare placing the entire project in “metajeopardy.”19 The central issue that we who conduct qualitative metasynthesis projects must address, and that is the subject of this article, is how these thrice-removed representations can serve as credible bases for effective and (physically, ethically, and culturally) safe practices. Safe practices are as much functions of power relations20 as they are of such expressly clinical activities as comprehensive appraisal and asepsis. The way research findings can perpetuate imbalances in power between researchers and participants is at the heart of the crisis of representation.
THE CRISIS OF REPRESENTATION AND THE DIFFERENCE PROBLEM The crisis of representation in the qualitative metasynthesis enterprise is complicated by the potentially large differences that may exist between studies, lived and narrated lives, and between participants’ and researchers’ points of view; and by the lack of difference thought to characterize the relationship between reality and representation.
The Differences Complicating Qualitative Metasynthesis Any method to integrate the results of empirical research, whether quantitative meta-analysis or qualitative metasynthesis, must have a means to address the J
“surplus of difference”21 between studies. Most often referred to in the quantitative meta-analysis literature as the problem of heterogeneity, this surplus of difference has been recurrently identified as the most important factor complicating the systematic reviews and syntheses of both quantitative and qualitative research findings.22–24 Even studies of ostensibly the same variables or phenomena employing ostensibly common methodological approaches will have differences that require finding a common metric or translation to enable the integration of findings. Reviewers conducting qualitative metasynthesis projects, in particular, must address the differences that exist not only among studies (ie, in research focus, theoretical framework, and methodology), but also among lives-as-lived, lives-as-experienced, and livesas-told.25 Even those narrating their own lives cannot fully close the gap between the events in their lives and their narratives of those events. Writers, in turn, cannot fully close the gap between these narratives and the texts they write to convey them. Spatiotemporal gaps always exist between an event (which is itself the construal of something as an event with a beginning and ending), the experiential (eg, cognitive, sensory) recall of that event, the telling and hearing of that event in an interview, and the written text depicting the event. These gaps in proximity to a lived event preclude the assumption of any one-to-one correspondence between lived event and its transformations into told, recorded, and re-told event.26 In the qualitative metasynthesis enterprise, as in the primary qualitative research on which it is based, large differences may also exist between interpretive and theoretical validity.27 As Maxwell defined these terms, interpretive validity refers to the accurate presentation of the meanings research participants intended to communicate in the accounts of their lives they give to researchers, while theoretical validity refers to researchers’ credible accounts of these accounts. The magnitude of difference that can exist between them is recurrently demonstrated when “they”—research participants— read and disagree with what “we” researchers write about them.28 Borland29 described the “interpretive conflict” that can arise from researchers’ “second-level” narrative re-shaping of participants’ personal narratives resulting in the complaint: “‘that’s not what I said.’” Lawless30 described the complexities of “negotiating interpretive differences” between researchers and participants. The literature addressing member validation and the disciplinary commitments of researchers to certain methodological stances, theories, and political agendas emphasizes the array of epistemological, ethical, and legal factors accounting for the differences between what participants intended to convey at the time they told their stories to researchers and what they wanted to convey after reading researchers’ transformations of their first accounts.24,31,32 Qualitative research-
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ers are regularly compelled to navigate the rocky terrain between voice and discourse.33 When, as in qualitative metasynthesis projects, the “they” are the researchers who conduct studies and disseminate their findings in research reports, and the “we” are the reviewers who strive to synthesize their findings, the problem of representing research participants faithfully and fairly is exponentially increased. In qualitative metasynthesis studies, the actors whose points of view are the targets of inquiry are other researchers, not the people who participated in their studies. The theoretical validity of qualitative metasyntheses rests on getting researchers’ interpretations right, not those of the research participants, per se, whose experiences have been transformed by researchers in the writing of their reports. Qualitative research findings are composed of these interpretations and it is only through the interpretations of researchers that reviewers have access to research participants.
representation. For example, until the advent of the Visible Human Project and its digitized images of the human body, the body was depicted as a book, with the layers of the body successively peeled away in imitation of turning the pages in a book. Waldby37 interpreted the science of anatomy as a “kind of writing practice” that makes the “body . . . readable.” The anatomy atlas does not “illustrate” bodies so much as it “demonstrates” them. Anatomical displays are not representations of the body as it is; rather, the body we know at any one moment is a function of how it is displayed. The patient record is conceived as a writing practice that constitutes the patient.38 The conventional report of scientific research is similarly conceived as a writing practice that shapes what comes to be taken as scientific knowing and knowledge. Studies are written in such a way as to conform to prescribed forms for reporting research, most notably, the APA/experimental style report.39 The research report is not a passive reflection of a study, but rather plays an active role in (re)producing what is conventionally understood to be a scientific study. In short, anatomy, the patient record, and the research report are representations that do not index reality so much as they constitute it.
