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The 6 Levels of Questioning in the Classroom (+ Examples)

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The 6 levels of questioning in the classroom.

The goal of questioning in the classroom is not simply to determine whether students have learned something, but rather to guide them in their learning process. Unlike  tests, quizzes, and exams , questioning in the classroom should be used to teach students, not test them! 

Questions as tests

Teachers spend a great deal of classroom time testing students through questions. Observations of teachers at all levels of education reveal that most spend more than 90 percent of their instructional time testing students (through questioning). And most of the questions teachers ask are typically factual questions that rely on short-term memory.

Although questions are widely used and serve many functions, teachers tend to overuse factual questions such as “What is the capital of California?” Not surprising, as many teachers ask upward of 400 questions every school day! And approximately 80 percent of all the questions teachers ask are factual, literal, or knowledge-based questions.

The result is a classroom in which there is little creative thinking taking place.

What is Bloom's Taxonomy? 

Bloom's Taxonomy  is a hierarchical model used in education to classify educational learning objectives into levels of complexity and specificity. It's named after Benjamin Bloom, who chaired the committee of educators that devised it in the 1950s.

The taxonomy has six levels, designed to help educators create more effective learning objectives and engage students in higher levels of thinking. These levels are arranged in hierarchical form, moving from the lowest level of cognition to the highest level of cognition.

Bloom's Taxonomy was revised in 2001 to better reflect the different types of cognitive processes used in learning and understanding.

Why use Bloom's Taxonomy? 

Bloom's Taxonomy is a powerful tool in the K-12 classroom because it provides a structured approach to questioning that promotes higher levels of thinking. Instead of focusing on rote memorization, Bloom's Taxonomy encourages students to analyze, evaluate, and create. This level of questioning not only enhances students’ understanding of the material, but it also fosters critical thinking and problem-solving skills.

Moreover, this level of questioning in the classroom provides teachers with a clear framework to design their lessons and assess student learning effectively. This approach shifts the focus from merely testing students to facilitating meaningful learning experiences.

Levels of questioning in the classroom (+ examples)

Graphic used with permission by Vanderbilt University

Level 1: Remember

The first level of questioning in the classroom according to Bloom’s Taxonomy is "Remember" (previously: “Knowledge”). This base level involves recalling or recognizing information from memory. It's the most basic level of cognition, where students are asked to remember facts, terms, basic concepts, or answers without necessarily understanding what they mean.

Examples of this level of questioning in the classroom might include "What is the capital of France?" or "Who wrote 'To Kill a Mockingbird'?" Although this level is necessary, it's important to progress beyond it to promote higher levels of thinking.

Words often used in “Remember” questions often include  know ,  who ,  define ,  what ,  name ,  where ,  list , and  when .

Remembering question examples:

• "What is the date of the Declaration of Independence?"
• "Who is the author of 'Pride and Prejudice'?"
• "Can you list the planets in our solar system?"
• "What is the formula for the area of a rectangle?"
• "Who was the first president of the United States?"

Level 2: Understand 

The second level of questioning in the classroom is "Understand" (previously: “Comprehension”). At this stage, students are expected to comprehend the material, which means they can interpret, translate, and summarize the information.

This level goes beyond simple recall of facts and asks students to explain ideas or concepts in their own words.

Keywords often used in "Understand" questions include  explain ,  describe ,  identify ,  discuss , and  interpret .

Understanding questions examples:

• "Can you summarize the main events in the book in your own words?"
• "How would you interpret the author's intentions in this scene?"
• "Can you explain the concept of photosynthesis to a 5-year-old?"
• "What do you think the significance of this event in history is?"
• "How would you translate this sentence into your own words?"

Level 3: Apply

The third level of questioning in the classroom, according to Bloom’s Taxonomy, is "Apply" (previously: “Application”). At this stage, students are expected to use the information they have learned in new situations.

This stage involves problem-solving, implementing methods, and demonstrating how concepts can be used in real-world scenarios.

This level of questioning is important because it encourages students to go beyond simply recalling information and understanding concepts and to start applying this knowledge in practical ways. It promotes critical thinking and problem-solving skills and helps students see the relevance and applicability of what they are learning.

Keywords often used in "Apply" questions include  demonstrate ,  apply ,  solve ,  use , and  illustrate .

Applying question examples:

• "How would you use the Pythagorean theorem to determine the length of the hypotenuse in a right-angled triangle?"
• "Can you construct a model to demonstrate how the solar system works?"
• "Using what you've learned about the water cycle, can you explain why it rains?"
• "How can you apply the principles of democracy to set up a student council in your school?"
• "Can you create an experiment to test the law of conservation of energy?"

Level 4: Analyze 

The fourth level of questioning in the classroom is "Analyze" (previously: “Analysis”). This level involves breaking down information into its component parts for better understanding. Students are expected to differentiate, organize, and relate the parts to the whole.

This stage is crucial as it encourages students to examine information in a detailed way and to understand how different parts relate to one another. This level of questioning promotes critical thinking and a deeper understanding of the subject matter.

Keywords often used in "Analyze" questions include  compare ,  contrast ,  examine ,  classify , and  break down .

Analyzing questions examples

• "How does the protagonist's journey in the novel reflect societal issues?"
• "What are the similarities and differences between two political systems?"
• "How do the different elements of this artwork contribute to its overall impact?"
• "Explain the cause and effect relationship between events in a historical period."
• "How do the different theories of economics apply to this case study?"

Level 5: Evaluate 

The fifth level of questioning in the classroom is "Evaluate" (previously: “Evaluation”). At this stage, students are expected to form judgments about the value and worth of information based on criteria and standards. This involves appraising, judging, critiquing, and defending positions. This level encourages students to formulate their own opinions and make judgments based on their understanding and analysis of the information.

Keywords often used in "Evaluate" questions include  judge ,  rate ,  evaluate ,  defend , and  justify .

Evaluating question examples:

• "Was the ending of the novel satisfactory? Defend your position."
• "What do you think about the author's point of view?"
• "How would you rate this character's decisions throughout the story?"
• "Evaluate the effectiveness of the government's response in a historical event."
• "Can you justify your solution to this problem?"

Level 6: Create 

The final level of questioning in the classroom according to Bloom’s Taxonomy is "Create" (previously: “Synthesis”). At this stage, students are expected to use what they've learned to create something new or original. This could involve developing a plan or proposal, deriving a set of abstract relations, or presenting an original idea. This level of questioning encourages creativity and innovation, as students are asked to generate new ideas, products, or ways of viewing things. Keywords often used in "Create" questions include  design ,  construct ,  create ,  invent , and  compose .

Creating question examples:

• "Can you devise a way to ensure clean water access in developing countries?"
• "How would you design a fair and effective classroom behavior policy?"
• "Can you create a short story based on the themes we've discussed?"
• "Compose a poem that expresses your feelings about a current event."
• "Invent a new product that solves a problem you've identified."

It's elementary! 

Many teachers think primary-level students (Kindergarten through 2nd Grade) cannot handle higher-level questions. But nothing could be further from the truth! Challenging all students through higher-order questioning is one of the best ways to stimulate learning and enhance brain development, regardless of age.

If you only ask your students one level of questioning, your students might not be exposed to higher levels of thinking. If, for example, you only ask your students knowledge-based questions, they might think that learning a specific subject is nothing more than the ability to memorize a select number of facts.

The 6 levels of questioning in the classroom according to Bloom’s Taxonomy provide a structured shift from simple factual recall to more complex cognitive processes. This approach not only deepens students' understanding of the subject matter, but also fosters critical thinking, problem-solving skills, creativity, and innovation.

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Higher Level Thinking: Synthesis in Bloom's Taxonomy

Putting the Parts Together to Create New Meaning

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Bloom’s Taxonomy  (1956 ) was designed with six levels in order to promote higher order thinking. Synthesis was placed on the fifth level of the Bloom’s taxonomy pyramid as it requires students to infer relationships among sources. The high-level thinking of synthesis is evident when students put the parts or information they have reviewed as a whole in order to create new meaning or a new structure.

The Online Etymology Dictionary records the word synthesis as coming from two sources:

"Latin synthesis  meaning a "collection, set, suit of clothes, composition (of a medication)" and also from the Greek  synthesis  meaning "a composition, a putting together."

The dictionary also records the evolution of the use of synthesis to include "deductive reasoning" in 1610 and "a combination of parts into a whole" in 1733. Today's students may use a variety of sources when they combine parts into a whole. The sources for synthesis may include articles, fiction, posts, or infographics as well as non-written sources, such as films, lectures, audio recordings, or observations.

Types of Synthesis in Writing

Synthesis writing is a process in which a student makes the explicit connection between a thesis (the argument) and evidence from sources with similar or dissimilar ideas. Before synthesis can take place, however, the student must complete a careful examination or close reading of all source material. This is especially important before a student can draft a synthesis essay.

There are two types of synthesis essays:

• A student may choose to use an explanatory synthesis essay in order to deconstruct or divide evidence into logical parts so that the essay is organized for readers. Explanatory synthesis essays usually include descriptions of objects, places, events or processes. Descriptions are written objectively because the explanatory synthesis does not present a position. The essay here has information gathered from the sources that the student places in a sequence or other logical manner.
• In order to present a position or opinion, a student may choose to use an argumentative synthesis. The thesis or position of an argumentative essay is one that can be debated. A thesis or position in this essay can be supported with evidence taken from sources and is organized so that it can be presented in a logical manner. 

The introduction to either synthesis essay contains a one-sentence (thesis) statement that sums up the essay's focus and introduces the sources or texts that will be synthesized. Students should follow the citation guidelines in referencing the texts in the essay, which includes their title and author(s) and maybe a little context about the topic or background information. 

The body paragraphs of a synthesis essay can be organized using several different techniques separately or in combination. These techniques can include: using a summary, making comparisons and contrasts, providing examples, proposing cause and effect, or conceding opposing viewpoints. Each of these formats allows the student the chance to incorporate the source materials in either the explanatory or the argumentative synthesis essay.

The conclusion of a synthesis essay may remind readers of the key points or suggestions for further research. In the case of the argumentative synthesis essay, the conclusion answers the "so what" that was proposed in the thesis or may call for action from the reader.

Key Words for the Synthesis Category:

blend, categorize, compile, compose, create, design, develop, form, fuse, imagine, integrate, modify, originate, organize, plan, predict, propose, rearrange, reconstruct, reorganize, solve, summarize, test, theorize, unite.

Synthesis Question Stems With Examples

• Can you develop a theory for the popularity of a text in English? 
• Can you predict the outcome of behavior in Psychology I by using polls or exit slips?
• How could you test the speed of a rubber-band car in physics if a test track is not available?
• How would you adapt ingredients to create a healthier casserole in Nutrition 103 class?'
• How could you change the plot of Shakespeare's Macbeth so it could be rated "G"?
• Suppose you could blend iron with another element so that it could burn hotter?
• What changes would you make to solve a linear equation if you could not use letters as variables?
• Can you fuse Hawthorne's short story "The Minister's Black Veil" with a soundtrack?
• Compose a nationalist song using percussion only.
• If you rearrange the parts in the poem "The Road Not Taken", what would the last line be?

Synthesis Essay Prompt Examples

• Can you propose a universal course of study in the use of social media that could be implemented across the United States?
• What steps could be taken in order to minimize food waste from the school cafeteria?
• What facts can you compile to determine if there has been an increase in racist behavior or an increase in awareness of racist behavior?
• What could you design to wean young children off video games?
• Can you think of an original way for schools to promote awareness of global warming or climate change?
• How many ways can you use technology in the classroom to improve student understanding?
• What criteria would you use to compare American Literature with English Literature?

Synthesis Performance Assessment Examples

• Design a classroom that would support educational technology.
• Create a new toy for teaching the American Revolution. Give it a name and plan a marketing campaign.
• Write and present a news broadcast about a scientific discovery.
• Propose a magazine cover for a famous artist using his or her work.
• Make a mix tape for a character in a novel.
• Hold an election for the most important element on the periodic table.
• Put new words to a known melody in order to promote healthy habits.
• Questions for Each Level of Bloom's Taxonomy
• Higher-Order Thinking Skills (HOTS) in Education
• Bloom's Taxonomy - Application Category
• How to Write a Good Thesis Statement
• Asking Better Questions With Bloom's Taxonomy
• An Introduction to Academic Writing
• How to Construct a Bloom's Taxonomy Assessment
• Using Bloom's Taxonomy for Effective Learning
• Beef Up Critical Thinking and Writing Skills: Comparison Essays
• Bloom's Taxonomy in the Classroom
• Definition and Examples of Analysis in Composition
• What an Essay Is and How to Write One
• Composition Type: Problem-Solution Essays
• What Is Expository Writing?
• How to Write a Solid Thesis Statement
• Tips on How to Write an Argumentative Essay

Literature Review Basics

• What is a Literature Review?
• Synthesizing Research
• Using Research & Synthesis Tables
• Additional Resources

Synthesis: What is it?

First, let's be perfectly clear about what synthesizing your research isn't :

• - It isn't  just summarizing the material you read
• - It isn't  generating a collection of annotations or comments (like an annotated bibliography)
• - It isn't  compiling a report on every single thing ever written in relation to your topic

When you  synthesize  your research, your job is to help your reader understand the current state of the conversation on your topic, relative to your research question.  That may include doing the following:

• - Selecting and using representative work on the topic
• - Identifying and discussing trends in published data or results
• - Identifying and explaining the impact of common features (study populations, interventions, etc.) that appear frequently in the literature
• - Explaining controversies, disputes, or central issues in the literature that are relevant to your research question
• - Identifying gaps in the literature, where more research is needed
• - Establishing the discussion to which your own research contributes and demonstrating the value of your contribution

Essentially, you're telling your reader where they are (and where you are) in the scholarly conversation about your project.

Synthesis: How do I do it?

Synthesis, step by step.

This is what you need to do  before  you write your review.

• Identify and clearly describe your research question (you may find the Formulating PICOT Questions table at  the Additional Resources tab helpful).
• Collect sources relevant to your research question.
• Organize and describe the sources you've found -- your job is to identify what  types  of sources you've collected (reviews, clinical trials, etc.), identify their  purpose  (what are they measuring, testing, or trying to discover?), determine the  level of evidence  they represent (see the Levels of Evidence table at the Additional Resources tab ), and briefly explain their  major findings . Use a Research Table to document this step.
• Study the information you've put in your Research Table and examine your collected sources, looking for  similarities  and  differences . Pay particular attention to  populations ,   methods  (especially relative to levels of evidence), and  findings .
• Analyze what you learn in (4) using a tool like a Synthesis Table. Your goal is to identify relevant themes, trends, gaps, and issues in the research.  Your literature review will collect the results of this analysis and explain them in relation to your research question.

Analysis tips

• - Sometimes, what you  don't  find in the literature is as important as what you do find -- look for questions that the existing research hasn't answered yet.
• - If any of the sources you've collected refer to or respond to each other, keep an eye on how they're related -- it may provide a clue as to whether or not study results have been successfully replicated.
• - Sorting your collected sources by level of evidence can provide valuable insight into how a particular topic has been covered, and it may help you to identify gaps worth addressing in your own work.
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Learning about Synthesis Analysis

What D oes Synthesis and Analysis Mean?

Synthesis: the combination of ideas to

• show commonalities or patterns

Analysis: a detailed examination

• of elements, ideas, or the structure of something
• can be a basis for discussion or interpretation

Synthesis and Analysis: combine and examine ideas to

• show how commonalities, patterns, and elements fit together
• form a unified point for a theory, discussion, or interpretation
• develop an informed evaluation of the idea by presenting several different viewpoints and/or ideas

Key Resource: Synthesis Matrix

Synthesis Matrix

A synthesis matrix is an excellent tool to use to organize sources by theme and to be able to see the similarities and differences as well as any important patterns in the methodology and recommendations for future research. Using a synthesis matrix can assist you not only in synthesizing and analyzing,  but it can also aid you in finding a researchable problem and gaps in methodology and/or research.

Use the Synthesis Matrix Template attached below to organize your research by theme and look for patterns in your sources .Use the companion handout, "Types of Articles" to aid you in identifying the different article types for the sources you are using in your matrix. If you have any questions about how to use the synthesis matrix, sign up for the synthesis analysis group session to practice using them with Dr. Sara Northern!

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Digital SAT Reading and Writing

Course: digital sat reading and writing   >   unit 2, rhetorical synthesis | lesson.

• Rhetorical synthesis — Worked example
• Rhetorical Synthesis — Quick example
• Rhetorical synthesis: foundations

What are "rhetorical synthesis" questions?

• The novel David Copperfield by Charles Dickens focuses on the adventures of its title character, David Copperfield.
• David Copperfield is considered a bildungsroman.
• In a bildungsroman, the main character grows, learns, and changes from experience.
• The novel Tom Jones by Henry Fielding focuses on the adventures of its title character, Tom Jones.
• Tom Jones is considered a picaresque novel.
• In a picaresque novel, the main character has many experiences but stays fundamentally the same.
• (Choice A)   David Copperfield and Tom Jones are both considered picaresque novels. A David Copperfield and Tom Jones are both considered picaresque novels.
• (Choice B)   Both David Copperfield and Tom Jones focus on the adventures of their title characters. B Both David Copperfield and Tom Jones focus on the adventures of their title characters.
• (Choice C)   David Copperfield was written by Charles Dickens; Tom Jones was written by Henry Fielding. C David Copperfield was written by Charles Dickens; Tom Jones was written by Henry Fielding.
• (Choice D)   In David Copperfield , unlike in Tom Jones , the main character grows, learns, and changes from experience. D In David Copperfield , unlike in Tom Jones , the main character grows, learns, and changes from experience.

Choice A: This choice does not accurately represent the information in the bullet points! Bullet point 2 tells us that David Copperfield is considered a bildungsroman. The next bullet points tell us that in a bildungsroman, the main character changes, while in a picaresque novel, the main character basically stays the same. This means that a bildungsroman can't also be a picaresque novel.

Choice B: This choice emphasizes a similarity and accurately represents the information in the bullet points. Bullet point 1 says that David Copperfield focuses on the adventures of its title character, and bullet point 4 says that Tom Jones focuses on the adventures of its title character.

