Keynote Address: Tenth Annual QHR Conference
QUALITATIVE HEALTH RESEARCH / December 2004Sandelowski / USING QUALIT ATIVE RESEARCH
Using Qualitative Research
A renewed urgency has emerged in the qualitative health research community concerning
the utility of qualitative research. This urgency is the result of several converging trends in
health care research, including the elevation of practical over basic knowledge, proliferation
of qualitative health research studies, and the rise of evidence-based practice as a paradigm
and methodology for health care. Diverse conceptualizations of use and users exist, and
ity of qualitative research findings. Issues affecting the utilization of these findings include
the varied ways in which they are conceived, presented, synthesized, signified, and trans-
lated, and the complex repertoire ofskillsrequired to activate the knowledge transformation
cycle in qualitative health research fully.
Keywords: knowledge transformation; knowledge dissemination; qualitative research;
studies have beenconductedin thehealth care arena, researchers, front-line practi-
tioners, policy makers, and other stakeholders in the health care community are
increasingly exhorted to use the findings of these studies to improve the public
ers are pressed to produce findings that are immediately or potentially relevant for
practice and to present findings in ways that enable their use by others. Front-line
use, and evaluate how useful they actually are in effecting desired change.
The current interest in the utility of qualitative research findings raises impor-
tant questions that go to the heart of the qualitative research enterprise, including
(a) Whatdoesusemeaninthecontextofqualitative research?(b) Whoaretheusers
should qualitative research findings be used? (d) Is the evidence-based practice
imperative to exploit research findings compatible with the non-exploitative
renewed urgency has emerged in the qualitative health research community
concerning the utility of qualitative research. Now that so many qualitative
Useless: The Discourse of Use Around Qualitative Research”—at the Tenth Annual Qualitative Health
Research Conference in Banff, Alberta, May 3, 2004.
QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 10, December 2004 1366-1386
© 2004 Sage Publications
imperatives of qualitative research? and (e) Of what use—and to whom—is all the
talk about use in qualitative research? I consider these questions in this article.
SITUATING THE UTILITY DISCOURSE
health research emerged in the 1980s as a distinctive domain and mode of inquiry.
because it was not objective and could not yield generalizable findings
(Sandelowski, 1997). Although these charges, unfortunately, continue to be made
by critics with an impoverished view of objectivity, generalization, and qualitative
result of several converging trends in health care research that have served both to
basic knowledge as the highest form of knowledge and the raison d’être of inquiry,
the proliferation of qualitative health research studies, and the rise of evidence-
based practice as a paradigm and methodology for health care. These events have,
in turn, contributed to the growing interest in incorporating qualitative health
research findings into evidence-based practice and in instilling an evidence-based
practice mindset into researchers conducting qualitative health research.
The New Primacy of the Practical
A resurgence of interest in the “actionability” of research findings (Greene, 1994,
criticism of Western science (Harman, 1996) and by activism to resolve persistent
social problems and health disparities engendered by differences in gender, race/
ethnicity, and class (Greene,1994), theemphasis onactionability has movedpracti-
cal knowledge from its lowly position in, to the top of the hierarchy of knowledge.
Once viewed as contaminated by discussions of use and usefulness, practical
knowledge is now increasingly privileged over pure knowledge by virtue of its
focus on use (Dickoff & James, 1992). Even scholars in such traditionally
nonpractice disciplines as anthropology are increasingly depicting these disci-
plines as “interventions” in scientific, technological, and medical practices
nography, have emerged in response to the new call to be useful (Chambers, 2000):
to produce knowledge that discernibly matters to someone for something.
Moreover, as fully embodied in participatory action research, knowing can be
consummatedonly in use (Heron, 1996). Indeed, practice disciplines, such as nurs-
ing, which are concerned with the doable and makeable (Johnson, 1991), are not
knowledge but, rather, sites where the utility of any knowledge can be put to the
ultimate test. And this testing function of the practice disciplines requires, in turn,
knowledge of how to put knowledge to the test, that is, in the language of research
utilization, how to transform it for use, implement it, and evaluate its implementa-
tion against specified outcomes. Knowledge in the practice disciplines entails not
just knowing that but also knowing how, when, why, whether, and for whom. As
Sandelowski / USING QUALITATIVE RESEARCH1367
Kim (1994) proposed for nursing, practice requires theories of intervention,
approach, deliberation, and enactment.
of health problems but also theories of diagnosis and treatment themselves and of
icalvalidity(Kvale,1995; Maxwell,1992) ofknowledgeinparticularsituationsisat
research procedures generating that knowledge and its putative generalizability
across situations. Research findings are expected to be accessible, relevant, signifi-
cant, and credible, and to hold the prospect of change to those who have a stake in
them (Chambers, 2000). Practitioners and patients are interested in the questions
(a) Does it work? and (b) If it works, should it be used?
The Proliferation of Qualitative Health Research
tive health research, which encompasses a diverse collection of approaches to
inquiry intended to generate knowledge actually grounded in human experience.
