Nurse author & Editor, 2016, 26(3), 3
As a faculty member, journal manuscript reviewer, grant reviewer, and mentor for scholars I have the opportunity to read many manuscript drafts, student papers, dissertations, scholarly reports, and grant proposals. Writers that I work with can easily summarize material but seem to struggle to adequately synthesize knowledge about their topic and express that in their writing. Synthesizing materials for a literature review seems to be particularly hard for writers to do well. Until recently I struggled to articulate how to do this work and thought if I just told others to synthesize they would understand what that meant, but that wasn’t the case. It turns out I wasn’t alone facing this teaching challenge as faculty who typically guide students find it challenging to help students learn how to synthesize material (Blondy, Blakesless, Scheffer, Rubenfeld, Cronin, & Luster-Turner, 2016; Kearney, 2015). Also, since there are many ways to synthesize the same information, it can be approached in different ways, making it even harder to explain to novices. Many writers need help learning how to perform this challenging task and there may be some ways to explain and guide this process for struggling writers.
Synthesis requires decision making, analysis, evaluation, and creation of new material, all rather high levels of thinking. These are skills that people use every day in nursing practice and probably don’t even think about it. The Merriam-Webster dictionary defines synthesis as something that is made by combining different things or the composition or combination of parts or elements so as to form a whole (Synthesis, n.d.). In other words, it involves taking information from a variety of sources, evaluating that information and forming new ideas or insights in an original way.
Building solid synthesis skills is important for nurses, writers, and researchers. Quality evidence-based practice initiatives and nursing care are based on understanding and evaluating the resources and research available, identifying gaps, and building a strong foundation for future work. Putting the data gathered, references read, and literature analyzed together in a new way that shows connections and relationships is what good synthesis is all about.
Steps to Synthesis
Synthesizing literature requires the use of several steps of the taxonomy of cognitive learning. The first step involves identifying the topic or defining the problem. Having a clear focus on the issue will help as you search the literature for relevant resources to review. It is important to have sufficient references to ensure that you have an adequate knowledge base about the topic. As you read the references you have gathered, learn what is known about the topic. Apply your critiquing skills and consider what was reported, what the findings mean in relationship to the topic, and what contribution it makes to the literature. Analyze each part of the reference and identify important information. Think about conclusions you can draw from the readings and how the references are related. As you evaluate the merit of each reference, appraise the work and compare and contrast what you are reading. At this point you will be using critical thinking skills to make judgments about the readings and assessing strengths and weaknesses. The last step of synthesis involves creating, the highest level of cognitive learning in the most recent revision of Bloom’s taxonomy of learning (Anderson, Krathwohl, Airasian, Cruikshank, Mayer, Pintrich, Raths, & Wittrock, 2001). Creating involves the construction of a new product. This is more than just repeating what is found in the original sources. It involves mental reorganization or drawing from those sources to generate a new idea. You will be combining the information from the readings into something new.
Many people find it helpful to create a literature review matrix or summary table to help sort and organize information and guide the synthesis process. This matrix is basically a table that summarizes key components of the readings. Information from each source reviewed is entered horizontally on the table. If reviewing research articles, the vertical columns of the matrix might include items such as the research problem/purpose, variables, design, sample, methods, findings, implications, and limitations. See Table 1 for a literature review matrix table template. After critically reading and appraising the rigor of the work, extract critical information from the article and enter that onto the literature review matrix. Record information in each column for all sources read and evaluated. Many novice writers simply use this table to then summarize each article when writing their literature review; however, this is not sufficient. To truly synthesize the literature, new information needs created. So, review the columns of the matrix and look for commonalities, areas of agreement and disagreement, and patterns of findings between studies. Compare and contrast the information across the different readings (Blondy et al., 2016). As you complete the matrix, review each column of the matrix and consider how the information is related. Make judgments about the readings and their relationship to each other. Pay particular attention to the findings column as you make your assessments from study to study. If there are many sources it may be helpful to use colored highlighters to visually identify and group common elements found in the matrix (Pinch, 1995). Use the common elements or themes that emerge from this critical review to organize your writing and construct your new ideas. As you review the columns you will also want to look for missing elements that emerge in the literature as those gaps will be important to report. Those gaps will provide you with suggestions for future research needed about the topic.