Choice C: This choice accurately represents the bulleted information, but it doesn't accomplish the goal. It highlights a difference between the two novels—the fact that they have different authors. But we're looking for a similarity.

Choice D: Like choice C, this choice accurately represents the bulleted information, but it doesn't accomplish the goal. It emphasizes a difference between the two novels, but, again, we're looking for a similarity.

How should we think about rhetorical synthesis questions?

Question structure.

• an introduction
• a series of bulleted facts
• a question prompt
• the choices

How to approach rhetorical synthesis questions

Step 1: Identify the goal

Step 2: Read the bullet points and identify relevant info

Step 3: Test the choices

Step 4: Select the choice that matches

Do two "passes" to eliminate choices!

Simplify the goal.

• Choice C emphasizes a difference between the two novels, not a similarity. We can eliminate choice C.
• Choice D also emphasizes a difference between the two novels, not a similarity. We can eliminate choice D.

Ignore the grammar

• Marine biologist Camille Jazmin Gaynus studies coral reefs.
• Coral reefs are vital underwater ecosystems that provide habitats to 25% of all marine species.
• Reefs can include up to 8,000 species of fish, such as toadfish, seahorses, and clown triggerfish.
• The Amazon Reef is a coral reef in Brazil.
• It is one of the largest known reefs in the world.
• (Choice A)   Providing homes to 25% of all marine species, including up to 8,000 species of fish, coral reefs are vital underwater ecosystems and thus of great interest to marine biologists. A Providing homes to 25% of all marine species, including up to 8,000 species of fish, coral reefs are vital underwater ecosystems and thus of great interest to marine biologists.
• (Choice B)   Marine biologist Camille Jazmin Gaynus studies coral reefs, vital underwater ecosystems that provide homes to 25% of all marine species. B Marine biologist Camille Jazmin Gaynus studies coral reefs, vital underwater ecosystems that provide homes to 25% of all marine species.
• (Choice C)   Camilla Jazmin Gaynus is a marine biologist who exclusively studies the Amazon Reef, a coral reef that is home to 8,000 different species of fish. C Camilla Jazmin Gaynus is a marine biologist who exclusively studies the Amazon Reef, a coral reef that is home to 8,000 different species of fish.
• (Choice D)   As Camille Jazmin Gaynus knows well, coral reefs are vital underwater ecosystems, providing homes to thousands of species of fish. D As Camille Jazmin Gaynus knows well, coral reefs are vital underwater ecosystems, providing homes to thousands of species of fish.
• Choice A doesn't mention the scientist at all. We can eliminate choice A.
• Remember to be strict : the goal is to introduce the scientist AND her field of study. Choice D names the scientist, but it doesn't introduce her field of study (it doesn't say she's a marine biologist). We can eliminate choice D.

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Home » Insights

Completing the Learning Loop: The Power of Synthesis and Reflection Prompts

by Jon Altbergs and Laurie Gagnon

At redesign, we encourage the adoption of a learning cycle that guides the learner through the habits and skills that support the development of competency with practice over time. in this post, we dig into the synthesis and reflection element of the learning cycle..

Let’s take a moment to revisit the two dimensions of the learning cycle. It represents the stages of meaningful learning that occur simultaneously during daily learning experiences (the “inner circle), and across multi-week units of study they constitute (the “outer circle”) that build toward authentic, competency-building work.

As our colleague Sydney Schaef explained in   A Friendly Introduction to the Competency-based Learning Cycle , 

In a nutshell, the Competency-based Learning Cycle is a visual framework that illustrates the cognitive and metacognitive processes that help learners develop competency with practice and feedback, as they work and learn in increasingly challenging contexts.  …The “outer circle” represents the four major stages of a competency-based project or unit of study through which learners explore a compelling question or issue.  …The “inner circle” structures daily learning experiences. … These learning experiences are purposefully and directly connected to the larger arc (outer circle), such that successful, recursive movement through this inner cycle enables progress through the four stages of the unit.

Ongoing synthesis and reflection anchor the learning cycle. Every learning experience, we believe, should culminate with synthesis and reflection questions.   Why are synthesis and reflection questions so important to close the loop of a lesson or learning experience? They are essential because the information they provide: 

• supports the provision of individualized feedback
• builds relationships through teacher attunement
• gauges student engagement
• offers insight into learners’ metacognition, the key to self-directed learning. 

Ultimately, synthesis and reflection questions are a moment of pause to “lift the hood” on learners’ thinking. 

Meaningful learning and assessment generate evidence of learning (as opposed to simply evidence of working). Synthesis and reflection help the learner situate new ideas into their overall understanding and helps the teacher gain insight into the thinking processes and conceptual understanding behind other work that the learner produces . When planning lessons, teachers often rightfully focus on designing assignments and activities that prompt students to think critically about the content they are learning. But rigorous assignments are not enough. Students need opportunities to synthesize and reflect on their learning. Synthesis connects the day’s learning to prior learning, helping students build schema and deepen their understanding. Reflection encourages metacognitive development by shifting the focus from the what of learning to the how. 

A synthesis prompt asks students to identify the important learning, summarize the learning, and articulate connections between the new learning and prior learning, knowledge, or experience in order to create or deepen understanding . Well-crafted synthesis questions lay the foundation for transferability of skills and knowledge. By incorporating synthesis into daily practice, building the connections that expand schema and ensure transferability is an ongoing process, rather than one that occurs at the end of a unit, the end of the year, or when new material is introduced. 

Synthesizing, like other strategies and skills, is a capability that develops over time and should be explicitly taught . Responding to a synthesis prompt calls upon three specific elements: determining importance, summarizing, and connecting. First, students identify the important parts of their learning, the key takeaways from the lesson or learning experience that were essential to completing the task at hand. Second, students summarize by concisely communicating the what and the why of their learning—the key content and its importance. Finally, when students synthesize they connect the day’s learning to a larger context, such as prior learning, the essential question, or their own experience and describe how connecting the two deepens their understanding. Connections can also be made to novel situations to extend thinking. 

Ultimately, the purpose of synthesis questions is the production, rather than reproduction, of knowledge . When students begin to explore a specific topic, their pool of knowledge may be limited, making rich connections and synthesis more difficult, but as they have more to call upon, those new (to them) insights happen more often. 

Though the thinking underlying synthesis prompts is complex, the prompts themselves don’t have to be. I used to think … but then I learned … and so now is a simple frame for synthesis. As part of an exit ticket, journaling prompt, or classroom discussion, this frame incorporates all three elements and creates the opportunity to uncover what students know and what gaps and misconceptions need to be addressed.

A reflection prompt asks students to look critically at their learning process from its inception to its completion . Reflection incorporates summarizing, evaluating, and inferring. When reflecting, students describe the steps they took to complete a task, focusing on their strategic action—the strategies and skills they used and the adjustments they made on their way toward their learning goal. They then make inferences about the influence of their actions on their outcomes to evaluate the effectiveness of those actions. Reflection is vital to fostering agency, self-efficacy, and independence, as it aids in building self-regulated learning skills: the ability to set goals and appraise tasks; monitor one’s learning progress; apply strategies as needed; and sustain motivation. 

Reflection helps the learner to evaluate whether their approach to their learning was successful and to surface lessons about how they learn, which can help them in being successful in their next learning endeavor. 

• What was my learning goal? Did I achieve my learning goal?
• How did I learn what I learned?
• What worked well as I learned? How do I know it worked well? What did not work as well as I wanted? How do I know it didn’t work well?
• What changes did I make on the fly? What was the effect of those changes?
• What did I learn about myself as a learner? How will this insight help me learn in the future?
• How did my thinking change as a result of my new learning?
• How can I use my new learning in the future?

If you are new to the idea of synthesis and reflection as a regular part of the learning process or if you want to bring more intention to how you craft questions, check out this self-assessment checklist for   Synthesis & Reflection Prompt Design . To see it in action, check out this   personal narrative unit outline   that illustrates how the reflection and synthesis prompts at each key stage of the unit build in complexity as learners move through the stages of the learning cycle: making meaning, investigating, creating, and finally, presenting, celebrating, and reflecting.

Back in the spring, our   first tip for meaningful learning in COVID   was to FOCUS ON EVIDENCE OF LEARNING (not evidence of working). Reflecting back, focusing on evidence of learning is actually a fundamental practice for learning. Now that schools and districts are getting back to school after the emergency learning situation of the spring, but still in very different conditions than before, we have the opportunity to design learning experiences that better incorporate key ideas from the research on how we learn. 

If you’re interested in hands-on learning and support to help you design learning experiences that are research-based and built around the learning cycle, check out this upcoming workshop series,   The Learning Cycle Workshop , offered through reDesign’s Institute in October/November. We hope to see you there!

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Sydney Schaef

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South Shore took a professional learning community approach to refining and implementing a range of school-wide shifts, designed to make grading more fair, accurate, and helpful.The Fellow designated to lead this project served in an administrator role, and helped the school community coalesce around four areas for change: 1) developing a competency-based grade scale, 2) directly linking all assignments and grades to standards; 3) instituting a universal late work policy; and 4) implementing a revision policy focused on relearning. Background knowledge-building, feasibility discussions that incorporated community input, and formalizing a plan for change were all part of the journey, with the recognition that the school would adjust the plan along the way. In Year 2, communication, transparency with all stakeholders, and continued education have been essential, as well as continued solicitation of feedback as assessments were developed that aligned with the rollout of the new grade scale. Ultimately, South Shore is not only rethinking grading – the school is also rethinking work habits, remediation, assessments, instruction, and curriculum.

The Melrose High School team identified 3 anchor questions: How can assessments best serve student learning? What do we want our students to leave with? How can students drive and discuss their learning? Guided by these, they developed an integrated approach to 21st century grading that fosters equity by: (1) Supporting students’ Habits of Learning, across the academic program (2) Increasing accuracy and transparency in grading; (3) Developing new policies for Retaking and Revising Assessments, and establishing a minimum grade of 50%; (4) Proactively communicating; (5) Explicitly nurturing student voice; and (6) Adopting universal design principles for efficient assessment-building within a flexible environment.

Revere High School identified three “rethinking” arenas: 1) Clarify what it means for students to be proficient; 2) Ensure alignment with standards and other frameworks; 3) Develop consistent practices for grade calculations, the use of rubrics, and grade reporting. The pilot team collaborated to design a prototype for a common grading table, category weights connected to power standards, and a plan to develop assessments tied to those standards-based learning targets. This approach sharpens the focus on student proficiency, takes gradebook construction out of the hands of teachers and considers every step of “the what” in a more comprehensive way.

Revere High School, Part 2 – Developing a Culture of Competency: 72% of the students who attend Revere High School are learning English. A number of them have struggled to pass the MCAS (state’ graduation exam), and have also experienced course failure. As an extension of their #RethinkingGrading efforts, the District is designing a customized and personalized graduation pathway, guided by a Profile of a Graduate. To ensure teachers can effectively support students, the district is partnering with reDesign to develop and facilitate professional learning experiences and modularized courses: a commitment to developing a culture of competency for both young people and the adults who serve them.

• Teaching Tips

Bloom’s Taxonomy Question Stems For Use In Assessment [With 100+ Examples]

This comprehensive list of pre-created Bloom’s taxonomy question stems ensure students are critically engaging with course material

Jacob Rutka

One of the most powerful aspects of Bloom’s Taxonomy is that it offers you, as an educator, the ability to construct a curriculum to assess objective learning outcomes, including advanced educational objectives like critical thinking. Pre-created Bloom’s Taxonomy questions can also make planning discussions, learning activities, and formative assessments much easier.

For those unfamiliar with Bloom’s Taxonomy, it consists of a series of hierarchical levels (normally arranged in a pyramid) that build on each other and progress towards higher-order thinking skills. Each level contains verbs, such as “demonstrate” or “design,” that can be measured to gain greater insight into student learning.

Click here to download 100+ Bloom’s taxonomy question stems for your classroom and get everything you need to engage your students.

Table of Contents

• Bloom’s Taxonomy (1956)

Revised Bloom’s Taxonomy (2001)

Bloom’s taxonomy for adjunct professors, examples of bloom’s taxonomy question stems, additional bloom’s taxonomy example questions, higher-level thinking questions, bloom’s taxonomy (1956).

The original Bloom’s Taxonomy framework consists of six levels that build off of each other as the learning experience progresses. It was developed in 1956 by Benjamin Bloom, an American educational psychologist. Below are descriptions of each level:

• Knowledge: Identification and recall of course concepts learned
• Comprehension: Ability to grasp the meaning of the material 
• Application: Demonstrating a grasp of the material at this level by solving problems and creating projects
• Analysis: Finding patterns and trends in the course material
• Synthesis: The combining of ideas or concepts to form a working theory 
• Evaluation: Making judgments based on the information students have learned as well as their own insights

A group of educational researchers and cognitive psychologists developed the new and revised Bloom’s Taxonomy framework in 2001 to be more action-oriented. This way, students work their way through a series of verbs to meet learning objectives. Below are descriptions of each of the levels in revised Bloom’s Taxonomy:

• Remember: To bring an awareness of the concept to learners’ minds.
• Understand: To summarize or restate the information in a particular way.
• Apply: The ability to use learned material in new and concrete situations.
• Analyze: Understanding the underlying structure of knowledge to be able to distinguish between fact and opinion.
• Evaluate: Making judgments about the value of ideas, theories, items and materials.
• Create: Reorganizing concepts into new structures or patterns through generating, producing or planning.

Free Download: Bloom’s Taxonomy Question Stems and Examples

Bloom’s Taxonomy questions are a great way to build and design curriculum and lesson plans. They encourage the development of higher-order thinking and encourage students to engage in metacognition by thinking and reflecting on their own learning. In The Ultimate Guide to Bloom’s Taxonomy Question Stems , you can access more than 100 examples of Bloom’s Taxonomy questions examples and higher-order thinking question examples at all different levels of Bloom’s Taxonomy. 

Bloom’s Taxonomy (1956) question samples:

• Knowledge: How many…? Who was it that…? Can you name the…? 
• Comprehension: Can you write in your own words…? Can you write a brief outline…? What do you think could have happened next…?
• Application: Choose the best statements that apply… Judge the effects of… What would result …? 
• Analysis: Which events could have happened…? If … happened, how might the ending have been different? How was this similar to…?
• Synthesis: Can you design a … to achieve …? Write a poem, song or creative presentation about…? Can you see a possible solution to…?
• Evaluation: What criteria would you use to assess…? What data was used to evaluate…? How could you verify…?

Click here to get 100+ Bloom’s taxonomy question stems that’ll help engage students in your classroom.

Revised Bloom’s Taxonomy (2001) question samples:

• Remember: Who…? What…? Where…? How…?
• Understand: How would you generalize…? How would you express…? What information can you infer from…?
• Apply: How would you demonstrate…? How would you present…? Draw a story map… 
• Analyze: How can you sort the different parts…? What can you infer about…? What ideas validate…? How would you categorize…?
• Evaluate: What criteria would you use to assess…? What sources could you use to verify…? What information would you use to prioritize…? What are the possible outcomes for…?
• Create: What would happen if…? List the ways you can…? Can you brainstorm a better solution for…? 

As we know, Bloom’s Taxonomy is a framework used in education to categorize levels of cognitive learning. Here are 10 Bloom’s Taxonomy example questions, each corresponding to one of the six levels in Bloom’s Taxonomy, starting from the lowest level (Remember) to the highest level (Create):

• Remember (Knowledge): What are the four primary states of matter? Can you list the main events of the American Civil War?
• Understand (Comprehension): How would you explain the concept of supply and demand to someone who is new to economics? Can you summarize the main idea of the research article you just read?
• Apply (Application): Given a real-world scenario, how would you use the Pythagorean theorem to solve a practical problem? Can you demonstrate how to conduct a chemical titration in a laboratory setting?
• Analyze (Analysis): What are the key factors contributing to the decline of a particular species in an ecosystem? How do the social and economic factors influence voting patterns in a specific region?
• Evaluate (Evaluation): Compare and contrast the strengths and weaknesses of two different programming languages for a specific project. Assess the effectiveness of a marketing campaign, providing recommendations for improvement.
• Create (Synthesis): Design a new and innovative product that addresses a common problem in society. Develop a comprehensive lesson plan that incorporates various teaching methods to enhance student engagement in a particular subject.

Download Now: Bloom’s Taxonomy Question Stems and Examples

Higher-level thinking questions are designed to encourage critical thinking, analysis, and synthesis of information. Here are eight examples of higher-level thinking questions that can be used in higher education:

• Critical Analysis (Analysis): “What are the ethical implications of the decision made by the characters in the novel, and how do they reflect broader societal values?”
• Problem-Solving (Application): “Given the current environmental challenges, how can we develop sustainable energy solutions that balance economic and ecological concerns?”
• Evaluation of Evidence (Evaluation): “Based on the data presented in this research paper, do you think the study’s conclusions are valid? Why or why not?”
• Comparative Analysis (Analysis): “Compare and contrast the economic policies of two different countries and their impact on income inequality.”
• Hypothetical Scenario (Synthesis): “Imagine you are the CEO of a multinational corporation. How would you navigate the challenges of globalization and cultural diversity in your company’s workforce?”
• Ethical Dilemma (Evaluation): “In a medical emergency with limited resources, how should healthcare professionals prioritize patients, and what ethical principles should guide their decisions?”
• Interdisciplinary Connection (Synthesis): “How can principles from psychology and sociology be integrated to address the mental health needs of a diverse student population in higher education institutions?”
• Creative Problem-Solving (Synthesis): “Propose a novel solution to reduce urban congestion while promoting eco-friendly transportation options. What are the potential benefits and challenges of your solution?”

These questions encourage students to go beyond simple recall of facts and engage in critical thinking, analysis, synthesis, and ethical considerations. They are often used to stimulate class discussions, research projects, and written assignments in higher education settings.

Click here to download 100+ Bloom’s taxonomy question stems

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How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

When you write a literature review or essay, you have to go beyond just summarizing the articles you’ve read – you need to synthesize the literature to show how it all fits together (and how your own research fits in).

Synthesizing simply means combining. Instead of summarizing the main points of each source in turn, you put together the ideas and findings of multiple sources in order to make an overall point.