Thousands of reports of qualitative health studies are now available concerning a
public health, and other consumers of health research. These topics include (a) the
personal and cultural constructions of disease, prevention, treatment, and risk;
(b) living with and managing the physical, psychological, and social effects of an
array ofdiseases andtheirtreatments;(c) decision making aroundandexperiences
with beginning- and end-of-life, and assistive and life-extending, technological
ing and militating against access to quality care, the promotion of good health, the
preventionofdisease, andthereductioninhealthdisparities. Thesereportsappear
not only in exclusively qualitative research publication venues but also in venues
that once rejected qualitative studies as unscientific.
Supporting the exponential growth of reports of qualitative studies is the dra-
matic increase in qualitative methods literature, institutes, conferences, academic
now a growth industry and a research methods utilization success story, the very
success of which has engendered a renewed imperative to make better use of all of
the research findings produced from qualitative research.
The Rise of Evidence-Based Practice
of another “growth industry” in health care (Estabrooks, 1999b, p. 274): evidence-
professional jurisdictions, and the explosion of health-related information
(Timmermans & Berg, 2003; Traynor, 2002; Trinder & Reynolds, 2000)—evidence-
1368 QUALITATIVE HEALTH RESEARCH / December 2004
the turn to evidence-based practice is evident in the burgeoning literature on the
subject; the rise in several Western countries of centers and institutes of evidence-
based practice; the establishment of new journals and special features in existing
journals devoted to evidence-based practice; local, regional, national, and interna-
tional conferences on evidence-based practice; and the increasing availability of
databases housing evidence syntheses and evidence-based guidelines for practice.
basedpracticemovement,isnowaglobal enterprisesaid torival inimportancethe
Human Genome Project (Naylor, 1995).
Although variously conceived across the disciplines, evidence-based practice
generally connotes the thoughtful, explicit, conscientious, and judicious use of the
best evidence available to develop the best practices for individual patients
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sackett, Straus, Richard-
wide gap that still exists between research and practice, evidence-based practice is
retrieval of all evidence available concerning the treatment of a clearly specified
clinical problem;(b)ranking ofevidenceinanevidencehierarchy;(c)evaluation of
evidence using quality criteria; (d) synthesis of evidence using clearly specified
research techniques; (e) translation of evidence syntheses into practice guidelines;
(f) implementation of these guidelines in practice settings; (g) evaluation of this
implementation against clearly specified outcomes; and (h) the subsequent refine-
ment of practice guidelines derived from this evaluation (Stevens, 2002). Champi-
more informed use of evidence, more effective treatments, more efficient use of
scarce resources, transparency and accountability in clinical decision making, and
the empowerment of both practitioners and patients (Trinder, 2000).
But critics (i.e., both critical inquirers and frank opponents) of evidence-based
practice view it as itself problematic and even as a potentially retrograde step
(Clarke, 1999) in the advancement of the public health and for the establishment of
professional identity and autonomy (Gupta, 2003; Timmermans & Berg, 2003;
Trinder&Reynolds,2000; Walker,2003). Focusingonthecasuistryinclinicalmedi-
prevails over nomothetic knowledge (or knowledge of the general) (Hunter, 1989),
and on the importance of the practical knowledge embedded in clinical expertise
(Benner, 1984), critics have decried the scientific aesthetic of averages and dispas-
sionate objectivity promoted by evidence-based practice (Colyer & Kamath, 1999;
White, 1997). For these critics, evidence-based practice appears to devalue the per-
sonal knowledge (Benner, 1984) and knowledge of persons (Liaschenko & Fisher,
1999) critical to excellent patient care that is drawn from and produced in irreplic-
able interactions between practitioners and their patients. Although proponents of
values in treatment decisions, critics argue that these have yet to be discernibly
included in the evidence-based practice process.
Advocates of qualitative research are especially incensed by the use of hierar-
chies of evidence that assume the randomized clinical trial as the gold standard in
inquiry, which thereby devalues or frankly excludes qualitative research (Evans,
2003; Mitchell, 1999). Instead of ensuring best practices that truly reflect the judi-
cious consideration of all of the evidence available, the evidence-based practice
Sandelowski / USING QUALITATIVE RESEARCH1369
paradigm—as actually put into practice—reinforces well-worn prejudices against
certain forms and sources of evidence (McKenna, Cutcliffe, & McKenna, 1999).
Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Forbes et al., 1999;
Hampton, 2002; Madjar & Walton, 2001; Upshur, 2001a, 2001b).
