JAN

JOURNAL OF ADVANCED NURSING

DISCUSSION PAPER

Pragmatism as the philosophical foundation for the Joanna Briggs

meta-aggregative approach to qualitative evidence synthesis
Karin Hannes & Craig Lockwood
Accepted for publication 22 January 2011

Correspondence to K. Hannes:
e-mail: karin.hannes@ped.kuleuven.be
Karin Hannes MSc PhD
Doctor-Assistant
Centre for Methodology of Educational
Research, Catholic University Leuven,
Belgium and,
Belgian Centre for Evidence-Based Medicine,
Belgian Cochrane Branch, Leuven, Belgium
Craig Lockwood RN MnSc
Associate Director Research
and Innovation
Joanna Briggs Institute, University of
Adelaide, South Australia, Australia

H A N N E S K . & L O C K W O O D C . ( 2 0 1 1 ) Pragmatism as the philosophical foundation for the Joanna Briggs meta-aggregative approach to qualitative evidence
synthesis. Journal of Advanced Nursing 67(7), 16321642.
doi: 10.1111/j.1365-2648.2011.05636.x

Abstract
Aim. This paper presents a discussion of the role of the philosophy of pragmatism
in the Joanna Briggs meta-aggregative approach to qualitative evidence synthesis.
Background. An increasing number of qualitative evidence syntheses are being
published in journals, many of them influenced by an interpretive or a critical-realist
perspective. One approach to qualitative evidence synthesis is meta-aggregation.
Originally designed to model the transparency, auditability and reliability of the
established process for effectiveness reviews, meta-aggregation makes a case for the
production of synthesized statements that refer to lines of action informing decision-making at the clinical or policy level.
Data sources. This paper draws from the literature written on the philosophy of
pragmatism (18772008) and from the user guidance on meta-aggregation developed by the Joanna Briggs Institute between 2004 and 2007.
Discussion. Meta-aggregation as a methodology is founded on the principles and
assumptions of the philosophical traditions of pragmatism. Meta-aggregation can
only reach its full potential if the lines of action suggested will somehow be supported by measures of effectiveness, as demonstrated in mixed method research.
Implications for nursing. The lines of action presented as the result of a metaaggregative synthesis are directive in nature and inform healthcare practitioners at
the point of practical decision-making.
Conclusion. The real verification of the lines of action suggested in a metaaggregation consists of the satisfactorily ending consequences, mental or physical,
which the synthesized statements that summarize the basic ideas emerging from the
studies are able to generate in end users.
Keywords: meta-aggregation, meta-synthesis, nursing, philosophy, pragmatism,
qualitative evidence synthesis

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JAN: DISCUSSION PAPER

Introduction
Since the early 1990s, debates on what constitutes evidence
have largely been influenced by the positivistic paradigm. The
dominant belief system in the field of health care is led by the
gold standard of the Systematic Review of Randomised
Controlled Trials (RCTs) that guides decision-making processes (Hannes et al. 2005). While clearly crucial in answering questions of effectiveness, these reviews fail to address
all the uncertainties in the complex field of health care
(Flemming 2007a). It is increasingly acknowledged that the
richness of qualitative evidence and process-related information provides credible, complementary material to address
practice and policy-related questions. For such findings to be
considered an in-depth analysis, it has been argued that larger
samples drawn together in a synthesis would be helpful
(Sandelowski et al. 1997).
Since the late 1980s, researchers with a qualitative background have engaged themselves in developing methods to
synthesize findings from qualitative research, providing an
alternate and complementary lens to informing practitioners
and policy makers (Noblit & Hare 1988, Paterson et al. 2001,
Sandelowski & Barroso 2003, Pawson et al. 2004, Pearson
2004, Thomas & Harden 2008). In the last couple of years,
there has been an increase in the number of qualitative
evidence syntheses (QES) published (Dixon-Woods et al.
2007, K. Hannes & K. Macaitis, unpublished data).
Approaches that have been used include amongst others
meta-ethnography, meta-study, thematic synthesis, narrative
synthesis, content analysis, formal grounded theory, crossstudy analysis and meta-aggregation (Finfgeld 2003, DixonWoods et al. 2005, Flemming 2007b). Some of these
approaches have been influenced by an interpretive paradigm,
including, for example, narrative synthesis (Popay et al.
2007), critical interpretive synthesis (Dixon-Woods et al.
2006) and meta-study (Paterson et al. 2001). These
approaches have a particular interest in placing qualitative
insights within a larger discourse and in the development of
conceptual, theoretical frameworks to increase the understanding of how things connect and interact. Other
approaches, such as realist synthesis (Pawson et al. 2004),
have found a theoretical base in critical realism, a paradigm
supporting the acquisition of knowledge about the external
world as it really is, while, recognizing that perception is a
function of, and thus fundamentally marked by, the human
mind (Collier 1994).
The Joanna Briggs meta-aggregative approach to QES was
designed to model the Cochrane Collaborations process of
systematic reviews summarizing results of quantitative studies, whilst being sensitive to the nature of qualitative research
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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

Pragmatism in the Joanna Briggs meta-aggregative approach

and its traditions (Pearson 2004). Currently, this particular

method is the only one that has aligned itself with the
philosophy of pragmatism, making a case for the production
of synthesized statements that refer to lines of action that
inform decision-making at the clinical or policy level based
on the utility of the synthesis. This paper illustrates how the
philosophy of pragmatism has shaped the meta-aggregative
approach to QES to meet the challenge of delivering readily
usable findings, based on the voices of relevant stakeholders
displayed through qualitative research reports. In the context
of this paper, the term end user refers to the potential reader
or user of the results of the QES, and stakeholder refers to
those people who were participating in original research
projects from studies included in the synthesis exercise.