At the most basic level, this involves looking for similarities and differences between your sources. Your synthesis should show the reader where the sources overlap and where they diverge.

Unsynthesized Example

Franz (2008) studied undergraduate online students. He looked at 17 females and 18 males and found that none of them liked APA. According to Franz, the evidence suggested that all students are reluctant to learn citations style. Perez (2010) also studies undergraduate students. She looked at 42 females and 50 males and found that males were significantly more inclined to use citation software ( p < .05). Findings suggest that females might graduate sooner. Goldstein (2012) looked at British undergraduates. Among a sample of 50, all females, all confident in their abilities to cite and were eager to write their dissertations.

Synthesized Example

Studies of undergraduate students reveal conflicting conclusions regarding relationships between advanced scholarly study and citation efficacy. Although Franz (2008) found that no participants enjoyed learning citation style, Goldstein (2012) determined in a larger study that all participants watched felt comfortable citing sources, suggesting that variables among participant and control group populations must be examined more closely. Although Perez (2010) expanded on Franz’s original study with a larger, more diverse sample…

Step 1: Organize your sources

After collecting the relevant literature, you’ve got a lot of information to work through, and no clear idea of how it all fits together.

Before you can start writing, you need to organize your notes in a way that allows you to see the relationships between sources.

One way to begin synthesizing the literature is to put your notes into a table. Depending on your topic and the type of literature you’re dealing with, there are a couple of different ways you can organize this.

Summary table

A summary table collates the key points of each source under consistent headings. This is a good approach if your sources tend to have a similar structure – for instance, if they’re all empirical papers.

Each row in the table lists one source, and each column identifies a specific part of the source. You can decide which headings to include based on what’s most relevant to the literature you’re dealing with.

For example, you might include columns for things like aims, methods, variables, population, sample size, and conclusion.

For each study, you briefly summarize each of these aspects. You can also include columns for your own evaluation and analysis.

The summary table gives you a quick overview of the key points of each source. This allows you to group sources by relevant similarities, as well as noticing important differences or contradictions in their findings.

Synthesis matrix

A synthesis matrix is useful when your sources are more varied in their purpose and structure – for example, when you’re dealing with books and essays making various different arguments about a topic.

Each column in the table lists one source. Each row is labeled with a specific concept, topic or theme that recurs across all or most of the sources.

Then, for each source, you summarize the main points or arguments related to the theme.

The purposes of the table is to identify the common points that connect the sources, as well as identifying points where they diverge or disagree.

Step 2: Outline your structure

Now you should have a clear overview of the main connections and differences between the sources you’ve read. Next, you need to decide how you’ll group them together and the order in which you’ll discuss them.

For shorter papers, your outline can just identify the focus of each paragraph; for longer papers, you might want to divide it into sections with headings.

There are a few different approaches you can take to help you structure your synthesis.

If your sources cover a broad time period, and you found patterns in how researchers approached the topic over time, you can organize your discussion chronologically .

That doesn’t mean you just summarize each paper in chronological order; instead, you should group articles into time periods and identify what they have in common, as well as signalling important turning points or developments in the literature.

If the literature covers various different topics, you can organize it thematically .

That means that each paragraph or section focuses on a specific theme and explains how that theme is approached in the literature.

Source Used with Permission: The Chicago School

If you’re drawing on literature from various different fields or they use a wide variety of research methods, you can organize your sources methodologically .

That means grouping together studies based on the type of research they did and discussing the findings that emerged from each method.

If your topic involves a debate between different schools of thought, you can organize it theoretically .

That means comparing the different theories that have been developed and grouping together papers based on the position or perspective they take on the topic, as well as evaluating which arguments are most convincing.

Step 3: Write paragraphs with topic sentences

What sets a synthesis apart from a summary is that it combines various sources. The easiest way to think about this is that each paragraph should discuss a few different sources, and you should be able to condense the overall point of the paragraph into one sentence.

This is called a topic sentence , and it usually appears at the start of the paragraph. The topic sentence signals what the whole paragraph is about; every sentence in the paragraph should be clearly related to it.

A topic sentence can be a simple summary of the paragraph’s content:

“Early research on [x] focused heavily on [y].”

For an effective synthesis, you can use topic sentences to link back to the previous paragraph, highlighting a point of debate or critique:

“Several scholars have pointed out the flaws in this approach.” “While recent research has attempted to address the problem, many of these studies have methodological flaws that limit their validity.”

By using topic sentences, you can ensure that your paragraphs are coherent and clearly show the connections between the articles you are discussing.

As you write your paragraphs, avoid quoting directly from sources: use your own words to explain the commonalities and differences that you found in the literature.

Don’t try to cover every single point from every single source – the key to synthesizing is to extract the most important and relevant information and combine it to give your reader an overall picture of the state of knowledge on your topic.

Step 4: Revise, edit and proofread

Like any other piece of academic writing, synthesizing literature doesn’t happen all in one go – it involves redrafting, revising, editing and proofreading your work.

Checklist for Synthesis

•   Do I introduce the paragraph with a clear, focused topic sentence?
•   Do I discuss more than one source in the paragraph?
•   Do I mention only the most relevant findings, rather than describing every part of the studies?
•   Do I discuss the similarities or differences between the sources, rather than summarizing each source in turn?
•   Do I put the findings or arguments of the sources in my own words?
•   Is the paragraph organized around a single idea?
•   Is the paragraph directly relevant to my research question or topic?
•   Is there a logical transition from this paragraph to the next one?

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

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Analysis vs. Synthesis

What's the difference.

Analysis and synthesis are two fundamental processes in problem-solving and decision-making. Analysis involves breaking down a complex problem or situation into its constituent parts, examining each part individually, and understanding their relationships and interactions. It focuses on understanding the components and their characteristics, identifying patterns and trends, and drawing conclusions based on evidence and data. On the other hand, synthesis involves combining different elements or ideas to create a new whole or solution. It involves integrating information from various sources, identifying commonalities and differences, and generating new insights or solutions. While analysis is more focused on understanding and deconstructing a problem, synthesis is about creating something new by combining different elements. Both processes are essential for effective problem-solving and decision-making, as they complement each other and provide a holistic approach to understanding and solving complex problems.

Further Detail

Introduction.

Analysis and synthesis are two fundamental processes in various fields of study, including science, philosophy, and problem-solving. While they are distinct approaches, they are often interconnected and complementary. Analysis involves breaking down complex ideas or systems into smaller components to understand their individual parts and relationships. On the other hand, synthesis involves combining separate elements or ideas to create a new whole or understanding. In this article, we will explore the attributes of analysis and synthesis, highlighting their differences and similarities.

Attributes of Analysis

1. Focus on details: Analysis involves a meticulous examination of individual components, details, or aspects of a subject. It aims to understand the specific characteristics, functions, and relationships of these elements. By breaking down complex ideas into smaller parts, analysis provides a deeper understanding of the subject matter.

2. Objective approach: Analysis is often driven by objectivity and relies on empirical evidence, data, or logical reasoning. It aims to uncover patterns, trends, or underlying principles through systematic observation and investigation. By employing a structured and logical approach, analysis helps in drawing accurate conclusions and making informed decisions.

3. Critical thinking: Analysis requires critical thinking skills to evaluate and interpret information. It involves questioning assumptions, identifying biases, and considering multiple perspectives. Through critical thinking, analysis helps in identifying strengths, weaknesses, opportunities, and threats, enabling a comprehensive understanding of the subject matter.

4. Reductionist approach: Analysis often adopts a reductionist approach, breaking down complex systems into simpler components. This reductionist perspective allows for a detailed examination of each part, facilitating a more in-depth understanding of the subject matter. However, it may sometimes overlook the holistic view or emergent properties of the system.

5. Diagnostic tool: Analysis is commonly used as a diagnostic tool to identify problems, errors, or inefficiencies within a system. By examining individual components and their interactions, analysis helps in pinpointing the root causes of issues, enabling effective problem-solving and optimization.

Attributes of Synthesis

1. Integration of ideas: Synthesis involves combining separate ideas, concepts, or elements to create a new whole or understanding. It aims to generate novel insights, solutions, or perspectives by integrating diverse information or viewpoints. Through synthesis, complex systems or ideas can be approached holistically, considering the interconnections and interdependencies between various components.

2. Creative thinking: Synthesis requires creative thinking skills to generate new ideas, concepts, or solutions. It involves making connections, recognizing patterns, and thinking beyond traditional boundaries. By embracing divergent thinking, synthesis enables innovation and the development of unique perspectives.

3. Systems thinking: Synthesis often adopts a systems thinking approach, considering the interactions and interdependencies between various components. It recognizes that the whole is more than the sum of its parts and aims to understand emergent properties or behaviors that arise from the integration of these parts. Systems thinking allows for a comprehensive understanding of complex phenomena.

4. Constructive approach: Synthesis is a constructive process that builds upon existing knowledge or ideas. It involves organizing, reorganizing, or restructuring information to create a new framework or understanding. By integrating diverse perspectives or concepts, synthesis helps in generating comprehensive and innovative solutions.

5. Design tool: Synthesis is often used as a design tool to create new products, systems, or theories. By combining different elements or ideas, synthesis enables the development of innovative and functional solutions. It allows for the exploration of multiple possibilities and the creation of something new and valuable.

Interplay between Analysis and Synthesis

While analysis and synthesis are distinct processes, they are not mutually exclusive. In fact, they often complement each other and are interconnected in various ways. Analysis provides the foundation for synthesis by breaking down complex ideas or systems into manageable components. It helps in understanding the individual parts and their relationships, which is essential for effective synthesis.

On the other hand, synthesis builds upon the insights gained from analysis by integrating separate elements or ideas to create a new whole. It allows for a holistic understanding of complex phenomena, considering the interconnections and emergent properties that analysis alone may overlook. Synthesis also helps in identifying gaps or limitations in existing knowledge, which can then be further analyzed to gain a deeper understanding.

Furthermore, analysis and synthesis often involve an iterative process. Initial analysis may lead to the identification of patterns or relationships that can inform the synthesis process. Synthesis, in turn, may generate new insights or questions that require further analysis. This iterative cycle allows for continuous refinement and improvement of understanding.

Analysis and synthesis are two essential processes that play a crucial role in various fields of study. While analysis focuses on breaking down complex ideas into smaller components to understand their individual parts and relationships, synthesis involves integrating separate elements or ideas to create a new whole or understanding. Both approaches have their unique attributes and strengths, and they often complement each other in a cyclical and iterative process. By employing analysis and synthesis effectively, we can gain a comprehensive understanding of complex phenomena, generate innovative solutions, and make informed decisions.

Comparisons may contain inaccurate information about people, places, or facts. Please report any issues.

Module 8: Writing Workshop—Analysis and Synthesis

Why it matters: writing workshop—analysis and synthesis.

Figure 1 . Effective scholarship is often a matter of making connections.

Why Analyze?

In college courses, you will be asked to read, reason, and write analytically. Effective analysts can distinguish the whole, identify parts, infer relationships, and make generalizations. Those skills enable individuals to connect ideas, detect inconsistencies, and solve problems in a systematic fashion. Understanding what analysis is, how to apply it, and how to convey the results effectively will be invaluable to you throughout your college and professional careers.

Analysis is at the heart of academic work in every area of study. Literary critics break down poems and novels, examining how the different parts of the text work together to create meaning. Sociologists conduct field research to observe how gender roles influence pay discrepancies in developing nations, often arriving at policy recommendations that might result in more equitable arrangements. Business students scrutinize data on consumer behavior in different markets to better understand why some products fail in one place while nearly identical ones succeed in a different place.

Note that each researcher started with a question. The literary critic asks: how does this text create meaning? The sociologist wants to know: how are gender and inequalities of pay related to broader economic development? And the business student is trying to get a sense of what regional market differences might account for success or failure for a given plan. The work of analysis gives each researcher an opportunity to complicate their initial question, to compile useful information, and then to draw–or infer–some conclusions based on this new, more thorough level of understanding.

While analysis is the term we use to describe the process of breaking something down, say a poem or novel, a transcript of interviews with workers and business owners, or a regional market overview, this is not the only work we perform as scholars.

In an academic context, we are often occupied by a kind of transaction. As students we demonstrate our learning in exchange for credits, and ultimately we redeem these credits for a degree. And while there is certainly nothing wrong with learning for its own sake, without any broader framework of approval or evaluation, if you are working toward a degree it is helpful to understand why your professors value particular demonstrations of ability. In short, your teachers are looking for complexity and thoroughness in your thinking and writing. They want to see that you can propose and sustain a defensible line of inquiry, and that you can select and utilize appropriate evidence to support your guiding questions.

But how, exactly, do you utilize your material? Two complicating techniques that you can employ, and that will increase the complexity and credibility of your work are inference and synthesis. Let’s say that our hypothetical sociologist writes a draft of her paper that describes the types of labor performed by men and women in different lines of work in a recently urbanized region. If she categorically breaks down and examines in detail these differently compensated positions, we can say that she has performed an analysis. However, if she cites her interview transcripts and argues that her subjects are implying that pay rates in newly established professional settings should be based on “traditional” pay rates from earlier forms of gender-segregated agricultural labor, then she has inferred this is an unspoken framework of inequality in need of more scrutiny. Her inference has complicated and built on the existing analysis. If she goes on to find similarities in this notion of “traditionally” gender-based pay discrepancies among company mission statements, her interview transcripts, and studies conducted by other sociologists in other developing countries, then she has synthesized these different viewpoints and sources. This will also demonstrate a more thorough and credible thought process, and one that is valued within her chosen academic discipline.

As we work through the next few pages you will have an opportunity to consider how analysis, inference, and synthesis can work together. You will also get to test your own ability to identify these concepts in action, and to practice applying them to a scholarly essay.

Writing Workshop: Your Working Document

Every component of the working document will be introduced throughout this module in a blue box such as this one.  Open your working document now and keep it open as you progress through the module .

• Go to the assignment for this module in your LMS. Click on the link to open the Working Document for this module as a Google Document.

• Now hold onto this document—we’ll need it soon! (You’ll submit the link to your instructor once you’ve completed the Writing Workshop activities).
• Photograph of Women Working at a Bell System Telephone Switchboard. Provided by : The U.S. National Archives. Located at : https://flic.kr/p/6zqGGV . License : Public Domain: No Known Copyright
• Why It Matters: Writing Workshopu2014Analysis and Synthesis. Authored by : Scott Barr for Lumen Learning. License : CC BY: Attribution

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What Synthesis Methodology Should I Use? A Review and Analysis of Approaches to Research Synthesis

Kara schick-makaroff.

1 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada

Marjorie MacDonald

2 School of Nursing, University of Victoria, Victoria, BC, Canada

Marilyn Plummer

3 College of Nursing, Camosun College, Victoria, BC, Canada

Judy Burgess

4 Student Services, University Health Services, Victoria, BC, Canada

Wendy Neander

Associated data, additional file 1.

When we began this process, we were doctoral students and a faculty member in a research methods course. As students, we were facing a review of the literature for our dissertations. We encountered several different ways of conducting a review but were unable to locate any resources that synthesized all of the various synthesis methodologies. Our purpose is to present a comprehensive overview and assessment of the main approaches to research synthesis. We use ‘research synthesis’ as a broad overarching term to describe various approaches to combining, integrating, and synthesizing research findings.

We conducted an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis. We searched five databases, reviewed websites of key organizations, hand-searched several journals, and examined relevant texts from the reference lists of the documents we had already obtained.

We identified four broad categories of research synthesis methodology including conventional, quantitative, qualitative, and emerging syntheses. Each of the broad categories was compared to the others on the following: key characteristics, purpose, method, product, context, underlying assumptions, unit of analysis, strengths and limitations, and when to use each approach.

Conclusions

The current state of research synthesis reflects significant advancements in emerging synthesis studies that integrate diverse data types and sources. New approaches to research synthesis provide a much broader range of review alternatives available to health and social science students and researchers.

1. Introduction

Since the turn of the century, public health emergencies have been identified worldwide, particularly related to infectious diseases. For example, the Severe Acute Respiratory Syndrome (SARS) epidemic in Canada in 2002-2003, the recent Ebola epidemic in Africa, and the ongoing HIV/AIDs pandemic are global health concerns. There have also been dramatic increases in the prevalence of chronic diseases around the world [1] – [3] . These epidemiological challenges have raised concerns about the ability of health systems worldwide to address these crises. As a result, public health systems reform has been initiated in a number of countries. In Canada, as in other countries, the role of evidence to support public health reform and improve population health has been given high priority. Yet, there continues to be a significant gap between the production of evidence through research and its application in practice [4] – [5] . One strategy to address this gap has been the development of new research synthesis methodologies to deal with the time-sensitive and wide ranging evidence needs of policy makers and practitioners in all areas of health care, including public health.

As doctoral nursing students facing a review of the literature for our dissertations, and as a faculty member teaching a research methods course, we encountered several ways of conducting a research synthesis but found no comprehensive resources that discussed, compared, and contrasted various synthesis methodologies on their purposes, processes, strengths and limitations. To complicate matters, writers use terms interchangeably or use different terms to mean the same thing, and the literature is often contradictory about various approaches. Some texts [6] , [7] – [9] did provide a preliminary understanding about how research synthesis had been taken up in nursing, but these did not meet our requirements. Thus, in this article we address the need for a comprehensive overview of research synthesis methodologies to guide public health, health care, and social science researchers and practitioners.

Research synthesis is relatively new in public health but has a long history in other fields dating back to the late 1800s. Research synthesis, a research process in its own right [10] , has become more prominent in the wake of the evidence-based movement of the 1990s. Research syntheses have found their advocates and detractors in all disciplines, with challenges to the processes of systematic review and meta-analysis, in particular, being raised by critics of evidence-based healthcare [11] – [13] .

Our purpose was to conduct an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis [14] – [15] . We synthesize and critique the main approaches to research synthesis that are relevant for public health, health care, and social scientists. Research synthesis is the overarching term we use to describe approaches to combining, aggregating, integrating, and synthesizing primary research findings. Each synthesis methodology draws on different types of findings depending on the purpose and product of the chosen synthesis (see Additional File 1 ).