Qualitative Health Research and Evidence-Based Practice
Thesheerproliferation ofqualitative healthresearchhasmadequalitative findings
difficult to dismiss and has generated urgent calls to incorporate them into the evi-
dence-based practice process. Scholars across the health-related disciplines have
increasingly recognizedtheerrorinexcludingqualitative researchfromsystematic
ria that automatically exclude qualitative studies from any consideration at all, let
alone consideration as best evidence (Barbour, 2000; Dixon-Woods, Fitzpatrick, &
Roberts, 2001; Giacomini, 2001; Green & Britten, 1998; Greenhalgh, 2002; Popay &
One manifestation of this new demand to incorporate qualitative research into
the evidence-based practice process is the recent upsurge of interest in conducting
variously referredtoasqualitative metasynthesis,qualitative meta-analysis, quali-
tative meta–data analysis, and meta-ethnography is evident in the burgeoning
methodological literature on the subject (e.g., Campbell et al., 2003; Finfgeld, 2003;
Jensen & Allen, 1996; Noblit & Hare, 1988; Paterson, Thorne, Canam, & Jillings,
2001; Sandelowski & Barroso, 2003a, 2003b, 2003c), in the growing number of
reports of studies designated as qualitative metasyntheses or the like (e.g., Barroso
& Powell-Cope, 2000; Kearney, 2001a; Thorne & Paterson, 1998), and in the forma-
tion of the Cochrane Qualitative Methods Group (http://mysite.freeserve.com/
Cochrane_Qual_Method/index.htm). Although they differ in their views of what
qualitative metasynthesis is as method and how metasynthesis studies should be
conducted, scholars engaged in qualitative metasynthesis agree that it represents
an advancement in making qualitative research findings more useful and in
moving them to the center of the evidence-based practice process.
The flip side to the call to incorporate qualitative research into evidence-based
practice is to instill an evidence-based practice mindset into qualitative research.
discourse around qualitative research and, therefore, to this article. Having briefly
reviewed the complex origins of the new discourse on use in qualitative research, I
turn now to the varied uses of use at its center.
Whether something is deemed to be usable or useful depends on what usable and
useful are deemed to be. As Baker, Norton, Young, and Ward (1998) proposed, use-
1370 QUALITATIVE HEALTH RESEARCH / December 2004
in what is generally referred to as “quantitative research,” usefulness derives from
the generalizability of findings from study samples to populations not studied but
deemed to be like those samples. In grounded theory inquiry, usefulness derives
from the transferability of theories to situations beyond the ones from which they
successively more abstract and formal theories that are both empirically faithful to
the cases from which they were developed and enduring beyond the single case.
These formal theories have the complexity to encompass increasingly more
diverse domains of research and practice (Kearney, 1998). In contrast to the formal
generalization thatis foundational toutility inquantitative inquiry,analytic gener-
alization and theoretical transferability are the bases for utility in grounded theory
which understanding is conceived to be fundamentally about applicability.
essary prelude to understanding in participatory action research in which knowl-
edge is produced only in use. The sine qua non of participatory action research is
action as the key criteria by which studies in this tradition are evaluated are the
critical vein, the extent to which oppressive structures were undermined and
liberatory/emancipatory goals were achieved.
ceptual, and symbolic is a useful frame of reference to examine the various mean-
ings of use and their implications for understanding, demonstrating, and enhanc-
ing utility in qualitative research. Instrumental utilizationis the concrete application
to practice of research findings that have been translated into material forms, such
cols, or algorithms. These forms are then put into practice and evaluated with spe-
cific groups of patients in specific practice settings to achieve specific outcomes. In
users themselves. By virtue of its emphasis on the visible, tangible, material, and
measurable, instrumental utilization is the ultimate goal of empirical/analytical
research (which may include qualitative and quantitative inquiry) and of the
evidence-based practice paradigm that favors this form of research.
rather, the use of research findings as a persuasive or political tool to legitimate a
zation may be a precursor to instrumental utilization as a change in practice may
and therefore the most dubious example of research utilization—as it entails no
persons, or events. Giacomini and Cook (2000) described qualitative research find-
Sandelowski / USING QUALITATIVE RESEARCH1371
a window through which to view aspects of life that would have remained
unknown. For individuals with personal experience of a target event, qualitative
research findings offer a mirror that allows them to look back on and reframe their
experience. Whether revealing or reflecting, in conceptual utilization, the action
happens in the user who is newly informed or enlightened, but this change in the
thing else. Indeed, the users who experienced this change may be unable to articu-
late the change experience even to themselves. Yet, like symbolic utilization, con-
ceptual utilization may be a precursor to instrumental utilization as users develop
the capacity to articulate the change experience and to translate it into more
observable or material form.
