Writing The Proposal For A Qualitative Research Methodology Project

ARTICLE
10.1177/1049732303255474
QUALITATIVE
Sandelowski,
Barroso
HEALTH
/ WRITING
RESEARCH
A QUALITATIVE
/ July 2003 PROPOSAL
Writing the Proposal for a Qualitative Research

Methodology Project
Margarete Sandelowski
Julie Barroso
Writing the proposal for a qualitative research methodology study is a double challenge
because of the emergent nature of qualitative research design and because a methodology
study entails describing a process to produce a process. How the authors addressed this challenge is shown in the annotated text of the grant proposalAnalytic Techniques for Qualitative Metasynthesisfunded by the National Institute of Nursing Research. Appealing
qualitative research proposals adhere to principles that engage writers and readers in an
informative and mutually respectful interaction.
Keywords: qualitative research; proposal writing; qualitative metasynthesis
riting the proposal for a qualitative study is a challenge because of the emergent nature of qualitative research design (Sandelowski, Davis, & Harris,
1989). Designing studies by conducting themas opposed to conducting studies by
designproposal writers can only anticipate how their studies will proceed. Qualitative research proposals are thus exercises in imaginative rehearsal. When the proposed study is directed toward developing qualitative methods, the challenge
becomes even greater as such a proposal entails the rehearsal of a process to develop
a process. In a methodology study, process is outcome.
In this article, we reproduce1 and annotate (in italics) the text of a grant proposalAnalytic Techniques for Qualitative Metasynthesis that we submitted
in 1999 to the National Institute of Nursing Research (NINR), National Institutes of
Health (NIH). This project received a priority score of 110 (0.6 percentile) and was
funded in June 2000 to run for 5 years. Our annotated comments are intended both
to be instructive and to serve as explanations for why we made certain statements or
placed these statements where we did. Because this proposal was a resubmission,
we then offer suggestions for revising and resubmitting proposals that initially do
not receive scores high enough for funding. We conclude by offering what we think
of as principles for writing effective qualitative proposals.
AUTHORSNOTE: The study featured in this article is supported by Grants NR04907 (6/1/00-2/28/05)
and NR04907S (6/1/03-2/28/05) from the National Institute of Nursing Research, National Institutes of
Health. Please address all correspondence to M. Sandelowski, 7460 Carrington Hall, Chapel Hill, NC
27599, USA.
QUALITATIVE HEALTH RESEARCH, Vol. 13 No. 6, July 2003 781-820
DOI: 10.1177/1049732303255474
2003 Sage Publications
781
782
QUALITATIVE HEALTH RESEARCH / July 2003
THE PROPOSAL: ANALYTIC TECHNIQUES

FOR QUALITATIVE METASYNTHESIS
Specific Aims
The immediate aim of the proposed study is to develop the analytic and interpretive
techniques to conduct qualitative metasynthesis projects, using research on women
with HIV/AIDS as the method case. In sections on aims, writers should state the aims
first; reviewers should not have to wait for them. Although all qualitative research, narrative integrations of quantitative research, and broad overviews of knowledge
fields entail synthesis, or some combination of two or more entities, qualitative
metasynthesis is a distinctive category of synthesis in which the findings from completed qualitative studies in a target area are formally combined. Qualitative
metasynthesis constitutes a specific kind of data-driven research that is analogous
to quantitative meta-analysis in its intent systematically, as opposed to
impressionistically (Fawcett, 1999), to combine the findings in a target domain of
scientific research. These last two statements constitute an example of what we call strategic disarmament, which entails anticipating likely areas of controversy, debate, or differences of opinion. Because the word synthesis is used in a variety of ways to refer to a variety
of entities, differentiating right away the kind of synthesis that was the focus of our proposal
was critical. These statements are also in response to a previous review in which our take on
synthesis was not sufficiently clear. We have chosen the area of women with HIV/AIDS
as our method case because a sufficient number of qualitative studies exists here to
warrant metasynthesis, and it is a field of great significance to womens health and
nursing practice. We were, in fact, funded as an HIV/AIDS project. HIV infection is a
priority area of Healthy People 2000.2 The development of techniques to improve
the analysis, interpretation, and use of data and, specifically, to integrate evidence
from qualitative research is also a goal of the National Institutes of Health. Referring
to research, practice, or policy priorities or initiatives of various national agencies helps to
underscore the significance of study aims. We specifically staged our application as a
response to the NIH Program Announcement concerning Methodology and Measurement
in the Behavioral and Social Sciences.
Qualitative research is on the crest of a wave (Morse, 1994, p. 139) and has
become immensely popular in the practice disciplines. The proliferation of qualitative studies on various aspects of health, illness, and life transitionsphenomena of
key interest to nurseshas been unprecedented. Despite its new prominence in the
practice disciplines, however, concerns remain about the ability of qualitative
research to resolve real-world problems. A key factor accounting for the perceived lack of usefulness of qualitative research is the relative absence of efforts to
integrate, synthesize, or otherwise put together the findings from this research.
Having stated the aim of the proposed study, we introduce here the problem that generated it
and the significance of the problem. We worked backward from the aims to the research problem and its significance.
Qualitative research findings contain information about the subtleties and complexities of human responses to disease and its treatment that is essential to the construction of effective and developmentally and culturally sensitive interventions.
However, for qualitative research findings to matter, they must be presented in a
Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL
783
form that is assimilable into the personal modes of knowing . . . valuing (Noblit,
1984, p. 95) and/or doing of potential users, including researchers and practitioners. Although a few laudable efforts have been made to integrate the findings of
qualitative health research (e.g., Jensen & Allen, 1994; Paterson, Thorne, & Dewis,
1998), qualitative metasynthesis as method remains largely undeveloped.
Moreover, calls for more research in a target domain do not necessarily entail
the collection of yet more data but, rather, might require the insightful mining of
data already collected. A new moral consciousness has emerged about inviting persons, already vulnerable by virtue of their health conditions or life circumstances, to
participate in yet more studies to obtain information we already have (e.g., Thorne,
1997). Recruitment of persons into qualitative studies, in particular, cannot be justified by the benefits of such participation alone (e.g., Hutchinson, Wilson, & Wilson,
1994). Qualitative metasynthesis is such a mining project, that is, an important avenue toward the development of knowledge (especially the soft knowledge often
eluding measurement) and an exemplar of clinical scholarship (Diers, 1995) equal
to primary research in its potential to improve health research instrumentation
and health care practices. In the preceding paragraph, we emphasized the significance of
the problem.
Here, we return to the aims and flesh them out with specific objectives. Accordingly,
we propose to develop a systematic, comprehensive, usable, and communicable
research protocol for conducting qualitative metasynthesis projects in any healthrelated field. To accomplish this objective, we will offer solutions to problems that
qualitative metasynthesis raises, including how to (a) define the limits of a synthesis
project, (b) group studies for comparison and combination, (c) evaluate the quality
of studies, (d) determine the true as opposed to surface topical and methodological comparability of studies, (e) choose and apply the analytic techniques most
appropriate for integrating the findings from a particular set of studies, and
(f) select and use the re-presentational form for the metasynthesis product best
suited to different consumers of qualitative research, including researchers and
practitioners. We will also provide a metasynthesis of research findings in the area
of women with and in a second area of research to test the metasynthesis protocol
we develop. The test case will involve research on couples undergoing prenatal
testing.
The outcomes of the proposed project will therefore include both a product (the
metasyntheses themselves) and a process (a research protocol to conduct qualitative metasynthesis projects). Our long-term goals are to advance substantive
knowledge in the field of HIV/AIDS and prenatal diagnostic technology and to
advance qualitative methodology. The project will enhance the analytic power of
qualitative research findings so that the understandings of human experience contained in them can serve as a basis for improved research and health care practices.
In this first section of the proposal, we adopted the following logic: immediate aim
significance of aim problem significance of problem aim with objectives outcome
and long-term aim. By the end of this section, reviewers should have been offered what
amounts to an executive summary of the proposed study emphasizing its significance. The
significance of establishing significance cannot be overestimated. A research proposal low in
significance, albeit high in technical perfection, is not likely to be funded.
784
Background and Significance

In the following paragraphs, we review the literature (accurate as of 1999) or develop ideas
previously introduced in the Aims section. A good literature review has a clearly defined
logic in the service of only one goal: making the case for the proposed study. We followed a
largely gap logic, in that our review was oriented to showing what was still missing in the
domain of research integration and the reasons for this gap. We have described other logics
for the literature review elsewhere (Sandelowski & Barroso, 2002). Over the past two
decades, largely in response to Glasss (1976) work in the area of meta-analysis, a
surge of efforts has been directed toward research integration, especially in the
health/medicine domain (Bausell, Li, Gau, & Soeken, 1995; Kavale, 1995). Although
research integrations were promoted and conducted prior to this time, the proliferation of empirical research in the behavioral and social sciences and science-based
practice disciplines has made ever more urgent the need for research integrations
both to reduce information anxiety (Harrison, 1996, p. 224) and to facilitate better
use of research findings (Cook, Mulrow, & Haynes, 1997). Not only do hundreds of
published reports of quantitative research integrations now exist, major collaborative efforts have also been directed toward such integrations, including the Sigma
Theta Tau Online Journal of Knowledge Synthesis and the Cochrane Collaboration to
synthesize the results of randomized controlled trials of health/medical practices
and treatments (Chalmers, 1993). In this paragraph, we have set the scene.
We now move quickly to the point: detailing the problem previously introduced in the
Aims section. Conspicuously absent from this thriving research integration scene are
efforts to integrate the findings of qualitative research. This absence is all the more
remarkable as few other research approaches now rival the interest shown in qualitative research by scholars in many different disciplines and fields of study. Since
the 1980s, at least 1,000 qualitative studies have been conducted in the health field
alone, which have been disseminated both in research journals once almost exclusively devoted to quantitative research reports and in media newly created to disseminate qualitative work (e.g., the interdisciplinary journal Qualitative Health
Research and the annual international Qualitative Health Research Conference).
These studies contain findings about a diverse range of health issues, including,
most notably, personal and cultural constructions of disease, prevention, and risk;
living with and managing the effects (including the treatment effects) of an array of
chronic conditions; and decision making around and responses to beginning- and
end-of-life technological interventions. Despite its new prominence, however, the
false notions still prevail that qualitative research is only a prelude to real
research, and that qualitative findings are ungeneralizable, noncumulative, and,
ultimately, irrelevant in the real world of clinical practice (Sandelowski, 1997).
The paradox is that qualitative research is conducted in the real worldthat is,
not in artificially controlled and/or manipulated conditionsyet is seen as not
applicable in that world. This perceived lack of relevance and utility has potentially
serious consequences for the use of qualitative methods and findings and, therefore, for nursing and other health-related practice fields.
One recent response to the utility problem has been the call for qualitative
metasynthesis. Qualitative metasynthesisas it is conceived in the few articles on
this subject (with this phrase, we reinforce how little there is on qualitative metasynthesis
and thus the significance of the proposed study)is a form of metastudy, that is, study of
the processes and results of previous studies in a target domain that moves beyond
785
those studies to situate historically, define for the present, and chart future directions in that domain. In metastudies, the researcher seeks not only to combine the
results of previous studies but also to reflect on them (Zhao, 1991, pp. 377-378). Like
phenomenology, ethnography, and grounded theory, the term qualitative metasynthesis
refers both to an interpretive product and to the analytic processes by which the
findings of studies are aggregated, integrated, summarized, or otherwise put
together (Estabrooks, Field, & Morse, 1994; Jensen & Allen, 1996; Kearney, 1998a;
Noblit & Hare, 1988; Sandelowski, Docherty, & Emden, 1997; Schrieber, Crooks, &
Stern, 1997). Although it can be considered an analogue to meta-analysis (Glass,
McGaw, & Smith, 1981) in that there is a shared interest in synthesizing empirical
studies (Noblit & Hare, 1988, p. 10) and a shared desire to use a systematic, comprehensive, and communicable approach to research integration, qualitative
metasynthesis is not about averaging or reducing findings to a common metric
(Wolf, 1986, p. 33). We again use the device of contrasts to clarify our focus and to differentiate qualitative metasynthesis from other entities reviewers might view (and, in the case of
one of our reviewers, did view) as similar to it. Instead, the aim of qualitative
metasynthesis is to create larger interpretive renderings of all of the studies examined in a target domain that remain faithful to the interpretive rendering in each
particular study. A prime directive for qualitative researchers, no matter what their
method or research purpose, is to preserve the integrity of each sampling unit or
case (Sandelowski, 1996). In qualitative metasynthesis projects, this prime directive
entails preserving the integrity of and the richness of findings in each individual
study.
Yet this prime directive is likely a major reason why few qualitative metasyntheses have been conducted. Indeed, by virtue of their emphasis on case-bound or
idiographic knowledge, qualitative studies seem to resist summing up (Light &
Pillemer, 1984). Efforts to summarize qualitative findings appear to undermine the
function and provenance of cases (Davis, 1991, p. 12) and to sacrifice the vitality,
viscerality, and vicariism of the human experiences re-presented in the original
studies. The very emphasis in qualitative research on the complexities and contradictions of N = 1 experiences (Eisner, 1991, p. 197) seems to preclude adding these
experiences up. Moreover, the sheer diversity of qualitative research practices is
another reason why so few efforts to synthesize qualitative findings have been
attempted. Qualitative researchers have vastly different disciplinary, philosophical,
theoretical, social, political, and ethical commitments, and they often have very different views of how to execute ostensibly the same kind of qualitative research.
Neopositivists and constructivists, feminists and Marxists, and nurses, educators,
and anthropologists conduct grounded theory, phenomenologic, ethnographic,
and narrative studies. Furthermore, given the wide variety of re-presentation styles
for disseminating qualitative research, even finding the findings can be a daunting
challenge. We are showing here that we know that not all qualitative researchers agree that
metasynthesis is warranted, feasible, or congruent with a qualitative attitude.
Yet, qualitative research is endangered by the failure to sum it up. By using the
yet device, we quickly move here to reinstate the need to address the problem of resistance
to qualitative research integration. We show here a yes-but logic, that is, yes, we support the
legitimacy of the arguments of those who might disagree with what we intend, but we also
affirm the need to try. A recurring concern is that qualitative researchers are engaged
in a cottage industry: working in isolation from each other, producing one-shot
research (Estabrooks et al., 1994, p. 510) and, therefore, eternally reinventing the
786
wheel. Early in the history of grounded theory, Glaser and Strauss (1971) warned
that continued failure to link local grounded theories into formal theories (a type of
qualitative metasynthesis) would relegate the findings of individual studies to little islands of knowledge, separated from each other and doomed ultimately never
to be visited (p. 181). Qualitative metasynthesis is increasingly seen as essential to
reaching higher analytic goals and also to enhancing the generalizability of qualitative research. Schofield (1990) viewed qualitative metasyntheses as cross-case generalizations created from the case-bound generalizations in individual studies. We
wanted reviewers to have a sense of a debate here and what side we were, and had to be, on
to propose this study.
Examples of Qualitative Metasyntheses