Once you have completed this review it is time to begin writing. Sometimes it is helpful to start writing the literature synthesis with an overview or general statement about common themes that emerged. Then, move onto writing about the specific components of the reviewed studies that provide support for your synthesis. You will be providing enough supportive details from the articles reviewed to build your case for your conclusions. The details you include when writing about the reviewed studies should provide the reader with context but should not resemble an abstract of the reviewed study. Refrain from using too many quotes for the reviewed articles (Galvan, 2009). The work that is found in good synthesized literature reviews will use your own words and not just excerpted statements from the references.
Table 1. Literature Review Matrix Template
Remember you are organizing the review by ideas and not by sources. The literature review is not just a summary of the already published works. Your synthesis should show how various articles are linked. Use connecting words or words that show transitions such as argues, suggests, agrees, disagrees, similarly, also, likewise, alternatively, conversely, in contrast, furthermore, or additionally to show how the references are related. These words, along with details from the sources, help to demonstrate your comparison and synthesis of the readings.
There are some common problems that writers experience when synthesizing literature and some things that can tip you off that you may not be writing the synthesis correctly. Of course, there are exceptions to these suggestions, but the items described below should force you to at least take a second look and question if your work is synthesizing the readings appropriately. There is not one absolute right way of writing about the synthesis as each topic and the literature may lead to differing approaches, but there are some correct ways to write about the findings and some common errors.
One error previously mentioned involves summary. If each paragraph of your literature review only describes one article then you may not be connecting references and creating new information appropriately. It is difficult to compare if you are only describing one source. Many writers that struggle with synthesizing literature use a cookie cutter approach. I typically see this used by graduate students who have many references and are writing the literature review portion for a capstone project or dissertation. They are struggling to incorporate a large number of readings and have limited time to complete their work. Some try to simplify their writing by using the same standard format for each paragraph or section that they write. Study information is very repetitive and easy to spot as information is just replaced from paragraph to paragraph. The template they use is something like the following: Authors YYY and ZZZZ studied variables AAA and BBB using tools Q, R, and S in their sample of X number of participants. Using statistical tests MM and NN they found OO and TT. Of course, there is a little more information reported and the order of information may change but you get the idea of how easy it would be to just substitute various components from the literature review matrix for each study. In an inadequate effort to make connections, those linking words mentioned above are inserted to transition from one study to the next or from paragraph to the next. When authors write using this format their work resembles an abstract or summary of the study and is not sufficient for a literature review that should be demonstrating synthesis and creation of new ideas. The writer needs to go beyond summary, repetition and even critique.
Unfortunately there is no exact or prescriptive approach that can be used as a guide when doing this writing. It will vary with each topic synthesized. Figure 1 may help to illustrate the difference between summary and synthesis.
Completing a synthesis of the literature also requires an adequate familiarity of the topic. Ensuring that you have read enough literature about the topic is critical. Sometimes beginners gather only a few articles about a topic or locate articles that are loosely related and then try to synthesize information. Novice writers may have difficulty because there is inadequate information or limited materials for comparison. Ensuring that a comprehensive literature search was conducted can help to alleviate this potential problem. Another related problem involves overlapping articles or studies with conflicting findings. Slight discrepancies between sources may be difficult to understand and explain. Students may not have the necessary skills for reading and critiquing difficult and complex research articles. They need to have developed strong foundational research knowledge and understand the research concepts before they can effectively read, filter, and analyze research reports.
Lastly, writing a synthesized literature review is risky. It requires the writer to be open minded and articulate new ideas. For some writers who are used to just repeating what is already in the literature, this is a new and potentially challenging experience.
Faculty and writing mentors who have good synthesis and writing skills can do some things that will assist others to learn this skill. They can role model the approaches used. It is helpful to show examples of the work they have done that involves synthesis. Showing struggling writers copies of completed literature review matrices and the corresponding finished literature reviews may be helpful. This teaching tool can visually show new writers how to move from the matrix to the paragraph. It is also helpful to encourage novices to read a variety of literature and suggest they examine the literature reviews and see how others have synthesized information.