Background
Meta-aggregation was developed through a consensus project, initiated by the Joanna Briggs Institute in 2001,
including qualitative researchers from different Australian
universities (Table 1). Drawing on the early work of
Estabrooks et al. (1994) and Sandelowski et al. (1997), this
group considered how a systematic process of extracting and
synthesizing qualitative data can occur to reflect a rigorous
process equivalent to the existing processes applied to the
results of RCTs and other quantitative research. The outcome
of the project was an aggregative approach that emphasized
the complexity of interpretive and critical understandings of
phenomena; recognized the need to ensure that the approach
to synthesis is transparent about the procedure of synthesis;
and ensure that the synthesized statements would be practical
and usable.
A particular feature of the Joanna Briggs meta-aggregative
approach is that it has been designed to move beyond the

Table 1 Participants in the consensus meeting aiming to develop

the meta-aggregative approach
University Professor
University Professor
University Professor
University Professor
University Professor
University Professor
Doctor
Doctor
Staff member
Staff member
Staff members

University of Adelaide,
Joanna Briggs Institute
University of Newcastle
University of Technology,
Sydney
James Cook University of
Northern Queensland
Curtin University
University of Southern
Queensland
University of Adelaide
Charles Sturt University
La Trobe University
La Trobe University
Joanna Briggs Institute

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K. Hannes and C. Lockwood

production of theory to produce statements in the form of

lines of action (close to recommendations) likely to be
undertaken and generally directive in nature. These statements are the actual outcomes of the synthesis exercise. This
is in contrast with many other methodologies of QES, where
suggestions for concrete actions are considered implications
to be drawn from the synthesis, but are not explicitly part of
the synthesis exercise itself. In what follows, we will expand
on the philosophy of pragmatism and link it to some of the
basic characteristics of the meta-aggregative approach. It is
not our aim to focus on the method of aggregation. Worked
examples of the meta-aggregative approach can be found in
the Joanna Briggs Library of systematic reviews (http://
www.joannabriggs.edu.au/pubs/systematic_reviews.php).
Rather, we intend to shed light on the philosophical
underpinnings of this approach and how these contribute to
the utility of the synthesized findings. We compare the
methodological features of the meta-aggregative approach
with those of other approaches, discuss the basic principles of
the philosophy of pragmatism and focus on the pragmatic
aspects that characterize meta-aggregation.

Data sources
This paper draws from the literature written on the philosophy of pragmatism between 1877 and 2008 and mainly
focuses on the work of Peirce, James and Dewey. In addition
to the more philosophically oriented books and papers, we
used the guidance on meta-aggregation developed and
produced by the Joanna Briggs Institute between 2004 and
2007 and published papers on a variety of qualitative
evidence synthesis approaches (from 1994 to 2010) as a
basis to discuss the specific features of the meta-aggregative
approach.

Discussion
Methodological characteristics of the Joanna Briggs metaaggregative approach
Although different methods to synthesis have aligned themselves with different epistemological frameworks or paradigms they seem to share some basic characteristics. They
seek to emphasize the complexity of interpretive and critical
understandings of phenomena and require a series of steps,
the first being a conceptualization of the phenomenon under
study based on the personal interest of a researcher, gaps in
current research or a response to priorities set by professional
organizations or policy makers. Most syntheses, if not all,
include a formulation of objectives and inclusion criteria, a
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search for relevant studies, an extraction of findings from the

original papers and a summary of findings that presents a
meaningful end result. However, synthesis approaches differ
in the way the synthesis exercise is executed (Table 2). Some
approaches clearly opt for a critical appraisal exercise to
evaluate the quality of original articles, including meta-study
and thematic synthesis, while others would not consider this
step necessary. Synthesis approaches also differ in whether or
not effect sizes or quantitative measures on the content of the
included articles are presented. This is, for example, the case
not only in content analysis but also in meta-summary
developed by Sandelowski and Barroso (2003). Meta-summary has not recently been used in practice and has therefore
not been included in the comparison (K. Hannes &
K. Macaitis, unpublished data). Some methods would
promote a very linear approach to synthesis, while other
methods such as meta-ethnography and grounded theory
would opt for a more iterative process. Searching is comprehensive in approaches such as meta-study and thematic
synthesis, however, selective and targeted in the more
inductively oriented synthesis approaches.
Meta-aggregation takes an inclusive approach to searching
and selecting studies and stresses the importance of methodological quality of studies to be included in a synthesis, from
the point of view that methodological flaws in a particular
study could have a negative impact on the findings of a
synthesis and increase the risk of bias. The procedure of
meta-aggregation involves three phases; assembling the findings of studies (variously reported as themes, metaphors,
categories) and pooling them through further aggregation
based on similarity in meaning to arrive at a set of synthesized
statements presented as lines of action for practice and
policy. In extracting the themes (phase 1) identified by the
authors of original studies, the reviewer takes the literal
descriptions presented in the results sections of original
articles into account and maintains representativeness with
the primary literature available. Similarity of meaning on the
level of categories (phase 2) is contingent on the reviewers
knowledge and understanding of the included papers. Having
read and re-read the papers, and extracted the findings from
each included study, the reviewer looks for commonality in
the themes and metaphors across all papers. Similarity may
be conceptual (where a particular theme, metaphor or part
thereof is identified across multiple papers) or descriptive
(where the terminology associated with a theme or metaphor
is consistent across papers). The actual move from findings to
categories is similar to procedures used in basic qualitative
research methods such as constant comparative analysis and
thematic analysis. However, in a basic qualitative research
project, the end result would be a particular framework, a
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To aggregate findings of
included studies