Two kinds of interpretive syntheses of findings from qualitative studies have been
attempted. One involves the integration of findings from multiple analytic paths
pursued within one program of research by the same investigator(s). An example is
the synthesis work Morse and her colleagues conducted in her program of research
on chronic illness (e.g., Morse, 1997a; Morse & Johnson, 1991). Another example is
the Field and Marck (1994) anthology, in which the faculty supervisors of six doctoral dissertations used uncertainty as the concept around which to organize findings about motherhood from these studies. Athird example is one of our own efforts
(Sandelowski, 1995) to synthesize the findings of different aspects of the transition
to parenthood of infertile couples. (This study is described in more detail in the Preliminary Studies section.) In all three of these studies, the investigators used
grounded theory techniques to produce larger conceptual renderings of substantive theories developed in their primary studies. In this kind of synthesis effort,
synthesists maintain the same relationship to data as they had in their primary
research, having created both data sets (the primary data and the studies derived
from these data). Moreover, they have direct access to the primary data for the synthesis.
A second kind of effort, and the one we will focus on in this project, involves the
interpretive synthesis of qualitative findings across studies conducted by different
investigators. Kearney (1998b) used grounded theory methods to synthesize the
findings from 10 studies on womens addiction recovery. The remaining efforts
were ostensibly based on the Noblit and Hare (1988) work, which involved three
kinds of translations of individual ethnographies into each other to produce three
metaethnographies in the field of education. Jensen and Allen (1994) synthesized
the findings from 112 studies on wellness-illness; Paterson et al. (1998) produced a
metaethnography of living with diabetes from 43 studies; Sherwood (1997) synthesized 16 qualitative studies on caring to produce a composite description (p. 39)
and therapeutic model (p. 40) of caring; and Barroso (a co-principal investigator
in the proposed project) and Powell-Cope (1998) synthesized the findings from 21
studies on living with HIV/AIDS. (This study is described in more detail in the Preliminary Studies section.) In this kind of synthesis effort, where the focus of analysis
is studies in a topical domain conducted by a range of investigators, synthesists are
far removed from, and typically have no access to, the primary data on which these
studies were based. (An exception here is when synthesists include one of their own
studies, as, for example, Noblit, Kearney, and Sherwood did in conducting their
projects.) Accordingly, their data are composed solely of what is on the pages of a
787
research report, which might be influenced by limitations in the research enterprise

itself and/or imposed by the publication venue.
These efforts to synthesize the findings of qualitative data are valuable for the
methodological direction they provide but, more important, also for the proposed
project, for the continuing methodological problems they illuminate and dramatize. For example, although Jensen and Allen (1994) cited Noblit and Hare (1988) as
their metasynthesis method source, the techniques they used, the product they generated, and the research purpose they stated were different from those of Noblit and
Hare. Jensen and Allens (1994) purpose was to inductively develop a theory of
wellness-illness from the commonalities among individual representations of
health and disease (p. 350). Noblit and Hare espoused interest not in developing
overarching generalizations (p. 25) but, rather, in determining how studies were
related to each other. Indeed, they argued against the notion of synthesisas accumulation or aggregationafter describing a failed effort at just such an aggregative
synthesis of several ethnographies on school desegregation. Instead, they proposed, studies can be judged in relation to each other as (a) comparable and, therefore, subject to reciprocal translation; (b) refuting each other; or (c) representing a
line of argument (p. 36). Moreover, they proposed their methods to fit explicitly
ethnographic studies, thereby calling into question the applicability of these methods to the kinds of studies Jensen and Allen reviewed and, therefore, to the kinds of
studies typically conducted in nursing and other health-related disciplines. Jensen
and Allen groupedby method112 studies (an enormous sample in qualitative
research) on wellness-illness (a concept incorporating many diverse dimensions
not explored in their study) reported in journal articles, dissertations, and theses.
They then used these same methods to synthesize the findings in each method
group (e.g., grounded theory to synthesize the findings of grounded theory studies,
phenomenology to synthesize the findings of phenomenology studies). Their final
product was reportedly one metasynthesis of wellness-illness composed of a blend
of conceptual and phenomenological description. Noblit and Hare produced one
comparable metaethnography from the findings of two published book-length
studies (one of which was a study Noblit had himself conducted), two
refutational syntheses of the findings from two book-length studies each, and one
line-of-argument synthesis of the findings from six studies (also including one
Noblit had conducted) published in one anthology on school desegregation. The
Paterson et al. (1998) study shows a similarly distant relationship to the Noblit and
Hare work but a close relationship to grounded theory work, despite the investigators naming Noblit and Hare as a method source. With references to the Jensen and
Allen and Noblit and Hare works, the Sherwood (1997) study is the most impressionistic of all the qualitative metasyntheses we reviewed, showing a greater similarity to a conventional narrative review of literature than to systematic integration
of findings across studies.
All of these studies are exciting efforts but lack sufficient communicable detail
concerning how they achieved their integrations, and none explicitly addressed or
showed how key dilemmas in conducting qualitative research syntheses were
resolved. Our intention here was to present the work of other scholars positively and
respectfully while also pointing out the gaps that our proposed study was designed to
address. Our two rules in presenting the work of others are (a) never to use the word fail in
describing what other scholars merely did not do (as this would only be a reflection of what
we wanted them to do, or thought they might have done, and not a failure on their part) and
788
(b) describe accurately what they did do. The dual imperatives to give other scholars their due
and to advance scholarship are somewhat antithetical, as finding something that requires
further researching is the sine qua non of the academic enterprise. These imperatives thus
require a delicate balancing act, as the continuation of this enterprise depends on scholars
finding gaps, errors, or inconsistencies in existing scholarship. Some of these dilemmas
are comparable to those still unresolved in quantitative research integrations, for
example, deciding whether and how to use quality as a criterion for inclusion of
studies in the bibliographic sample, and whether and how to integrate heterogeneous studies (e.g., Cook, Cooper, et al., 1992; Lynn, 1989; Mulrow, Langhorne, &
Grimshaw, 1997). Dilemmas distinctive to qualitative research integrations include
separating data from the interpretation of those data, preserving the integrity of
each study, and avoiding immersion in so much detail that no usable synthesis is
produced. Moreover, qualitative metasynthesis entails resolving persistent dilemmas in qualitative research itself, most notably, the problems of determining what
constitutes a trustworthy study and the influence of method on findings. Because
the proposed project is directed toward developing and explicating means to
resolve these and other dilemmas in conducting and creating qualitative
metasyntheses, we will address them in detail in the section on Research Design and
Methods. Here is where we begin to depart from standard procedure because we are proposing a study of method, and so we alert reviewers to this change. Generally, writers should
avoid presentations in which readers are constantly referred to what was said previously or
what has yet to be said later. Too many references to discussions that took place previously
or that will take place below suggest that writers have not placed material in the right
order in the first place. Writers might thereby be forced to repeat material unnecessarily and
thus to consume space better used for other components of their proposal.
Women With HIV/AIDS as a Method Case

We have chosen research on women with HIV infection as our method case because
of the many and complex health care needs these women have and because a sufficient number of qualitative studies containing information important to these
womens health has been conducted to warrant metasynthesis. No integrations of
these findings have been conducted. In 1991, Smeltzer and Whipple published an
article summarizing the state of the science on women with HIV infection. Since
then, researchers have published several reviews of the literature, all of which have
focused on the epidemiological profile of HIV infection and a variety of medical
problems (e.g., Burger & Weiser, 1997; Cohen, 1997; Fowler et al., 1997; Klirsfeld,
1998). Most recently, Sowell, Moneyham, and Aranda-Naranjo (1999) summarized
the major clinical, social, and psychological issues facing women with AIDS,
emphasizing the many differences between men and women.
Women now represent the fastest growing segment of persons infected with
HIV, with up to 160,000 adolescent and adult females living with HIV infection in
the United States alone (Centers for Disease Control and Prevention [CDC], 1999;
Cohen, 1997; Fowler, Melnick, & Mathieson, 1997). Between 1981 and 1997, the percentage of seropositive women increased from nearly zero to almost 20% of all new
cases (Cohen, 1997; Klirsfeld, 1998). As of December 1998, there were 109,311
reported cases of AIDS in women, which represents only a small proportion of all
women infected with the virus; this figure does not include those infected women
who have not progressed to AIDS. Of this number, 61,874 women are African
789
American, 21,937 are Hispanic, and 24,456 are White. The remaining women are in
other ethnic/racial categories, including Native American. The largest numbers of
AIDS cases in women are in the 30- to 39-year-old age group. HIV/AIDS was the
fourth leading cause of death among women in the United States between 25 and 44
and the leading cause of death among African American women in this age group
(CDC, 1999). AIDS disproportionately affects minority women, with women of
color making up approximately 75% of AIDS cases in women in the United States
(Cohen, 1997; Gaskins, 1997; Klirsfeld, 1998; Stein & Hanna, 1997). The typical
woman with HIV is a young, poor, minority woman in her childbearing years
(Russell & Smith, 1998; Sowell et al., 1999).
Since 1993, and as a consequence of the increasing rate of HIV infection in
women, there has been a proliferation of qualitative studies addressing womens
experiences as infected individuals. Prior to 1993, qualitative research that included
women was devoted largely to their roles as mothers of seropositive children or as
vectors of transmission. Even when researchers began to seek information from
women about their experiences with HIV, they combined it with information
obtained from men. (This is why women were not the focus of study in the research
integration of findings on HIV/AIDS described below in the Preliminary Studies
section.) We wanted to ensure that reviewers did not think a metasynthesis of qualitative
studies on HIV-positive women already existed and that we were simply repeating a previous study. Scholars in womens/gender studies and in womens health have shown
the importance of treating gender as a key variable differentiating experience (e.g.,
Fogel & Woods, 1995; Harding, 1991). Indeed, there is evidence that sex/gender is a
critical variable in understanding HIV/AIDS disease. For example, the findings
from a recent study suggest biological differences in HIV viral load between men
and women, with women developing AIDS at a lower viral load (after adjustment
for CD4 count) than men (Farzadegan et al., 1998). Women bear the greater burden
in the areas of reproduction, child care, and other family functions. Seropositive
women must make critical and even agonizing decisions about childbearing, abortion, sterilization, and child care (Arras, 1990; Levine & Dubler, 1990; Sowell et al.,
1999). Their parenting and other family responsibilities often preclude seeking
health care in a timely fashion. Because they are often disempowered in their relationships with male partners, women might find it more difficult to engage in practices to prevent HIV transmission. Heterosexual relations are the most rapidly
increasing mode of transmission of HIV in women, with most women infected in
this way reporting contact with male partners who inject drugs (CDC, 1999; Cohen,
1997). The imbalance of power between women and men often limits womens ability to negotiate condom use (Bedimo, Bennett, Kissinger, & Clark, 1998; Bedimo,
Bessinger, & Kissinger, 1998; Gaskins, 1997; Walmsley, 1998). Increasingly, women
with HIV infection are unaware of their male partners exposure to or risk for HIV
infection (Cohen, 1997; Fowler et al., 1997). Women who are abused are often prevented from practicing safe sex (Gaskins, 1997). Among 2,058 seropositive
women in the Womens Interagency HIV Study (Barkan et al., 1998), 66% reported
abuse by their partners. Violence has also emerged as a key variable in other studies
of women with HIV (e.g., Bedimo, Bennett, et al., 1998; Sowell et al.,1999). Finally,
some investigators have suggested that stigma might be differently and/or more
intensely experienced among HIV-infected women than men (Leenerts, 1998;
Raveis, Siegel, & Gorey, 1998).
790
Qualitative research findings are now available that contain information not
captured in biomedical and epidemiological studies on such topics as stigma and
disclosure, barriers to health care, symptom management, and alterations in
parenting. Bedimo, Bessinger, and Kissinger (1998) observed that although they
had obtained important facts about womens reproductive decision making from
their chart review, they had failed to learn anything about the meaning of those facts
to women themselves. At a recent meeting of the Society for Medical Anthropology,
researchers reportedly noted how little impact qualitative studies had on AIDS
research and prevention agendas (Swanson et al., 1997, p. 256). The proposed project will address these problems by creating a synthesis of findings from qualitative
research on women with HIV/AIDS that can be used for research and in practice.
What we intended here was to establish the significance of choosing the studies for the
method case, which is comparable to defending the choice of a particular sample.
Significance for Research and Practice