3. Method of Review

Based on our current knowledge of the literature, we identified these approaches to include in our review: systematic review, meta-analysis, qualitative meta-synthesis, meta-narrative synthesis, scoping review, rapid review, realist synthesis, concept analysis, literature review, and integrative review. Our first step was to divide the synthesis types among the research team. Each member did a preliminary search to identify key texts. The team then met to develop search terms and a framework to guide the review.

Over the period of 2008 to 2012 we extensively searched the literature, updating our search at several time points, not restricting our search by date. The dates of texts reviewed range from 1967 to 2015. We used the terms above combined with the term “method* (e.g., “realist synthesis” and “method*) in the database Health Source: Academic Edition (includes Medline and CINAHL). This search yielded very few texts on some methodologies and many on others. We realized that many documents on research synthesis had not been picked up in the search. Therefore, we also searched Google Scholar, PubMed, ERIC, and Social Science Index, as well as the websites of key organizations such as the Joanna Briggs Institute, the University of York Centre for Evidence-Based Nursing, and the Cochrane Collaboration database. We hand searched several nursing, social science, public health and health policy journals. Finally, we traced relevant documents from the references in obtained texts.

We included works that met the following inclusion criteria: (1) published in English; (2) discussed the history of research synthesis; (3) explicitly described the approach and specific methods; or (4) identified issues, challenges, strengths and limitations of the particular methodology. We excluded research reports that resulted from the use of particular synthesis methodologies unless they also included criteria 2, 3, or 4 above.

Based on our search, we identified additional types of research synthesis (e.g., meta-interpretation, best evidence synthesis, critical interpretive synthesis, meta-summary, grounded formal theory). Still, we missed some important developments in meta-analysis, for example, identified by the journal's reviewers that have now been discussed briefly in the paper. The final set of 197 texts included in our review comprised theoretical, empirical, and conceptual papers, books, editorials and commentaries, and policy documents.

In our preliminary review of key texts, the team inductively developed a framework of the important elements of each method for comparison. In the next phase, each text was read carefully, and data for these elements were extracted into a table for comparison on the points of: key characteristics, purpose, methods, and product; see Additional File 1 ). Once the data were grouped and extracted, we synthesized across categories based on the following additional points of comparison: complexity of the process, degree of systematization, consideration of context, underlying assumptions, unit of analysis, and when to use each approach. In our results, we discuss our comparison of the various synthesis approaches on the elements above. Drawing only on documents for the review, ethics approval was not required.

We identified four broad categories of research synthesis methodology: Conventional, quantitative, qualitative, and emerging syntheses. From our dataset of 197 texts, we had 14 texts on conventional synthesis, 64 on quantitative synthesis, 78 on qualitative synthesis, and 41 on emerging syntheses. Table 1 provides an overview of the four types of research synthesis, definitions, types of data used, products, and examples of the methodology.

Although we group these types of synthesis into four broad categories on the basis of similarities, each type within a category has unique characteristics, which may differ from the overall group similarities. Each could be explored in greater depth to tease out their unique characteristics, but detailed comparison is beyond the scope of this article.

Additional File 1 presents one or more selected types of synthesis that represent the broad category but is not an exhaustive presentation of all types within each category. It provides more depth for specific examples from each category of synthesis on the characteristics, purpose, methods, and products than is found in Table 1 .

4.1. Key Characteristics

4.1.1. what is it.

Here we draw on two types of categorization. First, we utilize Dixon Woods et al.'s [49] classification of research syntheses as being either integrative or interpretive . (Please note that integrative syntheses are not the same as an integrative review as defined in Additional File 1 .) Second, we use Popay's [80] enhancement and epistemological models .

The defining characteristics of integrative syntheses are that they involve summarizing the data achieved by pooling data [49] . Integrative syntheses include systematic reviews, meta-analyses, as well as scoping and rapid reviews because each of these focus on summarizing data. They also define concepts from the outset (although this may not always be true in scoping or rapid reviews) and deal with a well-specified phenomenon of interest.

Interpretive syntheses are primarily concerned with the development of concepts and theories that integrate concepts [49] . The analysis in interpretive synthesis is conceptual both in process and outcome, and “the product is not aggregations of data, but theory” [49] , [p.12]. Interpretive syntheses involve induction and interpretation, and are primarily conceptual in process and outcome. Examples include integrative reviews, some systematic reviews, all of the qualitative syntheses, meta-narrative, realist and critical interpretive syntheses. Of note, both quantitative and qualitative studies can be either integrative or interpretive

The second categorization, enhancement versus epistemological , applies to those approaches that use multiple data types and sources [80] . Popay's [80] classification reflects the ways that qualitative data are valued in relation to quantitative data.

In the enhancement model , qualitative data adds something to quantitative analysis. The enhancement model is reflected in systematic reviews and meta-analyses that use some qualitative data to enhance interpretation and explanation. It may also be reflected in some rapid reviews that draw on quantitative data but use some qualitative data.

The epistemological model assumes that quantitative and qualitative data are equal and each has something unique to contribute. All of the other review approaches, except pure quantitative or qualitative syntheses, reflect the epistemological model because they value all data types equally but see them as contributing different understandings.

4.1.2. Data type

By and large, the quantitative approaches (quantitative systematic review and meta-analysis) have typically used purely quantitative data (i.e., expressed in numeric form). More recently, both Cochrane [81] and Campbell [82] collaborations are grappling with the need to, and the process of, integrating qualitative research into a systematic review. The qualitative approaches use qualitative data (i.e., expressed in words). All of the emerging synthesis types, as well as the conventional integrative review, incorporate qualitative and quantitative study designs and data.

4.1.3. Research question

Four types of research questions direct inquiry across the different types of syntheses. The first is a well-developed research question that gives direction to the synthesis (e.g., meta-analysis, systematic review, meta-study, concept analysis, rapid review, realist synthesis). The second begins as a broad general question that evolves and becomes more refined over the course of the synthesis (e.g., meta-ethnography, scoping review, meta-narrative, critical interpretive synthesis). In the third type, the synthesis begins with a phenomenon of interest and the question emerges in the analytic process (e.g., grounded formal theory). Lastly, there is no clear question, but rather a general review purpose (e.g., integrative review). Thus, the requirement for a well-defined question cuts across at least three of the synthesis types (e.g., quantitative, qualitative, and emerging).

4.1.4. Quality appraisal

This is a contested issue within and between the four synthesis categories. There are strong proponents of quality appraisal in the quantitative traditions of systematic review and meta-analysis based on the need for strong studies that will not jeopardize validity of the overall findings. Nonetheless, there is no consensus on pre-defined criteria; many scales exist that vary dramatically in composition. This has methodological implications for the credibility of findings [83] .

Specific methodologies from the conventional, qualitative, and emerging categories support quality appraisal but do so with caveats. In conventional integrative reviews appraisal is recommended, but depends on the sampling frame used in the study [18] . In meta-study, appraisal criteria are explicit but quality criteria are used in different ways depending on the specific requirements of the inquiry [54] . Among the emerging syntheses, meta-narrative review developers support appraisal of a study based on criteria from the research tradition of the primary study [67] , [84] – [85] . Realist synthesis similarly supports the use of high quality evidence, but appraisal checklists are viewed with scepticism and evidence is judged based on relevance to the research question and whether a credible inference may be drawn [69] . Like realist, critical interpretive syntheses do not judge quality using standardized appraisal instruments. They will exclude fatally flawed studies, but there is no consensus on what ‘fatally flawed’ means [49] , [71] . Appraisal is based on relevance to the inquiry, not rigor of the study.

There is no agreement on quality appraisal among qualitative meta-ethnographers with some supporting and others refuting the need for appraisal. [60] , [62] . Opponents of quality appraisal are found among authors of qualitative (grounded formal theory and concept analysis) and emerging syntheses (scoping and rapid reviews) because quality is not deemed relevant to the intention of the synthesis; the studies being reviewed are not effectiveness studies where quality is extremely important. These qualitative synthesis are often reviews of theoretical developments where the concept itself is what is important, or reviews that provide quotations from the raw data so readers can make their own judgements about the relevance and utility of the data. For example, in formal grounded theory, the purpose of theory generation and authenticity of data used to generate the theory is not as important as the conceptual category. Inaccuracies may be corrected in other ways, such as using the constant comparative method, which facilitates development of theoretical concepts that are repeatedly found in the data [86] – [87] . For pragmatic reasons, evidence is not assessed in rapid and scoping reviews, in part to produce a timely product. The issue of quality appraisal is unresolved across the terrain of research synthesis and we consider this further in our discussion.

4.2. Purpose

All research syntheses share a common purpose -- to summarize, synthesize, or integrate research findings from diverse studies. This helps readers stay abreast of the burgeoning literature in a field. Our discussion here is at the level of the four categories of synthesis. Beginning with conventional literature syntheses, the overall purpose is to attend to mature topics for the purpose of re-conceptualization or to new topics requiring preliminary conceptualization [14] . Such syntheses may be helpful to consider contradictory evidence, map shifting trends in the study of a phenomenon, and describe the emergence of research in diverse fields [14] . The purpose here is to set the stage for a study by identifying what has been done, gaps in the literature, important research questions, or to develop a conceptual framework to guide data collection and analysis.

The purpose of quantitative systematic reviews is to combine, aggregate, or integrate empirical research to be able to generalize from a group of studies and determine the limits of generalization [27] . The focus of quantitative systematic reviews has been primarily on aggregating the results of studies evaluating the effectiveness of interventions using experimental, quasi-experimental, and more recently, observational designs. Systematic reviews can be done with or without quantitative meta-analysis but a meta-analysis always takes place within the context of a systematic review. Researchers must consider the review's purpose and the nature of their data in undertaking a quantitative synthesis; this will assist in determining the approach.

The purpose of qualitative syntheses is broadly to synthesize complex health experiences, practices, or concepts arising in healthcare environments. There may be various purposes depending on the qualitative methodology. For example, in hermeneutic studies the aim may be holistic explanation or understanding of a phenomenon [42] , which is deepened by integrating the findings from multiple studies. In grounded formal theory, the aim is to produce a conceptual framework or theory expected to be applicable beyond the original study. Although not able to generalize from qualitative research in the statistical sense [88] , qualitative researchers usually do want to say something about the applicability of their synthesis to other settings or phenomena. This notion of ‘theoretical generalization’ has been referred to as ‘transferability’ [89] – [90] and is an important criterion of rigour in qualitative research. It applies equally to the products of a qualitative synthesis in which the synthesis of multiple studies on the same phenomenon strengthens the ability to draw transferable conclusions.

The overarching purpose of emerging syntheses is challenging the more traditional types of syntheses, in part by using data from both quantitative and qualitative studies with diverse designs for analysis. Beyond this, however, each emerging synthesis methodology has a unique purpose. In meta-narrative review, the purpose is to identify different research traditions in the area, synthesize a complex and diverse body of research. Critical interpretive synthesis shares this characteristic. Although a distinctive approach, critical interpretive synthesis utilizes a modification of the analytic strategies of meta-ethnography [61] (e.g., reciprocal translational analysis, refutational synthesis, and lines of argument synthesis) but goes beyond the use of these to bring a critical perspective to bear in challenging the normative or epistemological assumptions in the primary literature [72] – [73] . The unique purpose of a realist synthesis is to amalgamate complex empirical evidence and theoretical understandings within a diverse body of literature to uncover the operative mechanisms and contexts that affect the outcomes of social interventions. In a scoping review, the intention is to find key concepts, examine the range of research in an area, and identify gaps in the literature. The purpose of a rapid review is comparable to that of a scoping review, but done quickly to meet the time-sensitive information needs of policy makers.

4.3. Method

4.3.1. degree of systematization.

There are varying degrees of systematization across the categories of research synthesis. The most systematized are quantitative systematic reviews and meta-analyses. There are clear processes in each with judgments to be made at each step, although there are no agreed upon guidelines for this. The process is inherently subjective despite attempts to develop objective and systematic processes [91] – [92] . Mullen and Ramirez [27] suggest that there is often a false sense of rigour implied by the terms ‘systematic review’ and ‘meta-analysis’ because of their clearly defined procedures.

In comparison with some types of qualitative synthesis, concept analysis is quite procedural. Qualitative meta-synthesis also has defined procedures and is systematic, yet perhaps less so than concept analysis. Qualitative meta-synthesis starts in an unsystematic way but becomes more systematic as it unfolds. Procedures and frameworks exist for some of the emerging types of synthesis [e.g., [50] , [63] , [71] , [93] ] but are not linear, have considerable flexibility, and are often messy with emergent processes [85] . Conventional literature reviews tend not to be as systematic as the other three types. In fact, the lack of systematization in conventional literature synthesis was the reason for the development of more systematic quantitative [17] , [20] and qualitative [45] – [46] , [61] approaches. Some authors in the field [18] have clarified processes for integrative reviews making them more systematic and rigorous, but most conventional syntheses remain relatively unsystematic in comparison with other types.

4.3.2. Complexity of the process

Some synthesis processes are considerably more complex than others. Methodologies with clearly defined steps are arguably less complex than the more flexible and emergent ones. We know that any study encounters challenges and it is rare that a pre-determined research protocol can be followed exactly as intended. Not even the rigorous methods associated with Cochrane [81] systematic reviews and meta-analyses are always implemented exactly as intended. Even when dealing with numbers rather than words, interpretation is always part of the process. Our collective experience suggests that new methodologies (e.g., meta-narrative synthesis and realist synthesis) that integrate different data types and methods are more complex than conventional reviews or the rapid and scoping reviews.

4.4. Product

The products of research syntheses usually take three distinct formats (see Table 1 and Additional File 1 for further details). The first representation is in tables, charts, graphical displays, diagrams and maps as seen in integrative, scoping and rapid reviews, meta-analyses, and critical interpretive syntheses. The second type of synthesis product is the use of mathematical scores. Summary statements of effectiveness are mathematically displayed in meta-analyses (as an effect size), systematic reviews, and rapid reviews (statistical significance).

The third synthesis product may be a theory or theoretical framework. A mid-range theory can be produced from formal grounded theory, meta-study, meta-ethnography, and realist synthesis. Theoretical/conceptual frameworks or conceptual maps may be created in meta-narrative and critical interpretive syntheses, and integrative reviews. Concepts for use within theories are produced in concept analysis. While these three product types span the categories of research synthesis, narrative description and summary is used to present the products resulting from all methodologies.

4.5. Consideration of context

There are diverse ways that context is considered in the four broad categories of synthesis. Context may be considered to the extent that it features within primary studies for the purpose of the review. Context may also be understood as an integral aspect of both the phenomenon under study and the synthesis methodology (e.g., realist synthesis). Quantitative systematic reviews and meta-analyses have typically been conducted on studies using experimental and quasi-experimental designs and more recently observational studies, which control for contextual features to allow for understanding of the ‘true’ effect of the intervention [94] .

More recently, systematic reviews have included covariates or mediating variables (i.e., contextual factors) to help explain variability in the results across studies [27] . Context, however, is usually handled in the narrative discussion of findings rather than in the synthesis itself. This lack of attention to context has been one criticism leveled against systematic reviews and meta-analyses, which restrict the types of research designs that are considered [e.g., [95] ].

When conventional literature reviews incorporate studies that deal with context, there is a place for considering contextual influences on the intervention or phenomenon. Reviews of quantitative experimental studies tend to be devoid of contextual considerations since the original studies are similarly devoid, but context might figure prominently in a literature review that incorporates both quantitative and qualitative studies.

Qualitative syntheses have been conducted on the contextual features of a particular phenomenon [33] . Paterson et al. [54] advise researchers to attend to how context may have influenced the findings of particular primary studies. In qualitative analysis, contextual features may form categories by which the data can be compared and contrasted to facilitate interpretation. Because qualitative research is often conducted to understand a phenomenon as a whole, context may be a focus, although this varies with the qualitative methodology. At the same time, the findings in a qualitative synthesis are abstracted from the original reports and taken to a higher level of conceptualization, thus removing them from the original context.

Meta-narrative synthesis [67] , [84] , because it draws on diverse research traditions and methodologies, may incorporate context into the analysis and findings. There is not, however, an explicit step in the process that directs the analyst to consider context. Generally, the research question guiding the synthesis is an important factor in whether context will be a focus.

More recent iterations of concept analysis [47] , [96] – [97] explicitly consider context reflecting the assumption that a concept's meaning is determined by its context. Morse [47] points out, however, that Wilson's [98] approach to concept analysis, and those based on Wilson [e.g., [45] ], identify attributes that are devoid of context, while Rodgers' [96] , [99] evolutionary method considers context (e.g., antecedents, consequences, and relationships to other concepts) in concept development.

Realist synthesis [69] considers context as integral to the study. It draws on a critical realist logic of inquiry grounded in the work of Bhaskar [100] , who argues that empirical co-occurrence of events is insufficient for inferring causation. One must identify generative mechanisms whose properties are causal and, depending on the situation, may nor may not be activated [94] . Context interacts with program/intervention elements and thus cannot be differentiated from the phenomenon [69] . This approach synthesizes evidence on generative mechanisms and analyzes contextual features that activate them; the result feeds back into the context. The focus is on what works, for whom, under what conditions, why and how [68] .

4.6. Underlying Philosophical and Theoretical Assumptions

When we began our review, we ‘assumed’ that the assumptions underlying synthesis methodologies would be a distinguishing characteristic of synthesis types, and that we could compare the various types on their assumptions, explicit or implicit. We found, however, that many authors did not explicate the underlying assumptions of their methodologies, and it was difficult to infer them. Kirkevold [101] has argued that integrative reviews need to be carried out from an explicit philosophical or theoretical perspective. We argue this should be true for all types of synthesis.

Authors of some emerging synthesis approaches have been very explicit about their assumptions and philosophical underpinnings. An implicit assumption of most emerging synthesis methodologies is that quantitative systematic reviews and meta-analyses have limited utility in some fields [e.g., in public health – [13] , [102] ] and for some kinds of review questions like those about feasibility and appropriateness versus effectiveness [103] – [104] . They also assume that ontologically and epistemologically, both kinds of data can be combined. This is a significant debate in the literature because it is about the commensurability of overarching paradigms [105] but this is beyond the scope of this review.

Realist synthesis is philosophically grounded in critical realism or, as noted above, a realist logic of inquiry [93] , [99] , [106] – [107] . Key assumptions regarding the nature of interventions that inform critical realism have been described above in the section on context. See Pawson et al. [106] for more information on critical realism, the philosophical basis of realist synthesis.