The Lack of Difference Complicating Qualitative Metasynthesis The large differences that can exist between lived and re-told lives, and between interpretive and theoretical validity, coupled with the virtual lack of difference between reality and representation, further complicate the qualitative research synthesis enterprise. Qualitative research is deemed to exist “at the lived border (emphasis in original) of reality and representation.”34 Indeed, for increasing numbers of qualitative researchers, no line is deemed to exist between them; what is taken to be reality is representation. Influenced by postmodern skepticism that empirical research can ever result in knowledge about anything other than researchers themselves, scholars in the social sciences have called attention to the extent to which scientific findings are composed of representations. Whereas a line used to be comfortably drawn between reality and representations of reality, social science and cultural studies over the last 20 years have promoted an “effacement of difference”35 between reality and representation. In their influential ethnographic study of Laboratory Life, Latour and Woolgar36 described the creation of “inscriptions” as constituting the work of science. For them, science is wholly comprised of these inscriptions, or the simplifications (eg, traces, charts, models, figures) that scientists create in the process of seeking to discover reality. For them, scientific discovery is scientific invention as reality, or nature, is what is made visible in the way nature is represented. Nature never exists by itself but always as nature-as-inscribed by scientists. Cultural studies of human anatomy have shown the science of anatomy to be almost wholly comprised of highly stylized visual depictions of the human body that represent not the body per se, but rather reflect, reproduce, and reinforce prevailing conventions for scientific 12
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ADDRESSING THE CRISIS OF REPRESENTATION The large gap that can exist between lived and re-told lives, and participants’ accounts and researchers’ accounts of those accounts, coupled with the postmodern tendency to minimize or deny that any gap exists between reality and representation, appear to subvert efforts to synthesize research findings. These orientations to difference (affirmation on the one hand and denial on the other) seem to counter the empirical/ analytical orientation to most qualitative research conducted in the health sciences and undermine the incorporation of qualitative research into evidence-based practice. In empirical/analytical inquiry, findings are viewed as “truthful. . . makeovers”40 of actual experience. Even to speak of findings is to assume that things exist out there waiting to be found: to assume a line between reality and the way that reality is depicted. The assumption that this line exists is a foundation of research synthesis and evidence-based practice.
Empirical/Analytical versus Critical/Discursive Readings of Qualitative Research Reports Although differences exist between quantitative and qualitative research syntheses, qualitative metasynthesis is typically conceived in the health sciences as the qualitative but still empirical/analytical counterpart to quantitative meta-analysis in that it is advanced as a methodology to build a usable knowledge base derived from cross-study syntheses of findings. Primary research findings are treated as if they represented something real about the lives featured in them. To ask a O
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research question—such as, how do couples respond to and manage a positive fetal diagnosis?—is to assume that it is possible to answer it by drawing conclusions, or generalizing, from a series of studies with such couples. Whereas qualitative metasynthesis projects conducted in an empirical/analytical frame of mind maintain the line between representation and reality, such projects conducted in a critical/ discursive frame of mind erase that line as qualitative metasynthesis is itself treated as discourse. In this kind of “meta-study,” exemplified in the work of Barbara Paterson, Sally Thorne, and their colleagues,41 the crisis of representation is front and center. The analysis and subsequent synthesis of the research findings presented in research reports is secondary to the analysis of the disciplinary, cultural, and other discourses or meta-narratives informing or dominating a body of empirical research. Here, qualitative findings become “creature[s] of the very worldliness . . . studie[d]” as the very possibility of building a “corpus of durable, stable findings” is called into question.42 When qualitative metasynthesis is treated as discourse, “it is unclear whether findings within an interpreted world can ever be found again.”42 Instead of “finding” that, for example, loss pervades couples’ experience of positive fetal diagnosis, reviewers focus on the discourse of loss itself: how it came to prevail as an interpretive frame for understanding this experience, what this discourse accomplishes, and for whom. Here, reviewers are conducting a kind of insider research as they are studying the habits of other researchers like themselves. Reviewers make visible the very language and social practices that underlie research findings. Just as representation is a feature of reality, researchers’ theoretical formulations of events are considered features of these events. This critical orientation suggests an alternative to an empirical/ analytical reading of findings. For example, in lieu of the finding that loss pervades the experience of positive fetal diagnosis is the finding that loss pervades researchers’ depictions of the experience of positive fetal diagnosis. In a critical/discursive reading, reviewers investigate how this came to be and why. Moreover, reviewers may argue that it is the latter finding that explains the former finding.
Assuming a “Quadri-Hermeneutic” Stance Toward Qualitative Metasynthesis To address the crisis of representation intensified in qualitative metasynthesis projects, reviewers must make room for both empirical/analytical and critical/ discursive readings of research reports. They must continue to strive to create credible empirical integrations of qualitative research findings, but also to conduct reflexive “meta-analyses” of the processes by which these integrations are produced. Finlay43 defined reflexivity as researchers’ engagement in an “explicit J