To generate new
knowledge/theory, using
processes of interpretation
To deconstruct research
traditions/theoretical
assumptions as a means of
contextualizing findings

Meta-aggregation

Meta-ethnography

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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

To seek and reveal

similarities and differences
and build new
interpretations
To analyse, then summarize
content of papers,
counting and tabulating
the occurence of themes
Generation of theory

Meta-study

Grounded theory

Content analysis

To aggregate findings of
original research papers

Thematic synthesis

Critical interpretive
synthesis

Purpose

Approach

Constant comparative
method

Not specified

Not comprehensive, seeks

saturation theoretical
sampling

Usually comprehensive with

predetermined search
strategy

Comprehensive, including
grey literature sources

Recommended, although
open to inclusion based
on relevance of particular
studies
Not specified

Use of a framework or
checklist for critical
appraisal

Refutational and/or
reciprocal translation, line
of argument synthesis
Identification of recurrent
themes and development
of a critique (on the included
literature) that informs
sampling, selection and
theory generation
Line-by-line coding,
development of descriptive
and analytical themes
(placed in an external
theoretical framework)
Comprehensive framework;
meta-data-analysis/
meta-method/meta-theory/
meta-synthesis
Coded data categorized
under thematic headings,
counted and tabulated
Opposed, includes all studies
that provide insight into the
phenomena of interest
Quality judged as the extent
to which it informs theory

Not comprehensive,
seeks saturation
theoretical sampling
Identification of potentially
relevant papers to provide
a sampling frame

Usually comprehensive,
although open to the
argument of conceptual
saturation

Synthesized statements
represented as lines of action
informing practice or policy
in the form of a
standardized chart
Higher order interpretation
of study findings

Aggregation of findings into

categories and of categories
into synthesized findings

Required, using a
standardized critical
appraisal instrument

Comprehensive, with a
detailed search strategy
required at protocol stage

Summary of primary study

findings and their rate of
occurrence under thematic
headings
Generalizable explanations
for phenomena under study

Mid-range theory, with direct

application for particular
areas of practice

Summary of findings of
primary studies under
thematic headings

Reconceptualization of
phenomenon based on
critique of epistemological
and normative assumptions
of the literature

Outcome

Method of synthesis

Critical appraisal

Search strategy

Table 2 Comparison of commonly used synthesis approaches in healthcare research

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Pragmatism in the Joanna Briggs meta-aggregative approach

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K. Hannes and C. Lockwood

matrix or a conceptual model. In a meta-aggregation, one

would arrive at declamatory statements or lines of action
(phase 3). Supporting tools such as the Qualitative Assessment and Review Instrument (QARI) can assist reviewers in
documenting each step of their decision process, linking
synthesized statement to the findings retrieved from original
studies (Joanna Briggs Institute 2007; http://qari.joannabriggs.edu.au/).
A meta-aggregation performs best for the synthesis of
findings where the concepts under which those findings are
summarized are assumed to be largely secure and well
specified (Joanna Briggs Institute 2007). Findings are considered secure and specified where the theme or metaphor is
unequivocally supported by direct quotes from the research
participants. In this instance, there is a clear relationship
between the authors theme or metaphor and the participants
expressed experiences. Where the participants expressed
experiences are less clearly related to the authors theme or
metaphor, the finding is considered to be credible in terms of
its security and specificity; however, it will be apparent to the
reviewer that the author has extended beyond the expressed
experiences of the participants based on the participant
quotes that have been used. In contrast, where there is no
relationship between the expressed experiences of the participants and the authors themes or metaphors, it is clear that
the author is generating findings that are unsubstantiated by
the participants. Such findings are not commonly included in
a meta-aggregation although they are identified and
extracted as part of the review audit trail.
Working with secure and well specified data also assists
with auditability of the reviewers decisions in aggregating
particular groups of findings. It is precisely in the presence
of secure and well specified findings that different research
teams are most likely to find common themes or concepts,
which leads to a reliable set of categories in the synthesis
exercise (not to be confused with the metaphors or themes
in original papers that should be perceived as findings for
the synthesis) to start from in the production of synthesized
statements. The consistency between synthesized findings
identified by reviewers using the meta-aggregative approach
was examined in a small-scale study examining the social
impact of diabetes (Florence 2005). Twenty-three out of 24
pairs of trainee reviewers in a systematic review training
programme conducted in seven different countries identified
a synthesized finding related to the need for a degree of
control by people with diabetes. Further 19 of 24 pairs
emphasized the embarrassment some people associate with
having diabetes that puts limitations on their social activities, which indicates a high level of agreement between
reviewers.
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Basic principles of pragmatic philosophy