Qualitative research findings lend themselves most obviously to symbolic and
conceptual utilization but less obviously to instrumental utilization. Because the
thrust of evidence-based practice is interventionist—that is, oriented toward
observable action—qualitative research appears to be less useful by virtue of
appearing less instrumentally useful. Instrumental utility is face utility. For many
people, what has no face utility has no utility at all. Moreover, because the material
forms into which research findings are translated are composed largely of stan-
dards of practice for problems primarily in the physical, physiological, or techni-
cal—that is, more visible and tangible—domains of practice, the qualitative
research imperative to eschew standards, combined with its focus on problems in
the less visible and tangible psychological, social, and cultural domains, seem to
of research utilization is used as the framework to appraise and address the utility
problem in qualitative research, the resolution to the problem lies in showing or
enhancing the instrumental utility of qualitative research findings, and in making
more apparent the value of symbolic and conceptual utilization by itself or as a
precursor to instrumental utilization.
practice movementand its emphasis on instrumental utility, champions of qualita-
tive research findings can be of material and measurable use in practice. For exam-
ple, Morse, Hutchinson, and Penrod (1998) described a process for transforming
theory generated in qualitative research into clinical assessment guides. Morse,
Penrod, and Hupcey (2000) described a process for evaluating interventions
derived from primary qualitative studies. Kearney (2001b) described three instru-
mental uses of qualitative research findings, including the development of tools or
guidelines for clinical assessment, anticipatory guidance, and active coaching. In
their review of the discussion and implications sections of a sample of qualitative
health research reports, Cohen, Kahn, and Steeves (2002) found that researchers
often promoted instrumental changes in communication among patients, families,
and clinicians. Included in the category of communication were recommendations
for active listening, appraisal, teaching, and the provision of social support.
In all of these instances, the “difference model” of the role of qualitative
research findings in health research is invoked by which qualitative findings are
valued for their contribution independent of quantitative methods (Popay & Wil-
and ways to enhance it are featured. Qualitative research findings are shown to
1372 QUALITATIVE HEALTH RESEARCH / December 2004
have face utility; they are shown to contribute materially to the development of
appraisal tools and communication protocols that have greater psychometric and
cultural specificity and sensitivity. Moreover, in these instances, qualitative
research findings do not necessarily have to be subjected to quantitative testing
evaluated in the field by qualitative, quantitative, or mixed methods research.
Promoting the value of symbolic and conceptual utilization. Although not necessar-
ily presented in research utilization terms, conceptual and symbolic utilization
appear as the most important objectives of qualitative research both in reports of
qualitative research and in literature promoting the utilization of qualitative
research findings. These objectives are most apparent in the recurring depiction of
understanding as the prime imperative of qualitative research and in the regular
allusions tothepersuasivepowerofnarratives,orstories.Inthequalitative research
ing ⇒ action) but, rather, is itself action, or a consequence of action (understanding
= action, or action ⇒ understanding). Whenever users see something for the first
time or see it differently, they change the world. If their prior understandings were
son,1996, p.25). Asworldsarecreatedwithwords,andwordsaretheprimarycur-
primary agenda in critical inquiry with marginalized individuals and groups is to
empower them to rename the world.
Accordingly, even in qualitative studies that are not hermeneutic or participa-
tory action research, understanding is the primary intervention on which all other
interventions are inescapably based. Moreover, the narratives (or stories) that are
prized in qualitative research, and which typically make up the largest portion of
data in qualitative studies, are themselves actionable research texts because they
in promoting empathetic, feeling, or visceral understandings of the people and
eventsin stories; and in movinglisteners orreaders toact. Stories areconsideredto
besymbolically useful bynature, because theyinvitelisteners/readers touse them
to tell new stories. Narrative utility is defined as the readability, writability, and
evocativeness of, and also the meaningfulness and transformative possibilities in,
stories. Because human beings characteristically use stories (i.e., read, write, tell,
and listen to them), stories must be useful.
In contrast to the difference model of the role of qualitative findings in health
(Popay & Williams, 1998, p. 34) focus on the utility of qualitative research findings
to enlarge and even to “salvage” quantitative research findings (Weinholtz, Kacer,
& Rocklin, 1995). Here, the utility of qualitative research findings resides in their
capacity to clarify, explain, verify, or show the instrumental utility (i.e., clinical sig-
nificance) of quantitative research findings (Barbour, 2000; Cohen & Saunders,
1996; Sandelowski, 1996, 1997). Statistically significant findings are not necessarily
clinical useful, and qualitative findings are said to show the tears that statistical
accounts wipe off (Selikoff, 1991). Because qualitative research findings address
realms of experience that quantitative findings cannot reach (Pope & Mays, 1995;
Power, 1998), they may complicate or even refute quantitative research findings.
Sandelowski / USING QUALITATIVE RESEARCH1373
Scholars have demonstrated the enhancement functions of qualitative research
findings to develop, refine, and validate instruments and interventions (e.g.,
Barroso & Sandelowski, 2001; Cox, 2003; Gamel, Grypdonck, Hengeveld, & Davis,
2001; Mallinson, 2002; Miller, Druss, & Rohrbaugh, 2003; Popay, Bennett, et al.,
In summary, the utility of qualitative research findings resides in their capacity—
by themselves or in conjunction with quantitative research—both to direct the
patient-centered, targeted, or tailored interventions that are effective, feasible, and
acceptable to users; and to redirect or reframe future research and research utiliza-
efficacy (or what works in research) and effectiveness (or what works in practice)
MAKING QUALITATIVE RESEARCH
FINDINGS USABLE AND USEFUL
of health research. But we qualitative health researchers can do more to demon-
demonstrate the utility of qualitative research findings, we must first meet several
Clarifying Conceptions of Findings
A key factor affecting the demonstration of the utility of qualitative research find-
ings is the way they are conceived. The empirical/analytical view of qualitative
findings is that they are the results of inquiry supported by and, therefore, distin-
guishable from data (Sandelowski & Barroso, 2002a, 2003a). Data here constitute
the evidence for (or ground for belief in the credibility of) research findings.
