Writing the Proposal for a Qualitative Research Methodology Project

Qualitative Qualitative Health Research R esearch http://qhr.sagepub.com/ 

Writing the Proposal for a Qualitative Research Methodology Project Margarete Sandelowski and Julie Barroso Qual Health Res 2003 13: 781 DOI: 10.1177/1049732303013006003

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10.1177/1049732303255474 ARTICLE

QUALITATIVEHEAL Sandelowski,Barroso/WRITINGAQUALITATIVEPROPOSAL THRESEARCH/July2003

Writing the Proposal for a Qualitative Research Methodology Project Margarete Sandelowski Margarete  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 stu dy ent entail ailss des descri cribin bingg a pro proces cesss to pr produ oduce ce a pr proce ocess. ss. Howthe aut author horss add addre resse ssedd thi thiss cha challlenge len ge is sho shown wn in theannot theannotate atedd tex textt of the gra grant nt pr propo oposal sal—“A —“Anal nalyti yticc Tech echniq niques ues forQuali forQuali-tative Metasynthesis”—funded 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

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riting ritin g th thee pr propo oposa sall fo forr a qu qual alita itativ tivee stu study dy is a ch chal allen lenge ge be beca caus usee of th thee em emer er-gent nature of qualitative research design (Sandelowski, Davis, & Harris, 1989).Design 198 9).Designing ing stu studiesby diesby con conduc ductingthem— tingthem—as as oppo opposed sed to con conduc ductin ting g stu studiesby diesby design— desi gn—pro proposa posall wri writers ters can onl only y ant anticip icipate ate how the their ir stu studieswill dieswill pro procee ceed. d. Qua Qualilitative tat ive res resear earch ch pro proposa posals ls ar aree thu thuss exer exercis cises es in imag imagina inativ tivee reh rehear earsal. sal. Whe When n the pro pro-posed 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 me thodology study, study, process is outcome. In this article, we reproduce1 and annotate annotate (in italics) the text of a grant proposal—“Analytic Techniques for Qualitative Metasynthesis” —that we submitted in 199 19999 to the Nat Nationa ionall Ins Institu titute te of Nur Nursin sing g Rese Resear arch ch (NI (NINR) NR),, Nat Nationa ionall Ins Institu titutes tes of  Health (NIH). This project received a priority score of 110 (0.6 percentile) and was fund fu nded ed in Ju June ne 20 2000 00 to ru run n fo forr 5 ye year ars. s. Ou Ourr an anno nota tate ted d co comm mmen ents ts ar aree in inte tend nded ed bo both th to be inst instruc ructiv tivee andto serv servee as exp explan lanatio ations ns for whywe mad madee cer certainstate tainstatement mentss 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 rec receiv eivee sco scores res hig high h eno enough ugh for fun fundin ding. g. We con conclu clude de by of offer fering ing wha whatt we thi think nk of as principles for writing effective qualitative proposals.

articlee is supp supportedby ortedby GrantsNR04907(6/1/0 GrantsNR04907(6/1/00-2/2 0-2/28/05 8/05)) AUTHORS’NOTE: The studyfeaturedin this articl and NR049 NR04907S 07S (6/1 (6/1/03-2 /03-2/28/0 /28/05) 5) from the Nation National al Institu Institute te of NursingResearch, Nation National al Instit Institutes utes 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: 10.1177/104 10.1177/1049732303255474 9732303255474 © 2003 Sage Publications

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THE PROPOSAL: “ANALYTIC TECHNIQUES FOR QUALITA QUALITATIVE TIVE MET METASYNTHESIS” ASYNTHESIS” Specific Aims Theimmediateaimoftheproposedstudyistodeveloptheanalyticandinterpretive techni tec hnique quess to con conduc ductt qua qualita litativ tivee met metasyn asynthes thesis is pro projec jects, ts, usi using ng res resear earch ch on wom women en sectio tions ns on aim aims, s, wri writer terss sho should uld sta state te the aim aimss with wit h HIV/AID AIDS S as the “me “method thod cas case.” e.” In sec  first; reviewers should not have to wait for them. them. Alth Althoug ough h all qua qualita litativ tivee res resear earch, ch, nar nar-rative integrations integrations of quanti quantitative tative research, research, and broad overv overviews iews of knowled knowledge ge fields entail synthesis, or some combination of two or more entities, qualitative metasy met asynth nthesis esis is a dis distinc tinctiv tivee cat categor egory y of syn synthe thesis sis in whi which ch the fin finding dingss fr from om com com-pleted 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 scienti fic resea research. rch.The These se las lastt twostate twostatemen ments ts con consti stitut tutee an exa exampl mplee of wha whatt we cal calll strategic disarmament, disarmament, which entails anticipating likely areas of controversy, debate, or differences enc es of opi opinio nion. n. Bec Becaus ausee the wor wordd synthesis is us used ed in a va vari riet etyy of wa ways ys to re refe ferr to a va vari riet etyy of ent entiti ities, es, dif differ ferent entiat iating ing rig right ht awa awayy the kin kindd of syn synthe thesis sis tha thatt was the foc focus us of our pr propo oposal sal was critical. These statements are also in response to a previous review in which our take on synthesis synth esis was not suffi sufficient ciently ly clear clear.. We hav havee cho chosen sen the are areaa of wom women en wit with h HIV/AID AIDS S as ou ourr met metho hod d ca case se be beca caus usee a su suff ffici icien entt nu numb mber er of qu qual alit itat ativ ivee st stud udie iess ex exist istss he here re to warra wa rrant nt me meta tasy synt nthe hesis sis,, an and d it is a fi fiel eld d of gr grea eatt si sign gnif ific ican ance ce to wo wome men’ n’ss he healt alth h an and d 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 fr om qua qualita litative tive res resear earch ch is als also o a goa goall of the Nat Nationa ionall Ins Institu titutes tes of Hea Health lth.. 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 qualitativee stu tiv studie diess on var variou iouss aspe aspectsof ctsof hea health lth,, illn illness,and ess,and lifetransi lifetransition tions—p s—phen henome omena na of  key int intere erest st to nur nurses— ses—has has been unp unprec receden edented ted.. Desp Despite ite its new pro promin minenc encee 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 sig signif nifica icance nce of the pr probl oblem. em. We wor worked ked bac backw kward ard fr from om the aim aimss to the re resea searc rchh pro probblem and its significance. Qualitative Qualit ativeresear research ch findin findings gs conta contain in inform information ation aboutthe subtle subtleties ties and complexit ple xitie iess of hu huma man n re respo spons nses es to dis disea ease se an and d itstrea itstreatm tmen entt th that at is es essen senti tial al to th thee co connstruction of effective and developmentally and culturally sensitive interventions. However, for qualitative research findings to matter, they must be presented in a

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form th form that at is ass assim imila ilabl blee int into o th thee “p “pers erson onal al mod modes es of kn know owin ing g . . . valu valuin ing” g” (N (Nob obli lit, t, 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  dataa alr dat alread eady y coll collect ected. ed. A new mor moral al con consci scious ousnes nesss has eme emerge rged d abo about ut inv invitin iting g per per-sons, son s, alr alread eady y vul vulnera nerable ble by vir virtue tue of thei theirr hea health lth con condit ditionsor ionsor lif lifee cir circum cumsta stance nces, s, to partic par ticipat ipatee in yet mor moree stu studie diess to obt obtain ain inf inform ormati ation on we alr alread eady y hav havee (e. (e.g., g., Tho Thorne rne,, 1997). 199 7). Rec Recrui ruitmen tmentt of per persons sons into qua qualita litativ tivee stu studies dies,, in par partic ticula ularr, can cannot not be jus justitified fie d by the ben benefi efits ts of suc such h par partic ticipat ipation ion alon alonee (e. (e.g., g., Hut Hutchi chinso nson, n, Wilso ilson, n, & Wilso ilson, n, 1994). 199 4). Qua Qualita litativ tivee met metasy asynth nthesis esis is suc such h a mini mining ng pro projec ject, t, tha thatt is, an impo importa rtant nt ave ave-nue 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 them out with specific 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 qualit qua litativ ativee met metasy asynth nthesisraises esisraises,, inc includ ludinghow inghow to (a)defin (a)definee thelimits of a synt synthes hesis is project pro ject,, (b) gro group up stu studies dies for com compar parison ison and com combin binati ation, on, (c) eva evalua luate te the qua quality lity of stu studies dies,, (d) det determi ermine ne the “tr “true” ue” as oppo opposed sed to sur surfac facee top topical ical and meth methodo odologi logi-cal 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 diffe different rent consumers of qualita qualitative tive research, including researchers researchers and practitioners. We will also provide a metasynthesis of research findings in the area of wo womenwithand menwithand in a se seco cond nd ar area ea of re resea searc rch h to “t “test est”” th thee me meta tasy synt nthe hesisprot sisprotoc ocol ol we develop. The “test case” will involve research on couples undergoing prenatal testing. The out outcom comes es of the pro propose posed d pro projectwill jectwill the theref refore ore inc includ ludee bot both h a pro produc ductt (th (thee 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 containedinthemcanserveasabasisforimprovedresearchandhealthcarepractices. In this first section of the proposal, we adopted the following logic: immediate aim → significan signi ficance ce of aim → problem → signi significan ficance ce of prob problem lem → aim with objec objective tivess → outcome and long-term aim. 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 significan signi ficance ce of esta establish blishing ing signi significan ficance ce canno cannott be over overestim estimated. ated. A res researc earchh prop proposal osal low in significance, albeit high in technical perfection, is not likely to be funded.

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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 followed a largel lar gelyy “ga “gap” p” log logic,in ic,in tha thatt our re revie view w was ori orient ented ed to sho showin wingg wha whatt wasstill mis missin singg 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 Glass’s (1976) work in the area of meta-analysis, a surge of efforts has been directed toward research integration, especially in the health hea lth/me /medici dicine ne doma domain in (Ba (Bause usell, ll, Li, Gau Gau,, & Soek Soeken, en, 199 1995; 5; Kav Kavale,1995) ale,1995).. Alt Althou hough gh resear res earch ch int integra egratio tions ns wer weree pro promote moted d andcondu andconducte cted d prio priorr to thi thiss time time,, theprolif theprolifera era-tion 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 usee of re us rese sear arch ch fi find ndin ings gs (C (Cook ook,, Mu Mulr lrow ow,, & Ha Hayn ynes es,, 19 1997 97). ). No Nott on only ly do hu hund ndre reds ds 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. Con Conspic spicuou uously sly abs absent ent fr from om thi thiss thr thrivin iving g res resear earch ch int integra egratio tion n scen scenee are efforts to integrate the findings of qualitative qualitati ve research. This absence is all the more remark rem arkabl ablee as few oth other er res resear earch ch appr approac oaches hes now riv rival al the int intere erest st sho shown wn in qua qualilitative 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 annua annuall intern international ational Qualitative Qualitative Healt Health h Resear Research ch Confer Conference). ence). These studies contain findings about a diverse range of health issues, including, most notably, personal and cultural constructions of disease, prevention, and risk; livin liv ing g wi with th an and d ma mana nagin ging g th thee ef effe fect ctss (i (inc nclu ludin ding g th thee tr trea eatm tmen entt ef effe fect cts) s) of an ar arra ray y 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 world”—that is, not in artificially controlled and/or manipulated conditions—yet is seen as not applica app licable ble in tha thatt wor world. ld. Thi Thiss per perceiv ceived ed lac lack k of rel releva evance nce and uti utility lity has pote potenti ntially ally 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 metasynthesis—as it is conceived in the few articles on this subject (with this phrase, we reinforce how little there is on qualitative metasynthesis and thu thuss thesigni thesignific ficanc ancee of thepropo theproposed sed stu study) dy)—i —iss a fo form rm ofmeta ofmetast stud udy y, th that at is,stud is,study y of  thee pr th proc oces esses ses an and d re resu sult ltss of pr prev eviou iouss stu studi dies es in a ta targ rget et dom domai ain n th that at mo move vess be beyo yond nd

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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 resu re sult ltss of pr prev eviou iouss st stud udie iess bu butt al also so to re refl flec ectt on th them em (Z (Zha hao, o, 19 1991 91,, pp pp.. 37 3777-37 378) 8).. Lik Likee  phenomenology,, ethnography  phenomenology ethnography,, and grounded theory, 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 McGaw s hared 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 (W olf,, 198 1986, 6, p. 33) 33).. Weagainusethedeviceofcontraststoclarifyourfocusandtodifferentiate qualitative metasynthesis from other entities reviewers 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 partic par ticula ularr stu study dy.. A pri prime me dir direct ective ive for qua qualita litativ tivee res resear earche chers, rs, no mat matter ter wha whatt the their ir method or research purpose, is to preserve the integrity of each sampling unit or casee (Sa cas (Sandel ndelows owski, ki, 199 1996). 6). In qua qualita litativ tivee meta metasyn synthes thesis is pro projec jects, ts, this prim primee dir direct ective ive 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 & Pilleme Pil lemerr, 198 1984). 4). Ef Effor forts ts to sum summar marize ize qua qualita litativ tivee fin findin dings gs app appear ear to und undermi ermine ne the “function and provenance” of cases (Davis, 1991, p. 12) and to sacrifice the vitality, viscerality viscer ality,, and vicariism of the human experiences experiences re-pr re-presented esented in the origina originall studies. The very emphasis in qualitative research on the complexities and contradictio dic tions ns of “N  N = = 1 exp experie erience nces” s” (Ei (Eisner sner,, 199 1991, 1, p. 197 197)) seem seemss to pre preclu clude de add adding ing the these se experiences up. Moreover, the sheer diversity of qualitative research practices is another reason why so few efforts to synthesize qualitative findings have been attempted. attempt ed. Qualit Qualitative ativeresear researchers chers have vastlydifferentdisciplinary vastlydifferentdisciplinary,, philosop philosophical, hical, theore the oretic tical, al, soc social, ial, poli politic tical, al, and ethi ethical cal com commit mitment ments, s, and they oft often en hav havee ver very y dif dif-ferent 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 nar narrat rative ive stu studies dies.. Fur Furthe thermo rmore, re, giv given en the wid widee var variety iety of rere-pre present sentati ation on sty styles les for diss dissemin eminati ating ng qua qualita litativ tivee res resear earch, ch, eve even n fin findin ding g the fin finding dingss can be a dau daunti nting ng challenge. We ar aree sho showin wingg her heree tha thatt we kno know w tha thatt not all qua qualit litati ative ve re resea searc rcher herss agr agree ee tha thatt 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 qua qualit litati ative ve re resea searc rchh int integr egrati ation. on. We sho show w her heree a yes yes-bu -butt log logic, ic, tha thatt is, yes yes,, we sup suppor portt the legitimacy of the arguments of those who might disagree with what we intend, but we also affirm the need to try. A rec recurr urring ing con concer cern n is tha thatt qua qualita litativ tivee res resear earche chers rs are eng engage aged d 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