Since synthesis involves the use of critical thinking, analysis and evaluation skills developing those skills can be crucial for success. Use the following questions to guide your reading. Review literature with these questions in mind. Faculty can also help students by using these sort of questions when teaching or discussing literature.
- What is the purpose of the reading?
- What issues are raised?
- What evidence is given?
- Why is this important?
- What are the implications?
- What are the strengths?
- What are the weaknesses?
- How is this reading like others I have read?
- How is this reading different than the other articles?
- What might be influencing the findings?
- What common elements are seen?
- What information is missing?
- What are the gaps?
Literature that is synthesized and reported properly contributes to nursing knowledge. It plays a vital role in guiding nursing practice and advancing research helping readers to understand what is known and not known about a topic. Synthesizing literature may still be challenging but understanding the steps to follow, adhering to the helpful hints, and avoiding the common pitfalls may assist in development of this important writing skill.
- Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K. A., Mayer, R. E., Pintrich, P. R., . . . Wittrock, M. C. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom’s taxonomy of educational objectives. New York, NY: Longman.
- Blondy, L. C., Blakeslee, A. M., Scheffer, B. K., Rubenfeld, M. G., Cronin, B. M., & Luster-Turner, R. (2016). Understanding synthesis across disciplines to improve nursing education. Western Journal of Nursing, 38(6), 668-685. doi: 10.1177/0193945915621720
- Galvan, J. L. (2009). Writing literature reviews. Glendale, CA: Pyrczak Publishing.
- Kearney, M. H. (2015). Moving from facts to wisdom: Facilitating synthesis in literature reviews. Research in Nursing and Health, 39, 3-6. doi: 10.1002/nur.21706
- Pinch, W. J. (1995). Synthesis: Implementing a complex process. Nurse Educator, 20(1), 34-40.
- Synthesis [Def. 1]. (n.d.). Merriam-Webster Online. In Merriam-Webster. Retrieved June 15, 2016, from http://www.merriam-webster.com/dictionary/citation.
About the Author
Teresa Shellenbarger, PhD, RN, CNE, ANEF is a Professor in the Department of Nursing and Allied Health Professions at Indiana University of Pennsylvania, Indiana, PA where she teaches graduate nursing courses. Dr. Shellenbarger also frequently mentors new faculty and graduate students as they develop into scholars and emerging writers. She is a member of the Authors-in-Residence for Nurse Author & Editor.
NAE 2016 26 3 3 Shellenbarger
Copyright 2016: The Author. May not be reproduced without permission.
Journal Complication Copyright 2016: John Wiley and Son Ltd
Ever since childhood, my dream was to be a nurse with my main desire being to serve and care for people in need. Now that am already into my dream profession I serve with empathy and compassion which has given me great satisfaction in what I do to an extent that given another opportunity to choose a career, my first priority would still be nursing. I believe that for one to deliver as a nurse patients must be in a position to access quality health care services at the right time, from the right providers and in a way that services given are engineered to meet their individual needs at a particular time. My education has brought change positive change by helping me acquire indispensable values that not only guide my career but my personal life too. The understanding of nursing as a discipline has gone a long way into helping me understand theories that explain the logic behind how the patients I meet behave. I have acquired this knowledge from a variety of sources ranging from books, to lectures as well as interpersonal relationships with both my clients and other health professionals.
As I continue to advance, acquisition of new knowledge with each single day of practice will continue to progress as I meet new patients. If it does not add value to my clinical judgment, I consider the patients affiliations, social status and race of no significant importance for I believe each person has a right to health irrespective of who they are. Each patient deserves my respect and attention that is constant regardless of who they are. It is time that we carried the nursing profession a notch higher where nurses will not serve only for monetary benefits that come along with the profession but will be guided by ethical practices associated with nursing as a vocation. This begins with the creation of enabling environment for patients, which I believe will go a long way in promoting recovery. In my practice I understand that I got to learn from others as well as share knowledge hence I position myself as a valuable member of the healthcare team of whatever workplace I find myself in.I have recognized that it is important to integrate curative and preventive measures in healthcare and for this reason health education is a priority to the patients I meet.