Researcher findings are data based, or composed of what researchers conclude,
infer, or interpret from the data they have collected in a study. Qualitative research
findings are the grounded theories, ethnographies, phenomenologies, and other
integrated descriptions or explanations produced from the analysis of data
obtained from interviews, observations, documents, and artifacts. The validity of
data-based studies is said todependprimarily ontheability of researcherstoshow
ies. Data-based findings ought, therefore, to be readily identifiable and separable
from (a) the data themselves, or the quotations, excerpts from field notes, stories,
a target phenomenon; (b) data and findings not about that phenomenon;
(c) imported data or findings, or data or findings from other studies to which
researchers referred to situate their own findings; (d) analytic procedures, or the
coding schemes and data displays researchers used to transform their data into
findings; and (e) researchers’ discussions of the meaning, implications, or signifi-
1374 QUALITATIVE HEALTH RESEARCH / December 2004
cance of their findings to research, education, practice, or policy making. The data-
based view of findings is highly compatible with evidence-based practice because
are distinguishable from data and other elements of inquiry are themselves ready
for use in evidence syntheses as these are conceived in evidence-based practice.
Less compatible with evidence-based practice than the data-based view of
qualitative findings is the data-as-constructed view, whereby both data and find-
ings are conceived of as indistinguishable from each other, from the participants
with whom these data and findings were produced, and from the researchers who
ing thatentities are out there waiting tobe found, is itself at odds withtheidea that
countable as this or that number of instances, but, rather, singular, or an uncount-
of argument, where data are commodities to be obtained from people from whom,
ation is inseparable from the (a) researchers who decide what will become data for
their projects; (b) specific and irreplicable encounters between researchers and the
people and events that are the subjects and objects of study that together produced
from each other, nor should such a separation be attempted.
Following the data-as-constructed line of argument, it is as impossible—and
evenas nonsensical—to extractfindings froma poetic,dramatic, or storied presen-
ceiving qualitative findings as evidence is as nonsensical as conceiving a poem as
son’s story or providing excerpts from interview data can be construed as the end
product of qualitative inquiry. As stories are considered to be actionable by them-
selves, researchers following the data-as-constructed logic to its extreme believe
they have fulfilled their obligations to produce something useful merely by
In summary, the empirical/analytical orientation to qualitative findings is in
line with evidence-based practice as it is typically conceived, but by virtue of its
view of findings as extractable, it may undermine the qualitative research impera-
tivetoattendtoparticulars aswholes,thatis, totakeinaresearchreportasawhole
story by itself, with no interpretation, may not be considered a research finding.
Research reportscomposedonly of uninterpreted stories or excerptsof stories con-
tain no findings that can be extracted for use in evidence syntheses.
Sandelowski / USING QUALITATIVE RESEARCH1375
Using Representational Styles Enabling Use
The way qualitative findings are conceived directly influences how they are pre-
sented in reports of qualitative studies and, therefore, their usability. Most qualita-
tive health research is reported in the experimental/APA style (Bazerman, 1988;
Sandelowski &Barroso,2002b). Theexperimental/APAstyleisastandardizedfor-
mat for presenting research mandating that the results of a study be provided in a
results section clearly separate from and immediately following a methods section
and immediately preceding a discussion section. This style reflects and reinforces
the data-based view of findings as objectively produced and as distinguishable
from and supported by data. The experimental/APAstyle of reporting qualitative
asthestyleitselfdemandsthatfindings notonlybeclearly statedinaresultsection
significant to specified persons for specified purposes.
A departure from the experimental/APA style of reporting is the amended-
along with references to literature that serve to situate those findings, or in which
Writers have to take more care, by their use of voice, tense, and other elements of
the various kinds of evidence used in support of it (Holliday, 2002).
Non-Experimental Experiments inStyle. Whollyoutsidetheempirical/analytical
ater (Richardson, 2000). Such artistic experiments in representation are partly
responsestothe“crisis of representation” (Denzin & Lincoln, 2000, p.16), whereby
scientific modes of reporting research are seen to misrepresent human experience,
ities. Literary and artistic modes of representing people and their lives are consid-
ered to be more amenable to the varied goals of qualitative researchers, including
giving voice to the voiceless, revealing the actor’s point of view, revealing the
tative education research and a painter, Eisner (1996) proposed that the novel be
accepted as a dissertation in the field of education.
utility of qualitative findings, as neither findings nor utility are requirements of lit-
erary and artistic presentations. Moreover, rather than resolving the crisis of repre-
forms of presenting findings do not resolve but, rather, generate new problems in
representing people and events; nor do they dependably evoke the feelings or pro-
voke the actions desired. Although well intended, researchers trained in the prac-
photography, drawing, choreography, and performance theater. In their eagerness
1376 QUALITATIVE HEALTH RESEARCH / December 2004
to be literary and artful, and understandably attracted to the beauty and novelty of
literary and art forms, qualitative health researchers too often lack the skills
representation and utilization (Eisner, 1991, 1997). Such researchers doom their
work to be not only useless but also artless.