Meta-narrative synthesis is explicitly rooted in a constructivist philosophy of science [108] in which knowledge is socially constructed rather than discovered, and what we take to be ‘truth’ is a matter of perspective. Reality has a pluralistic and plastic character, and there is no pre-existing ‘real world’ independent of human construction and language [109] . See Greenhalgh et al. [67] , [85] and Greenhalgh & Wong [97] for more discussion of the constructivist basis of meta-narrative synthesis.

In the case of purely quantitative or qualitative syntheses, it may be an easier matter to uncover unstated assumptions because they are likely to be shared with those of the primary studies in the genre. For example, grounded formal theory shares the philosophical and theoretical underpinnings of grounded theory, rooted in the theoretical perspective of symbolic interactionism [110] – [111] and the philosophy of pragmatism [87] , [112] – [114] .

As with meta-narrative synthesis, meta-study developers identify constructivism as their interpretive philosophical foundation [54] , [88] . Epistemologically, constructivism focuses on how people construct and re-construct knowledge about a specific phenomenon, and has three main assumptions: (1) reality is seen as multiple, at times even incompatible with the phenomenon under consideration; (2) just as primary researchers construct interpretations from participants' data, meta-study researchers also construct understandings about the primary researchers' original findings. Thus, meta-synthesis is a construction of a construction, or a meta-construction; and (3) all constructions are shaped by the historical, social and ideological context in which they originated [54] . The key message here is that reports of any synthesis would benefit from an explicit identification of the underlying philosophical perspectives to facilitate a better understanding of the results, how they were derived, and how they are being interpreted.

4.7. Unit of Analysis

The unit of analysis for each category of review is generally distinct. For the emerging synthesis approaches, the unit of analysis is specific to the intention. In meta-narrative synthesis it is the storyline in diverse research traditions; in rapid review or scoping review, it depends on the focus but could be a concept; and in realist synthesis, it is the theories rather than programs that are the units of analysis. The elements of theory that are important in the analysis are mechanisms of action, the context, and the outcome [107] .

For qualitative synthesis, the units of analysis are generally themes, concepts or theories, although in meta-study, the units of analysis can be research findings (“meta-data-analysis”), research methods (“meta-method”) or philosophical/theoretical perspectives (“meta-theory”) [54] . In quantitative synthesis, the units of analysis range from specific statistics for systematic reviews to effect size of the intervention for meta-analysis. More recently, some systematic reviews focus on theories [115] – [116] , therefore it depends on the research question. Similarly, within conventional literature synthesis the units of analysis also depend on the research purpose, focus and question as well as on the type of research methods incorporated into the review. What is important in all research syntheses, however, is that the unit of analysis needs to be made explicit. Unfortunately, this is not always the case.

4.8. Strengths and Limitations

In this section, we discuss the overarching strengths and limitations of synthesis methodologies as a whole and then highlight strengths and weaknesses across each of our four categories of synthesis.

4.8.1. Strengths of Research Syntheses in General

With the vast proliferation of research reports and the increased ease of retrieval, research synthesis has become more accessible providing a way of looking broadly at the current state of research. The availability of syntheses helps researchers, practitioners, and policy makers keep up with the burgeoning literature in their fields without which evidence-informed policy or practice would be difficult. Syntheses explain variation and difference in the data helping us identify the relevance for our own situations; they identify gaps in the literature leading to new research questions and study designs. They help us to know when to replicate a study and when to avoid excessively duplicating research. Syntheses can inform policy and practice in a way that well-designed single studies cannot; they provide building blocks for theory that helps us to understand and explain our phenomena of interest.

4.8.2. Limitations of Research Syntheses in General

The process of selecting, combining, integrating, and synthesizing across diverse study designs and data types can be complex and potentially rife with bias, even with those methodologies that have clearly defined steps. Just because a rigorous and standardized approach has been used does not mean that implicit judgements will not influence the interpretations and choices made at different stages.

In all types of synthesis, the quantity of data can be considerable, requiring difficult decisions about scope, which may affect relevance. The quantity of available data also has implications for the size of the research team. Few reviews these days can be done independently, in particular because decisions about inclusion and exclusion may require the involvement of more than one person to ensure reliability.

For all types of synthesis, it is likely that in areas with large, amorphous, and diverse bodies of literature, even the most sophisticated search strategies will not turn up all the relevant and important texts. This may be more important in some synthesis methodologies than in others, but the omission of key documents can influence the results of all syntheses. This issue can be addressed, at least in part, by including a library scientist on the research team as required by some funding agencies. Even then, it is possible to miss key texts. In this review, for example, because none of us are trained in or conduct meta-analyses, we were not even aware that we had missed some new developments in this field such as meta-regression [117] – [118] , network meta-analysis [119] – [121] , and the use of individual patient data in meta-analyses [122] – [123] .

One limitation of systematic reviews and meta-analyses is that they rapidly go out of date. We thought this might be true for all types of synthesis, although we wondered if those that produce theory might not be somewhat more enduring. We have not answered this question but it is open for debate. For all types of synthesis, the analytic skills and the time required are considerable so it is clear that training is important before embarking on a review, and some types of review may not be appropriate for students or busy practitioners.

Finally, the quality of reporting in primary studies of all genres is variable so it is sometimes difficult to identify aspects of the study essential for the synthesis, or to determine whether the study meets quality criteria. There may be flaws in the original study, or journal page limitations may necessitate omitting important details. Reporting standards have been developed for some types of reviews (e.g., systematic review, meta-analysis, meta-narrative synthesis, realist synthesis); but there are no agreed upon standards for qualitative reviews. This is an important area for development in advancing the science of research synthesis.

4.8.3. Strengths and Limitations of the Four Synthesis Types

The conventional literature review and now the increasingly common integrative review remain important and accessible approaches for students, practitioners, and experienced researchers who want to summarize literature in an area but do not have the expertise to use one of the more complex methodologies. Carefully executed, such reviews are very useful for synthesizing literature in preparation for research grants and practice projects. They can determine the state of knowledge in an area and identify important gaps in the literature to provide a clear rationale or theoretical framework for a study [14] , [18] . There is a demand, however, for more rigour, with more attention to developing comprehensive search strategies and more systematic approaches to combining, integrating, and synthesizing the findings.

Generally, conventional reviews include diverse study designs and data types that facilitate comprehensiveness, which may be a strength on the one hand, but can also present challenges on the other. The complexity inherent in combining results from studies with diverse methodologies can result in bias and inaccuracies. The absence of clear guidelines about how to synthesize across diverse study types and data [18] has been a challenge for novice reviewers.

Quantitative systematic reviews and meta-analyses have been important in launching the field of evidence-based healthcare. They provide a systematic, orderly and auditable process for conducting a review and drawing conclusions [25] . They are arguably the most powerful approaches to understanding the effectiveness of healthcare interventions, especially when intervention studies on the same topic show very different results. When areas of research are dogged by controversy [25] or when study results go against strongly held beliefs, such approaches can reduce the uncertainty and bring strong evidence to bear on the controversy.

Despite their strengths, they also have limitations. Systematic reviews and meta-analyses do not provide a way of including complex literature comprising various types of evidence including qualitative studies, theoretical work, and epidemiological studies. Only certain types of design are considered and qualitative data are used in a limited way. This exclusion limits what can be learned in a topic area.

Meta-analyses are often not possible because of wide variability in study design, population, and interventions so they may have a narrow range of utility. New developments in meta-analysis, however, can be used to address some of these limitations. Network meta-analysis is used to explore relative efficacy of multiple interventions, even those that have never been compared in more conventional pairwise meta-analyses [121] , allowing for improved clinical decision making [120] . The limitation is that network meta-analysis has only been used in medical/clinical applications [119] and not in public health. It has not yet been widely accepted and many methodological challenges remain [120] – [121] . Meta-regression is another development that combines meta-analytic and linear regression principles to address the fact that heterogeneity of results may compromise a meta-analysis [117] – [118] . The disadvantage is that many clinicians are unfamiliar with it and may incorrectly interpret results [117] .

Some have accused meta-analysis of combining apples and oranges [124] raising questions in the field about their meaningfulness [25] , [28] . More recently, the use of individual rather than aggregate data has been useful in facilitating greater comparability among studies [122] . In fact, Tomas et al. [123] argue that meta-analysis using individual data is now the gold standard although access to the raw data from other studies may be a challenge to obtain.

The usefulness of systematic reviews in synthesizing complex health and social interventions has also been challenged [102] . It is often difficult to synthesize their findings because such studies are “epistemologically diverse and methodologically complex” [ [69] , p.21]. Rigid inclusion/exclusion criteria may allow only experimental or quasi-experimental designs into consideration resulting in lost information that may well be useful to policy makers for tailoring an intervention to the context or understanding its acceptance by recipients.

Qualitative syntheses may be the type of review most fraught with controversy and challenge, while also bringing distinct strengths to the enterprise. Although these methodologies provide a comprehensive and systematic review approach, they do not generally provide definitive statements about intervention effectiveness. They do, however, address important questions about the development of theoretical concepts, patient experiences, acceptability of interventions, and an understanding about why interventions might work.

Most qualitative syntheses aim to produce a theoretically generalizable mid-range theory that explains variation across studies. This makes them more useful than single primary studies, which may not be applicable beyond the immediate setting or population. All provide a contextual richness that enhances relevance and understanding. Another benefit of some types of qualitative synthesis (e.g., grounded formal theory) is that the concept of saturation provides a sound rationale for limiting the number of texts to be included thus making reviews potentially more manageable. This contrasts with the requirements of systematic reviews and meta-analyses that require an exhaustive search.

Qualitative researchers debate about whether the findings of ontologically and epistemological diverse qualitative studies can actually be combined or synthesized [125] because methodological diversity raises many challenges for synthesizing findings. The products of different types of qualitative syntheses range from theory and conceptual frameworks, to themes and rich descriptive narratives. Can one combine the findings from a phenomenological study with the theory produced in a grounded theory study? Many argue yes, but many also argue no.

Emerging synthesis methodologies were developed to address some limitations inherent in other types of synthesis but also have their own issues. Because each type is so unique, it is difficult to identify overarching strengths of the entire category. An important strength, however, is that these newer forms of synthesis provide a systematic and rigorous approach to synthesizing a diverse literature base in a topic area that includes a range of data types such as: both quantitative and qualitative studies, theoretical work, case studies, evaluations, epidemiological studies, trials, and policy documents. More than conventional literature reviews and systematic reviews, these approaches provide explicit guidance on analytic methods for integrating different types of data. The assumption is that all forms of data have something to contribute to knowledge and theory in a topic area. All have a defined but flexible process in recognition that the methods may need to shift as knowledge develops through the process.

Many emerging synthesis types are helpful to policy makers and practitioners because they are usually involved as team members in the process to define the research questions, and interpret and disseminate the findings. In fact, engagement of stakeholders is built into the procedures of the methods. This is true for rapid reviews, meta-narrative syntheses, and realist syntheses. It is less likely to be the case for critical interpretive syntheses.

Another strength of some approaches (realist and meta-narrative syntheses) is that quality and publication standards have been developed to guide researchers, reviewers, and funders in judging the quality of the products [108] , [126] – [127] . Training materials and online communities of practice have also been developed to guide users of realist and meta-narrative review methods [107] , [128] . A unique strength of critical interpretive synthesis is that it takes a critical perspective on the process that may help reconceptualize the data in a way not considered by the primary researchers [72] .

There are also challenges of these new approaches. The methods are new and there may be few published applications by researchers other than the developers of the methods, so new users often struggle with the application. The newness of the approaches means that there may not be mentors available to guide those unfamiliar with the methods. This is changing, however, and the number of applications in the literature is growing with publications by new users helping to develop the science of synthesis [e.g., [129] ]. However, the evolving nature of the approaches and their developmental stage present challenges for novice researchers.

4.9. When to Use Each Approach

Choosing an appropriate approach to synthesis will depend on the question you are asking, the purpose of the review, and the outcome or product you want to achieve. In Additional File 1 , we discuss each of these to provide guidance to readers on making a choice about review type. If researchers want to know whether a particular type of intervention is effective in achieving its intended outcomes, then they might choose a quantitative systemic review with or without meta-analysis, possibly buttressed with qualitative studies to provide depth and explanation of the results. Alternately, if the concern is about whether an intervention is effective with different populations under diverse conditions in varying contexts, then a realist synthesis might be the most appropriate.

If researchers' concern is to develop theory, they might consider qualitative syntheses or some of the emerging syntheses that produce theory (e.g., critical interpretive synthesis, realist review, grounded formal theory, qualitative meta-synthesis). If the aim is to track the development and evolution of concepts, theories or ideas, or to determine how an issue or question is addressed across diverse research traditions, then meta-narrative synthesis would be most appropriate.

When the purpose is to review the literature in advance of undertaking a new project, particularly by graduate students, then perhaps an integrative review would be appropriate. Such efforts contribute towards the expansion of theory, identify gaps in the research, establish the rationale for studying particular phenomena, and provide a framework for interpreting results in ways that might be useful for influencing policy and practice.

For researchers keen to bring new insights, interpretations, and critical re-conceptualizations to a body of research, then qualitative or critical interpretive syntheses will provide an inductive product that may offer new understandings or challenges to the status quo. These can inform future theory development, or provide guidance for policy and practice.

5. Discussion

What is the current state of science regarding research synthesis? Public health, health care, and social science researchers or clinicians have previously used all four categories of research synthesis, and all offer a suitable array of approaches for inquiries. New developments in systematic reviews and meta-analysis are providing ways of addressing methodological challenges [117] – [123] . There has also been significant advancement in emerging synthesis methodologies and they are quickly gaining popularity. Qualitative meta-synthesis is still evolving, particularly given how new it is within the terrain of research synthesis. In the midst of this evolution, outstanding issues persist such as grappling with: the quantity of data, quality appraisal, and integration with knowledge translation. These topics have not been thoroughly addressed and need further debate.

5.1. Quantity of Data

We raise the question of whether it is possible or desirable to find all available studies for a synthesis that has this requirement (e.g., meta-analysis, systematic review, scoping, meta-narrative synthesis [25] , [27] , [63] , [67] , [84] – [85] ). Is the synthesis of all available studies a realistic goal in light of the burgeoning literature? And how can this be sustained in the future, particularly as the emerging methodologies continue to develop and as the internet facilitates endless access? There has been surprisingly little discussion on this topic and the answers will have far-reaching implications for searching, sampling, and team formation.

Researchers and graduate students can no longer rely on their own independent literature search. They will likely need to ask librarians for assistance as they navigate multiple sources of literature and learn new search strategies. Although teams now collaborate with library scientists, syntheses are limited in that researchers must make decisions on the boundaries of the review, in turn influencing the study's significance. The size of a team may also be pragmatically determined to manage the search, extraction, and synthesis of the burgeoning data. There is no single answer to our question about the possibility or necessity of finding all available articles for a review. Multiple strategies that are situation specific are likely to be needed.

5.2. Quality Appraisal

While the issue of quality appraisal has received much attention in the synthesis literature, scholars are far from resolution. There may be no agreement about appraisal criteria in a given tradition. For example, the debate rages over the appropriateness of quality appraisal in qualitative synthesis where there are over 100 different sets of criteria and many do not overlap [49] . These differences may reflect disciplinary and methodological orientations, but diverse quality appraisal criteria may privilege particular types of research [49] . The decision to appraise is often grounded in ontological and epistemological assumptions. Nonetheless, diversity within and between categories of synthesis is likely to continue unless debate on the topic of quality appraisal continues and evolves toward consensus.

5.3. Integration with Knowledge Translation

If research syntheses are to make a difference to practice and ultimately to improve health outcomes, then we need to do a better job of knowledge translation. In the Canadian Institutes of Health Research (CIHR) definition of knowledge translation (KT), research or knowledge synthesis is an integral component [130] . Yet, with few exceptions [131] – [132] , very little of the research synthesis literature even mentions the relationship of synthesis to KT nor does it discuss strategies to facilitate the integration of synthesis findings into policy and practice. The exception is in the emerging synthesis methodologies, some of which (e.g., realist and meta-narrative syntheses, scoping reviews) explicitly involve stakeholders or knowledge users. The argument is that engaging them in this way increases the likelihood that the knowledge generated will be translated into policy and practice. We suggest that a more explicit engagement with knowledge users in all types of synthesis would benefit the uptake of the research findings.

Research synthesis neither makes research more applicable to practice nor ensures implementation. Focus must now turn seriously towards translation of synthesis findings into knowledge products that are useful for health care practitioners in multiple areas of practice and develop appropriate strategies to facilitate their use. The burgeoning field of knowledge translation has, to some extent, taken up this challenge; however, the research-practice gap continues to plague us [133] – [134] . It is a particular problem for qualitative syntheses [131] . Although such syntheses have an important place in evidence-informed practice, little effort has gone into the challenge of translating the findings into useful products to guide practice [131] .

5.4. Limitations

Our study took longer than would normally be expected for an integrative review. Each of us were primarily involved in our own dissertations or teaching/research positions, and so this study was conducted ‘off the sides of our desks.’ A limitation was that we searched the literature over the course of 4 years (from 2008–2012), necessitating multiple search updates. Further, we did not do a comprehensive search of the literature after 2012, thus the more recent synthesis literature was not systematically explored. We did, however, perform limited database searches from 2012–2015 to keep abreast of the latest methodological developments. Although we missed some new approaches to meta-analysis in our search, we did not find any new features of the synthesis methodologies covered in our review that would change the analysis or findings of this article. Lastly, we struggled with the labels used for the broad categories of research synthesis methodology because of our hesitancy to reinforce the divide between quantitative and qualitative approaches. However, it was very difficult to find alternative language that represented the types of data used in these methodologies. Despite our hesitancy in creating such an obvious divide, we were left with the challenge of trying to find a way of characterizing these broad types of syntheses.