The larger significance of this project lies in the potential for qualitative research
integrations to enhance the practical value of qualitative research (Thorne, 1997),
that is, to serve as a creative bridge (Swanson, Durham, & Albright, 1997, p. 256)
between qualitative research findings and practice. Qualitative research is still
largely viewed as contributing primarily to enlightenment, something to the conceptual use of knowledge, and virtually nothing at all to the instrumental use of
knowledge. Indeed, contemporary models of research use emphasize quantitative
research findings (Cohen & Saunders, 1996; Estabrooks, 1997; Sandelowski, 1997;
Swanson et al., 1997). Moreover, contemporary notions of evidence-based practice,
with their virtually exclusive emphasis on randomized and controlled clinical trials
as the gold standard in methods, discount qualitative findings as evidence
(Estabrooks, 1999).
The proposed project will enhance the actionability of knowledge produced by
qualitative research by developing a user-friendly procedure for conducting qualitative research integrations that can stand as evidence for practice. A key deterrent
to researchers attempting qualitative metasynthesis projects is the virtual lack of
direction on how to conduct them. A persistent problem impeding practitioners
use of research findings is that they are presented in forms that are incomprehensible and irrelevant to practitioners (Funk, Tornquist, & Champagne, 1995).
The findings from the proposed project will also contribute to the actionability
of qualitative research by enhancing the generalizability of study findings. As
Sandelowski (1996, 1997) summarized it, in quantitative research, emphasis is
placed on nomothetic generalizations, or the formal knowledge toward which random sampling and assignment are directed. The objective is to enhance the external
validity of findings by permitting generalizations to be made from representative
samples to populations. In contrast, in qualitative research, the emphasis is placed
on idiographic or naturalistic generalizations, or the knowledge derived from and
about cases. Nursing and medical practice depend on both kinds of generalizations,
as practitioners must fit formal knowledge to the particulars of cases. Qualitative
metasynthesis is a means to enhance the analytic power of idiographic knowledge,
as it entails the intensive case-oriented study of target phenomena in larger and
more varied samples than are typically the rule in any one qualitative study. For
example, Kearney (1998b) combined the findings of 10 studies in the area of
791
womens substance abuse recovery, which involved more than 200 women in different cultural, racial, historical, and geographic circumstances. The power (Kearney, 1998a, p. 182) of this sample size and configuration lies in the ability not to draw
statistical inferences but, rather, to draw case-bound generalizations concerning a
target phenomenon across a range of cases. The practical value of this work lies in
making the most of the idiographic knowledge that qualitative research distinctively yields. Knowledge of the particular is critical to offset the frequent failure of
formal generalizations to fit the individual case. The development of valid instruments to measure health conditions and appropriate interventions to improve them
depend on just this kind of knowledge.
Finally, the findings from the proposed project will enhance the applicability of
qualitative findings directly to practice. A key deterrent to the use of qualitative
findings is the persistent notion that findings from qualitative studies cannot be
applied directly in practice without quantitative testing. This idea reprises the false
notion that qualitative research is always incomplete by itself (Morse, 1996). Moreover, it permits the idea of testing to remain appropriated exclusively for quantitative research. Testing is a sociocultural and linguistic concept and practice that does
not belong exclusively to the quantitative domain, as this word has meaning
beyond the mathematized definition it has there. Indeed, qualitative findings are by
definition findings validated against experience. Grounded theory, for example,
isby both definition and purposetheory grounded in and tested against human
experience. There is no more justification for applying tested nomothetic knowledge that often fails, or must be adapted, to fit the individual case than there is for
applying idiographic knowledge directly to a case. All findings, whether quantitatively or qualitatively generated and tested, must ultimately be tested in practice
with individual cases to ensure their pragmatic and ethical validity (Kvale, 1995).
The proposed project will provide a means to further this goal and to offset the current trend toward reducing our understanding of evidence to findings only from
experiments (Colyer & Kamath, 1999; French, 1999). Yet the findings from this project will likely also clarify how qualitative evidence can be used to improve the evidence from experiments, that is, to improve the design sensitivity and validity of
clinical trials (Lipsey, 1990; Sidani & Braden, 1998). In the preceding paragraph, we confronted the thorny issues of validity and generalizability by countering the quantitative
appropriation of the word testing.
In the previous section, we brought home the significance of the likely products of the
proposed study. Again, making the case for the significance of research problems, research
aims, and research outcomes is a defining attribute of a successful proposal. Reviewers are
more likely to forgive technical flaws in design if an excellent case is made for significance in
these three areas.
Preliminary Studies
The proposed project builds on metasynthesis studies the co-principal investigators
have conducted previously. Sandelowski (1995) has published a theoretical synthesis of findings generated from multiple analytic paths pursued in her study of the
transition to parenthood of infertile couples. (A copy of this article is in Appendix A.
Appendix A is not reproduced here.) This work is in the category of metasynthesis projects, characterized by the integration of findings from multiple analytic paths pur-
792
sued within the synthesists own program of research. The synthesist maintains
direct access to the data generating the findings and can easily answer questions
about the findings and the procedures that produced them. Moreover, the synthesist here does not have to deal with issues related to bibliographic retrieval.
Sandelowski used traditional grounded theory techniques to find a core variable
around which to organize the various findings generated from primary data analysis. This variable was work and, specifically, illness work and biographical
work. She then compared several groups of infertile couples to each other and to a
group of fertile couples to define the overlapping and special work distinctive
to each group. Although this work represents a kind of qualitative metasynthesis, it
did not entail a significant methodological departure from other grounded theory
efforts directed toward creating more abstract and transferable conceptual renderings of phenomena.
In contrast, Barroso and Powell-Cope (a member of the Expert Panel to be
described below) conducted the more difficult kind of qualitative metasynthesis
involving other investigators studies, where the synthesist has no direct access to
the data that generated the findings reported in these studies. (Acopy of the in-press
article reporting the results of this study is located in Appendix A. Appendix A is not
reproduced here; the article was published in 2000.) This is the kind of metasynthesis that
is the target of the proposed project. The focus of the Barroso/Powell-Cope project,
which began in 1996, was living with HIV disease. (As noted previously, women
were not the focus of study here. The participants involved in the studies reviewed
were largely gay men). An exhaustive search of multiple computer databases
showed a large number of qualitative studies had been conducted in this area. The
investigators limited their study to research published in refereed journals, because
they had limited resources with which to conduct this project and the refereed journal venue implied peer review. Accordingly, such important fugitive literature
(Lynn, 1989, p. 302) as doctoral dissertations was not included in their study. They
initially examined 45 English-language articles. The final bibliographic sample for
the metasynthesis included 21 studies consisting of a total of 245 pages of tightly
printed text. Studies were excluded for the following reasons: (a) They were not
qualitative but, rather, only qualitative adjuncts to quantitative studies; (b) qualitative data were analyzed quantitatively; (c) they did not address HIV/AIDS but,
rather, treated related topics, such as patients responses to hospital care; (d) they
consisted of secondary analyses of data collected in another study; and (e) they did
not meet quality standards.
Barroso and Powell-Cope (2000) evaluated quality using Burnss (1989) standards for qualitative research, which include determining whether all of the desired
elements of a research report are present and the extent to which a report meets five
critique standards. Burnss guide remains the most comprehensive guide for evaluating qualitative research. Each of the critique standards consisted of multiple items
the investigators used to score each study. As Burns did not offer a means to score
studies on her critique standards, the investigators had to create a scoring system.
An item was judged to be present, minimally present, or absent. The investigators
decided to include studies if 75% of these criteria were at least partially met. Each
investigator scored half of the studies. Studies deemed unacceptable by one investigator were reviewed by the other investigator, and studies deemed unacceptable by
both investigators were excluded. The investigators also reached consensus on
studies about which they initially disagreed.
793
In doing this work, Barroso and Powell-Cope (2000) were confronted with the
difficulty of applying critique standards to qualitative studies. For example, they
found that studies rarely met the Burns (1989) criteria fully, and they surmised this
was most likely because of publication limitations, that is, a study might have actually met the criteria in practice, but all of the information supporting these criteria
could not be included in the report of the study. Moreover, Barroso and PowellCope began to question whether all of the criteria were equally important to establishing the trustworthiness of the findings. They also questioned the meaning of
some of the criteria themselves. For example, they were uncertain about how to find
evidence for, score, or weigh the adequacy of a researchers self-awareness. Burns
listed inadequate self-awareness as a threat to descriptive vividness (p. 48) In
short, the investigators concluded there was a need to find a standardized, communicable, and useful means of judging the value of qualitative work that could both
(a) serve as a guide for what a qualitative report should include regardless of publication constraints and (b) account for the idiosyncratic ways in which qualitative
research is conducted.
After determining which HIV studies would be included in their study, Barroso
and Powell-Cope (2000) used constant comparison analysis as the major analytic
tool to create the metasynthesis. They acknowledged the Noblit and Hare (1988)
work but had difficulty applying the method described there, which involved analyzing two to six book- or chapter-length ethnographies in education, to their own
study involving multiple article-length studies in the domain of health. They developed a classification system based on findings after discovering that grouping studies by method did not allow them to focus on the findings and their relationships to
each other. They placed findings in a common area of HIV experience, such as dealing with stigma, in separate files. They then sought to develop ways to consolidate
findings in each of these areas, attempting to find metaphors or concepts to grab the
findings and to discern the variations in findings on a target experience. The findings in target experiences were then summarized in narrative form, with a section of
the report devoted to each target experience. Questions were raised in this phase of
the project concerning what to do with findings reported in only one or two studies,
how to use the primary data the original investigators used to support the integration of findings, and what form the metasynthesis product should have. The investigators decided to concentrate on findings reported in the majority of studies, to
use original quotes to support findings, and to present an informational summary
of the metasynthesis findings.
Despite the methodological issues they confronted in conducting this project,
the investigators found that their understanding of living with HIV/AIDS was
enhanced. Indeed, Barroso and Powell-Cope have used the findings from their
metasynthesis in their practice with HIV/AIDS patients as a basis for appraisal and
intervention. For example, they were surprised to find how common the effort to
find meaning in HIV/AIDS was among affected persons. This meta-finding enabled them to think of this effort as a positive outcome of coping toward which
patients strove. The findings of their metasynthesis also heightened their awareness
of the everyday work involved in living with HIV/AIDS and, therefore, of the need
to communicate this to patients. That is, living long and well with HIV/AIDS is not
a part-time job but, rather, requires daily work on the part of patients. The metafinding that social support and human connectedness served as buffers against
social stigma also encouraged Barroso and Powell-Cope to discuss more fully with
794
their patients the potential value of telling their loved ones about their infection.
Finally, the meta-finding of shattered meaning led them to become more aware of
patients who might require assistance to find meaning in HIV/AIDS. The net
effect of their metasynthesis was to confirm what they had intuited by working with
patients with HIV/AIDS but on which they had been hesitant to act.
In summary, our preliminary efforts confirmed our view of the potential value
for practice of conducting qualitative metasyntheses but also forced us to revisit
persistent issues in qualitative research related to quality and communicability of
procedural and analytic moves. Moreover, they raised questions about how to disentangle methodological orientation and data from findings to understand their
relationships to and mutual influence on each other and how to make judgments
about the practice of qualitative research from the reports of qualitative research.
We plan to offer answers to these questions in the proposed project.
Our goal here was not only to show that we had already engaged the research problem
but also to specify and discuss only those findings that served as the immediate basis for the
proposed study. What we found concerning infertility and HIV was not the point here, so
those findings are not featured. Rather, we feature those findings concerning methods, which
is congruent with the method objectives of the proposed project.
Bibliographic Retrieval for the Proposed Project

In specific preparation for the proposed project, 1,500 abstracts in 4 databases
(AIDSLINE, MEDLINE, CINAHL, and PsychInfo) were reviewed to locate qualitative studies on women with HIV/AIDS. Using such keywords as women, females,
mothers, HIV, AIDS, qualitative research, naturalistic research, grounded theory, phenomenology, ethnography, and interview, we have already located 25 conference abstracts,
26 published articles, and 1 book chapter, ranging from 4 to 22 pages. Our location of
25 research abstracts reveals that a large number of qualitative studies on women
with HIV/AIDS have been presented at conferences in the past 3 years, affirming the
importance of this area for metasynthesis efforts. A significant number of these conference papers will likely appear in print during the grant period and, therefore,
add to the rich body of literature for metasynthesis work. (Some of the reports of
studies that are not published will likely be retrievable and therefore also contribute
to the data base for this project.) Other results from this search are referred to in the
section on Research Design and Methods. In this paragraph, we emphasized our preparation for the proposed study and further defended the choice of HIV studies as constituting a
good method case. In the following section, we featured only those aspects of each research
team members biography that were directly relevant to the proposed study. We also included
key scholars in the area of metasynthesiswhose work we previously reviewedto participate as members of our Expert Panel.
Expertise of the Research Team

The research team is well prepared to conduct this project. Margarete Sandelowski,
principal investigator, is an internationally recognized expert in qualitative methods. Her research has been in womens health and gender studies, particularly in
the area of reproductive technology. She is Director and Principal Faculty of the
Annual Summer Institute in Qualitative Research held at the University of North
Carolina at Chapel Hill (UNC-CH) School of Nursing, which draws participants
795
from across the United States and several other countries. She is editor of and contributor to the Focus on Qualitative Methods series in Research in Nursing &
Health, a member of the editorial boards of Qualitative Health Research and Field
Methods (a new interdisciplinary journal devoted to qualitative methods), and the
North American editor of Nursing Inquiry, an Australian journal emphasizing critical qualitative methodologies. She is regularly invited to present keynote
addresses and distinguished lectures, conduct workshops, and provide individual
and program consultation on qualitative methods. She has served as visiting
scholar at universities in the United States, Canada, and Australia to disseminate
information about qualitative research and the findings from her qualitative work
on gender and technology. She has published extensively in both nursing and social
science journals and books, with 25 refereed articles on qualitative methods alone.
With Child in Mind (1993), a book-length synthesis of her qualitative studies with
infertile women and couples, was awarded a national book prize from the American Anthropological Association. She is skilled in a variety of qualitative methods
and techniques, including grounded theory, narrative analysis, and social history.
Her latest book, Devices and Desires: Gender, Technology, and American Nursing (to be
published in late 2000, or 2001),3 is a social history of technology in nursing. She is
also skilled in managing very large qualitative data sets, as were collected in the
Transition to Parenthood of Infertile Couples study, in which she served as principal investigator and which was funded by the former National Center for Nursing
Research from 1988-1993 (NRO1707).
Julie Barroso, co-principal investigator, brings both research and clinical experience to this project. She is an adult nurse practitioner with extensive clinical experience in caring for people with HIV disease. She currently maintains a practice with
HIV-positive patients. In addition to completing the qualitative metasynthesis project described above, she has conducted and published qualitative research with
long-term survivors of AIDS and long-term nonprogressors with HIV disease.
She has presented numerous papers on her research to both professional groups
and people with HIV disease. She has received two intramural grants to conduct a
qualitative study exploring fatigue in people with HIV disease. She will also conduct a study of HIV-related fatigue, with funding from OrthoBioTech and from the
UNC-CH School of Nursing, Center for Research on Chronic Illness, which recently
received renewed funding for 5 years from NINR. Moreover, she has maintained an
excellent network of relations in various HIV/AIDS communities, including
researchers and clinicians. She continues to present her work to practitioners and
people living with HIV/AIDS at Area Health Education Consortium (AHEC) HIV
conferences around the state.
The Expert Panel, whose members will provide both consultation and expert
peer review for the proposed project, is made up of scholars with the methodological, substantive, and clinical expertise required for this project. These scholars
include investigators on the metasynthesis projects we discussed previously. Cheryl
Tatano Beck is nationally known for her use of both qualitative and quantitative
research methods, primarily in the area of postpartum depression. She has also conducted quantitative meta-analyses and, therefore, brings to the project an understanding of the comparability of issues relating to quantitative and qualitative
research integrations. Louise Jensen has published one of the few qualitative
796
metasyntheses of health-related research findings. Having also conducted quantitative meta-analyses, she brings a broad view of issues related to research integration to this project. Margaret Kearney is well known for her qualitative research in the
area of women and substance abuse. She has also completed theoretical syntheses
from her own work and other studies in this area. George Noblit is well known for his
qualitative expertise in the field of education. His text on metaethnography provided the impetus for conducting qualitative metasynthesis research. In addition,
his research in education has been oriented toward the use of qualitative findings to
improve education. Gail Powell-Cope is a substantive and clinical expert in the HIV/
AIDS field. In addition to collaborating with Dr. Barroso in conducting a qualitative
metasynthesis project, she has published several studies on HIV symptom management and AIDS family caregiving. She also has extensive experience working as an
adult nurse practitioner with people with HIV disease. Sally Thorne is internationally known for her expertise in qualitative research, especially in the area of chronic
illness. She recently published the results of a metasynthesis project on diabetes.
Letters of support from these scholars are located in Section I. Section I is not reprinted
here.
Research Design and Methods