Furthermore, the current zeal to do “transgressive writing” (Schwalbe, 1995,
p. 394) enables researchers to avoid the responsibilities of inquiry. Unlike poets,
painters, and novelists, scholars in the practice disciplines are supposed to offer an
interpretation of the data they collect or the stories they generate (Eisner, 1997).
ture remain implicit and particular” (p. 19, emphasis in original). Qualitative
erary devices to analyze and interpret data and to write up the results. But qualita-
tiveinquiry beginswherepoetryends,thatis, withanexplicitinterpretationthatis
available for critique and that can be compared with other interpretations. As
Greene(1992) noted,“Unlike theartist...appliedsocial inquirer(sare)responsible
for how (their) stories are read, understood, and acted upon” (p. 42). Eisner (1991)
The use of particulars to provide guidelines for the future is a central function of
intended to influence our understanding and behavior; it has some instrumental
utility. (p. 104, emphasis added)
But unlike folklorists, qualitative health researchers are obliged to make the utility
of stories explicit.
Yet,recently, analysis and interpretationhave, unfortunately, toooftencometo
beseenas instancesofthedominationofthepowerfulovertheweak. Forresearch-
unethical subversion of the liberatory goal of voicing the voiceless. Lauding works
that privilege stories over analysis and arguing that the “narrative text refuses the
interpretation are antithetical both to the true mission of qualitative inquiry and to
use. As they observed,
substitute the companionship of intimate detail for the loneliness of abstracted
facts. (p. 744)
But theories are by their revisionist nature never settled and always debatable;
abstracted facts can be companionably intimate; intimacy can too easily become
voyeurism, sensationalism, and exhibitionism; and compelling emotions can be
In the name of the reflexivity that characterizes many of these experiments in
representation, researchers may now not only avoid the responsibility of
Sandelowski / USING QUALITATIVE RESEARCH1377
interpretation, but also completely abandon others as the subjects of inquiry. The
tionofworksdesignatedas auto-ethnography,autobiographical inquiry,experien-
tial analysis, and the like (Ellis & Bochner, 2000), which focus on researchers them-
events per se. Whereas the researchers advocating auto–modes of inquiry were ini-
pants’ voices in reports of research, these modes of inquiry too often wholly and
perversely replace participants with researchers as the subjects of inquiry. Hoping
as action research for the researcher and participant observation of the observer
(Ellis & Bochner, 2000; Tedlock, 1991), auto–modes of inquiry too often cast
researchers not only as the primary targets but also as the primary users of qualita-
tive research. In extreme examples, others are said ultimately to benefit when
inquiry promotes researchers’ understanding of themselves.
Traditional empirical/analytical inquiry allows researchers to get away with
categorizing, slicing, and dicing (Ellis & Bochner, 2000, p. 737) human experiences
into findings that no longer resemble these experiences; making insupportable
claims to objectivity and generalizability; and escaping accountability as the cre-
ators of research findings. But auto–modes of inquiry allow researchers to escape
the disciplined, skilled, and risky work of interpretation; study no one but them-
selves; legitimate virtually anything in the name of reflexivity and representation;
be therapeutic for participants.
tative health researchers to develop new ways of representation while remaining
odological versionof psychoanalysis” (p. 383) of themselves.Wequalitative health
researchers cannot lose sight of our goals to contribute to change. We cannot
address the crisis of representation by “retreat[ing] to the easy assumption that we
can understand no one but ourselves” (p. 383). As Tierney observed,
As we experiment by developing a play, a prose poem, or a short story, we consis-
not to avoid experimentation (with alternative forms of representation), but to be
certain that our experiments are efforts at creating change rather than merely an
exercise in intellectual narcissism. (p. 383)
Just as the abstraction of facts does not have to be a lonely, heartless, or surgical
enterprise, so, as Lawless (1992) observed, voicing the voiceless does not have to
mean that researchers lose their own voice or abdicate their responsibility to inter-
tation do not require that researchers relinquish the role of scholar as interpreter,
along with research participants, they may have their say, but no one gets the last
word. Entry into the hermeneutic circle that qualitative researchers prize requires
interpretations that can be subjected to others’ interpretations.
1378 QUALITATIVE HEALTH RESEARCH / December 2004
In short, the reflexivity at the heart of most experiments in representation in
qualitative inquiry does not mean placing researchers at the center of inquiry but,
rather, acknowledging their role and “vulnerability” (Behar, 1996) in inquiry.
