According to Rowe (2000), accountability and the quest for professional status has contributed to the acknowledgement that nursing needs to be knowledge centred.
VOL: 102, ISSUE: 20, PAGE NO: 32
Angela Hall MSc, PGCE, BSc, RGN, DN, RNT, is tutor, public health and primary care and care of the older person, Swansea University
Exploring sources of knowledge and their contribution should be a question the profession addresses (Hall, 2005). Nurses use a diverse range of knowledge, including that from research, to make their clinical decisions and to plan care with patients.
The development of qualitative research in nursing is a result of the influence of various traditions. Compared with quantitative, the qualitative approach is relatively new and various techniques and strategies are therefore emerging.
Eraut (1994) identified that research of all types should aim to systematically investigate and contribute to the body of knowledge that helps to shape and guide the profession. Therefore, nurses should use the ‘best’ research evidence available.
Despite the qualitative method being traditionally a less widely valued source of research evidence, there are a number of factors that add to the significance of the contribution qualitative research makes to nursing knowledge. Like all research, qualitative research needs to be assessed on its merits if practitioners are to be able to assess its worth.
The literature suggests that the contribution of qualitative research is growing and it is advancing nursing knowledge, particularly in relation to certain aspects of that knowledge. This implies it is important that nurses in practice understand it and can judge its worth and relate it to their care of patients.
It is logical that knowledge claims that originate from qualitative research should be open to critique and formal evaluation. This implies that there is a need for qualitative research to be open to searching, audit and criticism. This is the means to assess its contribution to advancing nursing knowledge in terms of testing, extending or challenging what is already known or believed.
Certainly, as Corner (1990) identified some time ago, the whole issue of the value of various research approaches and their roles to nursing knowledge advancement has been a source of debate in the literature. The recognition of the importance of qualitative nursing research has recently increased. More is known about the use of related research methods in nursing and a number of authors have contributed significantly (Holloway, 2005; Green and Thorogood, 2004; Mason, 2002; Brewer, 2000; Cresswell, 1998; Silverman, 1998; Koch, 1995; Bryman, 1992; Morse, 1991; Atkinson, 1990).
It is difficult to be definitive because both ‘qualitative research’ and ‘nursing knowledge’ are relatively new, evolving and complex aspects of the nursing profession. They are both dynamic, multidimensional and context-bound terms.
According to Denzin and Lincoln (2000), qualitative research is a distinct field of enquiry in its own right. The literature indicates that qualitative research methodology refers to the ideas and principles that researchers use to base their procedures and strategies (methods) on (Holloway, 2005; Green and Thorogood, 2004; Flick et al, 2004; Mason, 2002).
Qualitative research ‘is a form of social enquiry that focuses on the way people interpret and make sense of their experiences and the world in which they live’ (Atkinson, 1990, p7).
The main debate has traditionally been the value of the contribution of quantitative versus qualitative research in terms of knowledge development for nursing (Smith and Heshusius, 1986; Goodwin and Goodwin, 1984), although Webb (1989) claims the differences between the approaches are overstated.
The evidence indicates that ‘qualitative research’ is generally more interpretive and it is increasingly used to study ‘concepts’ and ‘phenomena’. It is different from quantitative research because it occurs in the natural context without an attempt to change or control the research. The aim is to understand complex relationships rather than demonstrate ‘cause and effect’. The diversity of responses is valuable.
Maggs-Rapport (2000) identified that qualitative research is often humanistic and descriptive in nature. It has many dimensions, where researchers need a self-conscious approach. As a result, the contribution of qualitative research not only reinforces knowledge but also uncovers new information that is perhaps less likely with other approaches.
‘Nursing knowledge’ is also multidimensional. It is about viewing patients as unique human beings and considering their social dynamics in a clinical setting or any setting where care is provided (Hall, 2005).
It is also knowledge nurses have that influences the process of professional caring and outcome. Parse (1996) highlights an important distinction between ‘general knowledge per se that can be used by nurses’ and ‘nursing knowledge’. This is what makes the key difference between lay carers or HCAs and nurses. This ‘nursing knowledge’ is recognised as the ‘body of knowledge’ that marks nursing as a profession and which can be communicated to other nurses.