The research design is directed toward developing method and therefore entails the
challenging tasks of describing a process-to-create-a-process and experimentation with various approaches to conducting and creating metasyntheses. As is the
case with any qualitative project, the design will be emergent, or highly dependent
on the ongoing results of this experimentation as the study progresses. Although
we separate data collection, analysis, and interpretation here, the better to communicate our research plans, these processes typically proceed together and strongly
influence each other in qualitative studies. Design dictates what the quantitative
researcher will do; in contrast, what the qualitative researcher does determines the
design. We have drawn heavily from what we have learned from our previous
work, discerned from the metasynthesis work of others, and gleaned from the
research integration literature initially to design this project. This literature includes
the work of Cooper (1982, 1989; Cooper & Hedges, 1994) and the Smith and
Stullenbarger (1991) prototype for conducting integrative reviews. These works
describe a reasonable way to begin this project, in that they offer useful guides for
locating, dimensionalizing, and appraising studies. Although we begin this project
with these works in mind, our objective is to build on them and to develop techniques that will fit the qualitative research integration enterprise especially well
and that will preserve the integrity of each study we analyze. We have organized the
description of our research plan to approximate the content and order commonly
associated with research integration studies (Cooper & Hedges, 1994). We describe
issues and/or plans related to (a) defining the limits of a study, (b) bibliographic
retrieval, (c) detailing studies, (d) evaluating studies, (e) conducting the
metasynthesis itself, and (f) ensuring the validity of study procedures.
Introductory paragraphs such as the previous one are crucial to setting the stage and
helping reviewers understand the mind-set of the investigators. This introduction is especially critical here to prepare reviewers for a research plan that looks different from a typical
human subjects study and to reinforce the method-on-method focus of the project. In essence,
797
the proposed project is one big audit trail. Here, we prepared reviewers for a highly specific
research plan but also assured them that we understood the emergent nature of qualitative
research design. We named the concepts and literatures to which we were sensitized but also
suggested that they would have to earn their way into the study to remain guides. The temporal logic of the sections that follow is actual clock time: What we describe first, subsequently,
and last is what we anticipate we will do first, subsequently, and last. The division of the
description of design into clearly defined sections helps writers to maintain their focus solely
on the topic of that section and it offers reviewers a clean and clear narrative flow. Devices
such as section headers and visual displays ease the reading process for reviewers, who often
have a dozen lengthy proposals to critique in any one reviewing period. Although qualitative
research designs, and research integration studies in particular, are iterative and deliberately
nonlinear processes and their phases experientially inseparable, the act of writing requires
that these processes be analytically separated and laid out in some temporal order. However,
we show our recognition of the nonlinear nature of the research process by emphasizing that
our plan is a reasonable way to start the study, even though it might not be the plan we will
actually follow.
Defining the Limits of the Study

In research integration studies, the researchers typically begin by defining the substantive, methodological, and temporal boundaries for study. To begin this study,
we have already identified the broad substantive area as encompassing the experiences of women with HIV/AIDS and the methodological area as qualitative
research. The initial data set for this study will be all qualitative studies published
and/or conducted between 1993 and March 2003 with women in the United States
who are seropositive for HIV in which some aspect of their experience is the primary subject matter. We define qualitative studies as empirical research conducted
in any research paradigm, using largely qualitative techniques for sampling, data
collection, data analysis, and interpretation, with human participants as the sole or
major sources of data. We therefore do not exclude studies conducted in a
neopositivist paradigm in which primarily qualitative techniques are used.
Neopositivism is the prevailing paradigm for quantitative inquiry but only one of
several competing paradigms for qualitative inquiry (Guba & Lincoln, 1994). For
example, grounded theory can be conducted in a neopositivist or constructivist paradigm (Annells, 1996). A neopositivist conducting grounded theory believes in
an external and objectively verifiable reality. In contrast, a constructivist conducting grounded theory believes in multiple, experientially based, and socially constructed realities. For the neopositivist, concepts emerge or are discovered, as if they
were there to be found. The act of discovery is separate from that which is discovered. For the constructivist, concepts are made, fashioned, or invented from data.
What constructivists find is what they made. For the constructivist, all human discovery is creation.
We will include studies completed between 1993, the year in which the first of
these studies appeared (as indicated by our search to date), and March 2003, 2 years
before the anticipated termination of the proposed project. Excluded from our project are (a) qualitative studies in which there are no human subjects per se (as, for
example, in discourse, qualitative content, semiotic, or other qualitative analyses of
media representations of women with HIV/AIDS); (b) qualitative studies about
nonseropositive women and their experiences as mothers, partners, relatives,
798
friends, and/or caregivers of seropositive persons; and (c) qualitative adjuncts

(such as open-ended questions at the end of a structured questionnaire) to largely
quantitative studies. We anticipate that approximately 30 to 35 studies, with a total
of 450 to 525 pages of text, will make up the bibliographic sample in the method
case. Here, we used numbers to emphasize the volume of data despite an ostensibly small
sample. Sample size is a key focus of strategic disarmament in writing qualitative research
proposals.
Retrieving Literature
We will locate these studies using the techniques for information retrieval that Cooper (1982, 1989) and Cooper and Hedges (1994) described, including (a) informal
approaches, (b) the ancestry approach, (c) the descendency approach, and (d) the
use of online computer databases. Informal approaches include gleaning information about studies by networking with researchers in the target area (here the HIV/
AIDS field) and at conferences and other professional meetings, such as the
National Conference on Women and HIV. The ancestry approach involves tracking
citations from one study to another until citation redundancy occurs. The
descendency approach involves the use of citation indices (such as Social Science
Citation Indexes) to locate studies. The use of computer databases involves the careful selection of keywords and phrases to locate studies in journals, books, dissertations, and conference proceedings included in these databases. A list of the electronic resources available to this project is included in the Resources section of this
proposal. The employment of all of these retrieval channels will make it more likely
we will capture fugitive literature, or studies that are not published or might otherwise escape retrieval. The failure to capture such literature is considered a threat to
the validity of research integrations.
Detailing the Studies

As soon as a study is retrieved, it will be scanned into its own computer file. Each
study will then be detailed, or analyzed for its structure, informational content, and
methodological orientation. We will initially use the guide shown in Figure 1 to do
this work. Our use of the word initially is to reinforce the emergent nature of qualitative
design. The results of an application of this guide, using one of the studies in the
Barroso/Powell-Cope (2000) project, are shown in Appendix B (not reproduced here).
Whenever possible, writers should show an example of how a process might be executed.
Concise visual displays are highly effective for communicating process and a sense of order.
This a priori guide will be further refined in the course of the project to ensure the
inclusion of all of the salient features of every study. Each member of the Expert
Panel will independently evaluate the content validity and usability of a refined
version of this tool by applying it to five studies randomly selected from the HIV
studies used to create it. After we receive their evaluations, we will further refine the
guide to include additions or amendments they recommend. The Expert Panel
members will then review a second version of this guide to determine whether the
revisions we made address the problems they noted in reviewing the first version
and to evaluate its broad applicability as a tool to detail any qualitative study. If
these revisions were extensive, each member will be asked to apply this second version of the guide to a different set of five randomly selected studies. They will also
799
Title of study
Investigator(s) name(s)/discipline/institutional affiliation(s)
Publication venue (name and type): e.g., journal, authored/edited book, conference proceeding,
dissertation
Mode of retrieval: e.g., computer database (specify), citation list (specify), personal
communication (specify)
Funding source for study
Research problem/significance
Research purpose(s)/question(s)
Type and area of literature reviewed
A priori theoretical orientations to, assumptions about the target phenomenon
Methodological orientation (name and type; specify with citations provided): e.g., naturalistic
inquiry (Lincoln & Guba, 1985), hermeneutic phenomenology (van Manen, 1990),
constructivist grounded theory (Charmaz, 1990)
Sample: e.g. size, composition, type
Data collection methods or sources (for each one, indicate kind; specify with citations
provided): e.g., interview (narrative, Mishler, 1986), observation (participant, Spradley,
1980), documents (diaries), artifacts (photos)
Data analysis techniques (type; specify citations provided): e.g., qualitative content analysis
(Altheide, 1987), phenomenological thematic analysis (van Manen, 1990), constant
comparison analysis (Strauss & Corbin, 1990)
Techniques to ensure validity/trustworthiness: e.g., audit trail, member validation, peer review,
prolonged contact with participants/time in the field
Interpretive product: e.g., informational summary, theory or other conceptual rendering,
phenomenological description, ethnographic description, visual displays
Major findings
Significance of findings: e.g., for research, for practice
Study format: e.g. conventional (literature review separated from method, results separated from
discussion), other (describe: e.g., results foreshadowed, data merged with interpretation)
Additional information/comments
FIGURE 1:
Topical Guide for Detailing Studies
be asked to comment on whether the revisions solved the problems raised for them
in reviewing the first set of studies. We will further refine the guide if any additional
revisions are warranted after this second review. Consensus on any persistently
troublesome features of the guide will be reached through a process of negotiation
described later in the section on Procedures for Enhancing Study Validity. Although
we will discuss validation techniques later, in a section of the proposal reserved for this purpose, the concern to ensure valid findings is foundational to every design choice. Accordingly, we embed these techniques throughout the design section.
Before the findings from studies can be synthesized, the studies themselves
must be understood for what they uniquely are. Each study must be understood as
providing a specific context for its findings before attempts are made at cross-study
comparisons or combinations of findings. The objectives here are to understand the
particular configuration and confluence of elements characterizing each study as
the investigators themselves presented them and to preserve the integrity of each
study. This objective can be difficult to achieve because of the great diversity in conducting and presenting qualitative research. A hallmark of qualitative research is
variability, not standardization (Popay, Rogers, & Williams, 1998, p. 346). Yet
our goal in this phase of the project is to find a standardized way to characterize
studies that retains their unique character.
The detailing of each study will allow us to address several key problems in
conducting qualitative research integrations. First, unlike quantitative researchers,
qualitative researchers are not necessarily obliged to separate the results of their
studies physically from their discussion of these results. Accordingly, the
reviewer must know how to find the results throughout the research report, and this
skill entails an understanding of various formats and language conventions for the
800
written presentation of qualitative research. Our goal is to specify these conventions

with the larger goal of ensuring that any two reviewers of any one qualitative study
will identify the same results.
Finding the results of studies is a necessary prelude to determining the topical
similarity of studies, or deciding which studies are really about the same substantive phenomenon, event, or experience. In the qualitative studies of women with
HIV/AIDS we have already located, the findings have addressed diverse topicsall
aspects of the HIV/AIDS experienceincluding responses to the diagnosis, concerns regarding the welfare of children, social relations and stigma, difficulties
obtaining health care, and managing symptoms. Our detailing of each study will
allow us to group studies by the aspects of womens experiences of HIV/AIDS
addressed in the findings of each study. Based on Barrosos metasynthesis (Barroso
& Powell-Cope, 2000), this kind of grouping appears to us now as more relevant
than grouping studies by method. We refer back to preliminary work here to show how it
informed our design choices in the proposed study. Because studies typically contain
findings on more than one aspect of experience, we will use an open system of classification, by which any one study may be placed in more than one group. We will
use Ethnograph 5.0 to place findings on each target experience in separate files for
retrieval and analysis. The specific text management system to be used is less important
than describing how data management, analysis, and interpretation might proceed. Indeed,
writers can simply state that they will use a system (which might simply be a word-processing program) to be determined later. We will then be able to focus on each aspect of
experience and all of the findings related to it. Our goal here is to develop and articulate techniques to isolate the findings around a target experience while maintaining
the connection each finding has both to the individual study generating it and to
other findings around other target experiences in each study. For example, there
will be a set of findings in individual studies and across studies on how women with
HIV manage social relations and on how women manage symptoms that will each
be filed separately. However, the findings in these two topical areas may be combined if we discern a link between managing social relations and managing symptoms. The detailing work in this phase of the project will allow us to see such relations and to communicate how to see them.
This detailing work will permit us also to address another problem in conducting qualitative metasynthesis, namely, determining the methodological comparability of studies and whether and/or how methods influence findings. Given the
varieties of ways in which, for example, grounded theories, phenomenologies, and
ethnographies are conducted and created, and the varieties of practices to which
these and other technical words are attached, we cannot rely solely on the surface
uses of method language to compare studies. Depending on their worldview or disciplinary commitments, one investigators phenomenology might be more like
another investigators grounded theory than the grounded theory of a third investigator. One investigators rendering of symbolic interactionism might be more like
another investigators rendering of critical theory. Accordingly, our work with the
guide in Figure 1 will involve developing a means to determine the methodological
comparability of studies below the surface of language and rhetoric. This work will
permit us to discern how methodological practices might have influenced the findings of a study, and will be a prelude to evaluating the quality of the studies. As
shown in Figure 1, we have included items that ask the reviewer to specify not just
the words investigators used to define their studies, but also the citations they used
801
and the actual interpretive product shown in the research report. We will further
develop these items in the course of the project.
When this work is completed, we will provide narrative and quantitative summaries of the information we collected from this process. For example, we will show
the total and mean sample sizes across studies. We will show the frequency with
which different methodological approaches were used and topics were studied. We
will look for any associations between methods used and topics addressed in studies. This work will provide an overall profile of qualitative research with women
with HIV/AIDS and permit us to suggest useful ways for synthesists to describe a
set of studies. This work will allow us also to suggest which features of a study are
necessary to detail. We surmise that there will be much less true diversity in
method in qualitative health-related studies than is commonly believed, but this
work will allow us to determine whether that impression is accurate.
Evaluating the Quality of Studies