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wheel. Early in the history of grounded theory, Glaser and Strauss (1971) warned that th at co cont ntin inue ued d fa failu ilure re to lin link k loc local al gr grou ound nded ed th theo eorie riess int into o fo form rmal al th theor eories ies (a ty type pe of  qualit qua litativ ativee met metasyn asynthes thesis) is) wou would ld rel relega egate te the fin findin dings gs of ind individ ividual ual stu studie diess to “li “litttle isla islands nds of kno knowled wledge, ge,”” sep separa arated ted fr from om eac each h othe otherr and doo doomed med ult ultima imately tely nev never er to be visited (p. 181). Qualitative metasynthesis is increasingly seen as essential to reachi rea ching ng high higher er ana analyti lyticc goa goals ls and als also o to enh enhanc ancing ing the gen general eraliza izabili bility ty of qua qualita lita-tivee res tiv resear earch. ch. Sch Schofi ofield eld (19 (1990) 90) vie viewed wed qua qualita litativ tivee meta metasyn synthe theses ses as cro crossss-cas casee gen gen-eralizations created from the case-bound generalizations in individual studies. We want wa nted ed re revi view ewer erss to ha have ve a se sens nsee of a de deba bate te he here re an andd wh what at “s “sid ide” e” we we were re,, an andd ha hadd to be 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 pursue pur sued d wit within hin one pro progra gram m of res resear earch ch by the sam samee inv investi estigat gator( or(s). s). An exa example mple is the syn synthe thesis sis wor work k Mor Morse se and her coll colleag eagues ues con conduc ducted ted in her pro progra gram m of res resear earch ch 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 findingsaboutmotherhoodfromthesestudies.Athirdexampleisoneofourownefforts (Sandelowski, 1995) to synthesize the findings of different di fferent aspects of the transition to pa pare rent ntho hood od of inf infert ertilecoup ilecouples les.. (T (Thisstud hisstudy y is de desc scrib ribed ed in mo more re det detai aill in th thee Pr Preeliminary 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 fr om th thes esee da data ta). ). Mo More reov over er,, th they ey ha have ve di dire rect ct ac acce cess ss to th thee pr prim imar ary y da data ta fo forr th thee syn syn-thesis. A se seco cond nd ki kind nd of ef effo fort rt,, an and d th thee on onee we wi will ll fo focu cuss on in th this is pr proj ojec ect, t, inv involv olves es th thee 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 women’s addiction recovery. The remaining efforts were ostensibly based on the Noblit and Hare (1988) work, which involved three kinds kin ds of “tr “trans anslat lations ions”” of ind individ ividualethnog ualethnograp raphie hiess intoeach oth other er to pro produc ducee thr three ee 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 metaeth met aethnogr nograph aphy y of livi living ng wit with h diab diabetes etes fr from om 43 stu studies dies;; She Sherwo rwood od (19 (1997) 97) syn synthe the-sized 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 stud st udies ies on liv living ing wi with th HI HIV V/AI AIDS DS.. (T (Thi hiss st stud udy y is des descr crib ibed ed in mo more re de deta tail il in th thee Pr Preeliminar limi nary y Stu Studie diess sec section tion.) .) In thi thiss kindof syn synthe thesis sis eff effort,where ort,where the foc focus us of ana analys lysis is is st stud udies ies in a top topic ical al do doma main in co cond nduc ucte ted d by a ra rang ngee of in inve vest stiga igato tors rs,, sy synt nthe hesis sists ts ar aree farr re fa remo move ved d fr from om,, an and d ty typi pica cally lly ha have ve no ac acce cess ss to to,, th thee pr prima imary ry da data ta on wh whic ich h th these ese studieswere stu dieswere bas based. ed. (An exc excepti eption on her heree is whe when n syn synthes thesist istss inc includ ludee one of thei theirr 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

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research resear ch rep report ort,, whi which ch migh mightt be inf influe luence nced d by limi limitat tations ions in the res resear earch ch ent enterpr erprise ise 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. ti ze. Fo Forr exa exampl mple, e, alt altho houg ugh h Je Jens nsen en an and d Al Allen len (1 (199 994) 4) cit cited ed Nob Nobli litt an and d Ha Hare re (1 (198 988) 8) as their the ir meta metasynt synthes hesis is met method hod sou sourc rce, e, the tec techni hnique quess the they y use used, d, the pro produc ductt the they y gen gen-erated,and era ted,and the res resear earch ch pur purposethey posethey sta stated ted wer weree dif differ ferent ent fr from om thos thosee of Nobl Noblit it and Hare. Jensen and Allen’s (1994) purpose was to “inductively develop a theory of  wellness-illne wellnes s-illness” ss” from the “commo “commonalitie nalitiess among individual representations 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 rela re lated ted to eac each h oth other er.. In Inde deed, ed, th they ey ar argu gued ed ag again ainst st th thee not notio ion n of syn synth thesi esis— s—as as ac accu cu-mulati mul ation on or agg aggreg regati ation— on—aft after er desc describ ribing ing a fai failed led eff effort ort at jus justt suc such h an agg aggreg regati ative ve synthesis of several ethnographies on school desegregation. Instead, they proposed pos ed,, stu studie diess ca can n be ju judg dged ed in re relat latio ion n to ea each ch ot othe herr as (a (a)) co comp mpar arab able le an and, d, th ther ereefore, for e, sub subjec jectt to “re “recip ciproc rocal al tra transla nslatio tion”; n”; (b) ref refuti uting ng eac each h oth other; er; or (c) rep repres resent enting ing a “line of argument” (p. 36). Moreover, they proposed their methods to fit explicitly ethnog eth nograph raphic ic stu studies dies,, ther thereby eby cal calling ling int into o que questio stion n the appl applica icabili bility ty of thes thesee met methhodss to th od thee ki kind ndss of st stud udies ies Je Jens nsen en an and d All Allen en re revi view ewed ed an and, d, th ther eref efor ore, e, to th thee ki kind ndss of  studies typically conducted in nursing and other health-related discip lines. Jensen and Allen grouped—by method—112 studies (an enormous sample in qualitative research) on “wellness-illness” (a concept incorporating many diverse dimensi ons 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 gro up (e. (e.g., g., gr groun ounded ded the theory ory to syn synthe thesizethe sizethe fin findin dings gs of gro ground unded ed the theory ory stu studies dies,, phenomenology to synthesize the findings of phenomenology studies). Their final produc pro ductt was rep reporte ortedly dly one met metasy asynth nthesis esis of wel wellnes lness-i s-illne llness ss com compose posed d of a ble blend nd 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 “refut “re futati ationa onal” l” syn synthe theses ses of the fin findin dings gs fr from om twobook-l twobook-leng ength th stu studie diess eac each, h, andone “line-of-argument” synthesis of the findings from six studies (also including one Noblit had conducted) published in one anthology on school desegregation. The Pater Pa terso son n et al al.. (1 (199 998) 8) st stud udy y sh show owss a sim simila ilarl rly y di dist stan antt re rela lati tions onshi hip p to th thee No Nobl blit it an and d Hare Ha re wo work rk bu butt a clo close se re rela latio tions nship hip to gr grou ound nded ed th theo eory ry wo work, rk, de desp spite ite th thee in inve vest stiga iga-tors’nami to rs’naming ng No Nobl blit it an and d Ha Hare re as a me meth thod od so sour urce ce.. Wit ith h re refe fere renc nces es to th thee Je Jens nsen en an and d 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 lar ity to a con conven ventio tional nal nar narrat rative ive rev review iew of lite literat ratur uree tha than n to sys system tematic atic int integr egratio ation n of findings across studies. All of these studies are exciting exciti ng efforts but lack sufficient communicable detail concerning how they achieved their integrations, and none expli citly 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 addr ad dres ess. s. Ou Ourr tw twoo ru rule less inpre inprese sent ntin ingg th thee wo work rk of ot othe hers rs ar aree (a (a)) ne neve verr touse th thee wo word rd “f “fai ail”in l”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

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(b)describeaccurate (b)describeaccur ately ly wha whatt the theyy diddo. Thedual imp impera erativ tives es to giv givee oth other er sch schola olars rs the their ir due and to advance scholarship are somewhat antithetical, as finding something that requires  further researching researching is the sine qua non of the academic enterprise. These imperatives imperatives thus require a delicate balancing act, as the continuation of this enterprise depends on scholars’  finding gaps, errors, errors, or inconsistencies in existing scholarship. 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, & Grimsha Grim shaw w, 199 1997). 7). Dile Dilemma mmass dist distinc inctiv tivee to qua qualita litativ tivee res resear earch ch int integra egration tionss inc includ ludee 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, itsel f, most notably, 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 metasy met asynth ntheses eses,, we wil willl add addres resss themin deta detail il in thesectio thesection n on Res Resear earch ch Desi Design gn and Methods. Here 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 whatt has yet to be sai wha saidd lat later er.. Too man manyy re refer ferenc ences es to dis discus cussio sions ns tha thatt too tookk pla place ce “pr “previ evious ously” ly” or that will take place “below” suggest that writers have not placed material in the right order ord er in the fir first st pla place. ce. Wr Write iters rs mig might ht the there reby by be for forced ced to re repea peatt mat materi erial al unn unnece ecessa ssaril rilyy and thus to consume space better used for other components of their proposal.

Women With HIV/AIDS as a Method Case We ha have ve ch chos osen en re resea searc rch h on wo wome men n wi with th HI HIV V inf infec ectio tion n as ou ourr me meth thod od ca case se be beca caus usee of th thee ma many ny an and d co comp mplex lex he healt alth h ca care re ne need edss th thes esee wo wome men n ha have ve an and d be beca caus usee a su suff ffiicient number of qualitative studies containing information important to these women’s 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” scie nce” on women with HIV infection. Since then, the n, res resear earche chers rs hav havee pub publish lished ed seve several ral rev review iewss of the lite literat ratur ure, e, all of whi which ch hav havee 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, 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, Coh en, 199 1997; 7; Fow Fowler ler,, Mel Melnic nick, k, & Mat Mathies hieson, on, 199 1997). 7). Betw Between een 198 19811 and 199 1997, 7, the per per-cent ce ntag agee of ser serop oposi ositiv tivee wo women men in incr crea ease sed d fr from om ne near arly ly zer zero o to alm almos ostt 20 20% % of all ne new w 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

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America Ameri can, n, 21 21,9 ,937 37 ar aree Hi Hispa spanic nic,, an and d 24 24,4 ,456 56 ar aree Wh White ite.. Th Thee re rema maini ining ng wo wome men n ar aree in other ethnic/racial categories, including Native American. Ameri can. The largest numbers of  AIDS cases in women are in the 30- to 39-year-old age group. HIV/AIDS was the four fo urth th le lead adingcau ingcause se of de deat ath h am amongwome ongwomen n in th thee Un Unit ited ed St Stat ates es be betw tween25 een25 an and d 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 women’s experien expe riences ces as inf infect ected ed ind individ ividual uals. s. Prio Priorr to 199 1993, 3, qua qualita litativ tivee res resear earch ch tha thatt inc includ luded ed women was devoted largely to their roles as mothers of seroposi tive children or as vectorss of transmission. Even when resea vector researcher rcherss began to seek information from women about their experiences with HIV, they combined it with information obta ob tain ined ed fr from om me men. n. (T (This his is wh why y wo wome men n we were re no nott th thee fo focu cuss of st stud udy y in th thee re resea searc rch h 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 HIV-positive women already existed and that we were simply repeating a previous study study.. Sch Schola olars rs in wom women’ en’s/g s/gend ender er stu studies dies and in wom women’ en’ss hea health lth hav havee show shown n the impo importa rtance nce of tre treatin ating g gend gender er as a key var variab iable le dif differ ferent entiat iating ing expe experien rience ce (e. (e.g., g., Fogel Fog el & Woods oods,, 199 1995; 5; Har Hardin ding, g, 199 1991). 1). Ind Indeed, eed, the there re is evi eviden dence ce tha thatt sex sex/ge /gender nder 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 forr CD fo CD44 co coun unt) t) th than an me men n (F (Far arza zade dega gan n et al al., ., 19 1998 98). ). Wome omen n be bear ar th thee gr grea eate terr bu burd rden en in the areas of reproduction, child care, and other family functions. Seropositive women wom en mus mustt mak makee cri critic tical al and eve even n ago agoniz nizing ing dec decisio isions ns abo about ut chi childb ldbeari earing, ng, abo aborrtion, 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 relations ti onshi hips ps wi with th ma male le pa part rtne ners rs,, wo women men mi migh ghtt fi find nd it mo more re di diff ffic icul ultt to en enga gage ge in pra pracctices to prevent HIV transmission. Heterosexual relations are the most rapidly increasing mode of transmission of HIV in women, with most women infected in thiss way rep thi reporti orting ng con contac tactt wit with h mal malee par partner tnerss who inj inject ect dru drugs gs (CD (CDC, C, 199 1999; 9; Coh Cohen, en, 1997). 199 7). The imb imbala alance nce of pow power er betw between een wom women en and men oft often en limi limits ts wom women’ en’ss abi abillity to negotiate condom use (Bedimo, Bennett, Kissinger, & Clark, 1998; Bedimo, Bessinger, & Kissinger, 1998; Gaskins, 1997; Walmsley almsley,, 1998). Increasingly Increasingly,, women with HIV infection are unaware of their male partner ’s 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 Women’s Interagency HIV Study (Barkan et al., 1998), 66% reported abus ab usee by th theirpart eirpartne ners.Vio rs.Violen lence ce ha hass al also so em emer ergedas gedas a ke key y va vari riab able le in ot othe herr st stud udies ies 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, Gorey, 1998).