. . .methodological[ly] self-consciousness . . . self-aware meta-analysis of the research process,” whereby the subjectivity inherent in all inquiry is transformed from problem to opportunity. In qualitative metasynthesis, this involves reviewers tacking back and forth between doing the traditional, empirical work of metasynthesis and thinking about how this work gets done. Objectivity in qualitative metasynthesis becomes an achievement of a disciplined subjectivity and reflexivity, which is itself a form of meta-study.43– 47 The goal of reviewers is to preserve and enhance the empirical quality of metasyntheses, while acknowledging the discursive processes at work in their production. For qualitative metasynthesis to mean anything in the practice disciplines, reviewers have to maintain a primary commitment to producing “faithful accounts of a ‘real’ world”: if not to big TRUTH, then to a “small[er]‘t’ truth.”9 But when they take an empirical/analytical view, reviewers must recognize that they are operating “as if truth holds still.”6 Murphy & Dingwall48 differentiated between radical relativism, the paralyzing ontological stance from which no truths can be achieved, and subtle realism, whereby inquiry is pursued with truth as a “regulative ideal.” Reviewers accept that truth is inescapably socially constructed, and that although multiple versions of truth can exist, multiple contradictory versions of it cannot. This can look like straddling the fence, or like “having your cake and eating it too.” Yet, in a more positive light, it can be seen as the qualitative research version of alternative explanation, satisfying the agenda to “postmodernize” inquiry by developing a sufficient amount of “representational humility.”6 Avoiding the excesses of both un-reflexive inquiry (where findings are non-problematically taken to be reflections of reality) and hyper-reflexive inquiry (where no one and nothing are studied but researchers and the research process),3,49,50 reviewers can engage in a “quadrihermeneutics,”51 making space for and showing awareness of the possibility of several alternative readings of the body of empirical research under investigation. When reviewers assume a quadri-hermeneutic stance toward the qualitative research synthesis enterprise, they: (a) maintain contact with the empirical material, while (b) demonstrating consciousness of the series of interpretive acts entailed in any effort to synthesize research findings, (c) clarifying (as necessary) the political-ideological contexts of the body of research that is the focus of study, and (d) addressing (as necessary) issues involving authority and representation.51 Although offering a host of interpretations may seem at odds with the evidence-based practice imperative to offer one (albeit provisional) synthesis, such methodological shape-shifting optimizes the validity of this synthesis by virtue of acknowledging the disciplinary commitments and ideologies contributing to it. Critical
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readings serve as alternative explanations for the empirical/analytical readings constituting evidence syntheses. By offering alternative readings of the findings in research reports, qualitative metasynthesis takes its place alongside quantitative meta-analysis in the evidence-based practice arena, but does not become so imitative of it that the critical imperatives of qualitative research are undermined.52 A concern among qualitative researchers as they see the growing popularity of qualitative research is that it will lose its distinctive and even revolutionary character by becoming more like quantitative research.53 Reviewers can take an empirical/analytical view in one report, alluding to alternative view(s) in the discussion section. An example of this is the Sandelowski and Barroso54 report of a qualitative metasynthesis, in which the reviewers offered a synthesis of findings pertaining to motherhood in HIV-positive women derived from an empirical/analytical reading of primary research findings and then offered an alternative discursive reading. In the former, women’s talk about motherhood was taken to be an index of their experiences of motherhood; in the latter, it was taken to be a strategy that women, researchers, and reviewers used to accomplish certain identities. Reviewers can use two or more reports to showcase different readings. An example of a program of research involving empirical/analytical and critical/discursive readings of primary research reports is that of Barbara Paterson, Sally Thorne, and their colleagues.55,56 They refer to their research program as “meta-study,” which involves not only the effort to integrate research findings, but also to critique the theories and methods used to produce them.41 Their initial research purpose, to synthesize empirical qualitative research on chronic illness, led to more critical treatments in which they analyzed disciplinary, theoretical, and methodological trends in chronic illness research and how these trends shaped findings in this field. This encompassing approach to meta-work has much in common with the shifting perspectives model of chronic illness57 Paterson proposed as a theoretical synthesis of findings whereby illness is, at some times, in the foreground of people’s lives, while, at other times, it is in the background. This tacking back and forth between different readings is also akin to the “paradox of the parallax” Thorne6 proposed, whereby the conclusions observers draw change relative to shifts in their viewing position. Critical readings of research reports may be foreground or background to empirical/analytical readings.
in a manner that acknowledges the language and social practices that constitute them even while maintaining truth as a regulative ideal. This effort to improve the transparency of the makeup of research findings is especially important for clinicians whose primary interests are in the pragmatic (are the findings usable?) and ethical (should the findings be used?) validity of research syntheses. Understanding the different ways that any one set of synthesized findings may be taken is essential to clinicians who must choose the “take” they find most useful and most worthy of use. To offset the potential meta-jeopardy of the tale thrice-removed from the teller’s lived life, reviewers can offer “thrice-told tale(s)”58 that serve as caveats to and foils for each other. That is, they can offer the metasyntheses themselves (or the evidence syntheses conducted from an empirical/analytical stance) and the critical readings that constitute alternative explanations or foundations for them. By doing so, they will address not only the crisis of representation but also maintain the critical character of qualitative research and enhance the credibility and “utilization value”59 of the evidence syntheses at the heart of evidence-based practice. References 1. Hazzard S. The great fire. New York, NY: Picador; 2003. p. 46. 2. Hegi U. The vision of Emma Blau. New York, NY: Scribner; 2001. p. 351. 3. Sandelowski M. Using qualitative research. Qual Health Res 2004;14:1366-86. 4. Finfgeld DL. Metasynthesis: the state of the art—so far. Qual Health Res 2003;13:893-904. 5. Sandelowski M, Docherty S, Emden C. Qualitative metasynthesis: issues and techniques. Res Nurs Health 1997;20:365-71. 6. Thorne S, Jensen L, Kearney MH, Noblit G, Sandelowski M. Qualitative metasynthesis: reflections on methodological orientation and ideological agenda. Qual Health Res 2004; 14: 1342-65. 7. Smith JK. Representation, crisis of. In: Lewis-Beck MS, Bryman A, Liao, TF, editors. The SAGE encyclopedia of social science research methods. Vol. 3. Thousand Oaks, CA: Sage; 2004. p. 962-3. 8. Fine M. Dis-stance and other stances: negotiations of power inside feminist research. In: Gitlin A, editor. Power and method: political activism and educational research. New York, NY: Routledge; 1994. p. 13-35. 9. Michalowski RJ. Ethnography and anxiety: field work and reflexivity in the vortex of U.S.-Cuban relations. In: Hertz R, editor. Reflexivity & voice. Thousand Oaks, CA: Sage; 1997. p. 45-69. 10. Ellis C. The ethnographic I: a methodological novel about autoethnography. Walnut Creek, CA: AltaMira Press; 2004. 11. Cheek J. Taking a view: qualitative research as representation. Qual Health Res 1996;6:492-505.