The developers of meta-aggregation, to a great extent, have
aligned themselves with the philosophy of pragmatism,
expounded by Charles Peirce (1877) and further developed
by amongst others William James (1909) and John Dewey
(1938). The foundation of pragmatism is that the meaning
and truth of any thought or idea are determined somehow by
criteria of practical usefulness, in other words, that the value
of an idea or proposition is to be found in the practical
consequences of accepting it. Pragmatism rejects some of the
basic ideas of earlier philosophies, most notably the Cartesian
way of thinking. Cartesian philosophy assumes that unless we
begin from the premises of which we can absolutely be
certain, we may never reach the truth. In contrast, pragmatists would generally state that when we do go wrong, further
discussion and investigation can identify and eliminate the
errors we made. It emphasizes probabilities more than fixed
beliefs, which is an attractive feature to be explored given the
contextual nature of qualitative research. The Cartesian
suggestion to step outside the contextual nature and reject
any belief or idea that has not been ratified through reflective
inquiry appears to be a very unnatural strategy for both
qualitative researchers and pragmatists, as all inquiries,
scientific and others, occur within a context (Stanford
Encyclopedia of Philosophy 2008).
A variety of philosophers have given very different
accounts of pragmatism. For Peirce generally known as
the founding father of pragmatism it is a method that uses
scientific logic to clarify the meaning of certain concepts or
ideas through investigating what their potential relationship
is with the real world. We must not only be familiar with a
concept and be able to define it; we must also know what
effects to expect from holding that very concept to be true. A
meaningful statement according to Peirce is one for which we
can derive practical and experiential consequences, which
means that potential conditional statements generated for a
concept or idea should list the practical outcomes we can
expect from them (Peirce 1878). James notion of pragmatism
begins where Peirces scientific explanations would potentially fall short. He moves pragmatism away from scientifically founded philosophy to an approach that looks into the
consequences of beliefs, particularly the effect of moral and
religious questions on individuals (Scheffler 1974). While
Peirces account of truth is merely presented as a means to
understand reality from an empirical point of view
eventually leading to one opinion which is fated to be
ultimately agreed to by all who investigate, James defended
the pluralist view that there can be different kinds of truth.
He claims that ideas and beliefs become true just in so far as
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JAN: DISCUSSION PAPER

they help people to get into satisfactory relations with other

parts of their experience (James 1907). Dewey, on the other
hand, has brought a more radical perception of pragmatic
inquiry to the field. The pattern of inquiry he promotes is
much more common to practical problem solving. He sees a
role for inquiry in transforming or fixing problematic
situations we are involved in (rather than fixing our beliefs)
and particularly challenges the dichotomy that other philosophers draw between theoretical beliefs and practical deliberations. For Dewey, all inquiry is primarily concerned with
transforming and evaluating the features of situations we find
ourselves in Biesta & Burbules (2003).
These different perspectives indicate that the pragmatic
school of thought, despite having a common ground in
emphasizing the practical usefulness and consequences of
ideas and statements, unfolds itself in many different directions. We do not wish to dwell on the differences between
Peirce, James and Dewey, nor do we claim that the
developers of meta-aggregation have aligned themselves with
one particular point of view. What is important here is how
the developers of meta-aggregation have drawn on the
pragmatist perspective, to develop an approach that has a
useful role to play in the evidence-based discourse.

Traces of pragmatism in the meta-aggregative approach

Meta-aggregation is aligned with pragmatism in that it is
particularly sensitive to the practicality and usability of its
findings. It takes the complex picture of the phenomenon of
interest derived from the original qualitative papers into
account, and, also proposes particular lines of action on
an individual and a community level. The developers of
meta-aggregation have been very responsive to the current
debates in the healthcare community revolving around the
need for approaches to synthesis, which aim to inform
policy and practice. Fieldworkers, practitioners, policy
makers, clients and consumers have stressed the practical
orientation and relevance of scientific research projects
(Russell et al. 2004, Shields 2006). Several authors have
reported on the existing gap between academics and
practitioners and the need to build bridges between them
to allow for the formation of relevant communities of
inquiry (Russell et al. 2004, Mold & Peterson 2005,
Hannes et al. 2009). Dewey identifies communities of
inquiry as one of the major building blocks of pragmatism.
These generally include all those interested in resolving a
problematic situation (Biesta & Burbules 2003). In the field
of health care, these stakeholders could be researchers and
analysts, patients or consumers, managers, politicians or
practitioners. Communities of inquiry investigate a problem
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Pragmatism in the Joanna Briggs meta-aggregative approach