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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 women’s reproductive decision making from their the ir cha chart rt rev review iew,, the they y hadfailedto lear learn n any anythi thing ng abo about ut themeanin themeaning g of tho those se fac facts ts to wom women en them themselv selves. es. At a rec recent ent mee meetingof tingof the Soc Societyfor ietyfor Med Medica icall Ant Anthr hropol opology ogy,, researchers reportedly noted how little impact qualitative studies had on “AIDS resear res earch ch and pre preven ventio tion n age agenda ndas” s” (Sw (Swans anson on et al., 199 1997, 7, p. 256 256). ). The pro propos posed ed pro pro- ject 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 th at is is,, to ser serve ve as a “c “cre reat ativ ivee br bridg idge” e” (S (Swa wans nson on,, Du Durh rham am,, & Alb Albri righ ght, t, 19 1997 97,, p. 25 256) 6)  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; Swanso Swa nson n et al. al.,, 199 1997). 7). Mor Moreov eover er,, con contemp tempora orary ry not notions ions of evi eviden dencece-bas based ed pra practic ctice, e, with wit h the their ir vir virtua tually lly exc exclus lusive ive emph emphasison asison ran randomi domized zed and con contro trolled lled clin clinica icall tri trials als as the gold standard in methods, discount qualitative findings as evidence (Estabrooks, 1999). The pro propose posed d pro projec jectt wil willl enh enhanc ancee the act actiona ionabili bility ty of kno knowle wledge dge pro produc duced ed by qualit qua litativ ativee res resear earch ch by dev develop eloping ing a use userr-fri friendl endly y pro proced cedur uree for con conduc ducting ting qua qualilitative 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’ usee of re us rese sear arch ch fi find ndin ings gs is th that at th they ey ar aree pr pres esent ented ed in fo form rmss th that at ar aree in inco compr mpreh ehens ensii ble and irrelevant to practitioners (Funk, Tornquist, & Champagne, 1995). Thee fi Th find ndin ings gs fr from om th thee pr prop opose osed d pr proje oject ct wi will ll al also so co cont ntri ribu bute te to th thee ac actio tiona nabi bilit lity y of qualitative research by enhancing the generalizability of study findings. As Sandelowski (1996, 1997) summarized it, in quantitative research, emphasis is placed plac ed on nom nomothe othetic tic gen genera eraliza lization tions, s, or the for formal mal kno knowle wledge dge tow toward ard whi which ch ran ran-dom sam samplin pling g and ass assign ignment ment ar aree dir direct ected. ed. The obje objecti ctive ve is to enh enhanc ancee the ext externa ernall 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 derivedfrom derived from and about cas cases. es. Nur Nursing sing and med medica icall pra practi ctice ce dep depend end on bot both h kin kinds ds of gen genera eraliza lizatio tions, ns, as practitioners must fit formal knowledge to the particulars of cases. Qualitative metasy met asynth nthesis esis is a mea means ns to enh enhanc ancee the ana analyti lyticc pow power er of idio idiogra graphi phicc kno knowle wledge dge,, as it entails the intensive case-oriented case-oriented study of targ target et phenomena in large largerr 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 

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women’ss sub women’ substa stanceabuse nceabuse rec recove overy ry,, whi which ch inv involv olved ed mor moree tha than n 200 wom women en in dif differ fer-ent cultural, racial, historical, and geographic circumstances. The “power” (Kearney ne y, 19 1998 98a, a, p. 18 182)of 2)of th this is sa samp mple le si size ze an and d co conf nfig igur urat atio ion n lie liess in th thee ab abili ilitynot tynot to dr draw aw 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 men ts to mea measur suree hea health lth con condit ditionsand ionsand appr appropr opriateinterv iateintervent entionsto ionsto impr improve ove the them m depend on just this kind of knowledge. Finally Fin ally,, the fin finding dingss fr from om the pro propos posed ed pro projec jectt wil willl enh enhanc ancee the appl applica icabili bility ty of  qualitative findings directly to practice. A key deterrent to the use of qualitative findings findin gs is the persistent notion that findings from qualitative qualitative studie studiess cannot be applied app lied dir direct ectly ly in pra practi ctice ce wit withou houtt qua quanti ntitat tative ive tes testin ting. g. This idea rep reprise risess the fal false se notion not ion tha thatt qua qualita litativ tivee res resear earch ch is alw always ays inc incomp omplete lete by itse itself lf (Mo (Morse, rse, 199 1996). 6). Mor Moreeover, it permits the idea of testing to remain appropriated exclusively for quantitative resear research. ch. Testing is a soc socioc iocul ultu tura rall an and d lin lingu guist istic ic co conc ncept ept an and d pr prac acti tice ce th that at do does es 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, is—by is— by bot both h def definit inition ion and pur purpose pose—th —theor eory y gro ground unded ed in and test tested ed aga agains instt hum human an experien expe rience. ce. The There re is no mor moree jus justifi tificat cation ion for appl applyin ying g “te “tested sted”” nom nomoth othetic etic kno knowlwledge that often fails, or must be adapted, to fit the individual case than there is for applyin app lying g idio idiogra graphic phic kno knowled wledge ge dir direct ectly ly to a cas case. e. All fin findin dings, gs, whe whether ther qua quantit ntitaatively or qualitatively generated and tested, must ultimately be tested in practice with individual cases to ensure their pragmatic and ethical validity (Kvale, 1995). Thee pr Th prop opose osed d pr proj ojec ectt wi will ll pr prov ovid idee a mea means ns to fu furt rthe herr th this is go goal al an and d to of offs fset et th thee cu currrentt tr ren trend end tow toward ard red reduci ucing ng our und underst erstand anding ing of “ev “eviden idence” ce” to fin findin dings gs only fro from m exper ex perime iment ntss (C (Coly olyer er & Ka Kama math th,, 19 1999 99;; Fr Fren ench ch,, 19 1999 99). ). Yet th thee fi find ndin ings gs fr from om th this is pr proo ject will likely also clarify how qualitative evidence can be used to improve the evi evi-dence from experiments, that is, to improve the design sensitivity and validity of  clinica clin icall tria trials ls (Li (Lipse psey y, 199 1990; 0; Sid Sidani ani & Bra Braden den,, 199 1998). 8).In In theprece theprecedin dingg par paragr agraph aph,, we con con- fronted 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. study. Again, making the case for the significance significance of research research problems, research research aims, and research outcomes is a defining attribute of a successful proposal. Reviewers are moree lik mor likely ely to for forgiv givee tec techni hnical cal fla flaws ws in des design ign if an exc excell ellent ent cas casee is mad madee for sig signif nifica icance nce in these three areas.

Preliminary Studies The propos proposed ed projec projectt builds buildson on metasy metasynthesisstudies nthesisstudies the co-pri co-principal ncipalinvesti investigators gators havee con hav conduc ducted ted pre previo viously usly.. San Sandelo delowsk wskii (19 (1995) 95) has pub publish lished ed a the theore oretic tical al syn synthe the-sis of findings generated from multiple analytic paths pursued in her study of the transit tra nsition ion to par parent enthoo hood d of inf inferti ertile le cou couples ples.. (Acopy of thi thiss art articleis icleis in Appe AppendixA. ndixA.  Appendix A is not reproduced here. here.)) Th This is wo work rk is in th thee ca cate tego gory ry of met metas asyn ynth thes esis is pr proo jects, characterized by the integration of findings from multiple analytic paths pur-

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sued within the synthes synthesist’s ist’s own progr program am of resear research. ch. The synthe synthesist sist 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 aro und whi which ch to org organi anize ze the var variou iouss fin findin dings gs gen generat erated ed fr from om prim primary ary dat dataa ana analylysis. This variable was “work” and, specifically, “illness work” and “biographical work wo rk.” .” Sh Shee th then en co compa mpare red d se seve vera rall gr grou oups ps of in infe fert rtile ile co coup uples les to ea each ch ot other her an and d to a group gro up of fer fertile tile cou couples ples to def define ine the “ov “overla erlappin pping” g” and “sp “specia ecial” l” wor work k dis distinc tinctiv tivee to eac each h gro group. up. Alth Althoug ough h thi thiss wor work k rep repres resent entss a kind of qua qualita litativ tivee meta metasyn synthe thesis, sis, 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 thedatathatgeneratedthefindingsreportedinthesestudies.(Acopyofthein-press Appe pend ndix ix A is no nott arti ar ticlerepo clereport rtin ing g th thee re resu sult ltss of th this is st stud udy y is lo loca cate ted d in App Appen endixA. dixA. Ap reproduce repr oducedd here here;; the artic article le was publi published shed in 2000. 2000.)Thisisthekindofmetasynthesisthat )Thisisthekindofmetasynthesisthat is the tar target get of the pro propos posed ed pro projec ject. t. The foc focus us of the Bar Barros roso/P o/Powe owellll-Cope Cope pro projec ject, t, which began in 1996, was living with HIV disease. (As noted previously, women were we re no nott th thee fo focu cuss of stu study dy he here re.. Th Thee par parti tici cipa pant ntss in invo volv lved ed in th thee st stud udie iess re revi view ewed ed 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 investi inv estigat gators ors limi limited ted the their ir stu study dy to res resear earch ch pub publish lished ed in ref refere ereed ed jou journa rnals, ls, bec becaus ausee they the y had limi limited ted res resour ources ces wit with h whi which ch to con conduc ductt thi thiss pro projec jectt and the ref refere ereed ed jou jourrnal venue implied peer review. Accordingly, such important “fugitive literature” (Lynn, 1989, p. 302) as doctoral dissertations dissertatio ns was not included in their study. 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 qualit qua litativ ativee but but,, rat rather her,, only qua qualita litativ tivee adj adjunc uncts ts to qua quantit ntitati ative ve stu studies dies;; (b) qua qualita lita-tive 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 cons co nsist isted ed of se seco cond ndar ary y an anal alys yses es of da data ta co colle llect cted ed in an anot othe herr stu study dy;; an and d (e (e)) th they ey did not meet quality standards. Barroso and Powell-Cope (2000) evaluated quality using Burns’s (1989) standards dar ds forqualit forqualitati ative ve res resear earch, ch, whi which ch inc includ ludee det determ erminin ining g whe whetherall therall of the desi desired red eleme ele ment ntss of a re resea searc rch h re repor portt ar aree pr prese esent nt an and d th thee ex exten tentt to wh whic ich h a re repo port rt mee meets ts fi five ve critiqu cri tiquee sta standa ndards rds.. Bur Burns’ ns’ss gui guide de rem remain ainss the mostcompr mostcomprehen ehensiv sivee gui guide de for eva evaluluating ati ng qua qualita litativ tivee res resear earch. ch. Eac Each h of the cri critiqu tiquee sta standa ndardsconsis rdsconsisted ted of mul multip tiple le item itemss 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 investi inv estigat gator or sco scoredhalf redhalf of the stu studies dies.. Stu Studiesdeemed diesdeemed una unacce cceptab ptable le by one inv investi esti-gator gat or wer weree rev review iewed ed by the oth other er inv investi estigat gator or,, and stu studiesdeemed diesdeemed una unacce cceptab ptable le by  both investigators were excluded. The investigators also reached consensus on studies about which they initially disagreed.

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In doing this work, Barroso and Powell-Cope (2000) were confronted with the difficulty of applying critique standards to qualitative studies. For example, they foun fo und d th that at stu studie diess ra rare rely ly me mett th thee Bu Burn rnss (1 (198 989) 9) cr crit iteri eriaa fu full lly y, an and d th they ey su surmi rmised sed th this is wass mo wa most st lik likel ely y be beca caus usee of pu publ blica icatio tion n lim limita itati tion ons, s, th that at is, a st stud udy y mi migh ghtt ha have ve ac actu tu-ally 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 PowellCopee be Cop bega gan n to qu quest estio ion n wh wheth ether er al alll of th thee cr crit iter eria ia we were re equ equal ally ly imp import ortan antt to est estab ab-lishing the trustworthiness of the findings. They also questioned the meaning of  someof the cri criter teria ia the themsel mselves ves.. For exa example mple,, theywere unc uncerta ertain in abo about ut how to fin find d evidence for, score, or weigh the adequacy of a researcher’s self-awareness. Burns listed “inadequate self-awareness” as a threat to “descriptive vividness” (p. 48) In short, sho rt, the inv invest estigat igators ors con conclu cluded ded the there re was a nee need d to fin find d a sta standa ndard rdized ized,, com commumunicable, and useful means of judging the value of qualitative work that could both (a)) se (a serv rvee as a gu guide ide fo forr wh what at a qu qual alita itati tive ve re repo port rt sho shoul uld d in incl clud udee re rega gard rdles lesss of pu publ bliication constraints and (b) account for the idiosyncratic ways in which qualitative research is conducted. After Aft er det determi erminingwhich ningwhich HIVstudie HIVstudiess wou would ld be inc includ luded ed in the their ir stu study dy,, Bar Barros roso o 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 wor k but had dif diffic ficult ulty y appl applyin ying g the meth method od desc describe ribed d the there, re, whi which ch inv involv olved ed ana ana-lyzing two to six book- or chapter-length ethnographies in education, to their own study stu dy inv involvi olving ng mul multipl tiplee art article icle-le -lengt ngth h stu studies dies in the doma domain in of hea health lth.. The They y dev develelopeda cla classif ssifica icatio tion n syst system em bas based ed on fin findin dings gs aft after er disc discove overingthat ringthat gro groupi uping ng stu studdies by met metho hod d di did d no nott al allowthem lowthem to fo focu cuss on th thee fi find nding ingss an and d th their eir re rela latio tions nshi hips ps to each ea ch oth other er.. Th They ey pl plac aced ed fi find ndin ings gs in a co comm mmon on ar area ea of HI HIV V exp exper erien ience ce,, su such ch as de deal al-ing in g wi with th sti stigm gma, a, in sep separ arat atee fi file les. s. Th They ey th then en sou sough ghtt to de deve velop lop wa ways ys to co conso nsolid lidat atee find fi ndin ings gs in ea each ch of th thes esee ar area eas, s, at attem tempt ptin ing g to fi find nd me meta taph phor orss or co conc ncep epts ts to gr grab ab th thee findings and to discern the variations in findings on a target experience. The findingss in tar ing target get expe experien rienceswere ceswere the then n sum summar marizedin izedin nar narrat rativeform, iveform, wit with h a sec sectionof  tionof  thee re th repo port rt de devo vote ted d to eac each h ta targ rget et ex exper perien ience ce.. Qu Ques estio tions ns we were re ra raise ised d in th this is ph phas asee of  thee pr th proj ojec ectt co conc ncer erni ning ng wh what at to do wi with th fi find ndin ings gs re repor porte ted d in on only ly on onee or tw two o st stud udie ies, s, how ho w to us usee th thee pri prima mary ry da data ta th thee ori origin ginal al in inve vest stiga igato tors rs us used ed to su suppo pport rt th thee in inte tegra gra-tion ti on of fi find ndin ings gs,, an and d wh what at fo form rm th thee me meta tasyn synth thesi esiss pr produ oduct ct sh shou ould ld ha have ve.. Th Thee in inve vesstigators 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 metasy met asynth nthesis esis in the their ir prac practice tice wit with h HIV/AID AIDS S pat patient ientss as a bas basis is for app apprais raisal al and intervention. For example, they were surprised to find how common the effort to “find meaning” in HIV/ HIV/AIDS was among affected persons. perso ns. This meta-finding enabled them to think of this effort as a positive outcome of coping toward which patient pat ientss str strove.The ove.The fin findin dings gs of the their ir met metasy asynth nthesisalso esisalso heig heighte htened ned the their ir awa awaren reness ess of th thee ev ever eryd yday ay wo work rk in invo volv lved ed in liv living ing wi with th HI HIV V/AI AIDS DS an and, d, th ther eref efor ore, e, of th thee nee need d to com commun munica icate te thi thiss to pat patien ients. ts. Tha Thatt is, liv living ing lon long g andwell wit with h HIV/AID AIDS S is no nott 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 soc ial st stigm igmaa al also so en enco cour urag aged ed Ba Barr rros oso o an and d Po Powe wellll-Co Cope pe to di disc scus usss mor moree fu fully lly wi with th

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their patients the potential value of telling their loved ones about their infection. Finally Fin ally,, the meta meta-fi -findi nding ng of “sh “shatt attere ered d mea meanin ning” g” led themto bec become ome mor moree awa aware re of  patients who might require assistance to “find meaning” in HIV/AIDS. The net effectof eff ectof the their ir met metasy asynth nthesiswas esiswas to con confir firm m wha whatt the they y hadintuit hadintuited ed by wor workingwith kingwith patients with HIV HIV/ /AIDS but on which they had been hesitant to act. In su summ mmar ary y, ou ourr pr prel elimi imina nary ry ef effo fort rtss co conf nfirm irmed ed ou ourr vie view w of th thee po poten tenti tial al va valu luee 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. study. What we found concerning infertility infertility and HIV was was not the point here, so so thosefindings are arenot not featu featured.Rather red.Rather,, we feat feature ure thosefindings conce concerning rningmeth methods, ods, whic whichh 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 (AIDSL (AI DSLINE, INE, MED MEDLIN LINE, E, CINA CINAHL, HL, and Psy PsychI chInfo nfo)) wer weree rev review iewed ed to loca locate te qua qualita lita-tive studies on women with HIV/AIDS. Using such keywords as women women,, females females,, mothers,, HIV , AIDS mothers  AIDS,, qualitative research, research , naturalistic research, research , grounded theory theory,, phenomenology,, ethnography enology ethnography,and ,and interview interview,, we hav havee alr alread eady y loc located ated 25 con confer ferenc encee abs abstra tracts cts,, 26 pub publish lished ed art article icles, s, and1 boo book k cha chapte pterr, ran rangin ging g fro from m 4 to 22 pag pages. es. Ourlocati Ourlocation on of  25 research abstracts reveals that a large number of qualitative studies on women with wit h HIV/AID AIDS S hav havee beenprese beenpresente nted d at con confer ferenc ences es in the pas pastt 3 yea years, rs, af affir firmingthe mingthe importa impo rtance nce of thi thiss are areaa for meta metasyn synthe thesis sis eff effort orts. s. A sign signifi ifican cantt num number ber of the these se con con-ference 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  studie stu diess tha thatt arenot pub publish lished ed wil willl lik likely ely be ret retriev rievabl ablee andtheref andthereforealso orealso con contrib tribute ute to th thee da data ta ba base se fo forr th this is pr proj ojec ect.) t.) Ot Othe herr re resu sults lts fr from om th this is se sear arch ch ar aree re refe ferr rred ed to in th thee section sec tion on Rese Researc arch h Des Design ign and Met Method hods. s. In this paragraph, we emphasized our preparationfor rat ionfor theprop thepropose osedd stu study dy andfurth andfurther er def defend ended ed thechoic thechoicee of HIVstud HIVstudiesas iesas con consti stitut tutinga inga  good method case. In the following section, section, we featured featured only those aspects of of each research research team tea m mem member’ ber’ss bio biogra graphythat phythat wer weree dir direct ectly ly re relev levantto antto theprop thepropose osedd stu study dy.. Wealso inc includ luded ed key scholars in the area of metasynthesis—w metasynthesis—whose hose work we previously reviewed—to partici pate as members of our Expert Panel. Panel.