The Four Metaparadigms
Nursing is definitely a professional discipline (Donaldson &Crowley, 1978). As I indicated earlier, patients should be given personalized quality care to meet their individual needs. For me to achieve this as a health professional, I have based my services on the four basic metaparadigms that universally guide the nursing profession. A metaparadigm act as a backbone that can be used as a foundation to the nursing profession from which all nurses can refer to before making clinical judgment (Eckberg & Hill, 1979). The four basic metaparadigms of nursing are person which is the most important of all, the environment, nursing practice and the patients’ health status. Different scholars derived a number of theories on nursing but each of them gives a different perspective of the four metaparadigms in terms of how they affect the patient’s well-being and their medical state at any given time. As a matter of fact the metaparadigm concepts are defined and linked by these theories differently. In this paper, I have discussed these metaparadigms separately while giving a personal input on how best I understand the four components interact and affect the patients’ well-being which has and will always be my agenda.
- Person component
The person component lays emphasis on an individual’s health care need, spiritual needs and most importantly social needs in terms of family ties and other groups of people regarded as important by the individual. How healthy a person is as a result of a complex interaction with both physical and social aspects of life. I agree with Rodgers theory which explains that a unitary human being develops via the three principles of helicy, resonance and integrality (Rodgers 1992). In Watson’s Philosophy and science of caring the person concept is described as an embodied spirit in which there is unity of mind, body and nature (Watson, 1989). On the other hand, Henderson in his philosophy further explains that the person is usually one receiving nursing care and is composed of biological, social physiological and spiritual components (Henderson 1966).
Through practice, I have understood that low self-esteem or stress in most cases hinders recovery. I f my patients are not at ease I take personal initiative to reassure the patient and use holistic approach to health care which in the end helps them to remain calm. By assessing patients’ needs and individual settings, I have been able to respect the uniqueness of each patient and their perspectives in relation to life. An individual gets defined in the course of living and more often than not, through effortless acquisition of knowledge of the self in the universe. There are major aspects of understanding that the person is influenced by their body’s genetic make-up, situation, their personal concerns and temporality (Henderson 1966).
- Environment component
On to the next metaparadigm that is the environment, it focuses on how interactions with the general surrounding affect the health of an individual as a patient. The influences from the environment could either be external or internal. Apart from the physical environment which includes geographical location, the social, cultural, technological and economic aspects of the environment play a crucial role in the wellbeing of a patient.
In Callista Roy’s adaptation model, the environment which includes earth resources that shape behavior can be used to influence health positively through encouraging the patients to cope with the environmental aspects that may not be changeable. The process of coping leads to optimum health and improved quality of life which culminates to death with dignity. In this model there are three adaptation levels which are integrated, compensatory and comprised life processes. The three do not remain constant as change is inevitable from time to time (Roy, 2009). Kings model states that human beings develop in their external environment, while the internal environment is the energy that enables patients to cope with changes in the external environment. This metaparadigm has changed my assessment to one that focuses on both my perspective as well as that of the patient. Through effective communication, I get to understand my patients’ environment and advise them accordingly .In this way our shared goal of the patient’s recovery is achieved.
- Health component
Health is the general wellbeing of an individual. The genetic make-up of a person may predispose the person to particular diseases but what ultimately determines whether the disease occurs or not are the secondary interactions with other factors that may heighten the risk resulting in disease. It is not unusual for patients to have a disease especially during the asymptomatic stage and fail to perceive themselves as ill (Benner, 1999)
All clients have a different inherent approach to stress and coping. I find the understanding of the meaning of health, illness and wellness as of paramount importance to my practice as a nurse since it has helped me understand that at times it’s more appropriate to use placebos to restore the wellness patients who are ill but have no disease. I have also understood that health is not an absolute term but one that is relative e.g. what is healthy in one individual may indicate ill health in another person.
- Nursing component
The nursing component is what involves the delivery of quality health services to the patient for optimal health outcomes. It includes but is not limited to the actions taken from the time of patient’s arrival that include therapeutic nursing interventions as well as the attributes and features of the health worker giving care in terms of their clinical judgment skills. The nurse who is an active participant aims at protecting, promoting and preserving human dignity.