6. Conclusion

Our findings offer methodological clarity for those wishing to learn about the broad terrain of research synthesis. We believe that our review makes transparent the issues and considerations in choosing from among the four broad categories of research synthesis. In summary, research synthesis has taken its place as a form of research in its own right. The methodological terrain has deep historical roots reaching back over the past 200 years, yet research synthesis remains relatively new to public health, health care, and social sciences in general. This is rapidly changing. New developments in systematic reviews and meta-analysis, and the emergence of new synthesis methodologies provide a vast array of options to review the literature for diverse purposes. New approaches to research synthesis and new analytic methods within existing approaches provide a much broader range of review alternatives for public health, health care, and social science students and researchers.

Acknowledgments

KSM is an assistant professor in the Faculty of Nursing at the University of Alberta. Her work on this article was largely conducted as a Postdoctoral Fellow, funded by KRESCENT (Kidney Research Scientist Core Education and National Training Program, reference #KRES110011R1) and the Faculty of Nursing at the University of Alberta.

MM's work on this study over the period of 2008-2014 was supported by a Canadian Institutes of Health Research Applied Public Health Research Chair Award (grant #92365).

We thank Rachel Spanier who provided support with reference formatting.

List of Abbreviations (in Additional File 1 )

Conflict of interest: The authors declare that they have no conflicts of interest in this article.

Authors' contributions: KSM co-designed the study, collected data, analyzed the data, drafted/revised the manuscript, and managed the project.

MP contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

JB contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

WN contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

All authors read and approved the final manuscript.

Additional Files: Additional File 1 – Selected Types of Research Synthesis

This Additional File is our dataset created to organize, analyze and critique the literature that we synthesized in our integrative review. Our results were created based on analysis of this Additional File.

GRE Verbal : Analysis and Synthesis in Single-Answer Questions

Study concepts, example questions & explanations for gre verbal, all gre verbal resources, example questions, example question #1 : single answer questions.

"The Chemistry of Cooking" by Will Floyd

Molecular gastronomy is a new take on cooking that has spread like wildfire through the culinary world in the last few decades. At its core, molecular gastronomy seeks to redefine and reimagine how food is cooked in restaurant kitchens, using technology, chemistry, and physics to transform pedestrian dishes into surprising forms and textures. These techniques create mystifying dining experiences, while using intimately familiar flavors. Chefs who use molecular gastronomy do not wish merely to be chemists or engineers, but are chefs above all else. To create a special dining experience, the chef begins first and foremost with the dish they wish to serve. Tools like an anti-griddle, a flat top that instantly freezes anything that touches it, or maltodextrin, an additive that can turn liquids into powder, are not there simply to play with the food. A molecular gastronomist will first think of the dish they want to serve, like fried chicken and mashed potatoes. Next, they will find a way to get the same flavors and textures in a unique way. The chicken might not be fried, but go through a process that will give it a crispy skin and juicy meat while never broaching hot oil. The mashed potatoes could become a light sauce, and then be put on an anti-griddle to give a new look, texture, and temperature. While the diner will have something that might look like a dessert or a soup, in actuality what they are having is a homestyle dish that they remember from childhood. This sense of familiarity is the ultimate goal of any chef utilizing molecular gastronomy.

A criticism of molecular gastronomy can be best summarized as __________ .

it is bringing unnecessary and unhelpful tools into a kitchen

it is transforming the way people look at food

it is based around technology, chemistry, and physics

it is creating exciting new opportunities for diners

it uses an anti-griddle and maltodextrin

The question asks for a criticism of molecular gastronomy. Looking over all of the answer choices, all but one choice state a fact about molecular gastronomy or are a compliment to molecular gastronomy. Only "it is bringing unnecessary and unhelpful tools to a kitchen" is truly a criticism.

Adapted from  Seven Discourses Delivered in the Royal Academy By the President  by Joshua Reynolds (1778)

All the objects which are exhibited to our view by nature, upon close examination will be found to have their blemishes and defects. The most beautiful forms have something about them like weakness, minuteness, or imperfection. But it is not every eye that perceives these blemishes. It must be an eye long used to the contemplation and comparison of these forms—and which, by a long habit of observing what any set of objects of the same kind have in common, that alone can acquire the power of discerning what each wants in particular. This long laborious comparison should be the first study of the painter who aims at the greatest style. By this means, he acquires a just idea of beautiful forms; he corrects nature by herself, her imperfect state by her more perfect. His eye being enabled to distinguish the accidental deficiencies, excrescences, and deformities of things from their general figures, he makes out an abstract idea of their forms more perfect than any one original—and what may seem a paradox, he learns to design naturally by drawing his figures unlike to any one object. This idea of the perfect state of nature, which the artist calls the ideal beauty, is the great leading principle by which works of genius are conducted. By this, Phidias acquired his fame. He wrought upon a sober principle what has so much excited the enthusiasm of the world—and by this method you, who have courage to tread the same path, may acquire equal reputation.

The author does NOT view imperfections in nature as __________ .

confounding

The author notes that "all the objects" in nature have "blemishes and defects." The author also notes that the "most beautiful forms" have a "weakness, minuteness, or imperfection." The only answer choice that makes sense with the passage is "abhorrent," meaning distasteful or offensive.

Example Question #1 : Analysis And Synthesis In Single Answer Questions

The following passage is adapted from  The God-Idea of the Ancients: or, Sex in Religion , by Elizabeth Burt Gamble (1897)

Regarding the introduction of Christianity into Ireland it is claimed by certain writers that the Irish did not receive the “new religion” from Greek missionaries; but when at the close of the cycle, a new solar deity, an avatar of Vishnu or Krishna was announced, and when missionaries from the East proclaimed the glad tidings of a risen Savior, the Irish people gladly accepted their teachings, not, however, as a new system, but as the fulfillment to them of the prophecy of the most ancient seers of the East, and as part and parcel of the religion of their forefathers. Therefore when the devotees of the Roman faith, probably about the close of the fifth century of the Christian era, attempted to “convert” Ireland, they found a religion differing from their own only in the fact that it was not subject to Rome, and was free from the many corruptions and superstitions which through the extreme ignorance and misapprehension of its Western adherents had been engrafted upon it.

The claim of "certain writers" referenced in the first sentence is __________ .

that the Irish wholeheartedly adopted Roman customs

that Greek missionaries brought Christianity to Ireland

the "new religion" never caught on in Ireland

that the Irish adopted Christianity in their own way

that the Romans never came to Ireland

The opening statement of the passage explicitly notes the "Irish did not receive the 'new religion' from Greek missionaries." The rest of the passage furthers the claim that the Irish adapted to Christianity at their own pace and largely from the inside.

"A Short History of Recent Zoos" by Will Floyd

Throughout the twentieth century, zoos underwent large-scale transformations. Before World War I, zoos were small parts of larger municipal parks, and featured sparse cages with little room for their inhabitants. This model held sway until mid-century, with many zoos struggling to remain open during the Great Depression and World War II. The successful zoos survived through making themselves cheap family entertainment. In the 1960s, zoos began to change in drastic ways. With the growing strength of environmental and animal rights movements, the public clamored for more naturalistic and spacious environments in which the animals could live.

The most emblematic of these transformations was the development of the Los Angeles Zoo. In 1966, the cramped and antiquated zoo used grants from the city government to move to a brand-new facility. Although the zoo moved just two miles away, the new location was exponentially bigger, and it featured fresh landscapes that resembled the animals’ natural habitats, instead of dilapidated cages. As the Los Angeles Zoo developed, it was able to work on preservation and conservation efforts for endangered species. New educational programs also became key elements of the Zoo’s mission. Now the old Zoo’s cages stand as ruins and reminders of what past generations saw when they visited years ago.

The author would suggest a new zoo should __________ .

build only sparse cages with few extra environments for the animals

not consult environmentalists or animal rights activists

look like pre-World War II zoos

ignore the desires of the public

focus on conservation, preservation, and educational programs

The author's main point throughout the passage is that zoos have changed for the better by becoming bigger, with more naturalistic environments, and through a focus on various kinds of programs. In particular, the author highlights the Los Angeles Zoo's conservation, preservation, and educational programs. It is safe to presume that the author views these as key elements of a modern zoo.

Example Question #2 : Single Answer Questions

"Political Representation" by Will Floyd

Pundits often decry the gridlock in Washington, D.C. Partisanship frequently makes legislators oppose bills they have supported in the past. Political grandstanding regularly takes the place of reasoned compromise or deal-making. Many political scientists are trying to find ways to resolve these issues within constitutional boundaries. One of the more popular suggestions is a different voting system called proportional representation. Proportional representation operates under the theory that each vote will help place a candidate in the legislature, rather than the current winner take all method of elections in the United States. Under proportional representation, candidates do not run for a specific seat in a particular district, but instead are part of a ranked list of candidates for each political party; therefore, if a political party receives thirty percent of the votes, thirty percent of the seats will be held by this party. Critics of proportional representation claim the system gives too much power to fringe candidates and political parties, whose only goal would be to destroy the political system. This cynical view of proportional representation stems from the example of countries currently using proportional representation. As it is, political scientists who do argue for proportional representation are trying to find a way around the current problems that exist in the United States’ political system, and feel a third party might create new pressures on the two party system currently causing such problems. The advocates of proportional representation do not argue that proportional representation is a perfect system, but also argue that we are not currently using a perfect system and that we need something to change.

The author would agree with the statement that __________ .

proportional representation is only argued for by outsiders and crazy people

the current political system in the United States works perfectly

proportional representation could introduce new voices into the legislature

proportional representation would never work in the United States

the current political system in the United States is imperfect, but as good as it can be

The author's own opinions are largely kept away from the passage, but by discussing proportional representation in the manner it does, some thoughts can be deduced. The use of "a third party might create new pressures" as the final word in the argument does indicate this idea is close to what  the author truly believes.

Adapted from  The Significance of the Frontier in American History  by Frederick Jackson Turner (1893)

But the larger part of what has been distinctive and valuable in America's contribution to the history of the human spirit has been due to this nation's peculiar experience in extending its type of frontier into new regions—and in creating peaceful societies with new ideals in the successive vast and differing geographic provinces which together make up the United States. Directly or indirectly these experiences shaped the life of both the Eastern and Western States, and even reacted upon the Old World, influencing the direction of its thought and progress. This experience has been fundamental in the economic, political, and social characteristics of the American people and in their conceptions of their destiny.

Writing at the close of 1796, the French minister to the United States, M. Adet, reported to his government that Jefferson could not be relied on to be devoted to French interests, and he added that "Jefferson, I say, is American, and by that name, he cannot be sincerely our friend. An American is the born enemy of all European peoples." Obviously erroneous as are these words, there was an element of truth in them. If we would understand this element of truth, we must study the transforming influence of the American wilderness, remote from Europe, and by its resources and its free opportunities affording the conditions under which a new people, with new social and political types and ideals, could arise to play its own part in the world, and to influence Europe.

The author views the frontier as being __________ .

inconsequential to American identity

a key factor in America's development

unimportant to Europe

difficult to define and analyze

a frivolous element of American politics

The author outright states that the frontier "experience has been fundamental" for the American people. The author also argues that this frontier experience has affected Europe.

Example Question #2 : Inference About The Subject

Adapted from The Idea of a University by John Henry Newman (1852)

I have been insisting, in my two preceding Discourses, first, on the cultivation of the intellect, as an end which may reasonably be pursued for its own sake; and next, on the nature of that cultivation, or what that cultivation consists in. Truth of whatever kind is the proper object of the intellect; its cultivation then lies in fitting it to apprehend and contemplate truth. Now the intellect in its present state, with exceptions which need not here be specified, does not discern truth intuitively, or as a whole. We know, not by a direct and simple vision, not at a glance, but, as it were, by piecemeal and accumulation, by a mental process, by going round an object, by the comparison, the combination, the mutual correction, the continual adaptation, of many partial notions, by the employment, concentration, and joint action of many faculties and exercises of mind.

Such a union and concert of the intellectual powers, such an enlargement and development, such a comprehensiveness, is necessarily a matter of training. And again, such a training is a matter of rule. It is not mere application, however exemplary, which introduces the mind to truth, nor the reading many books, nor the getting up many subjects, nor the witnessing many experiments, nor the attending many lectures. All this is short of enough. A man may have done it all, yet be lingering in the vestibule of knowledge. He may not realize what his mouth utters; he may not see with his mental eye what confronts him; he may have no grasp of things as they are, or at least he may have no power at all of advancing one step forward of himself, in consequence of what he has already acquired, no power of discriminating between truth and falsehood, of sifting out the grains of truth from the mass, of arranging things according to their real value, and, if I may use the phrase, of building up ideas. Such a power is the result of a scientific formation of mind; it is an acquired faculty of judgment, of clear-sightedness, of sagacity, of wisdom, of philosophical reach of mind, and of intellectual self-possession and repose—qualities which do not come of mere acquirement. The bodily eye, the organ for apprehending material objects, is provided by nature; the eye of the mind, of which the object is truth, is the work of discipline and habit.

This process of training, by which the intellect, instead of being formed or sacrificed to some particular or accidental purpose, some specific trade or profession, or study or science, is disciplined for its own sake, for the perception of its own proper object, and for its own highest culture, is called Liberal Education; and though there is no one in whom it is carried as far as is conceivable, or whose intellect would be a pattern of what intellects should be made, yet there is scarcely any one but may gain an idea of what real training is, and at least look towards it, and make its true scope and result, not something else, his standard of excellence; and numbers there are who may submit themselves to it, and secure it to themselves in good measure. And to set forth the right standard, and to train according to it, and to help forward all students towards it according to their various capacities, this I conceive to be the business of a University.

Based on the information provided in this passage, which of the following would you expect to be found in the previous chapters of the book from which this passage is drawn?

A defense for the use of Newman's particular religious creed in education.

A discussion that included some defense of learning for the sole sake of learning.

A plea to end all vocational education.

A diatribe against modernity and modern education.

None of the other answer choices

The whole topic of this selection is a defense of a general education that is not particular. At the beginning of the selection, Newman explicitly remarks about his previous "discourses." Among the topics there discussed, he apparently included, "The cultivation of the intellect, as an end which may reasonably be pursued for its own sake." Although this does not mean that he completely argued his case for this point, the implication is that he did make some defense for forms of learning that are not immediately useful (but are good in themselves). This does not mean that he necessarily argued against other forms of knowledge. You cannot go this far in your interpretation!

Example Question #1 : Literal Comprehension

Passage adapted from H.G Wells's  Anticipations  (1901)

Democracy of the modern type—manhood suffrage and so forth—became a conspicuous phenomenon in the world only in the closing decades of the eighteenth century. Its genesis is so intimately connected with the first expansion of the productive element in the State, through mechanism and a co-operative organization, as to point at once to a causative connection. The more closely one looks into the social and political life of the eighteenth century the more plausible becomes this view. New and potentially influential social factors had begun to appear—the organizing manufacturer, the intelligent worker, the skilled tenant, and the urban abyss, and the traditions of the old land-owning non-progressive aristocratic monarchy that prevailed in Christendom, rendered it incapable—without some destructive shock or convulsion—of any re-organization to incorporate or control these new factors. In the case of the British Empire an additional stress was created by the incapacity of the formal government to assimilate the developing civilization of the American colonies. Everywhere there were new elements, not as yet clearly analyzed or defined, arising as mechanism arose; everywhere the old traditional government and social system, defined and analyzed all too well, appeared increasingly obstructive, irrational, and feeble in its attempts to include and direct these new powers.

But now comes a point to which I am inclined to attach very great importance. The new powers were as yet shapeless. It was not the conflict of a new organization with the old. It was the preliminary dwarfing and deliquescence of the mature old beside the embryonic mass of the new. It was impossible then—it is, I believe, only beginning to be possible now—to estimate the proportions, possibilities, and inter-relations of the new social orders out of which a social organization has still to be built in the coming years. No formula of definite reconstruction had been evolved, or has even been evolved yet, after a hundred years. And these swelling inchoate new powers, whose very birth condition was the crippling, modification, or destruction of the old order, were almost forced to formulate their proceedings for a time, therefore, in general affirmative propositions that were really in effect not affirmative propositions at all, but propositions of repudiation and denial. "These kings and nobles and people privileged in relation to obsolescent functions cannot manage our affairs"—that was evident enough, that was the really essential question at that time, and since no other effectual substitute appeared ready made, the working doctrine of the infallible judgment of humanity in the gross, as distinguished from the quite indisputable incapacity of sample individuals, became, in spite of its inherent absurdity, a convenient and acceptable working hypothesis.

According to the author, what was the major reason for the British Empire taking part in the democratization of the period in discussion?

They were too distant from their colonies, which forced them to allow for local governance.

Their colonialism led to a clash of cultures and civic ideals.

They were unable to accommodate the cultural changes arising from the colonies' way of life.

There was no one, isolated factor that led to its development.

Their governmental apparatus was obsolete and based on an inflexible model of regal governance.

This question likely tempts you to answer in some way that reacts to the selection speaking of the "incapacity of the formal government to assimilate the developing civilization of the American colonies." Notice, however, that this was merely an "additional stress" on top of the others. The safest bet is to say that it was a constellation of factors that influenced shifts in governmental policy in the British Empire. Yes, it had its unique challenges; however none of these unique challenges were the  sole factor leading to the alterations in British governance according to Wells.

Passage adapted from H.G Wells'  Anticipations  (1901)

According to the author, what was the primary mode of operating for the new powers that brought forth democracy of the modern type?

Rejection of the old order

The establishment of new, urban structures of life

Forced exile of former rulers

Wholesale mayhem in civic violence

Revolutionary battling and war

The key passage for this question is: "In general affirmative propositions that were really in effect not affirmative propositions at all, but propositions of repudiation and denial..." Wells then goes on to describe how even seemingly "affirmative" statements of action were at base merely denials or repudiations of the existing order of things. Hence, at the heart of the action of this period, there was (according to Wells) a rejection of what came before, though it was not certain what should be the forms taken by the new order to be created.

Example Question #1 : Drawing Conclusions And Making Inferences In Single Answer Questions

Adapted from  The Frontier in American History , by Frederick Jackson Turner

It can be inferred from the passage that the author believes the French __________ .

have no diplomatic relations with America

automatically hate every American because of the frontier

are distinguished from the Americans because of America's interaction with the frontier

have no conception of the frontier or the wilderness

are isolated from the influence of the frontier

The French are only mentioned by quoting the French ambassador from 1796, regarding his dislike of Jefferson. The author only agrees with the Ambassador to say the French and Americans are different, although the author believes it is due to the frontier.