Expertise of the Research Team The research team is well prepared to conduct this project. Margarete Sandelowski, Sandelowski , principal investigator, is an internationally recognized expert in qualitative methods. Her research has been in women’s 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

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from across the United States and several other o ther countries. She is editor edito r of and contributor to the “Focus on Qualitative Methods” series in Research in Nursing &  Health,, a member of the editorial boards of Qualitative  Health of Qualitative Health Research and Field  Methods (a new interdisciplinary journal devoted to qualitative methods), and the North Nort h Ame America rican n edi editor tor of Nursing Nursing Inqui Inquiry ry,, an Aus Austra tralianjourn lianjournal al emph emphasiz asizing ing “cr “critiitical” qualitative methodologies. She is regularly invited to present keynote addres add resses ses and dist distingu inguishe ished d lec lectur tures, es, con conduc ductt wor worksh kshops, ops, and pro provid videe indi individ vidual ual 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 gen gender der and tec techno hnolog logy y. She has pub publish lished ed ext extens ensivel ively y in bot both h nur nursin sing g and soc social ial 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 i ncluding 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 “Tran “T ransiti sition on to Par Parenth enthood ood of Inf Inferti ertile le Cou Couples ples”” stu study dy,, in whi which ch she serv served ed as prin princicipall in pa inve vest stiga igator tor an and d wh whic ich h wa wass fu fund nded ed by th thee fo form rmer er Na Nati tiona onall Ce Cent nter er fo forr Nu Nursi rsing ng Research from 1988-1993 (NRO1707).  Julie Barroso Barroso,, coco-prin princip cipal al inv invest estiga igator tor,, bri brings ngs bot both h res resear earch ch and cli clinic nical al expe experirience en ce to th this is pr proje oject ct.. Sh Shee is an ad adul ultt nu nurse rse pra pract ctiti ition oner er wi with th ex exte tens nsiv ivee cl clin inica icall ex exper periience en ce in ca cari ring ng fo forr peo people ple wi with th HI HIV V dis disea ease. se. Sh Shee cu curr rrent ently ly ma maint intai ains ns a pra pract ctice ice wi with th HIV-po HIV -positi sitive ve pat patien ients. ts. In add additio ition n to com complet pleting ing the qua qualita litativ tivee meta metasyn synthe thesis sis pro pro- ject described d escribed above, she has conducted and published publi shed qualitative quali tative 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 conductt a stu duc study dy of HIV HIV-r -relat elated ed fat fatigu igue, e, wit with h fun funding ding fr from om Ort OrthoB hoBioT ioTech ech and fr from om the UNC-CH UNCCH Sch School ool of Nur Nursing sing,, Cen Center ter for Rese Researc arch h on Chr Chroni onicc Illn Illness, ess, whi which ch rec recentl ently y receiv rec eived ed ren renewe ewed d fun fundin ding g for 5 yea years rs fr from om NINR NINR.. Mor Moreov eover er,, she has mai mainta ntaine ined d 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/ HIV/AIDS at Area Health Education Consortium (AHEC) HIV conferences around the state. The Expert Panel, Panel, whose members will provide both consu consultation ltation and expert peer re peer revi view ew fo forr th thee pr prop opose osed d pr proje oject ct,, is ma made de up of sc scho hola lars rs wi with th th thee me meth thod odolo ologi gi-cal, substantive, and clinical expertise required for this project. These scholars includee investi includ investigators gators on the metasy metasynthesis nthesis projec projects ts we discus discussed sed previ previously ously..Cheryl Tatano Beck  is nationally known for her use of both qualitative and quantitative resear res earch ch meth methods ods,, prim primari arily ly in the are areaa of post postpar partum tum depr depress ession. ion. She has also con con-ducted 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

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metasyntheses of health-related research findings. Having also conducted quantitative meta-analyses, she brings a broad view of issues related to research integrationto thi thiss pro projec ject. t. MargaretKearney  Margaret Kearney is wel welll kno known wn for her qua qualita litativ tivee res resear earch ch in the area of women and substance abuse. She has also completed theoretical syntheses from fr om he herr ow own n wo work rk an and d oth other er st stud udiesin iesin th this is ar area ea.. Geor George ge Nobl Noblit it is we well ll kn know own n fo forr his qualitative expertise in the field of education. His text on metaethnography provided the impetus for conducting qualitative metasynthesis research. In addition, his res resear earch ch in edu educat cation ion has bee been n orie oriente nted d tow towar ard d the use of qua qualita litative tive fin finding dingss to improvee educa improv education. tion. Gail Powell-Cope is a su subs bsta tant ntiv ivee an and d cl clini inica call exp exper ertt in th thee HI HIV V/ AIDS AID S fie field. ld. In add additio ition n to coll collabo aborat rating ing wit with h Dr Dr.. Bar Barros roso o in con conduc ducting ting a qua qualita litativ tivee metasy met asynth nthesis esis pro projec ject, t, she has pub publish lished ed sev severa erall stu studie diess on HIV sym symptommanage ptommanage-ment me nt an and d AI AIDS DS fa famil mily y ca care regiv giving ing.. Sh Shee al also so ha hass ex exten tensiv sivee ex exper perie ienc ncee wo work rkin ing g as an adult nurse practitioner with people with HIV disease. Sally Thorne is internationally kno known wn for her expe experti rtise se in qua qualita litativ tivee res resear earch, ch, espe especia cially lly in the are areaa of chr chroni onicc illness. She recently published the results of a metasynthesis project on diabetes. Lettersof Let tersof sup suppor portt fr from om the these se sch scholar olarss arelocate arelocated d in Sec SectionI. tionI.Sec Sectio tion n I is notrepr notreprint inted ed here.

Research Design and Methods The res resear earch ch des design ign is dir direct ected ed tow towarddevelo arddevelopin ping g meth method od and the theref reforeentail oreentailss the challenging tasks of describing a process-to-create-a-process and “experimentation”” wit tion with h var variou iouss app approa roache chess to con conduc ducting ting and cre creati ating ng met metasyn asynthes theses. es. As is the case ca se wi with th an any y qu qual alita itativ tivee pr proj ojec ect, t, th thee des desig ign n wi will ll be eme emerg rgen ent, t, or hi high ghly ly de depen pende dent nt on the ongoing results of this experimentation as the study progresses. Although we sepa separat ratee dat dataa col collect lection, ion, ana analys lysis, is, and int interpr erpretat etation ion her here, e, the bet better ter to com commumunicate our research plans, these processes typically proceed together and strongly influence each other in qualitative studies. Design dictates what the quantitative resear res earche cherr will do; in con contra trast, st, wha whatt the qua qualita litative tive res resear earche cherr does det determi ermines nes 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 resear res earch ch inte integra grationlitera tionliteratur turee ini initial tially ly to desi design gn thisproje thisproject. ct. Thislitera Thisliteratur turee inc includ ludes es 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 locatin loc ating, g, dime dimensio nsional nalizin izing, g, and app apprais raising ing stu studies dies.. Alth Althoug ough h we beg begin in this pro projec jectt 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 andthat willprese willpreserve rve theintegr theintegrity ity of eac each h stu study dy we ana analyz lyze. e. We hav havee org organi anizedthe zedthe description of our research plan to approximate the content and order commonly associa ass ociated ted wit with h res resear earch ch inte integra gration tion stu studies dies (Co (Coope operr & Hed Hedges ges,, 199 1994). 4). We desc describe ribe 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 hum an sub subjec jects ts stu study dy andto re reinf infor orce ce themetho themethod-o d-on-m n-meth ethod od foc focus us of theproj theproject ect.. In ess essenc ence, e,

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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 resea re searc rchh des design ign.. We nam named ed the con concep cepts ts and lit litera eratur tures es to whi which ch we wer weree sen sensit sitize izedd but als alsoo suggestedthattheywouldhavetoearntheirwayintothestudytoremainguides.Thetemporal log logic ic of the sec sectio tions ns tha thatt fol follow low is act actual ual clo clock ck tim time: e: Wha Whatt we des descri cribe be fir first, st, sub subseq sequen uently tly,, and last is what we anticipate we will do first, subsequently, and last. The division of the descri des cripti ption on of des design ign int intoo cle clearl arlyy def define inedd sec sectio tions ns hel helps ps wri writer terss to mai mainta ntain in the their ir foc focus us sol solely ely on the topic of that section and it offers reviewers a clean and clear narrative flow. Devices suchh as sec suc sectio tion n hea header derss and vis visual ual dis displa plays ys eas easee the re readi ading ng pr proce ocess ss for re revie viewer wers, s, who oft often en havee a doz hav dozen en len length gthyy pr propo oposal salss to cri critiq tique ue in anyone re revie viewi wing ng per period iod.. Alt Althou hough gh qua qualit litati ative ve research rese archdesi designs, gns, and rese researchintegrat archintegration ion studi studies es in parti particular cular,, are areiter iterativeand ativeand delib deliberate erately ly nonlinear processes and their phases experientially inseparable, the act of writing requires thatt the tha these se pr proce ocesse ssess be ana analyt lytica ically lly sep separa arated ted and lai laidd out in som somee tem tempor poral al ord order er.. How Howeve everr, we sho show w our re recog cognit nition ion of the non nonlin linear ear nat nature ure of the re resea searc rchh pro proces cesss by emp emphas hasizi izing ng tha thatt 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 res resear earch ch int integra egratio tion n stu studies dies,, the res resear earche chers rs typ typica ically lly begi begin n by def definin ining g the sub sub-stantive, methodological, and temporal boundaries for study. To begin this study, we hav havee alr alread eady y ide identif ntified ied the bro broad ad sub substa stantiv ntivee are areaa as enc encompa ompassin ssing g the expe expeririences 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/ an d/or or co cond nduc ucte ted d be betw tween een 19 1993 93 an and d Ma Marc rch h 20 2003 03 wi with th wo wome men n in th thee Un Unite ited d St Stat ates es who are seropositive for HIV in which some aspect of their experience is the primary mar y sub subjec jectt mat matter ter.. We def define ine qua qualita litativ tivee stu studies dies as emp empiric irical al res resear earch ch con conduc ducted ted in any research paradigm, using largely qualitative techniques for sampling, data collect col lection ion,, dat dataa ana analysi lysis, s, and inte interpr rpreta etation tion,, wit with h hum human an part partici icipan pants ts 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 exa mple,, gro ground unded ed the theory ory canbe con conduc ducted ted in a neo neoposi positivi tivist st or con constr struct uctivi ivist st par par-adigm (Annells, 1996). A “neopositivist” conducting grounded theory believes in an ext externa ernall and obj object ective ively ly ver verifi ifiabl ablee rea reality lity.. In con contra trast, st, a “co “const nstruc ructiv tivist”conduc ist”conductting grounded theory believes in multiple, experientially based, and socially construct str ucted ed rea realiti lities. es. For the neo neoposi positiv tivist,concep ist,concepts ts emer emerge ge or ar aree disc discove overed red,, as if the they y 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  thes th esee st stud udiesappe iesappear ared ed (a (ass ind indic icat ated ed by ou ourr sea searc rch h to da date te), ), an and d Ma Marc rch h 20 2003 03,, 2 yea years rs  before the anticipated termination of the proposed project. Excluded from our pro ject are (a) qualitative studies in which there are no human subjects per se (as, for example exa mple,, in disc discour ourse, se, qua qualita litativ tivee con conten tent, t, sem semioti iotic, c, or oth other er qua qualita litativ tivee ana analys lyses es of  media representations of women with HIV/AIDS); (b) qualitative studies about nonseropositive women and their experiences as mothers, partners, relatives,

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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 quan qu antit titat ativ ivee st stud udies ies.. We an anti tici cipa pate te th that at app appro roxi xima matel tely y 30 to 35 stu studi dies, es, wi with th a tot total al of 450 to 525 pages of text, will make up the bibliographic sample in the method case. Here, 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 wil willl loca locate te the these se stu studie diess usi using ng the tec techniq hniques ues for inf inform ormatio ation n ret retriev rieval al tha thatt Coo Coo-per (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 ti on ab abou outt st stud udies ies by ne netw twork orkin ing g wi with th re rese sear arch chers ers in th thee ta targ rget et ar area ea (h (her eree th thee HI HIV V/ AIDS field) and at conferences and other professional meetings, such as the Nationa Nat ionall Con Confer ferenc encee on Women and HIV HIV.. The anc ancestr estry y appr approac oach h inv involv olves es tra tracki cking ng citations from one study to another until citation redundancy occurs. The descendency approach involves the use of citation indices (such as Social Science Citatio Cita tion n Ind Indexe exes) s) to loca locate te stu studies dies.. The use of com comput puter er dat databa abases ses inv involv olves es the car careefull sel fu selec ectio tion n of key keywo word rdss an and d ph phra rase sess to lo loca cate te st stud udie iess in jo jour urna nals ls,, bo books oks,, dis disse serta rta-tions, 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 propo pr oposa sal. l. Th Thee em emplo ploym ymen entt of al alll of th theseretr eseretriev ieval al ch chan anne nels ls wi will ll ma make ke it mo more re lik likely ely we wi will ll ca captu pture re fu fugi gitiv tivee lit liter erat atur ure, e, or st stud udies ies th that at ar aree no nott pu publ blish ished ed or mi migh ghtt ot othe herrwise wi se es esca cape pe re retr triev ieval. al. Th Thee fa failu ilure re to ca captu pture re su such ch lit liter erat atur uree is co cons nside idere red d a th thre reat at 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 stu dy wil willl the then n be deta detailed iled,, or ana analyze lyzed d for its str struct uctur ure, e, inf informa ormation tional al con content tent,, and meth me thodo odolo logic gical al or orien ienta tati tion on.. We wi will ll in initi itial ally ly us usee th thee gu guide ide sh show own n in Fi Figu gure re 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 studie studiess in the Barros Bar roso/P o/Powe owellll-Cope Cope (20 (2000) 00) pro projec ject, t, ar aree sho shown wn in Appe Appendi ndix x B (not repr reproduced oducedhere 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 studie stu diess use used d to cr createit. eateit. Aft After er we rec receiv eivee the their ir eva evalua luation tions, s, we wil willl fur furthe therr ref refine ine the guide to include additions or amendments they recommend. The Expert Panel memb me mbers ers wi will ll th then en re revi view ew a se seco cond nd ve versi rsion on of th this is gu guid idee to de deter termi mine ne wh whet ether her th thee 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  thes th esee re revi visio sions ns we were re ex exte tens nsive ive,, ea each ch me memb mber er wi will ll be as aske ked d to ap applythis plythis sec secon ond d ve verrsion of the guide to a different set of five randomly selected studies. They will also