Acknowledging the challenges of representing other people does not mean failing
to represent them at all. Although the auto-researcher’s goals to reinstate the
research are laudable, they do not legitimate leaving research audiences with a
mess. Experimental modes of inquiry require inquirers skilled in these modes and
able to show how these modes advance knowledge for the public good.
Addressing the Complexity of Qualitative Metasyntheses
Althoughtheincreasing effortstointegratequalitative healthresearchfindings are
laudable, qualitative metasynthesis itself presents dilemmas that researchers have
yet fully to recognize, address, and resolve. The most notable among these chal-
lenges are (a) distinguishing qualitative studies from other species of research,
(b) distinguishing qualitative metasynthesis fromotherspecies of synthesis or nar-
cipline-specific styles, (e) locating the findings in these reports, (f) classifying these
event, (h) determining which findings merit inclusion, (i) deciding which methods
and techniques to use to combine different kinds of findings, (j) determining what
form the product of analysis should take, and (k) determining how best to present
this product to showcase its relevance for a target audience.
The increasing publication of reports of studies designated as qualitative
newconcernsthatqualitative metasynthesisis becomingthelatest methodological
tative research, in particular. The methodological naivete of many of these studies
has generated a new threat to the utility of qualitative findings.
If the synthesis of qualitative findings remains a challenge, the combination of
qualitative and quantitative syntheses remains uncharted terrain. Virtually no
effort has been directed toward integrating syntheses of qualitative findings with
Although advancementsin theuse of mixed methodsin primary research have the
potential to offer solutions for accomplishing such meta–combinations of findings,
they have yet to be examined for their actual utility in producing evidence synthe-
ses that truly take account of all of the evidence available in a target domain of
Assuming and Sharing Responsibility
for Signifying and Translating Findings
Inaddition toclarifying our conceptionof qualitative findings and becomingmore
researchers must assume and share responsibility for signifying and translating
them. Health researchers are typically expected to attach significance to their find-
Sandelowski / USING QUALITATIVE RESEARCH 1379
and education. Qualitative health research findings are typically signified by
appeals toanalytical or idiographic generalizability and transferability, or totrans-
formative understanding: one that changes researchers, participants, and/or the
ings, we have also tended to shift more of this responsibility to readers of our
research reports. As we have typically argued, qualitative researchers are obliged
only to provide enough detail about our findings to enable readers to determine
their generalizability. Smaling (2003) referred to this transfer of obligation as
“receptive generalization,” a form of “communicative generalization” (pp. 17-18).
Here, the burden of signification rests primarily with audiences.
The presumption that qualitative health research audiences should carry the
primary responsibility for signifying qualitative research findings calls into ques-
tion how users, and the relationship between user groups, are generally conceived
researchers—are typically distinguished from users of knowledge, for example,
other researchers, members of the health professions, health care organizations,
government regulators, policy makers and analysts, health economists and epi-
demiologists, health insurers, lawyers, medical industries, patient groups, and the
general public (Ray & Mayan, 2001). The most common manifestations of this
binary distinction in the health-related disciplines are the line typically drawn
research findings. Here, producers and users are depicted in a one-way, hierarchi-
cal, and even adversarial relationship.
Yet, the line typically drawn between users and producers of research findings
is an artificial one, because producers of findings are also users of them, and users,
by virtue of their use alone, re-produce and re-create those findings. Following a
reader-response line of argument concerning the relationship among diverse read-
ers (i.e., users) and texts(i.e., research findings in reports), readers of research find-
ings transform them by the very act of reading, reading into, and even rewriting
findings (Sandelowski & Barroso, 2002b). Following a symbolic interactionist line
(Blumer, 1969), qualitative research findings do not exist as objects independent of
Dissemination is inherently social, even when, as is typically the case, writers
and readers of research reports never actually meet each other over the research
orevenanticipatedbythem)toproducetheirownfindings, whicharethenused to
and evaluates them. All of these producers/users generate and use findings for
some purpose, such as the promotion of quality care, enhancement of professional
effectiveness, ensuring of fiscal accountability, reduction of risk and liability, and
the satisfaction of personal needs (Ray & Mayan, 2001), which may include a
patient’s need for symptom relief and a researcher’s need for academic promotion
Research utilization thus involves a host of producers/users of research find-
ings with a host of agendas for use. But research utilization itself requires a
1380 QUALITATIVE HEALTH RESEARCH / December 2004
Among the complex skills required to use qualitative health research are under-
standing and evaluating qualitative research reports written in different styles and
with different disciplinary commitments, synthesizing the findings of qualitative
research, translating the findings from primary qualitative or qualitative meta-
synthesisstudies foruse inpractice,andimplementingandevaluating thesetrans-
lations in practice. Although researchers are recurrently exhorted to develop the
to develop the research acumen to appraise and use research, these goals are rarely
achieved. The research-practice gap recurrently referred to in the research utiliza-
tion literature derives, in part, from the failure to achieve these unrealistic goals.