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Analysis and Synthesis

• First Online: 18 February 2020

Cite this chapter

• Patricia A. Dwyer 3  

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Data analysis is a challenging stage of the integrative review process as it requires the reviewer to synthesize data from diverse methodological sources. Although established approaches to data analysis and synthesis of integrative review findings continue to evolve, adherence to systematic methods during this stage is essential to mitigating potential bias. The use of rigorous and transparent data analysis methods facilitates an evidence synthesis that can be confidently incorporated into practice. This chapter discusses strategies for data analysis including creating a data matrix and presents inductive analysis approaches to support the integration and interpretation of data from a body of literature. This chapter also discusses the presentation of results and includes examples of narrative and thematic syntheses from recently published integrative reviews.

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Dwyer, P.A. (2020). Analysis and Synthesis. In: Toronto, C., Remington, R. (eds) A Step-by-Step Guide to Conducting an Integrative Review. Springer, Cham. https://doi.org/10.1007/978-3-030-37504-1_5

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• Published: 15 May 2024

Sacred space: a qualitative interpretive meta-synthesis of women’s experiences of supportive birthing environments

• December Maxwell 1 ,
• Sarah R. Leat 2 ,
• Toni Gallegos 3 &
• Regina T. Praetorius 3  

BMC Pregnancy and Childbirth volume  24 , Article number:  372 ( 2024 ) Cite this article

Metrics details

In the United States there are roughly three million births a year, ranging from cesarean to natural births. A major aspect of the birthing process is related to the healing environment, and how that helps or harms healing for the mother and child. Using the theoretical framework, Theory of Supportive Care Settings (TSCS), this study aimed to explore what is necessary to have a safe and sacred healing environment for mothers.

This study utilized an updated Qualitative Interpretive Meta-synthesis (QIMS) design called QIMS-DTT [deductive theory testing] to answer the research question, What are mother’s experiences of environmental factors contributing to a supportive birthing environment within healthcare settings?

Key terms were run through multiple databases, which resulted in 5,688 articles. After title and abstract screening, 43 were left for full-text, 12 were excluded, leaving 31 to be included in the final QIMS. Five main themes emerged from analysis: 1) Service in the environment, 2) Recognizing oneself within the birthing space, 3) Creating connections with support systems, 4) Being welcomed into the birthing space, and 5) Feeling safe within the birthing environment.

Conclusions

Providing a warm and welcoming birth space is crucial for people who give birth to have positive experiences. Providing spaces where the person can feel safe and supported allows them to find empowerment in the situation where they have limited control.

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Introduction

In 2021, there were 3,664,292 births in the United States. Of those birth, 98.3% took place in hospitals [ 1 ]. In hospital settings, medical interventions such as induction of labor, cesarean sections, and the use of instruments like forceps or vacuum extractors may be more common [ 2 ]. These interventions can carry risks such as increased likelihood of complications for both the birthing person and the baby [ 2 , 3 ]. Some women may feel stressed or anxious in a hospital setting, which could potentially slow down labor or lead to other complications. This stress can be due to various factors such as unfamiliar surroundings, medical procedures, or concerns about interventions [ 2 ]. In a hospital setting, decisions about the birth process may be influenced by hospital policies, medical protocols, and the preferences of healthcare providers, potentially leading to a loss of autonomy for the birthing person in decision-making about their own birth experience [ 4 ]. The experience of giving birth in a hospital, especially if it involves unexpected interventions or complications, can contribute to postpartum depression or anxiety in some women [ 5 ]. Hospital routines and policies may not always be conducive to establishing breastfeeding immediately after birth, which can lead to challenges in breastfeeding initiation and continuation [ 6 ].

Birthing requires healing and a supportive environment at every stage of the birthing process, consisting of holistic support and agency [ 7 ]. This involves “constant emotional, physical, spiritual, and psychosocial” support [ 8 ]. Experiencing birthing trauma has shown to result in postpartum post-traumatic stress disorder (P-PTSD) and postpartum depression (PPD) [ 9 , 10 , 11 ]. Likewise, disempowering births can have long term impacts of maternal self-esteem [ 12 , 13 ]. Maternal mental health issues have resulted in numerous public health concerns, specifically regarding the decreased safety and negative health outcomes that the infant faces [ 14 , 15 ]. Postpartum mental health disorders can also have lasting impacts on family outcomes [ 16 , 17 ]. As such, understanding how to improve the birth experience has the potential to reduce postpartum mental health issues, as well as reduce maternal morbidities, which can improve outcomes for both mother and child.

Of note is the influence of the built environment on healing. Given that thoughtfully designed healthcare facilities can influence the amount of privacy and control a patient perceives [ 18 ], the built environment plays an integral part in healing. Ample daylight, thermal comfort, color, and noise control all contribute to environmental healing within a hospital [ 19 ]. Furthermore, patient health outcomes have been linked to the built environment of hospitals in multiple studies [ 13 , 20 , 21 ]. More specific to birthing, women have indicated that perceived hominess and control in the environment relate to their birthing experience [ 20 , 22 , 23 ].

Control over the birthing environment, including comfort and perceived healing also have mental health impacts for birthing mothers, and the birth environment can have an impact on the mother’s perception of the birth which in turn can influence maternal mental health outcomes [ 24 , 25 ]. Given that approximately 1 in 7 mothers will experience postpartum depression (PPD) in the United States [ 26 , 27 ] and 0.05%-60% of mothers will experience PPD globally [ 28 , 29 ], understanding the impact of birthing environment on maternal morbidities and mental health can create holistic approaches to birthing environment design.

Given the impacts of the birthing environment on maternal mental health, learning what is necessary to have a safe and sacred healing environment for mothers is an important endeavor and the purpose of this qualitative interpretive meta-synthesis (QIMS). A QIMS is a method that is specific to the social work field. It was created to review and analyze qualitative data to identify and synthesize themes surrounding different phenomena found in existing qualitative research [ 30 ]. QIMS has previously been used to synthesize existing data regarding social justice concerns around minority police encounters [ 31 ] and children’s exposure to intimate partner violence [ 32 ]. Concerning the topic of birthing and motherhood, one QIMS explored marginalized women’s experiences of postpartum depression [ 33 ] and another explored the experience of suicidality postpartum [ 34 ]. To date, no QIMS has considered the experiences of the birth environment for birthing mothers and the impact on maternal mental health. A synthesis of the literature qualitatively evaluating women’s perspectives on what is necessary to have a safe and sacred healing environment for mothers could bolster understanding of how hospitals could better support birthing mothers. As such, this study uses QIMS to answer the following research question: what is necessary to have a safe and sacred healing environment for mothers?

Theoretical framework

This study sought to understand how birthing mothers experienced the birthing environment and which environmental factors contributed to a safe and sacred healing environment for mothers. As such, the Theory of Supportive Care Settings (TSCS) was used to frame this synthesis [ 35 ].

Theory of supportive care settings

Theory of Supportive Care Settings (TSCS) was created through research to have a theoretical understanding of which “processes supported a supportive care setting” [ 35 ]. TSCS was developed using three different care settings–a hospice, geriatric, and acute care ward, through qualitative interviews with patients, significant others, and care staff’s experiences. Although TSCS was not developed within the birthing environment, given the raise of childbirth induced P-PTSD, it is appropriate to apply the concepts to the birthing environment. One aspect of this synthesis is to assess the utility of the application of TSCS to the birthing environment using it as the main theoretical approach. There are five main processes the theory addresses as creating a supportive care environment: experiencing welcoming in the environment, recognizing oneself in the environment, creating and maintaining social relations in the environment, experiencing a willingness to serve in the environment, and experiencing safety in the environment. An applied theoretical framework was created (Fig.  1 ).

Framework of theory of supportive birth settings

Experiencing welcoming in the environment

Experiencing welcoming in the environment has three properties which are intensely experienced when the patient first enters the healthcare setting [ 35 ]. Being expected is the first property that involves the care setting knowing the patient is coming. This happens by having the patient’s name displayed and knowing pertinent information about the person before the beginning of care [ 35 ]. Being seen entails a warm welcome upon entering the care setting, having personal introductions, and care staff showing an interest [ 35 ]. Lastly, being invited consists of being shown around the care setting for the patient to become familiar with the environment and the people within [ 35 ].

Certainly, experiencing welcoming in a care setting, such as a hospital, heightens mood among patients and increases their satisfaction with their experience of the care setting [ 36 ]. Within a birthing environment, there is also evidence that being believed and welcomed upon arrival to the hospital increases the satisfaction of mothers as well as enhances their birthing experience [ 37 ].

Recognizing oneself in the environment

Within TSCS, recognizing oneself in the environment encapsulates the intensity of which patients recognize themselves within the care environment [ 35 ]. For example, environments that are perceived as too sterile do not allow the patient to recognize themselves in the environment. Being able to recognize oneself in the care setting includes being in a familiar and calm environment [ 35 ]. A familiar environment includes objects that are familiar to the patients, as well as beauty in the environment that includes windows and warm colors [ 35 ]. Further, a calm environment has minimal loud noises from machines, phones, and patients are allowed to move freely [ 35 ]. Features of familiarity in the birthing environment can reduce the length of labor and reduce pain intensity [ 38 ].

Creating and maintaining social relations in the environment

Creating and maintaining social relations in the environment within TSCS describes the social relations a patient develops that create ease within the environment [ 35 ]. Within this concept, there are two processes: staying in contact with social relations and creating new social relations. Staying in contact entails the patient’s ability to stay in contact with those in their social circles while undergoing care and can include environmental factors that facilitate this such as access to a personal phone and privacy to visit with social relations while in care. Creating new social relations explains the way patients can create new social relationships through positive interactions such as those that include laughter and support from care staff or others in the care setting. The process further includes the structural environment and facilitation of such connections, including openness of concept, support places, and comfortable furniture in private and common areas of the care setting [ 35 ].

This process of TSCS is again supported in literature regarding birthing environments. Availability of social support is integral to the birthing experience and increased access to social support creates better birthing outcomes and perceptions of birth [ 39 ]. Similarly, those supporting the birth need to feel welcomed and included in the birth environment, and there are specific aspects of the built environment that facilitate increased support during birth such as familial alcoves in birthing rooms and increased attempts at including the supporter by care setting providers [ 40 ].

Experiencing a willingness to serve in the environment

The willingness to serve in the environment from TCSC involves both care staff and patients. In TSCS doing a little extra and receiving a little extra are the processes that promote a willingness to serve. To the patients, seeing the care staff demonstrate thoughtful actions shows the staff’s willingness to serve. These actions can include things like remembering a patient’s preferences for their pillow or water temperature or arranging food in an appealing way. The willingness to serve can also come from patients though; some patients reaching out to other patients to give support or even just showing caring attitudes towards either nurses or other patients. For patients, an environment which demonstrates the willingness to serve is one when care staff do things without being asked, are intuitive in their approaches, and do not make the patient feel like a burden [ 35 ].

Within the birthing environment, willingness to serve can look like staff providing welcome distractions from the birthing process through music or aromatherapy, dimming lights, changing ambient temperature, and ensuring loud sounds are minimal. Further, care staff can exhibit willingness to serve by advocating for the birthing mother to have less people in the room, creating a familiar space, and providing comfort [ 38 ].

Experiencing safety in the environment

TSCA defines safety in the birthing environment as the safe feelings that arise from knowing what is happening, feeling informed, being comforted, and feeling trustful of care providers. Understanding what is happening includes, knowing what is happening, having information in an accessible language, and being aware of the course of events. For the patient, being is safe hands means having trust in the providers through honest conversations, knowing that their needs and requests are honored, and that the physical environment is clean, organized, and aesthetically pleasing rather than chaotic and messy [ 35 ].

The safety in the birthing environment often ties honest conversations and knowing needs and requests will be met to feel in control over the birth and the experience. Feeling in control of the birth environment can also include creating a familiar, homey space by being allowed to personalize the space with music, design elements like personal photos, pillows, or plants, and controlling the temperature and lighting [ 40 ]. In addition, knowing that healthcare providers are respecting the birth plan as much as possible and supporting freedom to move and move through the birth process in their own way [ 38 ]. Furthermore, machinery that ties the mother down, inhibiting freedom to move, can be distracting and reduce the time midwives or nurses spend in the birthing room, diminishing the birthing mother’s trust in care providers [ 41 ].

Despite the lack of use of TCSC in birthing environment literature, all five concepts from TCSC are found within the existing literature to be recommended for use in birthing environments. That said, there is not a synthesis to date utilizing the framework to evaluate qualitative perspectives of the birthing environment. This review aims to organize the existing qualitative literature within TCSC to provide a roadmap for birthing space design that aligns with a supportive care environment, with the hopes of creating more functional birthing spaces which may reduce the rates of maternal mental health challenges following the birth of a child.

Ethics, consent for publication, availability of data and materials

The data used in this study are derived from publicly available, published research articles and thus, in the public domain. Similarly, Institutional Review Board approval was not required since all data used were in the public domain in publicly available, published research articles. Informed consent was not required as no participants were recruited to participate in this study. There is no identifiable information of participants used in this method nor do we as consumers of previously published qualitative research have access to the original data.

QIMS is a method that lets researchers find a deeper understanding of a phenomenon or shared experience using qualitative journal articles as secondary data. QIMS is focused on researchers synthesizing previously published qualitative findings on a topic across the literature to reveal insights of participants’ experiences with a phenomenon [ 30 ]. This process includes creating a research question, conducting a systematic search of existing literature, and finally analyzing identified articles through theme extraction, synthesis, and triangulation [ 30 ].

QIMS has a set analysis process that involves reviewing the original authors’ published themes, as well as the participant's quotations in the manuscript. Themes and quotations are extracted and compiled into a new dataset to capture participants’ experiences of shared phenomenon across literature, providing a larger, more diverse sample size.

Sometimes, the analysis ends with a methodological reduction as well. Methodological reduction is an accepted method within phenomenological inquiry that permits researchers to understand the phenomena being observed through a new contextual lens allowing for further abstraction [ 42 ]. That said, due to the paucity of research evaluating what is necessary to have a safe and sacred healing environment for mothers, this study utilized a rare approach to QIMS wherein the theoretical framework was provided at the outset of the study to guide the entirety of the synthesis. This deviates from the more inductive approach of traditional QIMS, but this deductive approach allows for a more pointed answer to a specific research question that seeks to operationalize a construct within a distinctive context or population and has been used previously [ 30 ]. Essentially, this analysis approach used a combination of both QIMS and theory-testing deductive analysis methods. The theory guides each step of the QIMS process, and specific steps have been applied (see Fig.  2 ). This combined approach is formalized here and is called QIMS-DTT [deductive theory testing].

Associations of birthing environment to Theory of Supportive Care Settings 

First, in line with theory-testing deductive analysis [ 43 ], a qualitative question was posed with a specific theoretical lens in mind, in this case, Edvardsson’s Theory of Supportive Care Setting. Then, following QIMS, a systematic search of the literature was conducted using PRISMA guidelines [ 44 ]. The keywords for the initial search included “birth or childbirth or labour or labor or delivery or birthing” as subject terms. The key terms “experiences or experience” and “qualitative” were added to “in abstract” as well as “birthing experiences” and “birthing perceptions.” Key terms were searched within the following databases: ERIC, Academic Search Complete, APA PsycInfo, CINAHL Complete, Family Studies Abstracts, MedicLatina, MEDLINE, Psychology and Behavioral Sciences Collection, Alt HealthWatch. This initial search yielded 5,688 articles. After duplicates were removed 5,167 articles remained. The title and abstract screened for content relating to the desired topic, and inclusion and exclusion criteria were applied.

Inclusion criteria were that the studies were U.S. based only, included pregnant women’s experiences of hospital or birthing center birth, and were qualitative research with quotations presented in the article. Inclusion was limited to U.S. based studies given that birthing practices differ vastly across the world; focusing on the U.S. provides homogeneity of context for understanding the birthing environment impact. Furthermore, even though the U.S. is a high resource country, the perinatal care system is considered unique as requires private pay insurance and not every woman has access to Medicaid or Medicare federal and state funded health insurance programs [ 45 ]. Furthermore, among 11 high resourced countries, the U.S. has the highest maternal mortality rate, which some scholars attribute to how the U.S. has the lowest supply of obstetricians and heavily lacks midwives and insurance coverage for midwifery care [ 46 ]. Theory was incorporated here as well as an inclusion criterion, and the results were filtered through the operationalization of Edvardsson’s Theory of Supportive Care Setting used for this study. Using the five constructs of the theory that were operationalized for this study, the articles were included if authors discussed at least one construct from the theory (the constructs that articles discussed can be found in Table  1 ). Articles not discussing at least one of the five constructs of the theory were excluded. In addition, other exclusion criteria included articles discussing future births or expectations about future births, choice of location for birth, mode of delivery, labor pain, healthcare providers’ perspectives, existing reviews or syntheses, and articles discussing techniques of or towards birthing [e.g., acupuncture, Lamaze, education]. After title and abstract screening, 3,178 articles were excluded, leaving 43 articles to be screened full text. During the full-text screen, 12 articles were excluded, leaving 31 total articles to be included in the QIMS.

Following this approach (inclusive of both QIMS and theory-testing deductive analysis) we have formalized within this study, the original themes (Table  2 ) from the articles were organized by one researcher into appropriate theoretical assumptions that most aligned with the constructs of TSCS (See Table  1 –providing theoretical triangulation). Then, the quotations from each article were extracted and uploaded to qualitative software, atlas.ti (v.8.1). The quotations were coded deductively by the first two authors using the theoretical framework as a guide for thematic development. The themes were then aligned with each of the five theoretical constructs by unanimous rating. This process provided a layer of analyst triangulation additional to the triangulation inherent in QIMS design resulting from triangulation in the individual studies prior to the QIMS.

Instrumentation

In addition to the analysis process, it is also important for researchers to bracket, or disclose, their experiences with a phenomenon to increase the trustworthiness of the synthesis. The authors are the main instruments of this study, as is frequently the case in qualitative research. To further lend credibility and transparency to the QIMS process, brief descriptions of the authors can be found in Table  3 . The authors purposefully include two mothers–one who experienced Postpartum Mood and Anxiety Disorders (PMADs) and one who did not, and two women who were not mothers at the time of this writing. This intentionally focused toward balancing any biases the two mothers might have brought to the analyses given their experiences further explained in Table  3 .