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FIGURE FIGUR E 1:

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Topica opicall Guide Guide for Deta Detailing iling Studi Studies es

 be asked to comment on whether the revisions solved the problems raised for them in rev reviewi iewing ng the fir first st set of stu studies dies.. We wil willl fur furthe therr ref refine ine the gui guide de if any add additio itional nal revisions are warranted after this second review. Consensus on any persistently troublesome features of the guide will be reached through a process of negotiation describe desc ribed d lat later er in the sect section ion on Pr Proce ocedur dures es for Enh Enhanc ancing ing Stu Study dy Valid alidity ity.. Although  Although we will discuss validation techniques later, in a section of the proposal reserved for this pur pose, the concern to ensure valid findings is foundational to every design choice. Accordingly, we embed these techniques throughout the design section. Beforee the findings from studies can be synthesized, the studies themselves Befor must mu st be un unde ders rstoo tood d fo forr wh what at th they ey un uniq ique uely ly ar are. e. Ea Each ch st stud udy y mu must st be un unde derst rstoo ood d as provid pro viding ing a spec specific ific con contex textt for its fin findin dings gs bef before ore att attempt emptss ar aree mad madee at cro crossss-stu study dy compar com parison isonss or com combina bination tionss of fin findin dings. gs. The obj object ective ivess her heree ar aree to und underst erstand and the particular configuration and confluence of elements characterizing each study as the investigators themselves presented them and to preserve the integrity of each study stu dy.. This obj objecti ective ve can be dif diffic ficult ult to ach achieve ieve bec becaus ausee of the gre great at div diversi ersity ty in con con-ducting 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 condu cting qualit qualitative ative resear research ch integra integrations. tions. First, unlike quanti quantitative tative resea researcher rchers, s, qualitative researchers are not necessarily obliged to sep arate the “results” of their studies physically from their “discussion” of these results. Accordingly, the review rev iewer er mus mustt kno know w howto fin find d the res result ultss thr throug oughou houtt theresear theresearch ch rep report ort,, andthis skilll ent skil entail ailss an und unders erstan tandin ding g of var variou iouss for format matss and lan langua guage ge con conven vention tionss for the

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written writte n pre presen sentat tation ion of qua qualita litativ tivee res resear earch. ch. Ourgoal is to spec specifythese ifythese con conven vention tionss with wi th th thee la larg rger er goa goall of en ensu surin ring g th that at an any y tw two o re revi view ewer erss of an any y on onee qu qual alita itati tive ve st stud udy y will identify the same results. Finding the results of studies is a necessary prelude to determining the topical topi cal 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/ HIV /AIDS we have alrea already dy locate located, d, the findin findings gs have addr addressed essed diversetopics—all aspects of the HIV/AIDS experience—including 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 women’s experiences of HIV/AIDS addres add ressed sed in the fin finding dingss of eac each h stu study dy.. Bas Based ed on Bar Barros roso’s o’s met metasy asynth nthesis esis (Ba (Barro rroso so & Powell-Cope, 2000), this kind of grouping appears to us now as more relevant than tha n gro groupi uping ng stu studie diess by met method hod.. We re refe ferr ba back ck to pr prel elim imin inar aryy wo work rk he here re to sh show ow ho how w it informed our design choices in the proposed study. Because studies typically contain find fi ndin ings gs on mo more re th than an one as aspec pectt of ex exper perien ience ce,, we wi will ll us usee an ope open n sy syste stem m of cl clas as-sification, by which any one study may m ay be placed in more than one group. We 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, writer wri terss can sim simply ply sta state te tha thatt the theyy wil willl use a sys system tem (wh (which ich mig might ht sim simply ply be a wor word-p d-pro roces cesssing program) to be determined later. We will then be able to focus on each aspect of  exper ex perien ienceand ceand al alll ofthe fi find nding ingss re rela latedto tedto it.Ourgoalher it.Ourgoalheree isto de deve velopandarti lopandarticu cu-latee tec lat techni hnique quess to isol isolate ate the fin findin dings gs aro around und a tar target get exp experie erience nce whi while le main maintain taining ing 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 wi ll bea se sett of fi find nding ingss in in indiv dividu idual al st stud udie iess an and d ac acro rossstud ssstudieson ieson ho how w wo womenwit menwith h HIV HI V ma mana nage ge soc social ial re relat latio ions ns an and d on ho how w wo women men ma mana nage ge sy symp mpto toms ms th that at wi will ll ea each ch  be filed separately s eparately.. However, the findings in i n these two topical areas may be com bined if we discern a link between managing social relations and managing symptoms.The to ms.The det detai ailin ling g wo work rk in th this is ph phas asee of th thee pr proje oject ct wi will ll all allow ow us to “s “see”suchrela ee”suchrela-tions and to communicate how to see them. This Th is de deta taili iling ng wo work rk wi will ll per permit mit us als also o to ad addr dress ess an anot other her pr prob oblem lem in co cond nduc uctting qualitative metasynthesis, namely, determining the methodological compara bility of studies and whether and/or how methods influence findings. Given the variet var ieties ies of way wayss in whi which, ch, for exa example mple,, gr groun ounded ded the theorie ories, s, phen phenome omenolo nologies gies,, 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 usess of meth use method od lan langua guage ge to comp compar aree stu studie dies. s. Depe Dependin nding g on the their ir wor worldv ldview iew or dis dis-ciplinary commitments, one investigator’s phenomenology might be more like anothe ano therr inv investi estigat gator’s or’s gr groun ounded ded theo theory ry tha than n the gro ground unded ed the theory ory of a thir third d inv investi esti-gator. One investigator’s rendering of symbolic interactionism might be more like another investigator ’s rendering of critical theory theory.. Accordingly, Accordingly, our work with the guide gui de in Fig Figure ure 1 will inv involve olve dev develop eloping ing a mea means ns to det determi ermine ne the met methodo hodolog logical ical compar com parabi ability lity of stu studies dies bel below ow the sur surfac facee of lang languag uagee and rhe rhetori toric. c. This wor work k wil willl permit perm it us to disc discern ern how meth methodo odologi logical cal pra practi ctices ces mig might ht hav havee inf influen luenced ced the fin finddings of a study, and will be a prelude to evaluating the quality of the studies. As show sh own n in Fi Figu gure re 1, we ha have ve in incl clud uded ed it item emss th that at as ask k th thee re revi view ewer er to sp spec ecif ify y no nott ju just st thee wo th word rdss in inve vest stiga igato tors rs us used ed to de defi fine ne th their eir st stud udies ies,, bu butt als also o th thee ci cita tatio tions ns th they ey us used ed

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and the actual interpretive product shown in the research report. We will further develop these items in the course of the project. When Wh en th this is wo work rk is co comp mplet leted ed,, we wi will ll pr prov ovid idee na narr rrat ativ ivee an and d qu quan antit titat ativ ivee su summmaries mar ies of the inf inform ormati ation on we col collec lected ted fro from m thi thiss pro proces cess. s. Forexampl Forexample, e, we wil willl sho show w the total and mean sample sizes across studies. We will show the frequency with which whi ch dif differ ferent ent met method hodolog ologica icall app approa roache chess wer weree use used d and top topics ics wer weree stu studied died.. We will wi ll lo look ok fo forr an any y as assoc sociat iatio ions ns be betw tween een met metho hods ds us used ed an and d to topic picss ad addr dress essed ed in st stud ud-ies. This work will provide an overall profile of qualitative research with women with HIV/ HIV/AIDS and permit us to suggest useful ways for synthesists synthesi sts to describe des cribe a set of studies. This work will allow allo w 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 th Once thee de deta taili iling ng wo work rk is co comp mplet lete, e, we wi will ll ad addr dres esss th thee pr prob oblem lem of ev evalu aluat atin ing g th thee 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 iss issue ue of qua qualit lity y rem remain ainss con contro trover versialamong sialamong res resear earche chers rs con conduc ductin ting g qua quanntitative integrations, with some scholars arguing that no study should be excluded forr re fo reas ason onss of qu quali ality ty an and d ot othe hers rs ar argu guing ing fo forr a “b “best est-e -evi vide denc nce” e” ap appr proa oach ch,, by wh whic ich h less rigorous studies can be excluded (Cooper, 1989; Slavin, 1995). Quantitative resear res earche chers rs also disa disagr gree ee on wha whatt aspe aspects cts of rig rigor or to emph emphasiz asizee in the their ir eva evalua luation tionss of stu studies dies,, for exa example mple,, inte interna rnall ver versus sus ext extern ernal al val validit idity y. Alth Althoug ough h iss issues ues rel relate ated d to qualit qua lity y arenot who wholly lly res resolv olved ed for qua quantit ntitati ative ve res resear earch ch inte integra gration tions, s, the there re appe appears ars to be rea reasona sonable ble con consen sensus sus amo among ng qua quanti ntitat tative ive res resear earche chers rs con concer cernin ning g wha whatt a goo good d 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 qualitativee res tiv resear earch ch as a who whole. le. In add additi ition, on, cri criteri teriaa of goo goodne dness ss (fo (forr any hum human an end endeav eavor) or) are hist historic oricall ally y and cul cultur turally ally con contex textt depe depende ndent. nt. Dif Differ ferent ent com commun munitie itiess of kno knowlwledgee mak edg makers ers and use users rs hav havee san sancti ctioneddiffe oneddifferen rentt crit criteri eriaa of good goodnes ness, s, and the these se cri cri-teria 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 havee emph hav emphasi asized zed suc such h fac factors tors as the rea real-w l-world orld sign signifi ifican cance ce of the que questi stions ons ask asked, ed, the prac practica ticall val value ue of the fin findin dings, gs, and the ext extent ent of inv involv olvemen ementt wit with, h, and per persona sonall  benefit to, the participants of the research (Heron, 1996; Lincoln Li ncoln & 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).

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FIGURE FIGUR E 2:

A Gene Generic ric Guide Guide for Evalua Evaluating ting the the Overall Overall Quali Quality ty of Qualita Qualitative tive Studie Studiess

We will address the problem of quality by experimenting with and adapting availab ava ilable le gen generic eric cri criteri teriaa for eva evalua luating ting any qua qualita litativ tivee wor work k (e. (e.g., g., Bur Burns, ns, 198 1989) 9) and specific criteria directed toward evaluating qualitative work in parti cular methodological domains, such as grounded theory (e.g., Corbin & Strauss, 1990). Indeed, an impo importa rtant nt pro produc ductt of the pro propos posed ed pro projec jectt wil willl be the dev develop elopmen mentt of mor moree use userrfriend fri endly ly gui guides des to eva evalua luate te qua qualita litativ tivee res resear earch. ch. In Figu Figure re 2, we sho show w a pre prelimi liminar nary y guide for evaluating any qualitative study that is di rected toward determining the adequacy and/or appropriateness of the design choices investigators made. Adequacy ref refers ers to whe whethe therr a desi design gn cho choice ice is qua qualita litativ tively ely and and/or /or qua quanti ntitat tative ively ly suf suffificien ci entt to su supp pportthe ortthe cla claimsmade imsmade fo forr it.For ex exam ample ple,, a sa samp mple le siz sizee mig might ht no nott be ad adeequate 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 study i nterrater reliability coding technique to appraise apprai se the findin fin dings gs pro produc duced ed fr from om int interv erviewdata iewdata doesnot fitthe nar narrat rativis ivist’sassump t’sassumptionthat tionthat 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. Thee re Th resu sult ltss of an ap appli plica catio tion n of th thee gu guide idess in Fi Figu gure ress 2 an and d 3 (t (to o th thee sa same me st stud udy y us used ed to apply the guide in Figure 1) are located in Appendix B (not reproduced here). here) . The memb me mbers ers of th thee Ex Exper pertt Pa Panel nel wi will ll al also so ev eval alua uate te th thee co cont nten entt va valid lidity ity an and d us usab abili ility ty of 

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FIGURE FIG URE 3:

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A Gui Guide de for Eval Evaluat uating ing Groun Grounded ded Theor Theory y Studies Studies

these guides by applying them to yet another set of five studies randomly selected from fr om th thee sa samp mple le ofHIV st stud udies ies.. We wi will ll th then en wo workto rkto re refi finethes nethesee gu guid ides es in th thee it itera era-tive manner we proposed above to develop the guide to detail studies. A key problem in current evaluation guides, 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 redund red undanc ancy y or the theore oretic tical al satu saturat ration. ion. The ove overal ralll meth methodo odologi logical cal app approa roach ch cho chosen sen 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 rat her tha than n con concre crete, te, pre precon concep ceptua tuall ren renderi derings ngs of exp experie erience nce.. The Theore oretica ticall dev develop elop-ment is, arguably, not a criterion at all for phenomenologies. As a re resu sult lt of exp exper erime iment ntin ing g wi with th th thes esee cr crit iter eria,we ia,we wi will ll be in a be bett tter er po posit sitio ion n to discern disc ern wha whatt rea really lly cou counts nts meth methodo odologi logical cally ly in dec decidin iding g whe whethe therr to disc discoun ountt fin finddings, 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 findin fin dings. gs. For exa example mple,, inv investi estigat gators ors migh mightt use wha whatt somerevie somereviewer werss wou would ld arg argue ue is