and commit themselves to act upon it. These actions are

than assessed using communication and reflection about
their consequences.
In a meta-aggregation, the authors of original articles
become part of the reviewers community of inquiry and add
to a sense of interconnectedness between reviewer and
stakeholders. Meta-aggregation follows the procedure of
deciding upon the meaning of experiences, views, beliefs and
ideas expressed by these stakeholders. It is through the
authors texts that a reviewer captures their voice. One of the
main advantages of working with themes and metaphors
produced by primary qualitative researchers is that they
reduce the complexity of certain problematic situations. As a
consequence, it takes far less mental effort to understand the
complexity of the world through these texts than through
original data or encounters with stakeholders. Texts usually
present both the big and little picture simultaneously and as
such may provide the reviewer with a short-cut to a potential
solution to a problem. Such synthesized findings are, of
course, only a representation of a reality [analogous to the
mapping metaphor used by Boisvert (1998) to illustrate how
a three-dimensional world is translated into a two-dimensional one]. The interplay between original data gathered
through scientific or other information sources and particular
interests implies that no single account made should be
considered fixed and final. Each text has practical utility in
presenting a line of thought or a potential pathway to solving
a particular problem. It is the reviewer, however, who
ascertains and formulates concrete lines of action that flow
from the ideas and experiences generated from original
papers, drawing on knowledge of the included literature.
These lines of action are the final level of synthesis that can
be used to guide and inform policy or practice. A major
advantage of meta-aggregation is that it does not seek to
re-interpret as some other methods of qualitative synthesis
do. It strives for a reliable representation of the primary
authors findings and intent, and this contributes to the
transparency and auditability associated with the metaaggregative approach.
Importantly, meta-aggregation allows for two different
formulations of a synthesized statement that indicate direct
action: an if-then structure or a declamatory form. Both
forms help authors of evidence syntheses to formulate
suggestions to practitioners and policy makers on how to
move forward with the results of the review. This is shown in
two examples of final syntheses derived from recently
published meta-aggregations. McInerney and Brysiewicz
(2009) concluded that if formal and informal support
structures are available to caregivers providing home-based
care to persons with HIV/AIDS, then the challenges and
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K. Hannes and C. Lockwood

burdens they face may be lessened. Konno (2006) explored

the experiences of overseas trained registered nurses working
in Australia and suggested that the clash of cultures between
overseas nurses and the dominant Australian culture should
be addressed in a transition program. These forms emphasize
the probability of the claim and lead directly to an
operational prediction; in these cases, the line of action is
for putting in place formal and informal support structures,
respectively for inclusion of cultural awareness training in
transition programs. In practice, the synthesized statements
are often accompanied by a short narrative summary
(McInnes & Wimpenny 2008).
Consistent with the philosophy of pragmatism, knowledge
derived from a meta-aggregation is not considered to be a
fixed belief ultimately agreed on by all who have been part
in creating or will be influenced by its outcome. Unlike
theoretical predictions, declamatory statements do not
indicate a hypothetical explanation for the insights emerging
from the synthesis as a whole. The outcome of a
meta-aggregation is best described as a confirmed belief
presenting a particular version of truth grounded in the
findings of the synthesis. In suggesting possible lines of
action it aims to effect something. When we act on the
basis of what we assume that an experience will result in
when acted on (inference), and this is indeed what happens,
then we can say that our inference has been made true
(Biesta & Burbules 2003). Choosing one explanation over
another, however, is similar to stating that the chosen one is
expected to be better than another in producing an
anticipated or desired outcome (Cherryholmes 1992). For
example, reviewers can advice on the basis of their
findings that putting in place transition programmes has a
bigger impact on the outcome reduction of culture clashes
between overseas nurses and Australian nurses than language training. But unless this proves to be successful in real
practice, it might be nothing more than an anticipated
consequence.
Whether the right choice has been made can be verified by
testing the declamatory statements for their impact on
practice and healthcare outcomes. Truth, in the context of
pragmatism, will always be related to actions that lead to
verification. In a meta-aggregation, these actions are directive
in nature, yet are not rule-bound or cook book style
recommendations. Clinicians and policy makers need to read
and apply them in their given context and in conjunction with
their own knowledge and experience as well as relevant
consumer perspectives that are important in their particular
local environment. The level of adaptation to a local context
might vary in intensity, depending on, for example, available
resources, services and interventions, acceptability to the
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public, differences in cultural and organizational features