THRICE-TOLD TALES TO OFFSET THRICE-REMOVED TALES Systematic reviews of research, whether qualitative metasynthesis or quantitative meta-analysis, become more credible and usable if conducted and presented 14
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12. Clifford J, Marcus GE, editors. Writing culture: the poetics and politics of ethnography. Berkeley, CA: University of California Press; 1986. 13. Geertz C. Works and lives: the anthropologist as author. Stanford, CA: Stanford University Press; 1988. 14. Richardson L. Writing: a method of inquiry. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks, CA: Sage; 2000:923-48. 15. Tierney WG. (Re)Presentation and voice. Qual Inquiry 1995;1:379-90. 16. Van Maanen J. Tales of the field: on writing ethnography. Chicago, IL: University of Chicago Press; 1988. 17. Spence DP. Narrative truth and historical truth: meaning and interpretation in psychoanalysis. New York, NY: Norton; 1982. 18. Richards L. Closeness to data: the changing goals of qualitative data handling. Qual Health Res 1998;8:319-28. 19. Richardson L. Meta-Jeopardy. Qual Inquiry. 1998;4:464468. Richardson used the word meta-jeopardy in an entirely different context. Although I borrow the word from her here, the meaning I give it is wholly my own. 20. Kirkham SR, Smye V, Tang S, Anderson J, Blue C, Browne A, et al. Rethinking cultural safety while waiting to do fieldwork: methodological implications for nursing research. Res Nurs Health 2002;25:222-32. 21. Page RN. The turn inward in qualitative research. Harv Educ Rev 2000:70;23-38. 22. Cooper H. Synthesizing research: a guide for literature reviews. 3rd ed. Thousand Oaks, CA: Sage; 1998. 23. Mulrow C, Langhorne P, Grimshaw J. Integrating heterogeneous pieces of evidence in systematic reviews. Ann Intern Med 1997:127;989-95. 24. Thorne S, Joachim G, Paterson B, Canam C. Influence of the research frame on qualitatively derived health science. International J Qual Methods. 2002;1(1): Article 1. On line journal at http://www.ualberta.ca/⬃ijqm/english/engframeset. html 25. Bruner EM. Introduction: the opening up of anthropology. In: Plattner S, Bruner EM, editors. Text, play and story: The construction and reconstruction of self and society. Washington, DC: American Ethnological Society; 1984. p. 1-16. 26. Van Loon J. Ethnography: a critical turn in cultural studies. In: Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, editors. Handbook of ethnography. London: Sage; 2001: p. 273-84. 27. Maxwell JA. Understanding and validity in qualitative research. Harv Educat Rev 1992;62:279-300. 28. Brettell CB, editor. When they read what we write: the politics of ethnography. Westport, CT: Bergin & Garvey; 1993. 29. Borland K. “That’s not what I said”: interpretive conflict in oral narrative research. In: Gluck SB, Patai D, editors. Women’s words: The feminist practice of oral history. New York, NY: Routledge;1991. p. 63-75. 30. Lawless EJ. “I was afraid someone like you . . . an outsider . . . would misunderstand”: negotiating interpretive differences between ethnographers and subjects. J Amer Folklore 1992;105:302-14. 31. Sandelowski M. Rigor, or rigor mortis: the problem of rigor in qualitative research revisited. ANS 1993;16:1-8.
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32. Smythe WE, Murray MJ. Owning the story: ethical considerations in narrative research. Ethics Behav 2000; 10:311-36. 33. Saukko P. Between voice and discourse: quilting interviews on anorexia. QI 2000;6:299-317. 34. Gubrium JF, Holstein JA. The new language of qualitative method. New York, NY: Oxford University Press; 1997. 35. Munro R. Ideas of difference: stability, social spaces and labor of division. In: Hetherington K, Munro R, editors. Ideas of difference: social spaces and the labor of division. Oxford, UK: Blackwell; 1997. p. 3-24. 36. Latour B, Woolgar S. Laboratory life: the construction of scientific facts. Princeton, NJ: Princeton University Press; 1986. 37. Waldby C. Virtual anatomy: from the body in the text to the body on the screen. J Med Human 2000;21:85-107. 38. Berg M. Practices of reading and writing: the constitutive role of the patient record in medical work. Sociol Health Illn 1996;18:499-524. 39. Bazerman C. Shaping written knowledge: the genre and activity of the experimental article in science. Madison, WI: University of Wisconsin Press; 1988. 40. Mantzoukas S. Issues of representation within qualitative inquiry. Qual Health Res 2004;14:994-1007. 41. Paterson BL, Thorne SE, Canam C, Jillings C. Meta-study of qualitative health research: a practical guide to meta-analysis and meta-synthesis. Thousand Oaks, CA: Sage; 2001. 42. Macbeth D. Qualitative methods and the “analytic gaze”: an affirmation of scientism? Interchange 1998;29:137-168. 43. Finlay L. “Outing” the researcher: the provenance, process, and practice of reflexivity. Qual Health Res 2002;12:531-45. 44. Kincheloe JL. Educational historiographical meta-analysis: rethinking methodology in the 1990s. Qual Studies Educ 1991;4:231-45. 45. Marcus GE. What comes (just) after “post”? The case of ethnography. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. Thousand Oaks, CA: Sage; 2000: 563-74. 46. Babcock BA. Reflexivity: definitions and discriminations. Semiotica 1980;30:1-14. 47. Macbeth D. On “reflexivity” in qualitative research: two readings, and a third. QI 2001;7:35-68. 48. Murphy E, Dingwall, R. The ethics of ethnography. In: Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, editors. Handbook of ethnography. London: Sage;2001. p. 339-51. 49. Charmaz K, Mitchell RG. The myth of silent authorship: Self, substance, and style in ethnographic writing. In: Hertz R, editor. Reflexivity & voice. Thousand Oaks, CA: Sage; 1997. p. 193-215. 50. Alcoff L. The problem of speaking for others. Cultural Critique 1991;20:5-32. 51. Alvesson M, Sköldberg K. Reflexive methodology: new vistas for qualitative research. London: Sage; 2000. 52. Barbour RS, Barbour M. Evaluating and synthesizing qualitative research: the need to develop a distinctive approach. J Eval Clin Prac 2003;9:179-86. 53. Cheek J. Advancing what? Qualitative research, scholarship, and the research imperative. Qual Health Res 2002;12:113040.