Once the detailing work is complete, we will address the problem of evaluating the
quality of studies. Whereas the initial detailing phase of the proposed project will
have been directed toward answering the question What is it?, the next phase of
the project will be directed toward answering the question What is it worth?
The issue of quality remains controversial among researchers conducting quantitative integrations, with some scholars arguing that no study should be excluded
for reasons of quality and others arguing for a best-evidence approach, by which
less rigorous studies can be excluded (Cooper, 1989; Slavin, 1995). Quantitative
researchers also disagree on what aspects of rigor to emphasize in their evaluations
of studies, for example, internal versus external validity. Although issues related to
quality are not wholly resolved for quantitative research integrations, there appears
to be reasonable consensus among quantitative researchers concerning what a good
correlational or experimental study is.
There appears to be much less consensus concerning what a good grounded
theory, ethnographic, or other qualitative study is, as there are no in principle
(Engel & Kuzel, 1992, p. 506) arguments that can adequately address goodness in
the varieties of practices designated as grounded theory, ethnography, or qualitative research as a whole. In addition, criteria of goodness (for any human endeavor)
are historically and culturally context dependent. Different communities of knowledge makers and users have sanctioned different criteria of goodness, and these criteria have changed over time (Emden & Sandelowski, 1998). For example, nursing
standards for conducting qualitative research have tended to emphasize procedural rigor and conformity. In contrast, other standards for qualitative research
have emphasized such factors as the real-world significance of the questions asked,
the practical value of the findings, and the extent of involvement with, and personal
benefit to, the participants of the research (Heron, 1996; Lincoln & Reason, 1996).
Indeed, in the most recent explorations of quality criteria for qualitative research,
scholars describe them as emerging (Lincoln, 1995) and the quest for validity as
an obsession interfering with quality (Kvale, 1995). Schwandt (1996) suggested
moving beyond criteriology, and Garratt and Hodkinson (1998) questioned
whether there could ever be preordained (p. 517) criteria for selecting research
criteria (p. 515).
802
Evaluation
_________________________________________________
_________________________
Focus of Evaluation
Adequately
Adequate and/or Appropriate
Described
for Purpose/Method/Claims
__________________________________________________
Yes/No
Yes/No
__________________________________________________
Research problem/significance
Comments:
Research purpose(s)/question(s)
Comments:
Literature reviewed
Comments:
Method
Comments:
Sampling strategy
Comments:
Sample size
Comments:
Sample composition
Comments:
Data collection methods/sources
Comments:
Data analysis techniques
Comments:
Validation techniques
Comments:
Interpretive product
Comments:
Significance of findings
Comments:
FIGURE 2:
A Generic Guide for Evaluating the Overall Quality of Qualitative Studies
We will address the problem of quality by experimenting with and adapting

available generic criteria for evaluating any qualitative work (e.g., Burns, 1989) and
specific criteria directed toward evaluating qualitative work in particular methodological domains, such as grounded theory (e.g., Corbin & Strauss, 1990). Indeed,
an important product of the proposed project will be the development of more userfriendly guides to evaluate qualitative research. In Figure 2, we show a preliminary
guide for evaluating any qualitative study that is directed toward determining the
adequacy and/or appropriateness of the design choices investigators made. Adequacy refers to whether a design choice is qualitatively and/or quantitatively sufficient to support the claims made for it. For example, a sample size might not be adequate to support a claim to maximum variation sampling. Appropriateness refers to
whether a design choice fits the stated purpose or methodological orientation of a
study. For example, using an interrater reliability coding technique to appraise the
findings produced from interview data does not fit the narrativists assumption that
those data are inherently revisionist.
In Figure 3, we show a beginning guide for evaluating qualitative studies in
particular methodological domains. The sample methodology is grounded theory.
The results of an application of the guides in Figures 2 and 3 (to the same study used
to apply the guide in Figure 1) are located in Appendix B (not reproduced here). The
members of the Expert Panel will also evaluate the content validity and usability of
803
Yes/No
__________________________________________________________________________
Research purpose/question is amenable to grounded theory.
Comments:
Literature/theoretical review is in the service of showing theoretical sensitivity.
Comments:
Sampling is theoretical.
Comments:
Data collection and analysis proceeded together.
Comments:
Constant comparison analysis is evident.
Comments:
Concepts are grounded in data.
Comments:
Concepts are the basic units of analysis.
Comments:
Concepts/categories are well developed.
Comments:
Concepts/categories are shown in relation to each other.
Comments:
Relationships among concepts/categories are verified.
Comments:
Negative cases are accounted for.
Comments:
The findings are re-presented in a fully integrated theoretical product.
Comments:
A psychosocial process is at the core of this product.
Comments:
FIGURE 3:
A Guide for Evaluating Grounded Theory Studies
these guides by applying them to yet another set of five studies randomly selected
from the sample of HIV studies. We will then work to refine these guides in the iterative manner we proposed above to develop the guide to detail studies.
A key problem in current evaluation guides, which we will attempt to resolve
by further developing the guides shown in Figures 2 and 3, is the conflation of different kinds of evaluations. For example, a sample might be adequately described
but inadequate to support the findings of the study or claims to informational
redundancy or theoretical saturation. The overall methodological approach chosen
might be appropriate for the research question but inadequately executed. We will
also consider how criteria might be differently weighted. For example, evoking a
vicarious experience may be more important in phenomenological studies than in
grounded theory studies, where the emphasis is on producing abstract conceptual
rather than concrete, preconceptual renderings of experience. Theoretical development is, arguably, not a criterion at all for phenomenologies.
As a result of experimenting with these criteria, we will be in a better position to
discern what really counts methodologically in deciding whether to discount findings, and whether quality should be a criterion at all for exclusion of studies from
the bibliographic sample, or yet another contextual factor on which all studies are
compared. The critical error here would be to exclude studies with valuable findings for only surface reasons, or reasons unlikely to devalue or invalidate the
findings. For example, investigators might use what some reviewers would argue is
804
the wrong language and method citations to describe their work. A study presented as a phenomenology that is better described as a qualitative descriptive
study may still be a generally good study. Using Burnss (1989) standards for the
critique of qualitative research, such a study might still have descriptive vividness (p. 48), analytic preciseness (p. 49), and heuristic relevance (p. 51).
Indeed, even a study misrepresented as a phenomenology can still have methodological congruence (p. 48). Moreover, a study presented as a phenomenology that
is really a qualitative descriptive study should be evaluated as a descriptive study
and not as a phenomenology. Similarly, a qualitative content analysis wrongly
presented as a narrative analysis should be evaluated as a content analysis. Evaluating the goodness of a qualitative study requires reviewers to distinguish between
nonsignificant errors and mistakes fatal enough to discount findings. Our goal is
to assist reviewers to do this, that is, to know specifically what to look at and for in a
study to judge the value of its findings. By meeting this goal, we hope to contribute
to a satisfactory resolution of the criterion problem in evaluating research.
Creating the Metasynthesis

This is the heart of the project, in which we will experiment with various analytic
techniques to discern, compare, combine, and re-present the findings of the studies
in the bibliographic sample. We anticipate that we will be using a variety of analysis
techniques, including qualitative content analysis techniques (Altheide, 1987; Morgan, 1993) entailing the development of data-derived coding rules to categorize
data that summarize their informational content in largely substantive categories.
Substantive categories stay closer to raw data and are less abstract than theoretical
categories. Raw data here refers to the findings in each study and the data investigators cite to support these findings. We will likely also experiment with techniques
other investigators have used in conducting metasyntheses. These include narrative analysis techniques (Riessman, 1993), in which larger collective, cultural, and/
or metaphoric storylines are discerned in studies, and constant comparison analysis
techniques (Corbin & Strauss, 1990), in which data are successively transformed
into larger theoretical categories. In addition to these larger methodological
approaches, we will use visual techniques for analysis, such as the various case-,
time-, and other variable-oriented data displays that Miles and Huberman (1994)
have described. Another useful technique for visual display is the Venn diagram
(Cieutat, Krimerman, & Elder, 1969). Visual displays permit analysts to see patterns in data; the act of looking at data re-presented in graphs, tables, and other displays enables analysts to discern similarities and differences among study findings
around a target event, thereby allowing them to draw conclusions about the extent
to which these findings converge, diverge, or frankly contradict each other.
The key objectives in this phase of the analysis are to determine which set of
analytic techniques is appropriate for which studies and purposes and then to communicate how these are determined. For example, we have already found a set of
studies that, after a surface reading, all address women living with HIV/AIDS.
However, there is one subset of these studies that addresses this topic
phenomenologicallyas a certain kind of lived experienceand a second that
addresses it theoreticallyas a disease to be medically and socially managed. Our
task will be to determine whether we must use phenomenological thematic analysis
as an initial strategy to synthesize the lived-experience data and constant
805
comparison techniques to synthesize the disease management data, as Jensen and

Allen (1994) did, or, whether it is possible to move directly to a technique that draws
together both data sets, as Noblit and Hare (1988) did in conducting their reciprocal translations of studies. The emphasis in qualitative research is on idiomatic
(meaning), as opposed to semantic (literal), translation (Noblit & Hare, 1988). Here,
we are using the literature we reviewed previously and referring back to our preliminary
work. Qualitative metasynthesis entails the analysis of culturally diverse texts in different languages (albeit all English, in this case), that is, texts created in different disciplinary and philosophical contexts. Accordingly, the key to integrating the findings of studies around a target event may well lie in recognizing, for example, how
they all reprise familiar cultural stories, such as the hero(ine) on a quest or the warrior battling an enemy (e.g., Martin, 1990). Such analytic experimentation is important for determining the best way to preserve the sense of each study without
becoming so immersed in the details of each study that no useful synthesis is produced. Our goal is to develop techniques that will be useful for combining the
results of multiple health-related studies conducted in different qualitative methodological traditions and to present these combinations in forms useful for health
researchers and clinicians.
Among the most important barriers to research use is the presentation of
research findings in forms that cannot easily be understood or applied (Funk et al.,
1995). The ultimate objective of all of the work detailed thus far is to create usable
knowledge, which necessarily entails a much more serious attention to how knowledge is presented than has hitherto been given in discussions of research use.
Despite the burgeoning literature on rhetoric and display in science (e.g., Gusfield,
1976; Lynch, 1985; Lynch & Woolgar, 1990; Moore & Clarke, 1995; Van Maanen,
1988), in which scientific reports, tables, graphs, and anatomical displays are
viewed as examples of how form is content, discussions of form are typically viewed
as outside the realm of and irrelevant to science. Moreover, despite the burgeoning
literature on writing texts that are audience appropriate (Noblit & Hare, 1988,
p. 75), little effort has been directed toward disseminating the findings of scientific
research with specific audiences in mind.
In this phase of the project, another of our goals will be to experiment with different ways to re-present metasynthesis findings to enhance their utility for
researchers and practitioners. This work is especially significant for qualitative
research where the interpretive goal is representation, not (statistical) inference.
Representation in qualitative research refers, not to representative samples but,
rather, to how qualitative researchers choose to re-present the lives of the participants as discerned from the data collected from and about them. Common representational forms in health-related qualitative research include conceptual renderings (e.g., theories, concepts, working hypotheses, analytic generalizations); storied
renderings emphasizing character, plot, scene, and/or metaphor; phenomenological
descriptions; and informational content summaries of events. Our goal is to discern
the different interpretive products that might be produced that will capture the subtleties in findings and be most useful to researchers and practitioners. (We will not
address here other audiences, most notably policy makers and patients.) Here is
another example of strategic disarmament. Writers should state explicitly what they will not
do whenever they anticipate that reviewers might expect it. This might involve developing techniques to transform findings into guidelines for practice for the clinician
and working hypotheses for the researcher. In a clinical sidebar attached to the
806
report of the Paterson et al. (1998) metasynthesis on living with diabetes, Gillespie
observed that the value of their research integration lay in helping clinicians see the
importance of reconceptualizing the target of appraisal and intervention in the care
of persons with the disease, that is, nurses were advised to see diabetic persons positivelyas actively striving to balance their disease with a normal lifeinstead of
negativelyas potentially noncompliant with prescribed regimens. The findings of
the integration suggested the working hypothesis and working course of
action, namely, that treating these patients as active managers led to better compliance, whereas treating them as potentially noncompliant led to noncompliance.
Procedures for Enhancing Study Validity