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the “wrong” language and method citations to describe their work. A study presented as a phenomenology that is better described as a qualitative descriptive stud st udy y ma may y sti still ll be a ge gene nera rally lly “g “good ood”” st stud udy y. Usi Using ng Bu Burn rns’ s’ss (1 (198 989) 9) st stan anda dard rdss fo forr th thee 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 “methodologica olog icall con congru gruenc ence” e” (p. 48) 48).. Mor Moreov eover er,, a stu study dy pre present sented ed as a phe phenom nomenol enology ogy tha thatt is “re “really ally”” a qua qualita litativ tivee des descrip criptiv tivee stu study dy sho shouldbe uldbe eva evalua luated ted as a desc descript riptive ive stu study dy and not as a phenomenology. Similarly, a qualitative content analysis “wrongly” presented as a narrative analysis should be evaluated as a content analysis. Evaluating ati ng the goo goodnes dnesss of a qua qualita litativ tivee stu study dy req requir uires es rev reviewe iewers rs to dist disting inguis uish h bet betwee ween n nonsign non signifi ifican cantt “er “error rors” s” and mist mistake akess fat fatal al enou enough gh to disc discoun ountt fin findin dings. gs. Our goa goall is to as assi sist st re revi view ewer erss to do th this, is, th that at is is,, to kn know ow sp spec ecif ific icall ally y wh what at to lo look ok at an and d fo forr in a stud st udy y to ju judg dgee th thee va valu luee of it itss fi find ndin ings. gs. By me meet eting ing th this is go goal al,, we ho hope pe to co cont ntri ribu bute te 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 techni tec hnique quess to dis discer cern, n, com compar pare, e, com combin bine, e, and rere-pre present sent the fin findin dings gs of the stu studies dies in the bib bibliog liograp raphic hic sam sample. ple. We ant anticip icipate ate tha thatt we wil willl be usi using ng a var variety iety of ana analys lysis is techni tec hnique ques, s, inc includ luding ing qua qualita litativ tivee con conten tentt ana analysi lysiss tec techni hnique quess (Alt (Althei heide, de, 198 1987; 7; Mor Mor-gan, 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 le ss abstract than theoretical categories. Raw dat dataa he here re re refe fers rs to th thee fi find ndin ings gs in eac each h st stud udy y an and d th thee da data ta in inve vest stiga iga-tors cite to support these findings. We will likely also experiment with techniques other investigators have used in conducting metasyntheses. These include narrativee ana tiv analys lysis is tec techniq hniques ues (Rie (Riessma ssman, n, 199 1993), 3), in whi which ch lar larger ger col collect lective ive,, cul cultur tural, al, and and/ / or met metaph aphoricstoryl oricstorylinesare inesare disc discern erned ed in stu studies dies,, andconsta andconstant nt com compari parison son ana analysi lysiss 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” pattern te rnss in da data ta;; th thee ac actt of loo lookin king g at da data ta re re-p -pre rese sent nted ed in gr grap aphs hs,, ta table bles, s, an and d ot other her di dissplayss ena play enables bles ana analyst lystss to disc discern ern sim similar ilaritie itiess and dif differ ferenc ences es amo among ng stu study dy fin finding dingss arou ar ound nd a ta targ rget et ev even ent, t, th ther ereb eby y al allow lowin ing g th them em to dr draw aw co conc nclu lusi sion onss ab abou outt th thee ext exten entt 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  analyt ana lytic ic tec techniq hniques ues is app approp ropria riate te for whi which ch stu studie diess and pur purpose posess and the then n to com com-municate 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 phenomenologically—as a certain kind of “lived experience”—and a second that addresses it theoretically—as a disease to be medically and socially managed. Our task tas k wil willl be to dete determin rminee whe whethe therr we mus mustt use phe phenome nomenol nologic ogical al the themat matic ic ana analysi lysiss as an initial strategy to synthesize the lived-experience data and constant

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comparison techniques to synthesize the disease management data, as Jensen and Allen All en (1 (199 994)did, 4)did, or or,, wh wheth ether er it is po possi ssibl blee to mo move ve di dire rect ctly ly to a te tech chni niqu quee th that at dr draw awss toget to gethe herr bo both th da data ta set sets, s, as Nob Noblit lit an and d Ha Hare re (1 (198 988) 8) did in co cond nduc ucti ting ng th their eir “r “rec ecip ipro ro-cal translations” translations” of studies studies.. The emphasis in qualit qualitative ative research research is on idiomatic (meani (me aning) ng),, as opp opposed osed to sema semantic ntic (li (litera teral), l), tra transla nslatio tion n (No (Noblit blit & Har Hare, e, 198 1988). 8). Here,  Here, we are using the literature we reviewed previously and referring back to our preliminary work. Qua Qualita litativemetasy tivemetasynth nthesisentail esisentailss the ana analysi lysiss of cul cultur turallydivers allydiversee text textss in dif dif-ferent fer ent lan langua guages ges (al (albeitall beitall Eng English lish,, in thi thiss cas case), e), tha thatt is, tex texts ts cre create ated d in dif differ ferent ent dis dis-ciplinary and philosophical contexts. Accordingly, the key to integrating the findings in gs of stu studi dies es ar arou ound nd a ta targ rget et ev even entt ma may y we well ll lie in re reco cogn gnizi izing ng,, fo forr ex exam ample ple,, ho how w they th ey all re repri prise se fa famil milia iarr cu cult ltur ural al sto stori ries, es, su such ch as th thee her hero( o(ine ine)) on a qu quest est or th thee wa warrrior bat battlin tling g an ene enemy my (e. (e.g., g., Mar Martin, tin, 199 1990). 0). Suc Such h ana analyti lyticc exp experim eriment entatio ation n is impo imporrtant 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  resea re searc rch h fi find nding ingss in fo forms rms th that at ca cann nnot ot ea easil sily y be un unde derst rstoo ood d or ap appli plied ed (F (Fun unk k et al al., ., 1995). The ultimate objective of all of the work detailed thus far is to create usable knowle kno wledge, dge, whi which ch nec necessa essarily rily ent entails ails a muc much h mor moree seri serious ous att attent ention ion to how kno knowlwledge is presented than has hitherto been given in discussions of research use. Despite Desp ite the bur burgeon geoning ing lite literat ratur uree on rh rhetor etoric ic and disp display lay in sci scienc encee (e. (e.g., g., Gus Gusfie field, ld, 1976; Lynch, 1985; Lynch & Woolgar, 1990; Moore & Clarke, 1995; Van Maanen, 1988), in which scientific reports, tables, graphs, and anatomical displays are view vi ewed ed as ex exam ample pless of ho how w form is content content,, dis discus cussion sionss of for form m are typ typica ically lly vie viewed wed as ou outsi tside de th thee re real alm m of an and d irr irrele eleva vant nt to sc scien ience ce.. Mo More reov over er,, des despit pitee th thee bu burg rgeon eonin ing g 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 th this is ph phas asee of th thee pr proj ojec ect, t, an anot othe herr of ou ourr go goal alss wi will ll be to ex expe peri rime ment nt wi with th di diffferent 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. Representatio Repres entation n in qualit qualitative ative research refers, not to repr representat esentative ive 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., theorie theories, s, concept concepts, s, workin working g hypothe hypotheses, ses, analyt analytic ic genera generalizatio lizations); ns); storied renderin ren derings gs empha emphasizin sizing g char characte acterr, plot, plot,scen scene, e, and/ and/or or meta metaphor phor;; phen phenomen omenolog ological ical descript desc riptions ions;; and inf inform ormatio ational nal con conten tentt sum summar maries ies of eve events nts.. Our goa goall is to disc discern ern the dif differ ferent ent int interpr erpreti etive ve pro produc ducts ts tha thatt mig might ht be pro produc duced ed tha thatt wil willl cap captur turee the sub sub-tleties in findings and be most useful to researchers and practitioners. (We will not address addre ss here other audiences, most notab notably ly policy makers and patient patients.) s.) Here is another anoth er examp example le of strat strategic egic disar disarmamen mament. t. Writ Writers ers shoul shouldd stat statee expli explicitly citlywhat whatthey they will willnot not do whenever they anticipate that reviewers might expect it. This mig might ht inv involv olvee dev develop elop-ing techniques to transform findings into guidelines for practice for the clinician and working hypotheses for the researcher. In a “clinical sidebar” attached to the

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report of the Paterson et al. (1998) metasynthesis on living with diabetes, Gillespie observ obs erved ed tha thatt the val value ue of the their ir res resear earch ch inte integra gration tion lay in help helping ing cli clinic nicians ians see the importa impo rtance nce of rec reconc oncept eptual ualizin izing g the tar target get of app apprais raisal al and inte interve rventi ntion on in the car caree ofpersonswiththedisease,thatis,nurseswereadvisedtoseediabeticpersonspositively—as actively striving to balance their disease with a normal life—instead of  negatively—as negativ ely—aspotenti potentially ally noncom noncompliant pliantwith with prescr prescribed ibed regim regimens. ens. The findin findings gs of  the integration suggested the “working hypothesis” and “working course of  action act ion,” ,” nam namely ely,, tha thatt tre treatin ating g the these se pat patient ientss as act active ive man manage agers rs led to bet better ter com complipliance, whereas treating them as potentially noncompliant led to noncompliance.

Procedures for Enhancing Study S tudy Validity We will use several techniques to maximize the validity of this study, including (a)the main maintena tenance nce of an aud audit it tra trail il (Ro (Rodge dgers rs & Cow Cowles,1993) les,1993),, (b)the neg negotia otiatio tion n 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 stud st udiesnot iesnot in inclu clude ded d in th thee me meth thod od ca case se,, an and d (e (e)) app applic licat ationof ionof th thee fi fina nall pr prot otoc ocol ol to a “tes “t estt ca case, se,”” or set of st stud udie iess in a di diff ffer eren entt do doma main in of re rese sear arch ch.. Th These ese tec techn hniqu iques es wi will ll  be directed toward ensuring the descriptive, theoretical (Maxwell, 1992), and pragmatic mat ic (Kv (Kvale,1995) ale,1995) val validit idity y of stu study dy fin findin dings. gs. Des Descrip criptiv tivee val validit idity y ref refers ers to the “fa “facctual tu al ac accu cura racy cy”” (M (Max axwe well, ll, 19 1992 92,, p. 28 285) 5) of ou ourr det detai ailin ling g of ea each ch of th thee st stud udie iess ma maki king ng up the dat dataa for thi thiss pro projec ject, t, for exa example mple,, ent enterin ering g thecorrec thecorrectt sam sample ple siz sizee andcharac andcharac-teristi ter istics, cs, set settin ting, g, and dat dataa col collect lection ion tec techni hnique ques. s. Desc Descript riptive ive val validit idity y is abo about ut rep repreresenting sen ting the “fa “facts cts of the cas case” e” acc accura urately tely and typi typical cally ly inv involv olves es lowlow-inf infere erence nce dat data, a, 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 procedu ce dure ress we us used ed to pr produ oduce ce th them em.. Th Theo eore retic tical al va valid lidit ity y is ab abou outt ma maki king ng th thee ca case se fo forr the analytic and re-presentational techniques developed in the study. Pragmatic validity refers to the utility and applicability of knowledge: for example, whether the tec techniq hniques ues and pro protoc tocol ol we dev developcan elopcan be eas easily ily use used. d. Here,  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 movee to nam mov namingand ingand def defini ining ng spe specif cific ic val valida idatio tion n tec techni hnique quess andto sho showin wingg the their ir app applic licati ation on 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  tech te chni niqu ques es oth others ers ca can n un under derst stan and d an and d us use. e. Th Thee au audi ditt tr trail ail in th this is stu study dy wi will ll be co commposed 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 why.. Ana Analyti lyticc doc docume umenta ntatio tion n ref refers ers to dec decisio isions ns mad madee in cod coding ing,, cat categor egorizin izing, g, and comparing data. In the proposed project, this documentation will not only servee to ens serv ensur uree the tru trustw stwort orthin hiness ess of fin findin dings gs but will its itself elf be dat dataa tha thatt con contri tribut butee to fin finding dings. s. Anal Analyti yticc doc docume umenta ntationwill tionwill inv involv olvee tra tracki cking ng pha phases ses in theevolut theevolution ion of  the various tools we will develop and the evolution of the actual metasynthesis.

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To enh enhanc ancee the uti utilityof lityof thisaudit tra trail il as bot both h dat dataa and doc docume umenta ntation tion,, we wil willl use a “th “think/ ink/talk talk-al -aloud oud”” stra strategy tegy (Fo (Fonte nteyn, yn, Ku Kuiper ipers, s, & Gro Grobe, be, 199 1993) 3) to cap captur turee 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 alway alwayss resist expression expression in langua language, ge, a think/ think/talk-a talk-aloud loud 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 whetherr a study meets quality criteria for inclus whethe inclusion, ion, discerning the findings of a study stu dy,, and dis discern cerning ing the rel relati ations onship hip bet betwee ween n fin findin dings gs acr across oss stu studie dies. s. The prin princicipal investi investigators gators will use this strate strategy gy periodic periodically ally,, indepen independently dently to docume document nt their individual thinking and with each other to play their thoughts off each other. Commu Com muni nica cati ting ng th thee pr proc ocesswe esswe us used ed to ar arri rive ve at th thee pr proc oces esss we wi will ll de deve velopto lopto co connduct 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 stu dy,, on the app approp ropria riate te mea means ns to disc discern ern thes these, e, on the fin final al int interpr erpretiv etivee pro produc ducts, ts, and on the process used to create these products. The negotiated validity process willl req wil requir uiree tha thatt tea team m memb members ers expl explica icate te the ori orienta entation tionss and ass assump umption tionss lead leading ing toward various interpretations of study data, and persuade others that they offer thee int th inter erpr pret etat ation ion th that at is mo most st gr grou ound nded ed in an and d th that at be best st fi fits ts th these ese da data ta.. Con Conse sens nsus us is ach achiev ieved ed not by con conven ventio tional nal tec techniq hniques ues for rel reliab iabilit ility y cod coding ing but but,, rat rather her,, ar aroun ound d 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 offe of fere red d fo forr a poi point nt of vi view ew,, th thee “c “cog ogenc ency y of ar argu gume ment nts” s” fo forr it, an and d th thee “in “incis cisiv iven eness ess of obse observa rvation tions” s” rel relati ating ng to it (pp (pp.. 11212-1113) 13).. Conse Consensual nsual valid validity ity he here re do does es no nott re rest st 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 niqu es for esta establi blishin shing g and dem demonst onstrat rating ing inte interra rrater ter rel reliab iabilit ility y off offers ers “no pur purcha chase se on reality” (Eisner, 1991, p. 47). Morse (1997b) cautioned qualitative researchers about abo ut the “my “myth th of int interer-rat rater er rel reliab iabilit ility y.” Suc Such h tec techni hnique quess simp simply ly sho show w tha thatt rat raters ers can, ca n, or ca can n be ma made de to to,, ag agre ree. e. A co corr rrela elati tion on co coef effi fici cien entt is it itsel selff a pr prod oduc uctt of a so soci ciall ally y negotia neg otiated ted pro process cess.. Acc Accord ording ingly ly,, suc such h qua quanti ntitat tative ive tec techni hnique quess ens ensure ure nei neither ther mor moree nor lessvalidi lessvalidity ty tha than n the exp explici licitt pro proces cesss of nego negotia tiationtypica tiontypically lly use used d in qua qualita litativ tivee 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 an d to dis disce cern rn th thee re reas ason onss fo forr ou ourr ag agre reem emen entt ab abou outt th thee det detai aill an and d qu qual alityof ityof st stud udie ies. s.