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54. Sandelowski M, Barroso J. Motherhood in the context of maternal HIV infection. Res Nurs Health 2003;26:47082. 55. Paterson B, Canam C, Joachim G, Thorne S. Embedded assumptions in qualitative studies of fatigue. West J Nurs Res 2003;25:119-33. 56. Thorne S, Paterson B, Acorn S, Canam C, Joachim G, Jillings C. Chronic illness experience: insights from a metastudy. Qual Health Res 2002;12:437-52.
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The surge of interest in qualitative metasynthesis coincides with qualitative researchers’ growing concern over the “crisis of representation.” Central to this crisis is the challenge to the assumption that any human subjects inquiry can ever authentically represent those subjects. The crisis of representation is intensified in qualitative metasynthesis projects because of the potentially large differences that can exist between lived and narrated lives, and between participants’ accounts and researchers’ accounts of those accounts, and because of the virtual lack of difference thought to characterize the relationship between reality and representation. This crisis can be offset by offering critical/discursive readings of research reports in addition to traditional empirical/analytical readings. Reviewers can thereby preserve both truth and representational humility as regulative ideals. Clinicians can thereby better appraise the utilization value of qualitative metasyntheses.
moving qualitative research to the center of the evidence-based practice movement and as increasing the capacity of qualitative research findings to make a difference in health care: to contribute to the “development of culturally-sensitive theories, culturallyappropriate research tools, and patient-centered, targeted, or tailored interventions that are effective, feasible, and acceptable to users.”3 The recent turn to qualitative research synthesis coincides with a renewed concern over what has come to be known in the qualitative research community as the “crisis of representation.”7 Central to this crisis is the challenge to the assumption that any human subject inquiry can ever faithfully and fairly represent the lives of those subjects. Qualitative researchers have generally found comfort in the belief that qualitative methods permit more intimate, empathetic, and, therefore, more accurate portrayals of the lives of the participants in their studies than quantitative methods. But the crisis of representation has shown this belief to be naive, at best, and hubris, at worst. Instead of giving voice to the voiceless, qualitative researchers have too often engaged in “ventriloquy,”8 controlling the voices of the voiceless and, thereby, maintaining their voicelessness. Accordingly, the crisis of representation continues to engender in qualitative researchers both “discursive” and “disciplinary anxiety.”9 Discursive anxiety arises from the recognition that scientific inquiry is itself composed of competing and often conflicting discourses (eg, about what truth is and how to reach it). Disciplinary anxiety arises from the recognition that the acceptance of studies as credible is dependent on the judgments of the disciplinary communities (eg, nurses, cancer researchers and clinicians) to which researchers belong and want their studies to appeal. To minimize the dangers of misrepresentation, qualitative researchers have increasingly experimented with artistic modes of representing research participants (eg, in poetry, play, and novel) and with participatory models of inquiry that authorize participants to represent themselves. A growing number of qualitative researchers have even gone so far as to abandon efforts to represent others, retreating instead to forms of research, such as auto-ethnography, where the focus is on the researcher.10 The crisis of representation has generated a spate of literature emphasizing the literary, performa-
Truth can be a synthesis, or an impression.1 If I tried to sum them up, they’d fall apart.2
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he proliferation of qualitative studies and renewed emphasis on the utility of all research findings over the last 20 years, and the rise in the 1990s of evidence-based practice as a paradigm, methodology, and pedagogy for the practice disciplines, have led to the current surge of interest in qualitative research synthesis.3 Qualitative research synthesis (most often referred to in the health sciences as qualitative metasynthesis) refers to the family of methods directed toward the systematic review and integration of findings from qualitative studies in target research domains.4 – 6 Typically conceived as the qualitative counterpart and even foil to quantitative meta-analysis, qualitative metasynthesis projects ideally yield novel yet experientially faithful interpretive integrations of qualitative research findings. Champions of qualitative research synthesis in the health sciences see it as Margarete Sandelowski is a Cary C. Boshamer distinguished Professor at the University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. Reprint requests: Dr. Sandelowski, UNC-CH, School of Nursing, #7460 Carrington Hall, Chapel Hill, NC 27599. E-mail: [email protected] Nurs Outlook 2006;54:10-16. 0029-6554/06/$–see front matter Copyright © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2005.05.004
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tive, political, and discursive aspects of inquiry and research dissemination.11–16 If representation remains a crisis in primary qualitative research, it is a potential calamity in qualitative metasynthesis projects. Although intended to be faithful representations of research participants’ experiences, metasyntheses of qualitative research findings are actually far removed from the lives of those persons participating in empirical qualitative research. Qualitative metasyntheses are composed of reviewers’ transformations of primary research findings, which are themselves composed of researchers’ transformations of the data they collected from (or, in a more constructivist vein, generated in concert with) research participants whose words are, in turn, transformations of their experiences in an unrepeatable “remembering moment.”17 (To avoid confusion, I use the word reviewer to refer to researchers conducting qualitative metasynthesis studies and reserve the word researcher to refer to those persons conducting the primary studies that comprise the sample in qualitative metasynthesis studies.) Qualitative metasyntheses are inescapably interpretations at least 3 times removed from the target experiences under investigation; they are themselves reviewers’ representations of researchers’ representations. And it is this distance from, as opposed to the much-celebrated closeness18 to, data and lived experience that makes the qualitative metasynthesis enterprise a potential representational nightmare placing the entire project in “metajeopardy.”19 The central issue that we who conduct qualitative metasynthesis projects must address, and that is the subject of this article, is how these thrice-removed representations can serve as credible bases for effective and (physically, ethically, and culturally) safe practices. Safe practices are as much functions of power relations20 as they are of such expressly clinical activities as comprehensive appraisal and asepsis. The way research findings can perpetuate imbalances in power between researchers and participants is at the heart of the crisis of representation.
