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BACKGROUND Framework synthesis is increasingly used in systematic reviews of health care practice and policy. We demonstrate how framework synthesis methods have been utilised and how they are situated within research synthesis methods. METHODS An overview and update was conducted of reports which applied, illustrated or discussed framework synthesis. Findings were incorporated into the evolving conceptual framework and higher order themes derived using constant comparative analysis. RESULTS Searches identified 61 publications (37 applied reviews and 24 illustrative or situated reports) describing varied contexts, concepts, challenges and processes of framework synthesis. DISCUSSION Framework synthesis is a realist method with a spectrum of approaches, the choice of which depends on the extent of existing developed theory. Where theory was underdeveloped, early sense-making either: constructed multidimensional frameworks with stakeholders' expert knowledge to fractionate/disaggregate the data into meaningful subsets; or utilised widely recognised concepts to frame/provide a shell then qualitatively identify subthemes. Well-established theory closely matching the topic was translated into a framework to test the fit between study data, framework and theory. Where the topic lacked an exact theoretical fit, an acceptable a priori theory was adopted and refined. CONCLUSIONS Our review establishes a spectrum of framework synthesis applications that invoke a framework as: an established theory to test; an analogous theory to be refined; a theoretical shell to hold emergent themes; or a multidimensional framework to fractionate then integrate heterogenous data. The choice of approach depends on the fit between data and existing theory or the scale and heterogeneity of the literature. This article is protected by copyright. All rights reserved.