We will use several techniques to maximize the validity of this study, including
(a) the maintenance of an audit trail (Rodgers & Cowles, 1993), (b) the negotiation of
consensual validity (Belgrave & Smith, 1995; Eisner, 1991), (c) expert peer review
(Lincoln & Guba, 1985), (d) application of the protocol to an additional set of HIV
studies not included in the method case, and (e) application of the final protocol to a
test case, or set of studies in a different domain of research. These techniques will
be directed toward ensuring the descriptive, theoretical (Maxwell, 1992), and pragmatic (Kvale, 1995) validity of study findings. Descriptive validity refers to the factual accuracy (Maxwell, 1992, p. 285) of our detailing of each of the studies making
up the data for this project, for example, entering the correct sample size and characteristics, setting, and data collection techniques. Descriptive validity is about representing the facts of the case accurately and typically involves low-inference data,
about which it is most easy to obtain consensus. Theoretical validity refers to
researchers constructions (p. 291) or interpretations of these facts: for example,
our evaluations of the studies, the interpretive syntheses we produce, and the procedures we used to produce them. Theoretical validity is about making the case for
the analytic and re-presentational techniques developed in the study. Pragmatic
validity refers to the utility and applicability of knowledge: for example, whether
the techniques and protocol we develop can be easily used. Here, we described our orientation to validity, an especially important move, as so many orientations exist in qualitative research, and validity is one of the most controversial areas. In the next sections, we
move to naming and defining specific validation techniques and to showing their application
to the proposed study.
If maintaining an audit trail is highly desirable for any qualitative project, it is
essential for this project, which will depend for its success on the development of
techniques others can understand and use. The audit trail in this study will be composed primarily of methodological (and) analytic documentation (Rodgers &
Cowles, 1993, pp. 221-222). Methodological documentation refers to the design
decisions made throughout the life of the project, especially important because of
the emergent nature of qualitative research designs. In the proposed project, such
decisions will include what sources of data to sample and what studies to exclude
and why. Analytic documentation refers to decisions made in coding, categorizing,
and comparing data. In the proposed project, this documentation will not only
serve to ensure the trustworthiness of findings but will itself be data that contribute
to findings. Analytic documentation will involve tracking phases in the evolution of
the various tools we will develop and the evolution of the actual metasynthesis.
807
To enhance the utility of this audit trail as both data and documentation, we will
use a think/talk-aloud strategy (Fonteyn, Kuipers, & Grobe, 1993) to capture the
procedural and analytic moves that often remain unexpressed in qualitative
research reports. Although there is a magic (May, 1994) in qualitative research
that will always resist expression in language, a think/talk-aloud approach can
overcome some of this resistance. Indeed, this approach is especially suitable for
this project as it entails that persons engaged in a problem-solving activity talk it
through out loud while in the act to capture the cognitive steps they are taking to
solve the problem. In this project, these acts include, for example, determining
whether a study meets quality criteria for inclusion, discerning the findings of a
study, and discerning the relationship between findings across studies. The principal investigators will use this strategy periodically, independently to document
their individual thinking and with each other to play their thoughts off each other.
Communicating the process we used to arrive at the process we will develop to conduct qualitative metasynthesis projects is essential to creating a useful audit trail
and to enhancing the value of the products of our research, namely, the research
integrations and the protocol for conducting them.
Negotiated validity (Belgrave & Smith, 1995) refers to a social process and
goal especially relevant to collaborative qualitative research, such as the proposed
project. Because the researcher is the primary instrument in qualitative research,
analysis and interpretation will vary with the orientations of each investigator. In
the proposed project, which will involve two investigators and a six-member
Expert Panel, consensus will have to be reached on the facts and meanings of each
study, on the appropriate means to discern these, on the final interpretive products,
and on the process used to create these products. The negotiated validity process
will require that team members explicate the orientations and assumptions leading
toward various interpretations of study data, and persuade others that they offer
the interpretation that is most grounded in and that best fits these data. Consensus
is achieved not by conventional techniques for reliability coding but, rather, around
the most persuasive argument.
The essence of consensual validation in qualitative research does not lie in a
coefficient of agreement. Instead, as Eisner (1991) proposed, it lies in the reasons
offered for a point of view, the cogency of arguments for it, and the incisiveness
of observations relating to it (pp. 112-113). Consensual validity here does not rest on
unanimity per se (p. 112). Indeed, efforts to achieve unanimity often result in
simplifications (that) compromise validity (p. 113) in qualitative research. Moreover, as Eisner argued, and as Hak and Bernts (1996) demonstrated in their field
study of research coders and coding, the consensus achieved via traditional techniques for establishing and demonstrating interrater reliability offers no purchase
on reality (Eisner, 1991, p. 47). Morse (1997b) cautioned qualitative researchers
about the myth of inter-rater reliability. Such techniques simply show that raters
can, or can be made to, agree. A correlation coefficient is itself a product of a socially
negotiated process. Accordingly, such quantitative techniques ensure neither more
nor less validity than the explicit process of negotiation typically used in qualitative
research.
The principal investigators will each initially detail and evaluate every study
using the guides in Figures 1 to 3 and then compare the results for each study. This
will allow us to develop these guides further, to negotiate areas of disagreement,
and to discern the reasons for our agreement about the detail and quality of studies.
808
Hak and Bernts (1996) found that the research coders they observed never discussed the codes on which they agreedonly the ones over which they disagreed
thereby losing the opportunity to check whether there was consensus on the reasons for consensus. Our goal here is to arrive at a set of techniques for detailing and
evaluating qualitative studies that will reduce the likelihood of disagreement
among investigators. Depending on the outcome of this work (and the Expert Panel
work to be described below), it might be possible to develop coding tools for detailing the contents and evaluating the quality of qualitative studies that can be subjected to quantitative techniques for interrater reliability testing that will not invalidate these tools by oversimplification.
The two investigators will work together to analyze the findings of each study
for metasynthesis and negotiate the analytic strategies best suited to each study.
Once a set of strategies is negotiated, each investigator will apply it to each study,
and then they will compare the results. This process will be documented as part of
the audit trail. The goal here is to develop techniques for analyzing and combining
qualitative findings that will result in interpretations on which different investigators can comfortably agree. Although it is axiomatic in qualitative research that
interpretations of the same data will vary with each interpreter, qualitative
researchers agree that a valid interpretation is one that is discernibly based on data.
Accordingly, our validation work here will be directed toward developing techniques around which consensus can be comfortably achieved, as opposed to quantitatively established. A key component of the analytic documentation for this project
will be to describe the process and outcomes of negotiations around issues where
this kind of consensus was both easy and difficult to achieve.
A critical component of the negotiation of validity in this project is the use of the
Expert Panel. The expertise required for the proposed project includes qualitative
analytic and interpretive skills and substantive/clinical knowledge in womens
health and HIV/AIDS. We will draw on the six members of the Expert Panel previously described to evaluate our work. This will entail their judgments about the
overall conduct of the study and specific judgments about the metasynthesis protocol we will develop in the course of the project. Members will be convened in Chapel Hill 2 days each year of the project for group discussion of the work completed
to date. They will also be convened 1 additional time per year by teleconferencing
for 2 hours, and they will participate in ongoing communicationsin between
these on-site and distance meetingsvia a online discussion group and discussion
forum. These activities are designed to permit members to participate fully (in a
manner that is practical and respectful of their other work and personal obligations)
in evaluating the content validity, appropriateness, and utility of the guides we
develop, and the trustworthiness and utility of the metasynthesis of qualitative
findings about women with HIV/AIDS we create.
As described previously, once the principal investigators have reached consensus on the detailing and evaluation guides, each member of the Expert Panel will be
asked to apply them to a common set of at least five randomly selected studies: one
set for detailing and a second set for evaluating the quality of studies. We will mail
these studies and the instructions that we have developed to date to each member.
Members will also review the documentation of our progress in developing guides
to conduct the metasynthesis itself, in analyzing the findings from each study, and
in combining them across studies. In addition, they will evaluate the time it takes
and how easy it is to use the techniques we develop.
809
The members of the Expert Panel will evaluate all of the various products of this
project using an adaptation of the questions Hunt and McKibbon (1997) developed
to appraise systematic reviews. These will be further developed in the course of the
project. The questions are (a) Did the metasynthesis focus on clearly defined areas?
(b) Is it likely that important, relevant studies were missed? (c) Were the inclusion
criteria used to select studies appropriate? (d) Was the quality appraisal of each
study included? (e) Were the various guides developed in the project appropriate
and easy to use? (f) Are the synthesis products plausible, usable, and significant for
research and/or practice?
In addition to the members of the Expert Panel, we will invite, in the final year
of the project, at least three clinicians (yet to be named) in HIV practice and three
researchers (yet to be named) experienced in conducting instrument development
and/or intervention studies in the HIV field to review the final metasynthesis products for their utility and applicability to their work. The clinicians will review a form
of the metasynthesis product oriented toward application of findings in practice,
and the researchers will review a form of the product oriented toward serving as a
basis for theory-based instrument and intervention research.
Protocol Application to Additional HIV and Test Cases

As a final validation technique, we will apply the entire protocol developed from
using research with women with HIV/AIDS as the method case to (a) qualitative
studies on women with HIV/AIDS published after March 2003, the temporal end
point for the method case, to March 2004, 1 year before the end of the project, and to
(b) a set of qualitative studies in an entirely different domain: namely, womens and
couples experiences with diagnostic/screening technology in pregnancy. Like
HIV/AIDS this is a knowledge field of great significance to the health of childbearing
families and nursing practice, and it is an area of expertise of one of the co-principal
investigators. Researchers interested in conducting qualitative metasynthesis projects will choose areas of research to which they are heavily committed and in which
they have clinical and/or research expertise.
The application of the protocol to the additional HIV/AIDS studies will ensure
as up-to-date a metasynthesis as possible and will allow us to fine-tune the protocol.
The application of this fine-tuned protocol to the test case (research on prenatal
testing) will allow us to evaluate the transferability of the protocol to other areas of
research. We will not only report the results of this metasynthesis effort but also document the process of applying the protocol, including any problems. The Expert
Panel members will review this report, with a special view toward evaluating the
clarity, fit, and trustworthiness of the procedures used.
Outcomes of the Proposed Project

The outcomes of the proposed project include (a) a guide to detail the informational
contents, methodological orientation, and re-presentational form of any qualitative
study; (b) a guide, or set of guides, to evaluate the quality of any qualitative study;
(c) a set of guidelines for choosing and using analytic techniques to discern the findings of any qualitative study; (d) a set of guidelines for choosing and using analytic
techniques to compare and combine findings across qualitative studies; (e) a set of
guidelines for choosing and using audience-appropriate representational forms to
810
Task
Literature retrieval
Development of techniques for detailing
and evaluating studies in method case
Development of techniques for
conducting and creating the metasynthesis
with studies in method case
Literature retrieval of additional HIV and
test case studies
Application of complete metasynthesis
protocol to additional HIV studies
Application of fine-tuned metasynthesis
protocol to test case studies
Consultation/peer review and evaluation
FIGURE 4:
Year
3
Study Time Line
disseminate the findings from qualitative metasynthesis projects; (f) an up-to-date

metasynthesis of qualitative studies on women with HIV/AIDS; and (g) an up-todate metasynthesis of qualitative studies on couples undergoing prenatal testing.
Here, we summarized the likely products of the proposed study to ensure that reviewers
would see its significance.
Time Line
Figure 4 shows the time line for the proposed project.
Gender and Minority Inclusion

By virtue of the method case chosen, women, and minority women in particular, are
included. In the 22 studies located to date, 532 women participated. Of these, 249
were African American, 151 were White, 76 were Hispanic/Latina, and 16 belonged
to other ethnic/racial minorities. (Ethnicity was not reported in 3 of these studies.)
These women ranged in age from 16 to 63 years. (One study did not report age.) Of
these women, 133 had less than a high school education. (Eight studies did not
report education level.) In the 5 studies reporting income, average yearly incomes
ranged from U.S. $8,355 to $12,500. From studies providing information on children, we determined that 314 women were mothers. Even though no human subjects
are included in the proposed project, we calculated the gender and minority attributes of the
proposed bibliographic sample. This move showed not only our recognition of the importance
of inclusion in research but also the underrepresented gender and minority signature of the
method case we selected.
Human Subjects
There are no human subjects in this research per se, although the project involves
the study of human subjects research.
811
Vertebrate Animals
There are no vertebrate animals in this study.
Literature Cited (Current as of 1999)

Altheide, D. L. (1987). Ethnographic content analysis. Qualitative Sociology, 10, 65-67.
Annells, M. (1996). Grounded theory method: Philosophical perspectives, paradigm of inquiry, and
postmodernism. Qualitative Health Research, 6, 379-393.
Arras, J. D. (1990). HIV and childbearing, 2: AIDS and reproductive decisionsHaving children in fear
and trembling. Milbank Quarterly, 68, 353-382.
Barkin, S. E., Melnick, S. L., Preston-Martin, S., Weber, K., Kalish, L. A., Miotti, P., et al. (1998). The
Womens Interagency HIV Study. Epidemiology, 9, 117-125.
Barroso, J., & Powell-Cope, G. M. (2000). Meta-synthesis of qualitative research on living with HIV infection. Qualitative Health Research, 10, 340-353.
Bausell, R. B., Li, Y.-F., Gau, M.-L., & Soeken, K. L. (1995). The growth of meta-analytic literature from
1980-1993. Evaluation & the Health Professions, 18, 238-251.
Bedimo, A. L., Bennett, M., Kissinger, P., & Clark, R. A. (1998). Understanding barriers to condom usage
among HIV-infected African American women. Journal of the Association of Nurses in AIDS Care, 9,
48-58.
Bedimo, A. L., Bessinger, R., & Kissinger, P. (1998). Reproductive choices among HIV-positive women.
Social Science & Medicine, 46, 171-179.
Belgrave, L. L., & Smith, K. J. (1995). Negotiated validity in collaborative ethnography. Qualitative
Inquiry, 1, 69-86.
Burger, H., & Weiser, B. (1997). Biology of HIV-1 in women and men. Obstetrics and Gynecology Clinics of
North America, 24, 731-742.
Burns, N. (1989). Standards for qualitative research. Nursing Science Quarterly, 2, 44-52.
Centers for Disease Control and Prevention. (1999). CDC AIDS InformationStatistics. Retrieved April
10, 1999, from http://www.cdc.gov/nchstp/hiv_aids/pubs/facts.htm
Chalmers, I. (1993). The Cochrane Collaboration: Preparing, maintaining, and disseminating systematic
reviews of the effects of health care. Annals of the New York Academy of Sciences, 703, 156-165.
Charmaz, K. (1990). Discovering chronic illness: Using grounded theory. Social Science & Medicine, 30,
1161-1172.
Cieutat, V. J., Krimerman, L. I., & Elder, S. T. (1969). Traditional logic and the Venn diagram. San Francisco:
Chandler.
Cohen, M. (1997). Natural history of HIV infection in women. Obstetrics and Gynecology Clinics of North
America, 24, 743-758.
Cohen, M. Z., & Saunders, J. M. (1996). Using qualitative research in advanced practice. Advanced Practice
Nursing Quarterly, 2, 8-13.
Colyer, H., & Kamath, P. (1999). Evidence-based practiceA philosophical and political analysis: Some
matters for consideration by professional practitioners. Journal of Advanced Nursing, 29, 188-193.
Cook, T. D., Cooper, H., Cordray, D. S., Hartmann, H., Hedges, L. V., Light, R. J., et al. (Eds.). (1992). Metaanalysis for explanation. New York: Russell Sage Foundation.
Cook, D. J., Mulrow, C. D., & Haynes, R. B. (1997). Systematic reviews: Synthesis of best evidence for clinical decisions. Annals of Internal Medicine, 126, 376-380.
Cooper, H. M. (1982). Scientific guidelines for conducting integrative research reviews. Review of Educational Research, 52, 291-302.
Cooper, H. M. (1989). Integrating research: A guide for literature reviews (2nd ed.). Newbury Park, CA: Sage.
Cooper, H., & Hedges, L. V. (Eds.). (1994). The handbook of research synthesis. New York: Russell Sage
Foundation.
Corbin, J., & Strauss, A. (1990). Grounded theory research: Procedures, canons, and evaluative criteria.
Qualitative Sociology, 13, 3-21.
Davis, D. S. (1991). Rich cases: The ethics of thick description. Hastings Center Report, 21(4), 12-17.
Diers, D. (1995). Clinical scholarship. Journal of Professional Nursing, 11, 24-30.
Eisner, E. W. (1991). The enlightened eye: Qualitative inquiry and the enhancement of educational practice. New
York: Macmillan.
812
Emden, C., & Sandelowski, M. (1998). The good, the bad, and the relative, Part 1: Conceptions of goodness in qualitative research. International Journal of Nursing Practice, 4, 206-212.
Engel, J. D., & Kuzel, A. J. (1992). On the idea of what constitutes good qualitative inquiry. Qualitative
Health Research, 2, 504-510.
Estabrooks, C. A. (1997). What kind of evidence does qualitative research offer cardiovascular nurses?
Canadian Journal of Cardiovascular Nursing, 8, 31-34.
Estabrooks, C. A. (1999). Will evidence-based nursing practice make practice perfect? Canadian Journal of
Nursing Research, 30, 273-294.
Estabrooks, C. A., Field, P. A., & Morse, J. M. (1994). Aggregating qualitative findings: An approach to
theory development. Qualitative Health Research, 4, 503-511.
Farzadegan, H., Hoover, D. R., Astemborski, J., Lyles, C. M., Margolick, J. B., Markham, R. B., et al. (1998).
Sex differences in HIV-1 viral load and progression to AIDS. Lancet, 352(9139), 1510-1514.
Fawcett, J. (1999). Preparing integrative reviews of research findings. In J. Fawcett & F. S. Downs, The relationship of theory and research (2nd ed., pp. 119-142). Philadelphia: F. A. Davis.
Field, P. A., & Marck, T. (1994). Uncertain motherhood: Negotiating risk in the childbearing years. Thousand
Oaks, CA: Sage.
Fogel, C. I., & Woods, N. F. (Eds.). (1995). Womens health care: A comprehensive handbook. Thousand Oaks,
CA: Sage.
Fonteyn, M. E., Kuipers, B., & Grobe, S. J. (1993). A description of think aloud method and protocol analysis. Qualitative Health Research, 3, 430-441.
Fowler, M. G., Melnick, S. L., & Mathieson, B. J. (1997). Women and HIV: Epidemiology and global overview. Obstetrics and Gynecology Clinics of North America, 4, 705-729.
French, P. (1999). The development of evidence-based nursing. Journal of Advanced Nursing, 29, 72-78.
Funk, S. G., Tornquist, E. M., & Champagne, M. T. (1995). Barriers and facilitators of research utilization.
Nursing Clinics of North America, 30(3), 395-407.
Garratt, D., & Hodkinson, P. (1998). Can there be criteria for selecting research criteria? A hermeneutical
analysis of an inescapable dilemma. Qualitative Inquiry, 4, 515-539.
Gaskins, S. W. (1997). Heterosexual transmission of HIV in women. Journal of the Association of Nurses in
AIDS Care, 8, 84-87.
Glaser, B. G., & Strauss, A. L. (1971). Status passage. Chicago: Aldine.
Glass, G. V (1976). Primary, secondary, and meta-analysis of research. Educational Researcher, 5, 3-8.
Glass, G. V, McGaw, B., & Smith, M. L. (1981). Meta-analysis in social research. Beverly Hills, CA: Sage.
Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K. Denzin & Y. S.
Lincoln (Eds.), Handbook of qualitative research (pp. 105-117). Thousand Oaks, CA: Sage.
Gusfield, J. (1976). The literary rhetoric of science: Comedy and pathos in drinking driver research. American Sociological Review, 41, 16-34.
Hak, T., & Bernts, T. (1996). Coder training: Theoretical training or practical socialization? Qualitative
Sociology, 19, 235-257.
Harding, S. (1991). Whose science? Whose knowledge? Thinking from womens lives. Ithaca, NY: Cornell University Press.
Harrison, L. L. (1996). Pulling it all together: The importance of integrative research reviews and metaanalyses in nursing [Editorial]. Journal of Advanced Nursing, 24, 224-225.
Heron, J. (1996). Quality as primacy of the practical. Qualitative Inquiry, 2, 41-56.
Hunt, D. L., & McKibbon, K. A. (1997). Locating and appraising systematic reviews. Annals of Internal
Medicine, 126, 532-538.
Hutchinson, S. A., Wilson, M. E., & Wilson, H. S. (1994). Benefits of participating in research interviews.
Image: Journal of Nursing Scholarship, 26, 161-164.
Jensen, L. A., & Allen, M. N. (1994). A synthesis of qualitative research on wellness-illness. Qualitative
Health Research, 4, 349-369.
Jensen, L. A., & Allen, M. N. (1996). Meta-synthesis of qualitative findings. Qualitative Health Research, 6,
553-560.
Kavale, K. A. (1995). Meta-analysis at 20: Retrospect and prospect. Evaluation & the Health Professions, 18,
349-369.
Kearney, M. H. (1998a). Ready-to-wear: Discovering grounded formal theory. Research in Nursing &
Health, 21, 179-186.
Kearney, M. H. (1998b). Truthful self-nurturing: A grounded formal theory of womens addiction recovery. Qualitative Health Research, 8, 495-512.
Klirsfeld, D. (1998). HIV disease and women. Medical Clinics of North America, 82, 335-357.
813
Kvale, S. (1995). The social construction of validity. Qualitative Inquiry, 1, 19-40.