THE CRISIS OF REPRESENTATION AND THE DIFFERENCE PROBLEM The crisis of representation in the qualitative metasynthesis enterprise is complicated by the potentially large differences that may exist between studies, lived and narrated lives, and between participants’ and researchers’ points of view; and by the lack of difference thought to characterize the relationship between reality and representation.
The Differences Complicating Qualitative Metasynthesis Any method to integrate the results of empirical research, whether quantitative meta-analysis or qualitative metasynthesis, must have a means to address the J
“surplus of difference”21 between studies. Most often referred to in the quantitative meta-analysis literature as the problem of heterogeneity, this surplus of difference has been recurrently identified as the most important factor complicating the systematic reviews and syntheses of both quantitative and qualitative research findings.22–24 Even studies of ostensibly the same variables or phenomena employing ostensibly common methodological approaches will have differences that require finding a common metric or translation to enable the integration of findings. Reviewers conducting qualitative metasynthesis projects, in particular, must address the differences that exist not only among studies (ie, in research focus, theoretical framework, and methodology), but also among lives-as-lived, lives-as-experienced, and livesas-told.25 Even those narrating their own lives cannot fully close the gap between the events in their lives and their narratives of those events. Writers, in turn, cannot fully close the gap between these narratives and the texts they write to convey them. Spatiotemporal gaps always exist between an event (which is itself the construal of something as an event with a beginning and ending), the experiential (eg, cognitive, sensory) recall of that event, the telling and hearing of that event in an interview, and the written text depicting the event. These gaps in proximity to a lived event preclude the assumption of any one-to-one correspondence between lived event and its transformations into told, recorded, and re-told event.26 In the qualitative metasynthesis enterprise, as in the primary qualitative research on which it is based, large differences may also exist between interpretive and theoretical validity.27 As Maxwell defined these terms, interpretive validity refers to the accurate presentation of the meanings research participants intended to communicate in the accounts of their lives they give to researchers, while theoretical validity refers to researchers’ credible accounts of these accounts. The magnitude of difference that can exist between them is recurrently demonstrated when “they”—research participants— read and disagree with what “we” researchers write about them.28 Borland29 described the “interpretive conflict” that can arise from researchers’ “second-level” narrative re-shaping of participants’ personal narratives resulting in the complaint: “‘that’s not what I said.’” Lawless30 described the complexities of “negotiating interpretive differences” between researchers and participants. The literature addressing member validation and the disciplinary commitments of researchers to certain methodological stances, theories, and political agendas emphasizes the array of epistemological, ethical, and legal factors accounting for the differences between what participants intended to convey at the time they told their stories to researchers and what they wanted to convey after reading researchers’ transformations of their first accounts.24,31,32 Qualitative research-
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ers are regularly compelled to navigate the rocky terrain between voice and discourse.33 When, as in qualitative metasynthesis projects, the “they” are the researchers who conduct studies and disseminate their findings in research reports, and the “we” are the reviewers who strive to synthesize their findings, the problem of representing research participants faithfully and fairly is exponentially increased. In qualitative metasynthesis studies, the actors whose points of view are the targets of inquiry are other researchers, not the people who participated in their studies. The theoretical validity of qualitative metasyntheses rests on getting researchers’ interpretations right, not those of the research participants, per se, whose experiences have been transformed by researchers in the writing of their reports. Qualitative research findings are composed of these interpretations and it is only through the interpretations of researchers that reviewers have access to research participants.
representation. For example, until the advent of the Visible Human Project and its digitized images of the human body, the body was depicted as a book, with the layers of the body successively peeled away in imitation of turning the pages in a book. Waldby37 interpreted the science of anatomy as a “kind of writing practice” that makes the “body . . . readable.” The anatomy atlas does not “illustrate” bodies so much as it “demonstrates” them. Anatomical displays are not representations of the body as it is; rather, the body we know at any one moment is a function of how it is displayed. The patient record is conceived as a writing practice that constitutes the patient.38 The conventional report of scientific research is similarly conceived as a writing practice that shapes what comes to be taken as scientific knowing and knowledge. Studies are written in such a way as to conform to prescribed forms for reporting research, most notably, the APA/experimental style report.39 The research report is not a passive reflection of a study, but rather plays an active role in (re)producing what is conventionally understood to be a scientific study. In short, anatomy, the patient record, and the research report are representations that do not index reality so much as they constitute it.
The Lack of Difference Complicating Qualitative Metasynthesis The large differences that can exist between lived and re-told lives, and between interpretive and theoretical validity, coupled with the virtual lack of difference between reality and representation, further complicate the qualitative research synthesis enterprise. Qualitative research is deemed to exist “at the lived border (emphasis in original) of reality and representation.”34 Indeed, for increasing numbers of qualitative researchers, no line is deemed to exist between them; what is taken to be reality is representation. Influenced by postmodern skepticism that empirical research can ever result in knowledge about anything other than researchers themselves, scholars in the social sciences have called attention to the extent to which scientific findings are composed of representations. Whereas a line used to be comfortably drawn between reality and representations of reality, social science and cultural studies over the last 20 years have promoted an “effacement of difference”35 between reality and representation. In their influential ethnographic study of Laboratory Life, Latour and Woolgar36 described the creation of “inscriptions” as constituting the work of science. For them, science is wholly comprised of these inscriptions, or the simplifications (eg, traces, charts, models, figures) that scientists create in the process of seeking to discover reality. For them, scientific discovery is scientific invention as reality, or nature, is what is made visible in the way nature is represented. Nature never exists by itself but always as nature-as-inscribed by scientists. Cultural studies of human anatomy have shown the science of anatomy to be almost wholly comprised of highly stylized visual depictions of the human body that represent not the body per se, but rather reflect, reproduce, and reinforce prevailing conventions for scientific 12
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ADDRESSING THE CRISIS OF REPRESENTATION The large gap that can exist between lived and re-told lives, and participants’ accounts and researchers’ accounts of those accounts, coupled with the postmodern tendency to minimize or deny that any gap exists between reality and representation, appear to subvert efforts to synthesize research findings. These orientations to difference (affirmation on the one hand and denial on the other) seem to counter the empirical/ analytical orientation to most qualitative research conducted in the health sciences and undermine the incorporation of qualitative research into evidence-based practice. In empirical/analytical inquiry, findings are viewed as “truthful. . . makeovers”40 of actual experience. Even to speak of findings is to assume that things exist out there waiting to be found: to assume a line between reality and the way that reality is depicted. The assumption that this line exists is a foundation of research synthesis and evidence-based practice.