The role of a nurse is to help patients through interpersonal relations and therapeutic management of their environment aimed at promoting health and well-being (Coward, 2010).Nursing is both an academic discipline and practice of profession. It is one guided by the values of human freedom, the choices they make and responsibilities given. As a nurse, critical thinking is an integral part of my career since it has guided me into making the right judgment in providing evidence based care to patients so as to achieve an optimal level of health in the different nursing contexts I find myself in. I as a person am engaged as an active partner in human care activities with people across the life span. Caring is where I source my power from, with which I can act autonomously to empower patients through sharing in their experiences and passing knowledge. I incorporate my decision-making processes, problem solving, communication, interpersonal, intellectual and technical skills n care through collaboration with other health care providers. My core values include commitment, mastery of scope and control over practice to achieve attainable standards of health for my clients.
Two Practice-Specific Concepts
A concept is a complex mental formulation of our perspective in terms of how we view the world .Concepts help us formulate a mental picture about situations. They also act as building blocks for theories (Chinn and Kramer, 1995).
- Health promotion
This involves my experiences of interacting with people suffering from chronic illnesses like diabetes and cancer. Chronic illnesses have in the recent years caused negative impact on the national economy. The direct cost involved in seeking medical care as well as indirect cost e.g. transport and the working hours lost while seeking medical attention are of great significance. Patients with these diseases may not attain recovery but as health professionals, we work to manage cases in a way that prolongs life and slows the rate of disease progression. In the nurse-patient relationship the nurse must work to empower the patient by restoring their will to live and not just give up on life because they suffer from conditions for which they are aware have no cure (Luggen, Travis & Meiner, 1998). I have recognized that health is a matter of social justice and must therefore be incorporated into the societal systems of governance.
I cannot give medication or ask the patients to undergo certain health care procedures without involving them since am aware from experience that unless I include them in my decision-making processes I may not satisfy them that my recommendations will relieve them of their pain and help them recover from illness. This has helped me greatly in achieving compliance of prescribed doses. I therefore feel that hospital processes and procedures must facilitate patient’s empowerment which will improve patient’s satisfaction with the care given. Transformational leadership is important in health promotion since its responsive and not reactive in nature. There is need for senior health professionals to be visionary and work towards influencing the health care team to commit towards achieving set goals.
- Evidence informed practice
I t is defined as the practice that integrates clinical expertise and patient values with the best research evidence available(Sackett et al 2000).I perceive several benefits of using evidence based practice in health care since patients accept recommended care from health workers based on the total trust that they know what’s best for them. One year ago, the mother to a friend of mine went to hospital and was labeled as having breast cancer. The health professional who handled her recommended that she undergo through chemotherapy to control the risk. After consultations with a different health care provider, samples of tissues from the lump were researched on and it was discovered that the lump on her breast was not cancerous. If she would have followed the recommendations of the previous health care provider she would have traumatized as well as her family incurring a lot of financial strain for no reason. Evidence based care supports the decisions made by health care providers in clinical settings as well as in legal issue as need arises.
To the health organizations evidence based practice boosts the image of organizations that embrace it as their approach since they can with ease defend the care delivered to clients as well as justify necessary additional expenditure to clients. To the community, evidence based care reduces strain on resources by minimizing wastage through ineffective or unnecessary interventions.
List of Propositions
A proposition is a structural element of a theory that in itself is a statement that proposes relationship between concepts (Sackett et al., 2000). From the metaparadigms discussed earlier on in this paper, I can derive the following propositions.
- It is possible for each person to manage their own health through positive self-image and behavioral practices that promote good health.
- Modifiable environmental factors can be altered to improve a person’s health and well -being.
- During care physical, emotional, intellectual, spiritual and social well-being must be brought into the picture since they influence the patient’s well- being
- If there is a conflict or misunderstanding between a patient stress and me, stress which may inhibit recovery develops.
- Nursing is not all about care as in the clinical set up but also involves a deeper understanding of all possible factors that influence a patient’s health.
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