between the context of the articles included in the synthesis
and the targeted context. The tailoring process of synthesized
statements will most likely involve trans-cultural modification (translation of language) and trans-contextual adaptation to make them more relevant to the context in which they
will be implemented and to make sure they reply to the needs
and policies of the targeted settings (Fervers et al. 2006).
Consistent with the logical principles promoted by Peirce
(1878), one could argue that synthesized statements can only
be true when they agree with a contextual reality, that is to
say, when they lead to actions which prove successful. James
(1908), on the other hand, would probably argue that any
suggestion that helps us deal with the reality on a practical or
an intellectual level and fits or adapts our life to a particular
setting, will hold true of that particular reality. Dewey would
most likely emphasize that the pattern of pragmatic inquiry is
to evaluate the relative attractions and value of various
concrete alternatives in solving a particular problematic
situation. Developers of the meta-aggregative approach
believe that we cannot exclude these acts of choice from
the responsibility of the reviewer. The role of a reviewer
conducting a meta-aggregation consists of bridging scientific
insights and the queries practitioners and policy makers deal
with in everyday practice through the development of
synthesized statements that are presented as lines of action
that direct practice and policy.
A meta-aggregation is meant to help understand and
support what takes place in human practice, not to say what
should or should not happen, but rather to assist practitioners
and policy makers who are part of the inquiry (and engage in
these practices) to achieve what they want or think should be
achieved. It embraces the notion that a synthesis should
encompass not only the reality of the past (what the research
participants have told us) but also what is possible, what we
can produce or create for the future given certain conditions.
It is the reviewers job to create a pool of possibilities that is
free from contradictions, that is recommending lines of
action to improve a particular feature of the problematic
situation without causing deterioration of another feature or
characteristic. For example: if we want more practitioners to
implement evidence-based practice, then we need financial
incentives but due to a lack of governmental budget these
incentives will be provided by commercial and/or pharmaceutical companies. In this case, there would be a contradiction between the implementation of evidence-based practice,
which is supposed to be an objective process, and the fact that
commercial companies are the ones financing extra efforts
from practitioners and most likely influence practitioners
choices.
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JAN: DISCUSSION PAPER

Limitations of meta-aggregation from a pragmatic

perspective
Apart from the challenge to produce a coherent set of
synthesized statements, there are other difficulties to overcome for meta-aggregation to be able to fulfil its pragmatic
promise. First, there is no guarantee that the stakeholders
involved in the community of inquiry will also be the end
users of the final outcome of the synthesis. Various audiences
will most likely have different definitions of what constitutes
usable findings. This implies that either reviewers who want
to initiate lines of action should determine their potential
end user(s) up front, or that users of findings of a metaaggregative synthesis should be aware of the need to consider
the evidence in light of their particular context and how it
might apply through their subjective lens. This is less the case
in approaches that arrive at implications for practice, policy
and research after their synthesis has been conducted.
However, with these approaches, there is a disconnect in
that the review development is separate from the lines of
action that may be developed. Whether these lines of action
are an optimal fit with such review findings remains unclear.
The main advantage of reflecting on your goals and intended
audience in advance is that reviewers can look at a set of data
with a particular lens, preferably the one that faithfully
captures the needs of their potential target group. This does
not mean that the statements should not primordially be
grounded in the data. However, it opens up the discussion on
the relevance of presenting results from QES in an international perspective. Without a contextual dimension, where
the target groups focus, cultural habits, political system and
other socialcultural aspects are kept in mind, lines of action
would probably become far too general to be really useful.
Secondly, there is the issue of the stakeholders represented
in a particular synthesis. The community of inquiry that
constitutes a QES is somehow limited by the boundaries of
which voices have been reported scientifically. The scope is
often determined by strict inclusion criteria for original
research papers, stated up front. It is the objective of the
reviewer that guides and directs specific review criteria in a
meta-aggregation, particularly in the consideration of phenomena and populations of interest. Here, the influence of
the Cochrane and Campbell Collaborations outlining the
procedures for systematic reviews is clearly felt and to a
certain extent contra productive to the philosophy of pragmatism. To create a better fit, developers of meta-aggregation
should consider working with very broad inclusion criteria
that allow for important stakeholders to be identified in the
process of conducting the synthesis exercise. This would
mean that developers need to consider borrowing elements
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

Pragmatism in the Joanna Briggs meta-aggregative approach

from inductive reasoning in their rather linear approach to

synthesis.
A third aspect that needs consideration is the profilation of
meta-aggregation as a tool that accounts for a social
atmosphere, where individual end users need to adjust their
individual approaches, perspectives and patterns of action in
such a way that a coordinated, meaningful, mutual response
to a problem or a given situation becomes possible (Dewey
1987). The response that a meta-aggregative type of synthesis
tries to establish has to do with a social or interpersonal way
of adaptation from the target group to a set of recommendations resulting from the synthesis to improve that situation.
A meta-aggregation succeeds in paraphrasing intentions, and
reveals connections between suggested lines of action and
consequences following from putting them into practice.
However, the real verification of the lines of action
suggested in a meta-aggregation consists of the satisfactorily
ending consequences, mental or physical, which the synthesized statements that summarize the basic ideas emerging
from the studies are able to generate. It follows that a metaaggregation could only reach its full potential if the lines of
action provided could somehow be supported by measures of
effectiveness, as demonstrated in recent mixed method
research (Thomas et al. 2003).