Empirical/Analytical versus Critical/Discursive Readings of Qualitative Research Reports Although differences exist between quantitative and qualitative research syntheses, qualitative metasynthesis is typically conceived in the health sciences as the qualitative but still empirical/analytical counterpart to quantitative meta-analysis in that it is advanced as a methodology to build a usable knowledge base derived from cross-study syntheses of findings. Primary research findings are treated as if they represented something real about the lives featured in them. To ask a O
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research question—such as, how do couples respond to and manage a positive fetal diagnosis?—is to assume that it is possible to answer it by drawing conclusions, or generalizing, from a series of studies with such couples. Whereas qualitative metasynthesis projects conducted in an empirical/analytical frame of mind maintain the line between representation and reality, such projects conducted in a critical/ discursive frame of mind erase that line as qualitative metasynthesis is itself treated as discourse. In this kind of “meta-study,” exemplified in the work of Barbara Paterson, Sally Thorne, and their colleagues,41 the crisis of representation is front and center. The analysis and subsequent synthesis of the research findings presented in research reports is secondary to the analysis of the disciplinary, cultural, and other discourses or meta-narratives informing or dominating a body of empirical research. Here, qualitative findings become “creature[s] of the very worldliness . . . studie[d]” as the very possibility of building a “corpus of durable, stable findings” is called into question.42 When qualitative metasynthesis is treated as discourse, “it is unclear whether findings within an interpreted world can ever be found again.”42 Instead of “finding” that, for example, loss pervades couples’ experience of positive fetal diagnosis, reviewers focus on the discourse of loss itself: how it came to prevail as an interpretive frame for understanding this experience, what this discourse accomplishes, and for whom. Here, reviewers are conducting a kind of insider research as they are studying the habits of other researchers like themselves. Reviewers make visible the very language and social practices that underlie research findings. Just as representation is a feature of reality, researchers’ theoretical formulations of events are considered features of these events. This critical orientation suggests an alternative to an empirical/ analytical reading of findings. For example, in lieu of the finding that loss pervades the experience of positive fetal diagnosis is the finding that loss pervades researchers’ depictions of the experience of positive fetal diagnosis. In a critical/discursive reading, reviewers investigate how this came to be and why. Moreover, reviewers may argue that it is the latter finding that explains the former finding.
Assuming a “Quadri-Hermeneutic” Stance Toward Qualitative Metasynthesis To address the crisis of representation intensified in qualitative metasynthesis projects, reviewers must make room for both empirical/analytical and critical/ discursive readings of research reports. They must continue to strive to create credible empirical integrations of qualitative research findings, but also to conduct reflexive “meta-analyses” of the processes by which these integrations are produced. Finlay43 defined reflexivity as researchers’ engagement in an “explicit J
. . .methodological[ly] self-consciousness . . . self-aware meta-analysis of the research process,” whereby the subjectivity inherent in all inquiry is transformed from problem to opportunity. In qualitative metasynthesis, this involves reviewers tacking back and forth between doing the traditional, empirical work of metasynthesis and thinking about how this work gets done. Objectivity in qualitative metasynthesis becomes an achievement of a disciplined subjectivity and reflexivity, which is itself a form of meta-study.43– 47 The goal of reviewers is to preserve and enhance the empirical quality of metasyntheses, while acknowledging the discursive processes at work in their production. For qualitative metasynthesis to mean anything in the practice disciplines, reviewers have to maintain a primary commitment to producing “faithful accounts of a ‘real’ world”: if not to big TRUTH, then to a “small[er]‘t’ truth.”9 But when they take an empirical/analytical view, reviewers must recognize that they are operating “as if truth holds still.”6 Murphy & Dingwall48 differentiated between radical relativism, the paralyzing ontological stance from which no truths can be achieved, and subtle realism, whereby inquiry is pursued with truth as a “regulative ideal.” Reviewers accept that truth is inescapably socially constructed, and that although multiple versions of truth can exist, multiple contradictory versions of it cannot. This can look like straddling the fence, or like “having your cake and eating it too.” Yet, in a more positive light, it can be seen as the qualitative research version of alternative explanation, satisfying the agenda to “postmodernize” inquiry by developing a sufficient amount of “representational humility.”6 Avoiding the excesses of both un-reflexive inquiry (where findings are non-problematically taken to be reflections of reality) and hyper-reflexive inquiry (where no one and nothing are studied but researchers and the research process),3,49,50 reviewers can engage in a “quadrihermeneutics,”51 making space for and showing awareness of the possibility of several alternative readings of the body of empirical research under investigation. When reviewers assume a quadri-hermeneutic stance toward the qualitative research synthesis enterprise, they: (a) maintain contact with the empirical material, while (b) demonstrating consciousness of the series of interpretive acts entailed in any effort to synthesize research findings, (c) clarifying (as necessary) the political-ideological contexts of the body of research that is the focus of study, and (d) addressing (as necessary) issues involving authority and representation.51 Although offering a host of interpretations may seem at odds with the evidence-based practice imperative to offer one (albeit provisional) synthesis, such methodological shape-shifting optimizes the validity of this synthesis by virtue of acknowledging the disciplinary commitments and ideologies contributing to it. Critical