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Hak and Bernts (1996) found that the research coders they observed never discussed cus sed the cod codes es on whi which ch the they y agr agreed— eed—onl only y the onesover whi which ch the they y disa disagre greed— ed— thereby losing the opportunity to check whether there was consensus on the reasonss fo son forr co cons nsen ensu sus. s. Ou Ourr go goal al he here re is to ar arriv rivee at a se sett of te tech chni niqu ques es fo forr de deta taili iling ng an and d evaluating qualitative studies that will reduce the likelihood of disagreement among amo ng inv invest estiga igators tors.. Depe Dependi nding ng on the out outcom comee of this wor work k (an (and d the Exp Expert ert Pan Panel el work wo rk to be de desc scrib ribed ed be below low), ), it mig might ht be po possi ssibleto bleto dev develo elop p co codin ding g to tools ols fo forr det detai ailling the contents and evaluating the quality of qualitative studies that can be sub jected 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  thee au th audit dit tr trail ail.. Th Thee goa goall her heree is to de deve velop lop te tech chniq nique uess fo forr an anal alyz yzin ing g an and d co comb mbini ining ng qualitative findings that will result in interpretations i nterpretations on which different investigators can comfor comfortably tably agree. Although it is axioma axiomatic tic in qualit qualitative ative research research that interpretations of the same data will vary with each interpreter, qualitative resea re searc rche hers rs ag agre reee th that at a va valid lid int inter erpr pret etat ation ion is on onee th that at is di disc scern ernib ibly ly ba base sed d on da data ta.. Accordingly, our validation work here will be directed toward developing techniques niqu es ar aroun ound d whi which ch con consen sensuscan suscan be com comfor fortab tably ly ach achiev ieved, ed, as oppo opposed sed to qua quanti nti-tative tat ively ly est establ ablishe ished. d. A key comp compone onent nt of the ana analyti lyticc doc docume umenta ntationfor tionfor thisproje thisproject ct will be to describe the process and outcomes of negotiations around issues where this kind of consensus was both easy and difficult to achieve. Acritic Acrit ical al co comp mpon onen entt of th thee neg negot otia iatio tion n of va valid lidit ity y in th this is pr proje oject ct is th thee us usee of th thee Expert Panel. Panel. The expertise required for the proposed project includes qualitative analytic analyt ic and interpretive skills and subst substantive/ antive/clinica clinicall knowle knowledge dge in women’ women’ss health and HIV/ 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 ove rall con conduc ductt of the stu study dy and spec specific ific jud judgmen gments ts abo about ut the met metasyn asynthes thesis is pro prototocoll we wi co will ll de deve velo lop p in th thee co cour urse se of th thee pr proj ojec ect. t. Me Memb mber erss wi will ll be co conv nven ened ed in Ch Chaapell Hi pe Hill ll 2 da days ys ea each ch ye year ar of th thee pr proj ojec ectt fo forr gr grou oup p di disc scus ussi sion on of th thee wo work rk co comp mple lete ted d to date. They will also be convened 1 additional time per year by teleconferencing for 2 hours, and they will participate in ongoing communications—in between these the se onon-sit sitee and dist distanc ancee meet meeting ings—v s—via ia a onli online ne dis discus cussion sion gro group up and disc discuss ussion ion forum.. These activi forum activities ties are designed to permit members to participate fully (in a manner man ner tha thatt is pra practi ctical cal and res respec pectfu tfull of the their ir oth other er wor work k and pers persona onall obli obligat gation ions) s) in evaluating the conten contentt validit validity y, appro appropriaten priateness, ess, and utilit utility y of the guides we develop, and the trustworthiness and utility of the metasynthesis of qualitative findings about women with HIV/AIDS we create. As desc describ ribed ed pre previo viousl usly y, onc oncee the pri princi ncipal pal inv investi estigat gators ors hav havee rea reache ched d con consen sen-suss on th su thee de deta taili iling ng an and d ev eval alua uatio tion n gu guide ides, s, ea each ch mem membe berr of th thee Ex Expe pert rt Pa Pane nell wi will ll be aske as ked d to ap apply ply th them em to a co comm mmon on se sett of at lea least st fi five ve ra rand ndom omly ly sel selec ecte ted d st stud udie ies: s: on onee set fo forr det detai ailin ling g an and d a se seco cond nd set fo forr ev evalu aluat atin ing g th thee qu qual ality ity of st stud udies ies.. We wi will ll ma mail il these studies and the instructions that we have develope d to date to each member. Member Mem berss will als also o rev review iew the doc docume umenta ntation tion of our pro progre gress ss in dev develop eloping ing gui guides des to conduct the metasynthesis itself, itsel f, 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.

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Thee me Th memb mber erss of th thee Ex Expe pert rt Pa Pane nell wi will ll ev eval alua uate te al alll ofthe va vari riou ouss pr prod oduc ucts ts of th this is project usi project using ng an ada adapta ptatio tion n of the que questio stions ns Hun Huntt and McK McKibb ibbon on (19 (1997) 97) dev develop eloped ed to ap appra prais isee sy syst stema ematic tic re revi view ews. s. Th These ese wi will ll be fu furt rthe herr de deve velop loped ed in th thee co cour urse se of th thee proje pr oject ct.. Th Thee qu ques estio tions ns ar aree (a (a)) Di Did d th thee met metas asyn ynth thes esis is fo focu cuss on cl clea early rly de defi fine ned d ar area eas? s? (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 an d ea easy sy to us use? e? (f (f)) Ar Aree th thee sy synt nthe hesis sis pr prod oduc ucts ts pl plau ausi sible ble,, us usab able, le, an and d sig signi nifi fica cant nt fo forr research and/or practice? In addition addition to the members of the the Expert Panel, Panel, we will invite, invite, in the final year 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 and /or int interv erventi ention on stu studiesin diesin the HIVfield to rev review iew the fin final al meta metasyn synthe thesis sis pro prodductss for the uct their ir uti utilityand lityand app applica licabil bility ity to the their ir wor work. k. The clin clinici icians ans wil willl rev review iew a for form m 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 H IV 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 poi nt fo forr th thee me meth thod od ca case se,, to Ma Marc rch h 20 2004 04,, 1 ye year ar be befo fore re th thee endof th thee pr proj ojec ect, t, an and d to (b) a set of qua qualita litativ tivee stu studies dies in an ent entire irely ly dif differ ferent ent dom domain: ain: nam namely ely,, wom women’ en’ss and couples’ experiences with diagnostic/screening technology in pregnancy. Like HIV/AIDS this is a know knowledg ledgee fiel field d of gre great at sign signific ificanc ancee to the hea health lth of chi childbe ldbearing aring famil fa milies ies an and d nu nursi rsing ng pr prac acti tice ce,, an and d it is an ar area ea of exp exper ertis tisee of on onee of th thee co co-p -pri rinc ncipa ipall investigators. Researchers interested in conducting qualitative metasynthesis pro jects will choose areas of research to which they are heavily committed and in which they have clinical and/or research expertise. The app applica lication tion of the pro protoc tocol ol to the add additio itional nal HIV/AID AIDS S stu studies dies will ens ensure ure as upup-toto-dat datee a met metasy asynth nthesisas esisas poss possibleand ibleand wil willl allo allow w us to fin fine-t e-tunethe unethe pro protoc tocol. ol. The application of this fine-tuned protocol to the “test case” (research on prenatal testi te sting ng)) wi will ll all allow ow us to ev eval alua uate te th thee tr tran ansf sfer erab abili ility ty of th thee pr proto otoco coll to ot othe herr ar area eass of  resear res earch. ch. We wil willl notonly rep report ort theresult theresultss of thi thiss met metasy asynth nthesiseffor esiseffortt butalso doc doc-ument 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. clarity

Outcomes of the Proposed Project  The out outcom comes es of the pro propose posed d pro projec jectt inc includ ludee (a) a gui guide de to det detail ail the inf inform ormatio ational nal contents, conten ts, methodo methodological logical orienta orientation, tion, and re-pr re-presentat esentational ional form of any qualita qualitative tive study; (b) a guide, or set of guides, to evaluate the quality of any qualitati ve study; (c)) a se (c sett of gu guid ideli eline ness fo forr ch choos oosin ing g an and d us usin ing g an anal alyt ytic ic te tech chniq nique uess to dis disce cern rn th thee fi find nd-ings in gs of an any y qu quali alita tati tive ve st stud udy; y; (d (d)) a set of gu guid ideli eline ness fo forr ch choo oosin sing g an and d us usin ing g an analy alyti ticc techniques to compare and combine findings across qualitative studies; (e) a set of  guidelines for choosing and using audience-appropriate representational forms to

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Task 

1

2

 Year 3

4

5

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 fine-tuned metasynthesis protocol to “test case” studies Consultation/peer review and evaluation FIGU FI GURE RE 4:

Stud St udy y Tim Time e Lin Line e

disseminate the findings from qualitative metasynthesis projects; (f) an up-to-date metasynthesis of qualitative studies on o n women with HIV 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 vir virtue tue of the met method hod cas casee cho chosen,women,and sen,women,and mino minorit rity y wom women en in par partic ticula ularr, are included. In the 22 studies located to date, 532 women participated. Of these, 249 weree Afr wer Africa ican n Ame America rican, n, 151were Whi White, te, 76 wer weree His Hispan panic/ ic/Lat Latina ina,, and16 bel belong onged ed to other ethnic/racial minorities. (Ethnicity was not reported in 3 of these studies.) Thes Th esee wo wome men n ra rang nged ed in ag agee fr from om 16 to 63 ye year ars. s. (O (One ne st stud udy y di did d no nott re repo port rt ag age. e.)) 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 aree inc ar includ luded ed in the pr propo oposed sed pr proje oject, ct, we cal calcul culate atedd the gen gender der and min minori ority ty att attrib ribute utess 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.

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Vertebrate Animals There are no vertebrate animals in this study.

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REVISING AND RESUBMITTING This proposal was funded after one previous submission. Because any writing enterpr ent erprise ise typ typica ically lly req requir uires es rev revisio ision n and res resubm ubmissi ission, on, wri writer terss ar aree well adv advised ised to develop dev elop the their ir skil skills ls in the these se are areas, as, whi which ch inc includ ludee emo emotion tion and inf inform ormatio ation n man manage age-ment. The most typical initial responses to having a research proposal not approved for funding are sadness, frustration, and anger, with researchers choosing to

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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 readi ng their reviews will often find—in true qualita qualitative tive fashion—that fashion—that 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 com commen ments ts and rev revisio isions ns wer weree thu thuss prim primaril arily y orie orientedtowar ntedtoward d emph emphasi asizin zing g the positiv posi tivee vie views, ws, ove overco rcomingthe mingthe dou doubt bt the two rev review iewers ers exp expres ressed sed,, and spe specif cifica ically lly 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 applica app lication tion RO1 NRO NRO490 4907, 7, “Ana “Analyti lyticc tec techniq hniques ues for qua qualita litativ tivee meta metasynt synthes hesis.” is.” In it,, we su it summa mmariz rizee th thee str stren engt gths hs an and d pr prob oblem lemss no note ted d in ea each ch of th thee fo four ur cr crit itiqu iques es an and d the revisions we made to resolve the problems. All of thereview thereviewers ers eva evalua luatedthe tedthe pro propose posed d stu study dy hig highly hly on its sign signific ificanc ancee and novelty, the strong qualifications of the research team, and the excellent resources availab ava ilable le to the stu study dy.. Rev Review iewer er 2 (Cr (Critiq itique ue 2) eva evalua luated ted thi thiss pro proposa posall as “ou “outsta tstandnding” and as having “exceptionally high scientific merit.” He or she “supported” it “att th “a thee hig highe hest st lev level el of en enth thus usia iasm sm,” ,” (p (p.. 6) 6),, st stat ating ing th that at th thee fi find nding ingss of th thee pr prop opose osed d study could “revolutionize the place of o f qualitative research in the advancement of  ourr kn ou know owle ledg dgee ba base se”” (p (p.. 4) 4).. Re Revie viewe werr 3 fo foun und d th thee pr propo oposa sall “h “high ighly ly sig signi nifi fica cant nt an and d innovative,” and likely to “make a major contribution to nursing science” (p. 7) if  existing barriers to qualitative metasynthesis metasynthesi s could be overcome. Reviewer 1 similarly expressed “enthusiasm,” “enthusiasm,” and Reviewe Reviewerr 4 noted its “poten “potential tial significance” significance” (p. 9). We begin by emphasizing the positive. Yet, alth althoug ough h Revi Reviewe ewerr 2 obs observ erved ed tha thatt our stu study dy cou could ld “mov “movee nur nursing sing scie science nce 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 simi lar “sk “skepti epticism cism”” (p.4) con concer cernin ning g theoutcom theoutcomee of thepropos theproposed ed stu study dy.. Alth Althoug ough h Reviewer 2 found our proposal to be “very ‘user friendly,’ ” comprehensive, and though tho ughtfu tfully lly con conceiv ceived, ed, Rev Review iewer er 4 expr expresse essed d con concer cerns ns abo about ut the lite literat ratur uree rev review iew,, representat repr esentation ion of argu arguments, ments, and design. design.In In theprece theprecedin dingg par paragr agraph aph,, we pla playedrevie yedreviewwers’ comments off each other to emphasize emphasize contradictory opinions. opinions. In sum summar mary y, Rev Reviewe iewerr 2 was ent enthus husiast iastic ic abo about ut the pro proposa posall and sug sugges gested ted 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 sucsuccess” ce ss” of th thee pr propo opose sed d pr proje oject ct (p (p.. 5) 5).. Fo Forr Rev Review iewers ers 1 an and d 3, th thee ess essen enti tial al pr prob oblem lem 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

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successful success fully ly butstill haddoubtsconcer haddoubtsconcernin ning g whe whethe therr qua qualita litativ tivee met metasy asynth nthesiswas esiswas feas fe asib ible le at all all.. Rev Revie iewe werr 4 it itemi emize zed d wh what at he or she be belie lieve ved d to be su subs bsta tant ntiv ivee omi omisssions 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 nowfoc nowfocus us on sp spec ecif ific ic iss issue uess ra raise ised d in Cri Critiq tique uess 1, 3, an and d 4. We ad addr dress essed ed th thee problem of ambition by adding one more year to the study. Although Reviewer 3 sugges sug gested ted omit omittin ting g the test testing ing of the meta metasyn synthe thesis sis pro protoc tocol ol we wil willl dev develop elop wit with ha group of studies on prenatal testing, we think this validation exercise is critical to any an y cl claim aimss we wi will ll wa want nt to ma make ke ab abou outt th thee cr cred edib ibili ility ty,, fe feas asib ibili ility ty,, an and d ut utili ility ty of th that at 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 negotia neg otiated ted val validit idity y. We hav havee add added ed mor moree “di “dista stance nce”” and fac face-t e-to-f o-face ace meet meeting ing tim times es amon am ong g th thee me memb mber erss of th thee re rese sear arch ch te team am in ea each ch ye year ar of th thee st stud udy y to in incr crea ease se th thei eirr 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 meta me tasy synt nthes hesis is ou ough ghtt to be su subj bjec ectt to as mu much ch in inte tere rest st an and d ef effo fort rt as ha hass be been en sh show own n in quantitative research integration. In the preceding statement, we specifically countered this reviewer’s reading. Responding to reviewer comments does not necessarily mean accepting everything reviewers say. Our reference to 1,000 qualitative health studies was sim simply ply to sho show w tha thatt ther theree exis existt mor moree tha than n enou enough gh stu studie diess to war warran rantt suc such h int intererest. This reviewer also stated that we spent too much time justifying qualitative research. We We agree with the reviewer that qualitative research requires no defense. What Wh at we di did d in th thee ori origin ginal al pr propo oposa sall wa wass to ju just stif ify y th thee sig signi nifi fica canc ncee of ef effo fortsto rtsto co connduct du ct qu quali alita tati tive ve me meta tasy synt nthe heses ses an and d to de desc scrib ribee th thee pr prob oblem lemss th they ey ra raise ise by vi virt rtue ue of  the nat natur uree of qua qualita litativ tivee res resear earch. ch. Here,  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. Ou Ourr ai aim m fo forr th thee st stud udy y, an and d th thee in indi divid vidua uall st stepswe epswe wi will ll ta take ke to acco ac comp mplis lish h it it,, ar aree sta statedon tedon p. 36 an and d pp.36-3 pp.36-37. 7.Whene Whenever ver refe referrin rringg to speci specific fic revi revisions sions,, writers should give the page numbers where reviewers will find them. The purposes of  every design feature are stated in the relevant method sectio n. Our aims are stated to cap captur turee the pro proble blem-s m-solvi olving ng ori orienta entationof tionof ourapproa ourapproach ch to dev develop eloping ing a pro process cess,, namely,, conducting qualitative namely qualitati ve metasyntheses. We ha have ve eli elimin minat ated ed th thee re refe fere renc ncee to co corr rrec ectin ting g sc scan anne ned d tex texts ts,, as it see seeme med d to be misleading. What we were referring to here was that scanning technology fails to retr re triev ievee ev everywordof erywordof th thee te text xtss it sc scan anss an and d th that at we wo woul uld d ad add d th thos osee wo word rdss to ha have ve a cor correc rectt cop copy y. The rev review iewer er also des describ cribed ed a pot potent ential ial pro proble blem m in det detaili ailing ng stu studies dies,, namely, whether two reviewers would identify the same results from one study. This is one of the many problems associated with understanding and evaluating qual qu alit itat ativ ivee re resea searc rch h th that at we wi will ll ex explo plore re an and d ho hope pe to re resol solve ve in th thee pr prop opose osed d st stud udy y. We have clarified this thi s on p. 49 of the revised proposal.