Leenerts, M. H. (1998). Barriers to self-care in a cohort of low-income White women living with HIV/
AIDS. Journal of the Association of Nurses in AIDS Care, 9, 22-36.
Levine, C., & Dubler, N. N. (1990). HIV and childbearing 1: Uncertain risks and bitter realitiesThe
reproductive choices of HIV-infected women. Milbank Quarterly, 68, 321-351.
Light, R. J., & Pillemer, D. B. (1984). Summing up: The science of reviewing research. Cambridge, MA: Harvard University Press.
Lincoln, Y. S. (1995). Emerging criteria for quality in qualitative and interpretive research. Qualitative
Inquiry, 1, 275-289.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
Lincoln, Y. S., & Reason, P. (Eds.). (1996). Quality in human inquiry [Special issue]. Qualitative Inquiry,
2(1).
Lipsey, M. W. (1990). Design sensitivity: Statistical power for experimental research. Newbury Park, CA: Sage.
Lynch, M. (1985). Discipline and the material form of images: An analysis of scientific visibility. Social
Studies of Science, 15, 37-66.
Lynch, M., & Woolgar, S. (Eds.). (1990). Representation in scientific practice. Boston: MIT Press.
Lynn, M. R. (1989). Meta-analysis: Appropriate tool for the integration of nursing research? Nursing
Research, 38, 302-305.
Martin, E. (1990). Toward an anthropology of immunology: The body as nation state. Medical Anthropology Quarterly, 4, 410-426.
Maxwell, J. A. (1992). Understanding and validity in qualitative research. Harvard Educational Review, 62,
279-300.
May, K. A. (1994). Abstract knowing: The case for magic in method. In J. M. Morse (Ed.), Critical issues in
qualitative research methods (pp. 10-21). Thousand Oaks, CA: Sage.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage.
Mishler, E. G. (1986). Research interviewing: Context and narrative. Cambridge, MA: Harvard University
Press.
Moore, L. J., & Clarke, A. E. (1995). Clitoral conventions and transgressions: Graphic representations in
anatomy texts, c1900-1991. Feminist Studies, 21, 255-301.
Morgan, D. L. (1993). Qualitative content analysis: A guide to paths not taken. Qualitative Health Research,
3, 112-121.
Morse, J. M. (1994). On the crest of a wave? [Editorial]. Qualitative Health Research, 4, 139-141.
Morse, J. M. (1996). Is qualitative research complete? [Editorial]. Qualitative Health Research, 6, 3-5.
Morse, J. M. (1997a). Responding to threats to integrity of self. Advances in Nursing Science, 19, 21-36.
Morse, J. M. (1997b). Perfectly healthy, but dead: The myth of inter-rater reliability. Qualitative Health
Research, 7, 445-447.
Morse, J. M., & Johnson, J. L. (1991). Toward a theory of illness: The illness-constellation model. In J. M.
Morse & J. L. Johnson (Eds.), The illness experience: Dimensions of suffering (pp. 315-341). Newbury
Park, CA: Sage.
Mulrow, C., Langhorne, P., & Grimshaw, J. (1997). Integrating heterogeneous pieces of evidence in systematic reviews. Annals of Internal Medicine, 127, 989-995.
Noblit, G. W. (1984). The prospects of an applied ethnography for education: A sociology of knowledge
interpretation. Educational Evaluation and Policy Analysis, 6, 95-101.
Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Synthesizing qualitative studies. Newbury Park, CA:
Sage.
Paterson, B. L., Thorne, S., & Dewis, M. (1998). Adapting to and managing diabetes. Image: Journal of
Nursing Scholarship, 30, 57-62.
Popay, J., Rogers, A., & Williams, G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative Health Research, 8, 341-351.
Raveis, V. H., Siegel, K., & Gorey, E. (1998). Factors associated with HIV-infected womens delay in seeking medical care. AIDS Care, 10, 549-562.
Riessman, C. K. (1993). Narrative analysis. Newbury Park, CA: Sage.
Rodgers, B. L., & Cowles, K. V. (1993). The qualitative research audit trail: A complex collection of documentation. Research in Nursing and Health, 16, 219-226.
Russell, J. M., & Smith, K. (1998). HIV infected women and womens services. Health Care for Women International, 19, 131-139.
814
Sandelowski, M. (1993). With child in mind: Studies of the personal encounter with infertility. Philadelphia:
University of Pennsylvania Press.
Sandelowski, M. (1995). A theory of the transition to parenthood of infertile couples. Research in Nursing
and Health, 18, 123-132.
Sandelowski, M. (1996). One is the liveliest number: The case orientation of qualitative research. Research
in Nursing & Health, 19, 525-529.
Sandelowski, M. (1997). To be of use: Enhancing the utility of qualitative research. Nursing Outlook, 45,
125-132.
Sandelowski, M., Docherty, S., & Emden, C. (1997). Qualitative metasynthesis: Issues and techniques.
Research in Nursing & Health, 20, 365-371.
Schofield, J. W. (1990). Increasing the generalizability of qualitative research. In E. W. Eisner & A. Peshkin
(Eds.), Qualitative inquiry in education: The continuing debate (pp. 201-232). New York: Teachers College Press.
Schrieber, R., Crooks, D., & Stern, P. N. (1997). Qualitative meta-analysis. In J. M. Morse (Ed.), Completing
a qualitative project (pp. 311-326). Thousand Oaks, CA: Sage.
Schwandt, T. A. (1996). Farewell to criteriology. Qualitative Inquiry, 2, 72.
Sherwood, G. D. (1997). Metasynthesis of qualitative analyses of caring: Defining a therapeutic model of
nursing. Advanced Practice Nursing Quarterly, 3, 32-42.
Sidani, S., & Braden, C. J. (1998). Evaluating nursing interventions: A theory-driven approach. Thousand
Oaks, CA: Sage.
Slavin, R. E. (1995). Best evidence synthesis: An intelligent alternative to meta-analysis. Journal of Clinical
Epidemiology, 48, 9-18.
Smeltzer, S. C., & Whipple, B. (1991). Women and HIV infection. Image: Journal of Nursing Scholarship, 23,
249-256.
Smith, M. C., & Stullenbarger, E. (1991). A prototype for integrative review and meta-analysis of nursing
research. Journal of Advanced Nursing, 16, 1272-1283.
Sowell, R. L., Moneyham, L., & Aranda-Naranjo, B. (1999). The care of women with AIDS: Special needs
and considerations. Nursing Clinics of North America, 34, 179-199.
Spradley, J. (1980). Participant observation. New York: Holt, Rinehart & Winston.
Stein, M. D., & Hanna, L. (1997). Use of mental health services by HIV-infected women. Journal of Womens
Health, 6, 569-574.
Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques.
Newbury Park, CA: Sage.
Swanson, J. M., Durham, R. F., & Albright, J. (1997). Clinical utilization/application of qualitative
research. In J. M. Morse (Ed.), Completing a qualitative project (pp. 253-281). Thousand Oaks, CA:
Sage.
Thorne, S. (1997). The art (and science) of critiquing qualitative research. In J. M. Morse (Ed.), Completing a
qualitative project (pp. 117-132). Thousand Oaks, CA: Sage.
Van Maanen, J. (1988). Tales of the field: On writing ethnography. Chicago: University of Chicago Press.
van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Albany:
State University of New York Press.
Walmsley, S. (1998). The new antiretroviral cocktails: Is the stage set for women to benefit? Canadian
Medical Association Journal, 158(3), 339-341.
Wolf, F. M. (1986). Meta-analysis: Quantitative methods for research synthesis. Beverly Hills, CA: Sage.
Zhao, S. (1991). Metatheory, metamethod, meta-data-analysis: What, why, and how? Sociological Perspectives, 34, 377-390.
REVISING AND RESUBMITTING

This proposal was funded after one previous submission. Because any writing
enterprise typically requires revision and resubmission, writers are well advised to
develop their skills in these areas, which include emotion and information management.
The most typical initial responses to having a research proposal not approved
for funding are sadness, frustration, and anger, with researchers choosing to
815
withdraw or confront. Although researchers are entitled to these emotions, their

response to the agency denying them funding should never be informed by them.
Indeed, after a cooling down period, they will likely see that the reviews of their
study were not as bad as they appeared on the first reading. Indeed, researchers
reading their reviews will often findin true qualitative fashionthat no more
than three themes sum up the negative critiques. Once researchers have ascertained this, the task of revising will seem, and actually be, less onerous.
For example, from the reviews our original proposal received, we ascertained
that one reviewer liked it, two reviewers liked it but were dubious we could overcome the barriers to integrating qualitative studies, and one reviewer disliked it.
Our comments and revisions were thus primarily oriented toward emphasizing the
positive views, overcoming the doubt the two reviewers expressed, and specifically
addressing the comments of the reviewer who expressed the most negative opinions. What follows is the full text of our response (with our annotations in italics),
which was placed before the section on aims in the revised proposal.
Our Response to the Initial Review