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readings serve as alternative explanations for the empirical/analytical readings constituting evidence syntheses. By offering alternative readings of the findings in research reports, qualitative metasynthesis takes its place alongside quantitative meta-analysis in the evidence-based practice arena, but does not become so imitative of it that the critical imperatives of qualitative research are undermined.52 A concern among qualitative researchers as they see the growing popularity of qualitative research is that it will lose its distinctive and even revolutionary character by becoming more like quantitative research.53 Reviewers can take an empirical/analytical view in one report, alluding to alternative view(s) in the discussion section. An example of this is the Sandelowski and Barroso54 report of a qualitative metasynthesis, in which the reviewers offered a synthesis of findings pertaining to motherhood in HIV-positive women derived from an empirical/analytical reading of primary research findings and then offered an alternative discursive reading. In the former, women’s talk about motherhood was taken to be an index of their experiences of motherhood; in the latter, it was taken to be a strategy that women, researchers, and reviewers used to accomplish certain identities. Reviewers can use two or more reports to showcase different readings. An example of a program of research involving empirical/analytical and critical/discursive readings of primary research reports is that of Barbara Paterson, Sally Thorne, and their colleagues.55,56 They refer to their research program as “meta-study,” which involves not only the effort to integrate research findings, but also to critique the theories and methods used to produce them.41 Their initial research purpose, to synthesize empirical qualitative research on chronic illness, led to more critical treatments in which they analyzed disciplinary, theoretical, and methodological trends in chronic illness research and how these trends shaped findings in this field. This encompassing approach to meta-work has much in common with the shifting perspectives model of chronic illness57 Paterson proposed as a theoretical synthesis of findings whereby illness is, at some times, in the foreground of people’s lives, while, at other times, it is in the background. This tacking back and forth between different readings is also akin to the “paradox of the parallax” Thorne6 proposed, whereby the conclusions observers draw change relative to shifts in their viewing position. Critical readings of research reports may be foreground or background to empirical/analytical readings.
in a manner that acknowledges the language and social practices that constitute them even while maintaining truth as a regulative ideal. This effort to improve the transparency of the makeup of research findings is especially important for clinicians whose primary interests are in the pragmatic (are the findings usable?) and ethical (should the findings be used?) validity of research syntheses. Understanding the different ways that any one set of synthesized findings may be taken is essential to clinicians who must choose the “take” they find most useful and most worthy of use. To offset the potential meta-jeopardy of the tale thrice-removed from the teller’s lived life, reviewers can offer “thrice-told tale(s)”58 that serve as caveats to and foils for each other. That is, they can offer the metasyntheses themselves (or the evidence syntheses conducted from an empirical/analytical stance) and the critical readings that constitute alternative explanations or foundations for them. By doing so, they will address not only the crisis of representation but also maintain the critical character of qualitative research and enhance the credibility and “utilization value”59 of the evidence syntheses at the heart of evidence-based practice. References 1. Hazzard S. The great fire. New York, NY: Picador; 2003. p. 46. 2. Hegi U. The vision of Emma Blau. New York, NY: Scribner; 2001. p. 351. 3. Sandelowski M. Using qualitative research. Qual Health Res 2004;14:1366-86. 4. Finfgeld DL. Metasynthesis: the state of the art—so far. Qual Health Res 2003;13:893-904. 5. Sandelowski M, Docherty S, Emden C. Qualitative metasynthesis: issues and techniques. Res Nurs Health 1997;20:365-71. 6. Thorne S, Jensen L, Kearney MH, Noblit G, Sandelowski M. Qualitative metasynthesis: reflections on methodological orientation and ideological agenda. Qual Health Res 2004; 14: 1342-65. 7. Smith JK. Representation, crisis of. In: Lewis-Beck MS, Bryman A, Liao, TF, editors. The SAGE encyclopedia of social science research methods. Vol. 3. Thousand Oaks, CA: Sage; 2004. p. 962-3. 8. Fine M. Dis-stance and other stances: negotiations of power inside feminist research. In: Gitlin A, editor. Power and method: political activism and educational research. New York, NY: Routledge; 1994. p. 13-35. 9. Michalowski RJ. Ethnography and anxiety: field work and reflexivity in the vortex of U.S.-Cuban relations. In: Hertz R, editor. Reflexivity & voice. Thousand Oaks, CA: Sage; 1997. p. 45-69. 10. Ellis C. The ethnographic I: a methodological novel about autoethnography. Walnut Creek, CA: AltaMira Press; 2004. 11. Cheek J. Taking a view: qualitative research as representation. Qual Health Res 1996;6:492-505.
THRICE-TOLD TALES TO OFFSET THRICE-REMOVED TALES Systematic reviews of research, whether qualitative metasynthesis or quantitative meta-analysis, become more credible and usable if conducted and presented 14
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54. Sandelowski M, Barroso J. Motherhood in the context of maternal HIV infection. Res Nurs Health 2003;26:47082. 55. Paterson B, Canam C, Joachim G, Thorne S. Embedded assumptions in qualitative studies of fatigue. West J Nurs Res 2003;25:119-33. 56. Thorne S, Paterson B, Acorn S, Canam C, Joachim G, Jillings C. Chronic illness experience: insights from a metastudy. Qual Health Res 2002;12:437-52.
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