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Critique 3 Thisreviewer af Thisreviewer affir firmed med tha thatt qua qualita litativ tivee res resear earch ch desi designs gns areemerg areemergent ent and ack acknow nowlledged that we had likely done the best anyone could in explicating our strategies  but still seemed hesitant. Accordingly, Accordingly, we have added some material to the design section sec tion to fur furthe therr expl explica icate te our pla plans ns wit withou houtt viol violati ating ng the “de “design sign-by -by-do -doing ing”” tene tenett of qua qualita litativeresear tiveresearch. ch. We beli believe,though eve,though,, tha thatt any stu study— dy—qua qualita litativ tivee or qua quanti ntitatative—requires 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’ Mor se’ s qua qualita litativ tivee met metasy asynth nthesis esis wor work—w k—whic hich h this rev review iewer er sta stated ted we had not 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 (this scholar) scholar ) stated she doubted whether anything she had done could be categorized as qualitative metasynthesis metasy nthesis unless we widened the definit definition ion of that term to includ includee conve convenntional narrative reviews of the literature or broad overviews of a field. Indeed, we susp su spec ectt th that at th thee pr prob oble lem m he here re lie liess in th thee re revi view ewer’s er’s ho hold lding ing a mo more re ex expa pansi nsive ve vi view ew of metasynthesis than we do. Looking back, we now believe that a better way to convey this th is id idea ea wo woul uldd ha have ve be been en to st stat atee th that at we had not suf suffic ficien iently tly cla clarif rified ied our foc focus us rat rather her tha than n transf tra nsferr erringthe ingthe obl obliga igatio tion n to und unders erstan tandd ourfocusto therevi thereviewe ewerr. Theuse of thefirs thefirstt per person son conveys the assumption of the burden of agency: the researcher—as opposed to the revie re viewer wer—do —doing ing or not doi doing ng som someth ething ing he or she sho should uld hav have. e. Eve Even n tho though ugh re revie viewer werss hav havee obligations to be careful and informed readers, the greater burden is on writers to inform clearly. Accordingly, we have added material further defining qualitative metasy met asynth nthesis esis for this stu study dy.. We stat statee on p. 36 tha thatt qua qualita litativ tivee met metasy asynth nthesis esis ref refers ers to the synthesis of findings in completed qualitative studies. Qualitative metasy met asynth nthesis esis con consti stitut tutes es a kin kind d of dat data-b a-base ased d res resear earch ch tha thatt is ana analogo logous us to qua quanti nti-tative tat ive met meta-a a-anal nalysis ysis in its inte intent nt syst systema ematic tically ally to “pu “putt tog togeth ether” er” or “su “sum m up” fin finddings in a specific domain of scientific research. This reviewer also stated that we were taking a demons demonstrably trably “nonfruitful” “nonfruitful” approach to metasynthesis and that we misrepresented the Noblit and Hare work. We ha have ve ch chec ecke ked d al alll ou ourr re refe fere renc nces es,, an and d th they ey we were re ac accu cura rate te in wo wordand rdand me mean anin ing g in the orig origina inall pro proposa posal. l. Neve Neverth rtheles eless, s, we hav havee sign signifi ifican cantly tly rev revised ised our pre presen sentat tation ion of the Noblit and Hare work on pp. 39-40. We were countering this reviewer’s opinion butneverthe butnever theles lesss mak makingchange ingchangess bas based ed on it. Mor Moreov eover er,, in thi thiss rev revisio ision, n, we hav havee spec specifi ifi-cally 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 Har Haree wor work k is con consid sidere ered d a key wor work k in a meth methodo odologi logical cal doma domain in (na (namely mely,, qua quallitative metasynthesis), that domain has yet to be developed. Their work cannot be held as the gold standard against which all other approaches to qualitative

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metasynthesis in other fields of research are judged. Our aim in the proposed pro ject is to contribute to the development developm ent of this methodological domain. We dis disagr agree ee wit with h the rev review iewer er tha thatt the Bar Barros roso o and Pow Powellell-Cope Cope (20 (2000) 00) syn synthe the-sis 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 fin findin dings gs enla enlarg rgee ourunders ourunderstan tandin ding g of hav having ing HIV/AID AIDS S and sug suggestnew gestnew stra strattegies for caring for persons pe rsons with HIV/ HIV/AIDS, the very act of conducting this study dramat dra matized ized the pro problem blemss tha thatt mus mustt stil stilll be res resolve olved d in qua qualita litativ tivee res resear earch ch int integra egra-tions ti ons.. We ha have ve ad addedmate dedmateria riall to th thee pr preli elimi mina nary ry stu studie diess sec sectio tion n on p. 44 to su suppo pport rt our view of its contribution. This reviewer stated that we were unclear about the criteria we will use to includee studies. One of the major objectives of the proposed project is to specify includ thes th esee cr crit iteri eriaa fu furt rthe herr. As we st stat atee on p. 46 46,, th thee pr propo opose sed d pr proj ojec ectt is ab abou outt dev develo elopin ping g a process to conduct a process. Moreover, contrary to this reviewer’s observation, we have already done the preliminary work (described in the proposal) to specify  both the criteria we tentatively plan to use and 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 view.. Revi Re view ewer er 4 al also so st stat ated ed th thatit atit wa wass no nott ne nece cess ssar ary y to de deta tail il ea each ch st stud udy y to th thee ex exte tent nt 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. Mor Moreov eover er,, no rea reader der can saf safely ely inf infer er fr from om the few oth other er meta metasynt synthes heses es don donee how detailed their authors’ examinations of studies were as they did not provide much inform inf ormatio ation n in the their ir pub publica lication tionss on tha thatt sub subjec ject. t. We cit cited ed thi thiss lac lack k of inf inform ormatio ation n as a problem that had yet to be resolved. In addition, we emphasized in the original proposa pro posall the nee need d to res resolve olve pers persiste istent nt dile dilemma mmass in und underst erstand anding ing and eva evalua luatin ting g qualitative studies that can be resolved only by this attention to detail. We believe that th at it is on only ly by th this is la labo borio rious us de deta tail il th that at we ca can n ar arriv rivee at a cr credi edibl blee an and d les lesss la labo bori ri-ous 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. Howe Ho weve verr, to ac achi hiev evee th that at go goal al,, we mu must st do th thee de deta tail il wo work rk th that at wi will ll al allo low w us to sa say y with confidence what details can be excluded in the future. For example, our prelimin lim inar ary y wo worksugg rksugges ests ts th thatthe atthe st stat ated ed me meth thodin odin a st stud udy y mig mightbe htbe a de deta tail il th thatis atis no nott 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 proposal have again consented to participate in this study after receiving a summary of the proposed study, study, including its aims and methods. In summary, we have revised this proposal to address the issues raised by revi re view ewer erss an and d to up upda date te in info form rmat atio ion. n. Th Thes esee re revi visi sions ons ar aree in ita italic licss (not shown here). here) . As mo most st of th thes esee is issu sues es re rela late ted d to se sect ctio ions ns A to C (Specific Aims, Background and Significance, and Preliminary Studies), Studies) , most of the revisions are in these sections. We appreciate the dilemma some reviewers face in encountering what they recognize to be a pr proj ojec ectt we well ll wo worthdoin rthdoing g bu butt th that at th they ey su suspe spect ct ca cann nnot ot be do done.In ne.In ou ourr re revi vised sed 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

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offered here and the revisions we have made to the proposal itself, in combination with wi th th thee po poten tentia tiall co cont ntri ribu buti tion on th this is stu study dy co coul uld d ma make ke,, wi will ll en enco cour urag agee re revi view ewers ers to take a leap of faith.

REMEMBER THE SCIENCE, PRIVILEGE THE ART In summary, appealing qualitative research proposals are exercises in “artful design”(Sandelowski, design”(Sandelowsk i, Davis, Davis,& & Harris Harris,, 1989) 1989),, reflex reflexivity ivity,, elegan elegantt expres expression, sion, 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 researcher’s talent for conceptualizing, synthesizing, imagining, and writing, and the ability to perform the kind of work promised. The grounded theory proposal should show the researcher’s ability to theorize; the phenomenological proposal, to engage in phenomenologic phenome nological al reflec reflection; tion; and the ethnog ethnographicproposal, raphicproposal, to interpr interpret et “cult “culture.” ure.” The qua qualita litativ tivee res resear earch ch pro proposa posall sho should uld com commun munica icate te the res resear earche cher’s r’s kno knowled wledge ge of the field and method, and convey the emergent nature of qualitative design by the use of words such as tentative tentative,, anticipate anticipate,, project project,, and plan plan.. The proposal should follow a discernible logic in the introduction i ntroduction to the proposed study (aim (aim → problem → significance of problem → aims detailed with objectives → research outcome → significance can ce of out outcom come); e); in the re revie view w of lit litera eratur turee (e. (e.g., g., a gap gap,, err error or,, con contra tradic dictio tion, n, or oth other er log logic) ic);; and in the description of design (tell → show → tell, or define → apply → illustrate). The qua qualita litativ tivee res resear earch ch pro proposa posall sho should uld of offer fer an expl explana anation tion for eve every ry desi design gn choice and disarm the reviewer in favor of the design choices made, especially in cases cas es whe where re rev review iewers ers arelikely to expe expect ct a dif differ ferent ent cho choice.This ice.This mea means ns tha thatt wri writers ters must mu st kn know ow,, an and d sh show ow re respe spect ct fo forr, th thee au audi dien ence ce to wh whom om th they ey wa want nt th their eir pr propo oposa sals ls to app appeal. eal. Theyshould def defend end the their ir cho choices ices wit withou houtt bein being g off offensi ensive ve (e. (e.g., g., by impl implyying in g th that at qu qual alit itat ativ ivee re rese sear arch ch is su supe perio riorr to ot other her me meth thod odss or by des descr crib ibin ing g th thee “f “fai aillures” ur es” of oth other er res resear earche chers rs or res resear earch ch meth methods) ods) or def defensi ensive ve (e. (e.g., g., by unn unneces ecessar sarily ily defending qualitative research when it needs no defense). Indeed, qualitative research proposals should not contain apologies for qualitative research, as it requir req uires es non none. e. Acc Accord ording ingly ly,, any limi limitat tations ions to thei theirr pro propose posed d stu study dy wri writers ters dis discus cusss ought not to convey that qualitative research is itself a limitation. Instead, discussionss of limi sion limitat tation ionss oug ought ht to be con confin fined ed to thedistin thedistincti ctive ve fea featur tures es of thestudy itse itself. lf. Forr exa Fo exampl mple, e, a lim limita itati tion on of a gr grou ound nded ed th theo eory ry stu study dy mig might ht be th thee ina inabil bility ity to co connduct du ct th theor eoret etic ical al sa samp mplin ling, g, no nott th thee fa fact ct of th theor eoreti etica call sa samp mplin ling g or it itss mo mode de of ge gene nerralizing per se. Although reviewers are obliged to demonstrate connoisseurship in reading and criticism, the greater burden is on writers of qualitative research proposals to conv co nvey ey th thei eirr re resea searc rch h int inten enti tion ons. s. Writ riter erss sh shou ould ld be beco come me sk skill illed ed in th thee us usee no nott on only ly of wo word rdss bu butt als also o of nu numb mber erss an and d vis visua uall di displ splay ayss to co comm mmun unic icat atee mo more re ef effe fect ctiv ively ely and thereby also to reduce reader burden. Other techniques to reduce reader burden and enha enhance nce cla clarity rity inc includ ludee stra strategi tegicc non nonrep repetit etitiou iouss rei reitera teratio tion n and loc locati ation on of  materia mat eriall and sec sectionheader tionheaderss tha thatt cap captur turee the cen centra trall them themee of the mat materia eriall inc includ luded ed 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 symboli sym bolicc int intera eractio ctionis nism m arenot inf inform ormativ ativee if res resear earche chers rs do not add addres resss howthese

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mind-sets mind-s ets inf influe luence nced d thedesignand willinflu willinfluenc encee the exe execut cution ion andfindin andfindings gs of the study. Rote descriptions of theories of and techniques for maximizing validity in qualit qua litativ ativee res resear earch ch ar aree not inf inform ormati ative ve if res resear earche chers rs do not sho show w how the they y wil willl be applied to and operate in the proposed study. study. Successful qualitative research proposals in the practice disciplines appeal as scienc sci encee andart. The They y emb embody ody the att attent ention ion to com commun munica icable ble pro proced cedureexpect ureexpected ed 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 curren currentt inform information ation about the Health Healthy y People initiative, see http://www /www.healt .health.gov/ h.gov/ healthypeople (retrieved May 1, 2003). 3. Devices and Desires: Gender Gender,, Technology, 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.u  Methods http://www.ualberta.ca/~ijqm/english/ alberta.ca/~ijqm/english/ engframeset.html Sandel San delowsk owski, i, M., Dav Davis, is, D. H., & Har Harris ris,, B. G. (19 (1989) 89).. Artf Artful ul des design:Wri ign:Writingthe tingthe pr propo oposal sal for res resear earch ch in the naturalist paradigm. Research in Nursing and Health, Health , 12 12,, 77-84. Sandelowski, M., Docherty, S., & Emden, C. (1997). Qualitative metasynthesis: Issues and techniques. Research in Nursing & Health, Health, 20 20,, 365-371.

 Margarete Sandelowski,  Margarete Sandelowski,Ph.D., 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., A.N.P., C.S., is an assistant professor of nursing at the University of North Carolina at Chapel Hill.

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