Implications for nursing

The tenets of pragmatism offer an attractive philosophical
framework for QES. Meta-aggregation is a valuable synthesis
method, in which each synthesized finding is considered for
its practical value. The lines of action presented in a metaaggregation indicate the way in which realities may be
changed in a systematic and transparent manner, allow for
greater control over the problematic situations we are
confronted with in the field of health care and may contribute
to the reduction of variation in practice, which is a key aspect
of evidence-based practice. This is particularly interesting for
end users who desire a field richly supported by academic
rigour and who want high quality, methodologically sound
syntheses to resonate with their professional experience and
direct their everyday professional lives (Bolton & Stolcis
2003). Academic rigour can be provided by several welldeveloped synthesis methods. However, the particular focus
on presenting declamatory statements as part of the synthesis
exercise and the requirement of reviewers to nominate a
particular direction resulting from the findings of the synthesis is a feature that distinguishes meta-aggregation from other
QES approaches. Presenting lines of action is particularly
challenging as every stakeholder may have his or her own
truth, wisdom and experience. The development of guidance
1639

K. Hannes and C. Lockwood

What is already known about this topic

Qualitative evidence syntheses are recognized as
providing credible and useful material to address
practice and policy related questions.
Recently developed approaches to qualitative evidence
synthesis have aligned themselves with paradigms such
as interpretivism, constructivism and critical-realism.
Authors of qualitative evidence syntheses often present
implications for policy and practice derived from
synthesized findings.

What this paper adds

Meta-aggregation distinguishes itself from other
approaches in aligning itself with the philosophy of
pragmatism, with a particular focus on the utility of
synthesized findings.
Originally designed to model the Cochrane
Collaborations process of systematic reviews
summarizing results of quantitative studies, metaaggregation makes a case for the presentation of lines
of action within (as part of) the synthesis exercise, by
nominating a particular direction to the end user of the
synthesis.
Where and when possible, the lines of action suggested
should be tested and supported by measures of
effectiveness.

Implications for practice and/or policy

Meta-aggregation as a methodology for synthesis is
particularly interesting for end users who desire a field
richly supported by academic rigour and who want high
quality, methodologically sound syntheses to contribute
to informing their professional practice.
Meta-aggregation brings out of each synthesized
statement its practical value.
Guidance should be developed on how to conduct a
trans-contextual adaptation of lines of action
presented in a meta-aggregation to fit particular settings
better.
on how to conduct a trans-contextual adaptation of lines of
action would be beneficial.

Acknowledgements
This article has been produced as part of a visiting research
fellowship at the Joanna Briggs Institute, Australia. We
1640

sincerely thank Alan Pearson for his professional guidance in

developing the meta-aggregative approach. We also thank
Christina Hagger for discussing policy implications of using
this approach.

Conflict of interest
No conflict of interest has been declared by the authors.

Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Author contributions
KH was responsible for the study conception and design,
performed the data collection, performed the data analysis
and was responsible for the drafting of the manuscript. CL
made critical revisions to the paper for important intellectual
content and provided administrative, technical or material
support.

References
Biesta G. & Burbules N.C. (2003) Pragmatism and Educational
Research. Rowman & Littlefield Publishers Inc, Lanham.
Boisvert R.D. (1998) Deweys metaphysics: ground-map of the prototypically real. In Reading Dewey: Interpretations for a Postmodern Generation (Hickman L., ed.), Indiana University Press,
Bloomington, IN, USA, pp. 149166.
Bolton M. & Stolcis G. (2003) Ties that do not bind: musings on the
specious relevance of academic research. Public Administration
Review 63(5), 626630.
Cherryholmes C.H. (1992) Notes on pragmatism and scientific
realism. Educational Researcher 21(6), 1317.
Collier A. (1994) Critical Realism: An Introduction to Roy Bhaskars
Philosophy. Verso, London, UK.
Dewey J. (1938) Logic: The Theory of Inquiry. Longman Green and
Co, New York, USA.
Dewey J. (1987) The Later Works of John Dewey, 1925-1953, 1st
edn. Southern Illinois University, Carbondale, IL, USA.
Dixon-Woods M., Agarwal S., Jones D., Young B. & Sutton A.
(2005) Synthesising qualitative and quantitative evidence: a review
of possible methods. Journal of Health Service Research and Policy
10, 4553.
Dixon-Woods M., Cavers D., Agarwal S., Annandale E., Arthur A.,
Harvey J., Hsu R., Katbamna S., Olsen R., Smith L., Riley R. &
Sutton A.J. (2006) Conducting a critical interpretive synthesis of
the literature on access to healthcare by vulnerable groups. BMC
Medical Research Methodology 6, 3548.
Dixon-Woods M., Booth A. & Sutton A.J. (2007) Synthesizing
qualitative research: a review of published reports. Qualitative
Research 7(3), 375422.
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