This introduction contains our response to the summary statement concerning
application RO1 NRO4907, Analytic techniques for qualitative metasynthesis. In
it, we summarize the strengths and problems noted in each of the four critiques and
the revisions we made to resolve the problems.
All of the reviewers evaluated the proposed study highly on its significance and
novelty, the strong qualifications of the research team, and the excellent resources
available to the study. Reviewer 2 (Critique 2) evaluated this proposal as outstanding and as having exceptionally high scientific merit. He or she supported it
at the highest level of enthusiasm, (p. 6), stating that the findings of the proposed
study could revolutionize the place of qualitative research in the advancement of
our knowledge base (p. 4). Reviewer 3 found the proposal highly significant and
innovative, and likely to make a major contribution to nursing science (p. 7) if
existing barriers to qualitative metasynthesis could be overcome. Reviewer 1 similarly expressed enthusiasm, and Reviewer 4 noted its potential significance
(p. 9). We begin by emphasizing the positive.
Yet, although Reviewer 2 observed that our study could move nursing science
forward by a giant leap (p. 5), Reviewer 3 found that our proposal demanded a
certain leap of faith about (its) feasibility (p. 7). Reviewer 3 was also concerned
that the proposed study was extremely ambitious (p. 6). Reviewer 1 expressed a
similar skepticism (p. 4) concerning the outcome of the proposed study. Although
Reviewer 2 found our proposal to be very user friendly, comprehensive, and
thoughtfully conceived, Reviewer 4 expressed concerns about the literature review,
representation of arguments, and design. In the preceding paragraph, we played reviewers comments off each other to emphasize contradictory opinions.
In summary, Reviewer 2 was enthusiastic about the proposal and suggested no
changes. He or she noted that our approach, expertise, and ability to communicate
ideas effectively convey(ed) a strong sense of confidence in the likelihood of success of the proposed project (p. 5). For Reviewers 1 and 3, the essential problem to
be resolved was largely a matter of a leap of faith, as opposed to substance. They
suggested that we had the qualifications to complete the proposed project
816
successfully but still had doubts concerning whether qualitative metasynthesis was
feasible at all. Reviewer 4 itemized what he or she believed to be substantive omissions and errors. In the preceding paragraph, we summarized what we saw to be the
themes across all four reviews. This set the stage for the revisions we would describe.
We now focus on specific issues raised in Critiques 1, 3, and 4. We addressed the
problem of ambition by adding one more year to the study. Although Reviewer 3
suggested omitting the testing of the metasynthesis protocol we will develop with a
group of studies on prenatal testing, we think this validation exercise is critical to
any claims we will want to make about the credibility, feasibility, and utility of that
protocol. Adding a year to the study will permit us more time to accomplish this
critical step. It will also address the lack of time Reviewer 4 noted for achieving
negotiated validity. We have added more distance and face-to-face meeting times
among the members of the research team in each year of the study to increase their
involvement.
Critique 1
This reviewer stated that we believed conducting qualitative metasynthesis was
more pressing than quantitative metasynthesis. Although we neither made nor
implied this claim in the original proposal, we did state that qualitative
metasynthesis ought to be subject to as much interest and effort as has been shown
in quantitative research integration. In the preceding statement, we specifically countered this reviewers reading. Responding to reviewer comments does not necessarily mean
accepting everything reviewers say. Our reference to 1,000 qualitative health studies
was simply to show that there exist more than enough studies to warrant such interest. This reviewer also stated that we spent too much time justifying qualitative
research. We agree with the reviewer that qualitative research requires no defense.
What we did in the original proposal was to justify the significance of efforts to conduct qualitative metasyntheses and to describe the problems they raise by virtue of
the nature of qualitative research. Here, we again countered a reading by deriving an area
of agreement from a comment with which we frankly disagreed. Reviewer 2 found very
convincing (p. 4) the case we made for why qualitative research has still not been
wholly accepted as real research. Reviewer 1 stated both that we had no explicit
aims and that our aims were explicitly focused on resolving the problems qualitative metasynthesis raises. Here, we featured what we perceived to be between- and intrareviewer contradiction. Our aim for the study, and the individual steps we will take to
accomplish it, are stated on p. 36 and pp. 36-37. Whenever referring to specific revisions,
writers should give the page numbers where reviewers will find them. The purposes of
every design feature are stated in the relevant method section. Our aims are stated
to capture the problem-solving orientation of our approach to developing a process,
namely, conducting qualitative metasyntheses.
We have eliminated the reference to correcting scanned texts, as it seemed to be
misleading. What we were referring to here was that scanning technology fails to
retrieve every word of the texts it scans and that we would add those words to have
a correct copy. The reviewer also described a potential problem in detailing studies,
namely, whether two reviewers would identify the same results from one study.
This is one of the many problems associated with understanding and evaluating
qualitative research that we will explore and hope to resolve in the proposed study.
We have clarified this on p. 49 of the revised proposal.
817
Critique 3
This reviewer affirmed that qualitative research designs are emergent and acknowledged that we had likely done the best anyone could in explicating our strategies
but still seemed hesitant. Accordingly, we have added some material to the design
section to further explicate our plans without violating the design-by-doing tenet
of qualitative research. We believe, though, that any studyqualitative or quantitativerequires a leap of faith about its techniques and promises.
Critique 4
This reviewer stated that we did not adequately review the literature. We cited
Morse s qualitative metasynthesis workwhich this reviewer stated we had not
and we found no research integrations of the kind addressed in our proposal by
(specific name of a nationally known scholar mentioned by this reviewer) or anyone else
not cited in the proposal. In a personal e-mail communication, (this scholar) stated
she doubted whether anything she had done could be categorized as qualitative
metasynthesis unless we widened the definition of that term to include conventional narrative reviews of the literature or broad overviews of a field. Indeed, we
suspect that the problem here lies in the reviewers holding a more expansive view
of metasynthesis than we do. Looking back, we now believe that a better way to convey
this idea would have been to state that we had not sufficiently clarified our focus rather than
transferring the obligation to understand our focus to the reviewer. The use of the first person
conveys the assumption of the burden of agency: the researcheras opposed to the
reviewerdoing or not doing something he or she should have. Even though reviewers have
obligations to be careful and informed readers, the greater burden is on writers to inform
clearly. Accordingly, we have added material further defining qualitative
metasynthesis for this study. We state on p. 36 that qualitative metasynthesis refers
to the synthesis of findings in completed qualitative studies. Qualitative
metasynthesis constitutes a kind of data-based research that is analogous to quantitative meta-analysis in its intent systematically to put together or sum up findings in a specific domain of scientific research.
This reviewer also stated that we were taking a demonstrably nonfruitful
approach to metasynthesis and that we misrepresented the Noblit and Hare work.
We have checked all our references, and they were accurate in word and meaning in
the original proposal. Nevertheless, we have significantly revised our presentation
of the Noblit and Hare work on pp. 39-40. We were countering this reviewers opinion
but nevertheless making changes based on it. Moreover, in this revision, we have specifically addressed these authors views of aggregation as an inadequate approach to
metasynthesis. We have not committed ourselves to any one approach in the proposed study as our plan is to experiment with different approaches to
metasynthesis. Noblit and Hare found aggregation to be inadequate for the very
specialized kind of ethnographic work in which they were engaged. Such an
approach might not be inadequate for other kinds of studies. Although the Noblit
and Hare work is considered a key work in a methodological domain (namely, qualitative metasynthesis), that domain has yet to be developed. Their work cannot be
held as the gold standard against which all other approaches to qualitative
818
metasynthesis in other fields of research are judged. Our aim in the proposed project is to contribute to the development of this methodological domain.
We disagree with the reviewer that the Barroso and Powell-Cope (2000) synthesis featured in the preliminary studies section does not advance the science. Since
the original proposal was submitted, this work was accepted for publication in a
peer review journal, indicating its value for dissemination. Moreover, not only do
the findings enlarge our understanding of having HIV/AIDS and suggest new strategies for caring for persons with HIV/AIDS, the very act of conducting this study
dramatized the problems that must still be resolved in qualitative research integrations. We have added material to the preliminary studies section on p. 44 to support
our view of its contribution.
This reviewer stated that we were unclear about the criteria we will use to
include studies. One of the major objectives of the proposed project is to specify
these criteria further. As we state on p. 46, the proposed project is about developing
a process to conduct a process. Moreover, contrary to this reviewers observation,
we have already done the preliminary work (described in the proposal) to specify
both the criteria we tentatively plan to use and the problems that must be resolved
to further specify them. Reviewer 3 found a strength of our approach to be that it
was based on tested experience (p. 7), that is, that we had each completed and
reported our preliminary metasynthesis work. Here, again, we use other reviewers
comments to support our view.
Reviewer 4 also stated that it was not necessary to detail each study to the extent
that we will, and justifies this claim by saying that no one else has done that. We
believe that it is essential to do this, in part because no one else appears to have done
it. Moreover, no reader can safely infer from the few other metasyntheses done how
detailed their authors examinations of studies were as they did not provide much
information in their publications on that subject. We cited this lack of information as
a problem that had yet to be resolved. In addition, we emphasized in the original
proposal the need to resolve persistent dilemmas in understanding and evaluating
qualitative studies that can be resolved only by this attention to detail. We believe
that it is only by this laborious detail that we can arrive at a credible and less laborious protocol for conducting qualitative metasyntheses that will preserve only that
detail work necessary to do them. Our aim is to provide a user-friendly protocol.
However, to achieve that goal, we must do the detail work that will allow us to say
with confidence what details can be excluded in the future. For example, our preliminary work suggests that the stated method in a study might be a detail that is not
relevant to evaluating the quality of a study or to creating credible metasyntheses.
We have added material to the design section on p. 50 to clarify the detail issue.
All of the members of the Expert Panel named in the original proposal have
again consented to participate in this study after receiving a summary of the proposed study, including its aims and methods.
In summary, we have revised this proposal to address the issues raised by
reviewers and to update information. These revisions are in italics (not shown here).
As most of these issues related to sections A to C (Specific Aims, Background and Significance, and Preliminary Studies), most of the revisions are in these sections. We
appreciate the dilemma some reviewers face in encountering what they recognize
to be a project well worth doing but that they suspect cannot be done. In our revised
submission, we sought to clarify further the process we propose to engage in to
develop a process for engaging in a process. We hope the explanations we have
819
offered here and the revisions we have made to the proposal itself, in combination
with the potential contribution this study could make, will encourage reviewers to
take a leap of faith.
REMEMBER THE SCIENCE, PRIVILEGE THE ART

In summary, appealing qualitative research proposals are exercises in artful
design (Sandelowski, Davis, & Harris, 1989), reflexivity, elegant expression, imaginative rehearsal, and strategic disarmament. Key targets of disarmament are
small sample sizes and the generalizability and validity of methods and outcomes. Winning qualitative proposals should convey the researchers talent for
conceptualizing, synthesizing, imagining, and writing, and the ability to perform
the kind of work promised. The grounded theory proposal should show the
researchers ability to theorize; the phenomenological proposal, to engage in
phenomenological reflection; and the ethnographic proposal, to interpret culture.
The qualitative research proposal should communicate the researchers knowledge
of the field and method, and convey the emergent nature of qualitative design by
the use of words such as tentative, anticipate, project, and plan. The proposal should
follow a discernible logic in the introduction to the proposed study (aim problem
significance of problem aims detailed with objectives research outcome significance of outcome); in the review of literature (e.g., a gap, error, contradiction, or other logic);
and in the description of design (tell show tell, or define apply illustrate).
The qualitative research proposal should offer an explanation for every design
choice and disarm the reviewer in favor of the design choices made, especially in
cases where reviewers are likely to expect a different choice. This means that writers
must know, and show respect for, the audience to whom they want their proposals
to appeal. They should defend their choices without being offensive (e.g., by implying that qualitative research is superior to other methods or by describing the failures of other researchers or research methods) or defensive (e.g., by unnecessarily
defending qualitative research when it needs no defense). Indeed, qualitative
research proposals should not contain apologies for qualitative research, as it
requires none. Accordingly, any limitations to their proposed study writers discuss
ought not to convey that qualitative research is itself a limitation. Instead, discussions of limitations ought to be confined to the distinctive features of the study itself.
For example, a limitation of a grounded theory study might be the inability to conduct theoretical sampling, not the fact of theoretical sampling or its mode of generalizing per se.
Although reviewers are obliged to demonstrate connoisseurship in reading
and criticism, the greater burden is on writers of qualitative research proposals to
convey their research intentions. Writers should become skilled in the use not only
of words but also of numbers and visual displays to communicate more effectively
and thereby also to reduce reader burden. Other techniques to reduce reader burden and enhance clarity include strategic nonrepetitious reiteration and location of
material and section headers that capture the central theme of the material included
in those sections. Although the naming of methods and techniques is important,
name dropping should never substitute for a clear description of how researchers
will apply the techniques named. Recitations on Heideggerian hermeneutics or
symbolic interactionism are not informative if researchers do not address how these
820
mind-sets influenced the design and will influence the execution and findings of the
study. Rote descriptions of theories of and techniques for maximizing validity in
qualitative research are not informative if researchers do not show how they will be
applied to and operate in the proposed study.
Successful qualitative research proposals in the practice disciplines appeal as
science and art. They embody the attention to communicable procedure expected in
the sciences and the creativity and expression associated with the arts.
NOTES
1. Material was used in the proposal that originally appeared in Sandelowski, Docherty, and
Emden (1997).
2. For current information about the Healthy People initiative, see http://www.health.gov/
healthypeople (retrieved May 1, 2003).
3. Devices and Desires: Gender, Technology, and American Nursing was published in 2000 by the University of North Carolina Press, Chapel Hill.
REFERENCES
Sandelowski, M., & Barroso, J. (2002). Reading qualitative studies. International Journal of Qualitative
Methods, 1(1), Article 5. Retrieved March 24, 2003, from http://www.ualberta.ca/~ijqm/english/
engframeset.html
Sandelowski, M., Davis, D. H., & Harris, B. G. (1989). Artful design: Writing the proposal for research in
the naturalist paradigm. Research in Nursing and Health, 12, 77-84.
Sandelowski, M., Docherty, S., & Emden, C. (1997). Qualitative metasynthesis: Issues and techniques.
Research in Nursing & Health, 20, 365-371.
Margarete Sandelowski, Ph.D., R.N., F.A.A.N., is Cary C. Boshamer Professor of Nursing at the University of North Carolina at Chapel Hill.
Julie Barroso, Ph.D., A.N.P., C.S., is an assistant professor of nursing at the University of North
Carolina at Chapel Hill.

Writing The Proposal For A Qualitative Research Methodology Project

Uploaded by

Copyright:

Available Formats

Writing The Proposal For A Qualitative Research Methodology Project

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Writing The Proposal For A Qualitative Research Methodology Project

Uploaded by

Copyright:

Available Formats

ARTICLE

Writing the Proposal for a Qualitative Research

QUALITATIVE HEALTH RESEARCH / July 2003

THE PROPOSAL: ANALYTIC TECHNIQUES

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Background and Significance

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Examples of Qualitative Metasyntheses

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

research report, which might be influenced by limitations in the research enterprise

QUALITATIVE HEALTH RESEARCH / July 2003

Women With HIV/AIDS as a Method Case

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Significance for Research and Practice

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Bibliographic Retrieval for the Proposed Project

Expertise of the Research Team

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Research Design and Methods

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

Defining the Limits of the Study

QUALITATIVE HEALTH RESEARCH / July 2003

friends, and/or caregivers of seropositive persons; and (c) qualitative adjuncts

Detailing the Studies

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

Topical Guide for Detailing Studies

QUALITATIVE HEALTH RESEARCH / July 2003

written presentation of qualitative research. Our goal is to specify these conventions

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

Evaluating the Quality of Studies

QUALITATIVE HEALTH RESEARCH / July 2003

A Generic Guide for Evaluating the Overall Quality of Qualitative Studies

We will address the problem of quality by experimenting with and adapting

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

A Guide for Evaluating Grounded Theory Studies

QUALITATIVE HEALTH RESEARCH / July 2003

Creating the Metasynthesis

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

comparison techniques to synthesize the disease management data, as Jensen and

QUALITATIVE HEALTH RESEARCH / July 2003

Procedures for Enhancing Study Validity

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

QUALITATIVE HEALTH RESEARCH / July 2003

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

Protocol Application to Additional HIV and Test Cases

Outcomes of the Proposed Project

QUALITATIVE HEALTH RESEARCH / July 2003

Study Time Line

disseminate the findings from qualitative metasynthesis projects; (f) an up-to-date

Gender and Minority Inclusion

Sandelowski, Barroso / WRITING A QUALITATIVE PROPOSAL

Literature Cited (Current as of 1999)