Unrealistic is the expectation that clinicians will have the knowledge of grounded
theory, ethnography, qualitative metasynthesis, and the like required fully to
understand and appraise these works. Conducting qualitative metasynthesis pro-
jects, like quantitative meta-analysis projects, requires the knowledge and skill of
experts—not novices—in research. Equally unrealistic is the expectation that
researchers will have the knowledge of patients, clinical problems, and practice
settings required to accommodate qualitative research findings.
Because different user groups come to the research utilization enterprise with
tions processes more participatory: to enhance the “participative value” (Smaling,
of one or more other user groups to realize the full utility potential of qualitative
findings and to instill in each other confidence in the expertise they uniquely bring
to the research utilization enterprise. To activate all phases of the knowledge trans-
formation cycle fully, clinicians must be able to trust the primary research findings
and evidence syntheses produced by researchers, not produce these findings and
ings produced by clinicians and their ability ethically to accommodate research
findings to the constraints of practice settings, not merely use clinicians to gain
access to clinical sites for research.
Most urgently, diverse user groups must work separately and together to
enhance the knowledge transformation process itself in the qualitative health
research context so that its findings can become transformative for practice. Work-
ing to improve the “utilization value” (Smaling, 2003, pp. 20-21) of reports,
researcherscandomoretowriteupfindings inwaysthatwill moredirectlyappeal
how poetic or reflexive our efforts are, we qualitative researchers can be more
We would thereby show our understanding that in qualitative health research,
poetry and reflexivity are means to an end, not ends in themselves. Instead of writ-
ing formulaic and clichéd discussion and implications sections, wecan writeinfor-
mative significance and translation sections in which we point the way to one or
more material forms in which our findings might be used and the one or more
health objectives they might satisfy.
Sandelowski / USING QUALITATIVE RESEARCH 1381
The utility discourse can be put to good use to advance the qualitative health
research enterprise without compromising it. Discussions of utility move qualita-
not have to undermine qualitative research as itself a protest to mainstream
Qualitative health research is thebestthing tobe happening toevidence-based
practice. Qualitative health research complicates and thereby unfreezes the idea of
prejudices against certain kinds of evidence. Qualitative health research is the best
chance for evidence-based practice to realize its ideal of using the best evidence to
create the best practices for individuals. With its emphasis on the contingencies,
subjectivities, discursiveness, and politics of evidence, qualitative research can
make evidence-based practice a truly mindful (as opposed to mindless or rote)
ings of qualitative research will help reverse the current trend toward making evi-
dence-based practice a technologized professional discourse (Holliday, 2002) and
disciplinary technology (Walker, 2003) that serve only to reinforce invidious dis-
tinctions and to reproduce the very problems it was intended to solve. Qualitative
health research offers the best chance for incorporating the critical consciousness
(Berkwits, 1998) required tooffset thetendencytodogmatism in efforts topromote
evidence-based practice (Traynor, 1999). Qualitative health research offers the best
chance of producing truly transformative knowledge and fully activating the
knowledge transformation cycle foundational to the evidence-based practice
Evidence-based practice, in turn, directs qualitative health researchers to
address the utility question as seriously as they continue to address the validity
question and even to see validity as residing in utility. Qualitative researchers can
use evidence-based practice, not as a prescriptive rhetoric or disciplinary technol-
ogybut,rather,asauseful guidetoaction.Wequalitative researcherscannotevade
the utility question by dismissing it as irrelevant and antithetical to qualitative
research. Prideful assertions that qualitative health research is not about solving
problems or “doing” anything at all, or that it is useful merely by virtue of being,
stitute a misuse of qualitative research. Qualitative research is misused when it is
used to escape the disciplined and risky work of inquiry and interpretation. Quali-
tative research is misused when it is used largely as therapy for researchers. Quali-
tative research is misused when it is used to proclaim that discussions of utility in
qualitative health research are useless.
The turn to evidence-based practice moves us as qualitative health researchers
vidualize, specify, sensitize, persuade, evoke, and provoke. As researchers in prac-
tice disciplines, we have a special obligation to conduct transformative inquiry by
lic health of these revelations, clarifications, distillations, elaborations, extensions,
and the like. Emphasizing the artfulness of qualitative research does not preclude
1382 QUALITATIVE HEALTH RESEARCH / December 2004
the incorporation of qualitative research findings as evidence in evidence-based
practice, nor the requirement that artful scholarship be transformative and meet
canons of criticism and utility.
Iconclude witha call touse in thehealth practice disciplines adapted fromone
research can do for you, ask what qualitative research can do “with” (van Manen,
1990, p. 45) you and what you can do better with qualitative research. Answer not
qualitative health research is about answering them too.
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MargareteSandelowski,Ph.D.,R.N.,F.A.A.N.,isCaryC.Boshamer ProfessorintheSchool of Nurs-
ing, University of North Carolina at Chapel Hill.
1386QUALITATIVE HEALTH RESEARCH / December 2004