JAN: DISCUSSION PAPER

Estabrooks C.A., Field P.A. & Morse J.M. (1994) Aggregating
qualitative findings: an approach to theory development. Qualitative Health Research 4(4), 503511.
Fervers B., Burgers J.S., Haugh M.C., Latreille J., Mlika-Cabanne N.,
Paquet L., Coulombe M., Poirier M. & Burnand B. (2006)
Adaptation of clinical guidelines: literature review and proposition
for a framework and procedure. International Journal for Quality
in Health Care 18(3), 167176.
Finfgeld D.L. (2003) Metasynthesis: the state of the artso far.
Qualitative Health Research 13(7), 893904.
Flemming K. (2007a) The knowledge base for evidence-based nursing: a role for mixed methods research? Advances in Nursing
Science 30(1), 4151.
Flemming K. (2007b) The synthesis of qualitative research and
evidence-based nursing. Evidence-Based Nursing 10(3), 6871.
Florence Z. (2005) Inter-reviewer Agreement, XIII Cochrane
Colloquium. Cochrane Collaboration, Melbourne, Australia.
Hannes K., Aertgeerts B., Schepers R., Goedhuys J. & Buntinx F.
(2005) Evidence-based medicine: a discussion of the most
frequently occurring criticisms. Nederlands Tijdschrift voor
Geneeskunde 149(36), 19831988.
Hannes K., Staes F., Goedhuys J. & Aertgeerts B. (2009) Obstacles to
the implementation of evidence-based physiotherapy in practice: a
focus group-based study in Belgium (Flanders). Physiotherapy:
Theory and Practice 25(7), 476488.
James W. (1907) Pragmatism: A New Name for Some Old Ways of
Thinking. Harvard University Press, Cambridge, UK.
James W. (1908) Pragmatism: A New Name for Some Old Ways of
Thinking; Popular Lectures on Philosophy. Longman Green and
Co, New York, USA.
James W. (1909) The Meaning of Truth. Longman Green and Co,
New York, USA.
Joanna Briggs Institute (2007) SUMARI: The Joanna Briggs Institute
System for the Unified Management, Assessment and Review of
Information (No. version 4.0). Joanna Briggs Institute, Adelaide,
Australia.
Konno R. (2006) Support for overseas qualified nurses in adjusting to
Australian nursing practice: a systematic review. International
Journal of Evidence-Based Healthcare 4(2), 83100.
McInerney P. & Brysiewicz P. (2009) A systematic review of the
experiences of caregivers in providing home-based care to persons
with HIV/AIDS in Africa. JBI Library of Systematic Reviews 7(4),
130153.
McInnes E. & Wimpenny P. (2008) Using Qualitative Assessment
and Review Instrument software to synthesise studies on older
peoples views and experiences of falls prevention. International
Journal of Evidence-Based Healthcare 6(3), 337344.
Mold J.W. & Peterson K.A. (2005) Primary care practice-based
research networks: working at the interface between research and
quality improvement. Annals of Family Medicine 3(Suppl. 1), S12
S20.

 2011 The Authors

Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

Pragmatism in the Joanna Briggs meta-aggregative approach

Noblit G. & Hare R. (1988) Meta-ethnography: Synthesising Qualitative Studies. Sage Publications Inc, London, UK.
Paterson B.L., Thorne S.E., Jillings C. & Canam C. (2001) Metastudy of Qualitative Health Research: A Practical Guide to MetaAnalysis and Meta-Synthesis. Sage Publications Inc, Thousand
Oaks.
Pawson R., Greenhalgh T., Harvey G. & Walshe K. (2004) Realist
Synthesis: An Introduction. ESRC Research Methods Programme:
RMP Methods Paper. University of Manchester, Manchester, UK.
Pearson A. (2004) Balancing the evidence: incorporating the synthesis
of qualitative data into systematic reviews. Joanna Briggs Institute
Reports 2, 4564.
Peirce C. (1877) The fixation of belief. Popular Science Monthly, 15.
Retrieved from http://www.peirce.org/writings.html on 23 April
2010.
Peirce C. (1878) How to make our ideas clear. Popular Science
Monthly 12. Retrieved from http://www.peirce.org/writings.html
on 23 April 2010.
Popay J., Roberts H., Sowden A., Pettticrew M., Arai L., Rodgers M.
& Britten N. (2007) Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. University of Lancester, Lancester,
UK. Retrieved from http://www.lancs.ac.uk/fass/projects/nssr/2007
on 17 July 2010.
Russell J., Greenhalgh T., Boynton P. & Rigby M. (2004) Soft networks for bridging the gap between research and practice: illuminative evaluation of CHAIN. British Medical Journal 328(7449),
1174.
Sandelowski M. & Barroso J. (2003) Creating metasummaries of
qualitative findings. SO - Nursing Research 52(4), 226233.
Sandelowski M., Docherty S. & Emden C. (1997) Qualitative
metasynthesis: issues and techniques. Research in Nursing &
Health 20(4), 365371.
Scheffler I. (1974) Four Pragmatists: A Critical Introduction to
Peirce, James, Mead, and Dewey. Routledge & Kegan Paul,
London, UK.
Shields P. (2006, April 14) Using Pragmatism to Bridge the Gap
Between Academe and Practice. Conference of the American
Society for Public Administration, Denver, Colorado, USA.
Stanford Encyclopedia of Philosophy (2008) Pragmatism. Retrieved
from http://plato.stanford.edu/entries/pragmatism on 17 June
2010.
Thomas J. & Harden A. (2008) Methods for the thematic synthesis of
qualitative research in systematic reviews. BMC Medical Research
Methodology 8(1), 4555.
Thomas J., Sutcliffe K., Harden A., Oakley A., Oliver S., Rees R.,
Brunton G. & Kavanagh J. (2003) Children and healthy eating: a
systematic review of barriers and facilitators. EPPI-centre of University of London, London, UK. Retrieved from http://eppi.ioe.
ac.uk/cms/Default.aspx?tabid=1910 on April 22 2010.

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