The final sample included 30 qualitative studies giving ear to the voices of 1,802 postpartum mothers. These mothers ranged in age from 12 to 71 and represented a wide range of races and ethnicities. For more demographic information including data collection methods and settings, see Table  4 .

Using a theory-testing deductive analysis process in conjunction with QIMS, the analysis results in five themes with various subthemes. The supporting quotations can be found in Table  5 . In addition, thematic constructs of TSCS were found across the included articles and the theoretical deduction was sound. Evidence of theoretical constructs can be found in Table  1 .

Theme 1: service in the environment

The first theme consists of ways that participants experienced service within the birthing environment. This service can be either from the healthcare team or the woman themselves and can be expressed in ways more encompassing than just direct labor. Participants described providers who exhibited exceptional care as a memorable part of their birthing experience. This aspect of service within the environment contributed to warm feelings towards their providers and allowed them to feel important and cared for. Many described how taking time out of their busy schedules to focus on the woman one-on-one, accommodating disabilities or medical conditions without being asked, and going out of their way to encourage and empower women was how a provider demonstrated “above and beyond” care.

Theme 2: recognizing oneself within the birthing space

The second theme described how birthing persons saw themselves within the birthing space. This included their personhood being acknowledged and their maternal role being validated by providers.

Subtheme 2A: acknowledging personhood

Recognizing oneself within the environment should be facilitated by feeling acknowledged as persons with dignity. For participants in these studies, this was expressed in their experiences of not having their personhood acknowledged and valued during the birthing process. One participant was not allowed to walk to the bathroom and was also not clearly told why. Her dignity was wounded, and the situation introduced emotional trauma into her birth story. Other women had a similarly emotionally traumatic experience that compromised their dignity and devalued their personhood.

Subtheme 2B: validating maternal role

Validation in becoming a mother is an important step in a woman’s transition into motherhood. The birth is an experience that will forever impact how the person views their maternal role. Many participants felt that their role as mother was overlooked by providers or not validated in a way that made them feel unequipped to mother their children. Often, participants described how providers made decisions for their newborns for them without consulting or trusting them to make such decisions.

Theme 3: creating connections with support systems

The third theme describes the ability of participants to forge or maintain social connection while experiencing birth. This could be availability of social support through communication from providers or through inclusion of support persons. Furthermore, disrespect hampered the formation of social connections.

Subtheme 3A: communication is key

This subtheme revolved around the necessity of communication to forge a strong, trusting social connection between provider and women. This communication included informing the women of medically necessary interventions and allowing them to understand the necessity of them before consenting when medically possible. Communication also included introducing themselves and accepting a patient introduction genuinely through learning womens’ names and making eye contact and gathering consent before touching the client. When providers communicated in this fashion, the participants indicated that they felt a stronger social bond to the providers and their trust and satisfaction with them was increased.

Subtheme 3B: team effort among providers

Relationships required a team effort, which meant that multiple providers needed to be on the same page and operating in good communication with one another to support mothers. Participants in the included studies described how both providers and the birthing person, as well as their support people could work together to ensure the birthing process was a positive one. Others explained that when providers did not work together or communicate among each other the birthing process felt chaotic and disjointed, leaving them feeling unsatisfied and unsafe.

Subtheme 3C: respect forges social connection

This sub theme describes how care providers can forge social connection with their patients through respecting the wishes of the birthing person. Examples included respecting their birthing plan even when it was not medically necessary, allowing the birthing person to make choices about pain interventions, and not respecting the minimal birthing requests that were not related to medical interventions. Conversely, not hearing or respecting the birthing person created a negative experience which was detrimental to social connection in the birthing space.

Theme 4: being welcomed into the birthing space

The fourth theme that emerged encompassed participants’ desires to be welcomed into the birthing space. This involved experiences of being admitted into the maternity ward or birthing suite upon arrival at the hospital and being made to feel comfortable in the space.

Subtheme 4A: being believed and admitted

Participants within the included articles discussed the importance of being believe when they presented to the hospital in what they perceived as active labor. Participants described being unsure if the sensations they were feeling were in labor and expressed anxiety as to whether they would be admitted into the maternity ward. Participants worried that if they arrived at the hospital too early, they would be treated poorly for “over-reacting” and be sent home, even though they were in pain. Participants also described the feeling of being rejected as failure. Being admitted into the birthing space was crucial for participants in the included articles to feel supported and validated.

Subtheme 4B: comfortable birthing space

In addition to being admitted, having the birthing space be comfortable was also necessary for participants to feel welcomed. Participants described spaces that had enough room for all their family members, single-occupancy rooms that allowed the birthing mother to have the whole room to herself, and rooms that had calming items present to be the most comfortable. In addition, participants in the included articles described experiences of uncomfortable spaces. Several participants expressed discomfort at having to be moved to multiple locations within the hospital. Participants also found hospitals challenging to navigate which caused stress on the family and the laboring mothering. Some participants described how the temperature of the space affected them as well, with the ability to control the temperature helping them to feel comfortable, both themselves and their families.

Theme 5: feeling safe within the birthing environment

The fifth theme encompasses various ways birthing persons felt or did not feel safety in the birthing environment. Either through consent in procedures, being able to follow birth plans, having freedom to move, and having trust and confidence in the healthcare team, there were many ways participants expressed their perceptions of safety in the birthing environment.

Subtheme 5A: interpersonal safety

This theme described how interpersonal relationships contributed to feeling safety in the birthing environment. Participants in the original studies talked about how they took action to ensure they had interpersonal safety through choosing obstetricians that felt safe to them, either due to gender or validation tactics. Others described how having continuity of care when possible created safe feeling interpersonal relationships, such as having the same nurse throughout or when they did change shifts- the outgoing nurse took extra steps to introduce the new nurse and supported the forging of an interpersonal relationship between birthing person and new nurse. Having a familiar face consistently throughout the birthing process was comforting. In addition, many quotations described how a provider could focus on the woman in a way that was comforting and forged and interpersonal connection by ensuring they knew they were being heard and supported.

Subtheme 5B: Confidence in the healthcare team

Feeling safe in the birthing environment was also influenced by how much confidence the women had in their healthcare team. Some participants in the original study described how they trust doctors because they know better through education, while others felt like their care providers were not listening to their concerns, eroding their trust and making them feel unsafe. Others explained actions the healthcare team took to ruin the trust between them, either by not sharing the full truth of the current process or by giving false information. When the providers were not honest with their patients, the birthing person was less likely to feel safe and therefore it tainted their birthing experience with anxious feelings.

Subtheme 5C: Feeling in control of the birth

Participants also described feeling in control of the space allowed them to feel safe within the birthing space. Participants who were given the ability to make decisions about positions, movements, and even presented with a way to watch the birth felt in control and supported by staff. Conversely, participants who were restricted in their movement felt trapped.

The findings of this QIMS-DTT highlight what is necessary to have a safe and sacred healing environment for mothers. Filtered through the adapted Theory of Supportive Care Settings, the findings of this deductive theory-testing study found multiple overlaps with the theoretical approach and as such, propose the importance of utilizing a Theory of Supportive Birthing Environments when evaluating birthing care environments. The five main components of Edvardsson’s theory can be found across all included articles and in the findings of this QIMS-DTT, making the findings unique in the application of the theory as a framework to approach environmental birth design.

For instance, a novel finding was the participant-described need for a welcoming birthing environment, including their initial admission to the hospital, being believed, and validated about their labor process, and the birthing environment itself being welcoming to them and their support persons. The initial moments upon arrival at the birthing facility or the presence of the healthcare team can significantly impact the birthing person's emotional well-being, comfort, and sense of security. Indeed, research does indicate that a warm welcome can help alleviate these feelings by making the birthing person feel valued, respected, and cared for from the moment they arrive. A positive and supportive atmosphere can contribute to a more relaxed state of mind [ 47 ]. Although the findings illuminate that a warm welcome into the birthing environment is critically important as it sets the tone for the entire childbirth experience, there is scant literature on this phenomenon as an attribute of the birth environment experience. A warm welcome also fosters trust and rapport between the birthing person and the healthcare team [ 46 ] which is essential for effective communication and cooperation throughout labor and childbirth. When trust is established early on, it can lead to a more collaborative and positive birthing experience. Beyond alleviating stress, feeling welcomed and respected empowers the birthing person to actively engage in their care and decision-making [ 47 ]. When they are treated with kindness and dignity, they are more likely to voice their preferences, concerns, and questions, leading to informed decision-making [ 47 , 77 ]. As many participants shared, the birthing environment itself was responsible for the welcoming feeling and contributed to a positive and comfortable birthing environment. In this study, this included friendly greetings, a clean and inviting room, soft lighting, and soothing sounds. Such an environment can promote relaxation and facilitate a smoother labor and birth [ 77 ].

The findings also illuminate the importance of social connection within the birthing space, through feeling respected and heard, clear communication, and acknowledgment and validation. Social relationships, including those with partners, family members, friends, and healthcare providers, offer emotional support during a time that can be physically and emotionally challenging. Previous literature has supported these findings, indicating that when there are people who care about the birthing person's well-being and provide comfort and encouragement, it can reduce stress and anxiety for the birthing person [ 40 ]. Trust is a critical component of any healthcare relationship, especially during childbirth [ 52 ]. Unique within these findings, however, is the importance of social connection between the women and providers on the recounting of birth stories and satisfaction with the birth environment. Furthermore, although support by providers is well documented, the findings here offer a unique approach as establishing these relationships as a facet of the birth environment. Establishing trust with healthcare providers and support staff is essential for effective communication, which, in turn, leads to better decision-making and a more positive birthing experience.

Safety in the environment was a salient finding of this study, and with good reason. Participants expressed that having interpersonal safety, seeing a good team effort among healthcare providers, and confidence in that healthcare team all contributed to their perceptions of safety in the birthing environment. Creating feelings of safety in the birthing environment is of paramount importance for several reasons. A safe and supportive birthing environment not only ensures the physical well-being of the birthing person and baby but also has a profound impact on the overall childbirth experience. Feelings of safety help reduce stress and anxiety during labor and childbirth [ 78 ]. Perceived safety benefits medical providers as well- when the birthing environment is perceived as safe, it can facilitate the release of endorphins, the body's natural pain relief hormones, and contribute to a smoother labor and birth process without unnecessary medical interventions [ 79 ].

Another important, but already substantiated, finding within safety in the environment was the element of control and agency within the birthing environment that was necessary to have positive birth experiences. Participants engaged in self-advocacy and described the importance of feeling in control over the birthing process to their well-being. Agency and control in the birthing environment are documented crucial aspects of the childbirth experience, as they can significantly impact the physical and emotional well-being of the birthing person and their overall satisfaction with the process [ 45 ]. When birthing people have a sense of agency and control over their birth experience, they report higher levels of satisfaction with the process, regardless of whether their birth unfolds as planned or not [ 45 ]. Agency and control also empower the birthing person to make informed decisions about their birth plan and medical interventions and endorse their maternal role. Informed decision-making allows individuals to choose the options that align with their values, preferences, and health needs. Notably, the findings in this study indicate that when birthing persons do not feel in control of their birth, they had poor retrospective memories about their birth and sometimes felt shame or anger about it. Indeed, a lack of agency and control during childbirth can sometimes lead to feelings of trauma or dissatisfaction [ 80 ]. Although this phenomenon is well documented, the findings from this review contextualize the need for agency and control within the theoretical approach and creates a more comprehensive look at birth environment attributes.

Implications for providers and research

The findings of this study illuminate numerous implications for providers and researchers. For providers, the knowledge that a warm welcome extends beyond them to the entire birthing team, including nurses, midwives, doulas, and support persons. A cohesive and supportive team that welcomes the birthing person with open arms can enhance the overall birthing experience. Furthermore, welcoming includes initial contact and the way a birthing person is received and treated upon arrival can significantly influence their overall perception of their birth experience. A warm welcome contributes to positive birth memories and can have long-lasting emotional and psychological benefits [ 47 ].

Empowering birthing people to have control over their experience can help reduce the risk of trauma. Establishing trust and effective communication between the birthing person, their support team, and healthcare providers is essential for maintaining agency and control. When there is open dialogue and mutual respect, the birthing person is more likely to feel comfortable expressing their preferences and concerns. In some cases, having control over the birthing environment can lead to better physical outcomes. For example, a birthing person who can move freely, choose their birthing position, and have access to comfort measures may experience shorter labor and fewer complications [ 77 ]. In addition, providers should recognize that every birthing experience is unique and respecting cultural and individual differences is essential for promoting agency and control. What one person values or finds empowering in their birthing experience may differ from another, and healthcare providers should strive to accommodate these variations. More research may be needed to understand the prevalence of agency and control better quantitatively in the birthing environment and its relationship to maternal mental health outcomes using measurements surveying the birth environment that combine the attributes of the framework presented in the findings.

Building social relationships in the birthing environment can create a supportive and celebratory atmosphere. The birthing person, their partner, and their support network can share in the joy and excitement of welcoming a new life into the world, enhancing the overall experience.

Social relationships formed during childbirth can extend into the postpartum period, providing ongoing emotional support, advice, and assistance as the birthing person navigates the challenges of early parenthood. Social relationships in the birthing environment can also be a source of valuable information and education. Healthcare providers and support persons can share knowledge about the birthing process, available options, and potential interventions, empowering the birthing person to make informed decisions.

Another implication for providers is building a culture of safety within the environment. When the birthing environment feels unsafe or traumatic, it can have long-lasting negative effects on the birthing person's mental and emotional well-being. Feelings of trauma during childbirth can lead to post-traumatic stress disorder [PTSD] and have a significant impact on future pregnancies [ 80 , 81 ]. Safety also includes trust. Trust is a cornerstone of the birthing experience and when the birthing person trusts their healthcare providers and the birthing environment, they are more likely to follow recommendations, cooperate with care plans, and have a positive overall experience. More research is needed to better understand how women experience trust in the birthing environment specifically, including better understanding of the frequencies of agency, consent, and control over their environments. In addition, research surveying the use of interdisciplinary communication and communication mechanisms with women regarding birth plans might illuminate fragmented communication in the birth environment.

Limitations

Within this study there were some primary limitations related to sampling of studies. When identifying studies through databases and services such as GoogleScholar, embargoes and artificial intelligence interference [e.g., search algorithms] create challenges in replicating and updating searches. For this study, the search was initially conducted then redone to ensure all studies were identified since sufficient time had passed since the initial search. Although exact keywords and procedures were followed from search one to search two, algorithms and embargoes may have led to some key studies not emerging in the search. A second limitation is that given the breadth of birthing environments and cultural orientations to birthing, despite the number of studies analyzed, it is likely that some experiences are not represented in this study.

While the experiences of the participants appeared to range, the scope of the search did not include birthing person experiences outside of the US. Consequently, this leaves the results of this study to only be applicable to what is needed in the small context of the US. Problems that are faced by participants in this study may not be seen as harmful to others. Likewise, since QIMS-DTT is a social work focused method, it can limit how the researchers approached the material from the participants. This can be related to the complex nature of constraints that are often faced in the health-care field. Furthermore, there is a limitation related to the relevancy of applying the TSCS to the birthing space. A key difference between the concept of service in birthing space is that mothers only spend an average of 24 to 48 h in the birthing space, whereas those in nursing care, the environmental in which TSCS originated, could spend an extended period of time in the environment.

In conclusion, a new framework using the Theory of Supportive Care Settings can be applied to evaluate a sacred and healing birthing experience. This new framework includes a balance of already documented phenomenon such as agency and control during birth, as well as integrates new findings, such as the necessity of a warm welcome into the birthing environment to promote trust, comfort, and empowerment. Indeed, the importance of a welcoming environment cannot be overstated. It sets the initial tone for the birthing experience, influencing the individual's stress levels and emotional state, which, in turn, can affect the physiological aspects of childbirth. This study supports the hypothesis from applying TSCS to the birth environment that when individuals feel welcomed, they are more likely to experience a sense of calm and readiness for birth, which can lead to more positive outcomes.

Our study contributes to the growing body of literature that underscores the significance of the birth environment in shaping birth experiences. It calls for a reevaluation of current practices and environments in which childbirth takes place, advocating for a more holistic approach that encompasses emotional, psychological, and physical well-being. The implications of our findings extend beyond the individual, suggesting that by improving birth experiences, we can foster better early bonding experiences, potentially leading to long-term benefits for both the mother and child.

Authors’contributions

Authors DM and SL contributed to the initial design and concept. DM, SL, RT, and TG all performed data collection, data analysis, interpretation of results, and drafting of the article. All authors made substantial contributions to the initial and revised manuscript. All authors have read and approved the final version and are accountable for all aspects of the work.

Availability of data and materials

The data used in this study are from publicly available existing literature, therefore the data is available within this article from the data tables.

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Maxwell, D., Leat, S.R., Gallegos, T. et al. Sacred space: a qualitative interpretive meta-synthesis of women’s experiences of supportive birthing environments. BMC Pregnancy Childbirth 24 , 372 (2024). https://doi.org/10.1186/s12884-024-06544-6

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The Human Synthesis: An Exploration of Anxiety, Love, and Selfhood under the Domain of the Will to Power

• Daniel Andrews

This paper elucidates the conception of the self by reading prominent philosophers such as Sartre and Kierkegaard against the backdrop of Nietzsche’s “will to power”. By understanding this central tenet of Nietzschien thought as a self-overcoming force - ubiquitous in all life - that wills only its own growth, we are left with the question of how the will to power manifests. I will argue that in order to self-overcome, the will to power must have individuated life, i.e., a myriad of “selves” who, under the Sartrean definition of consciousness, are able to be what they are not yet. A singularity, I will claim, would be unable to become what it is not because there is no being it is not; therefore, life individuates into selves capable of Sartrean self-consciousness. Kierkegaardian anxiety can then be conceived as a pull into selfhood away from what he terms “the race”. With this groundwork laid, I will return to Nietzsche’s philosophy to provide an answer for the self’s purpose: one that is paradoxically supplemented by De Rougemont’s analysis of love.

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