Qualitative nursing knowledge is dynamic and is always provisional because new data can refute it. Despite these and other complications in trying to define knowledge that belongs to the profession, numerous authors have tried to classify what nurses know. These authors come from a range of perspectives (Chinn and Kramer 1999; Marriner-Tomey, 1994; Benner and Wrubel, 1989; Parse, 1987; Benner, 1984; Watson, 1979; Carper, 1978).
Some authors refer to ‘domains’. These links with the various ‘domains’ or ‘classifications’ of nursing knowledge are influential because any valid theory developed will guide the discipline of nursing. There appears to be an affinity between knowledge needed to care for patients and the relatively holistic approach of qualitative research knowledge.
Most aspects of care generally draw on knowledge from a range of sources. Nursing is much more than just application of knowledge. It is an interactive ‘art’. Maggs-Rapport (2000) claims nursing is a complex concept, perhaps ‘unknowable’ in its entirety.
Qualitative knowledge is dependent on information on the social context with a core item being the understanding of human experiences. It is especially useful when little is known about the topic and in nursing this is true with many aspects of care.
The contribution is often in terms of generation of concepts and new theoretical ideas. Conversely, the underlying philosophy and methods leave the approach vulnerable to criticism that it is potentially unsystematic, subjective, lacks objectivity and generalisibility and that it is a ‘soft’ approach compared with approaches that contribute to so-called ‘empirical’ and ‘scientific’ knowledge.
Parahoo (1997) and Morse and Field (2002) claim the evidence is not viewed as being as powerful as that generated by quantitative work. Many of the strengths of qualitative research are viewed as weaknesses by those who subscribe to different methodologies.
It ensures a unique perspective and is often a relatively deep insight into human beings. It generates knowledge that is needed to care for patients as it is usually person centred, holistic, interactive and inductive. It is based on ‘emic’ perspectives - views of people, their perceptions and meanings - and is useful for exploring knowledge questions related to feelings, behaviour, experiences and meanings (Parahoo, 1997).
Roots of knowledge
Qualitative research in nursing in a similar way to nursing practice has, in a relatively short period of time, descended from numerous other disciplines of often diverse traditions. It has its roots in history, anthropology, philosophy and sociology. It tends to be research carried out in the field or natural settings where data is analysed in non-statistical ways.
Usually analysis is thematic and constantly comparative in nature. The outcome is usually written text or ‘stories’. Researchers’ reports from the field are often based on some form of observation, for example, ‘field work’, ‘case studies’ or ‘stories from the field’ (Darlington and Scott, 2002; Burgess,1984). Within qualitative research the various methods have their individual perspective in terms of nursing knowledge. Morse and Field (2002) advise the most appropriate method to answer the question should be selected.
Qualitative research is traditionally divided into ethnography (social issues - individuals studied in context), phenomenology (focuses upon individuals’ perceptions) and grounded theory (develops theory).
There are also many new and flexible forms of enquiry such as conversational analysis and discourse analysis. Each method has developed from a different background. There is also a tendency for certain forms of social enquiry that are especially relevant to nursing to use qualitative methods such as ‘feminist approaches’ and ‘action research’.
Nursing is a profession that borrows much of its knowledge from other often diverse disciplines such as medicine and psychology. It seems appropriate that the research strategy should encompass elements from other disciplines. The strategy should be dependent to some extent on which aspect of the profession is being researched. Of course there are difficulties in applying any method when researching nursing, which is a complicated practice profession and where many participants are particularly vulnerable.
In relation to the development of qualitative research in the UK, it is important to remember the wider nursing context. Nurses have traditionally been taught the quantitative approaches, partly because the nursing profession initially tried to align and compete with medicine and science (Sim and Wright, 2000).
As the nursing profession began attempting to produce its own knowledge base, it started to identify the differences with medical knowledge. During these decades nurse education changed dramatically with an increasing awareness of accountability. Slowly these factors began to give more credence to qualitative methods and the knowledge generated from these approaches.
Many experienced nurses have only relatively recently been introduced to qualitative approaches. It is important to realise that knowledge created by quantitative research also has its place in enhancing patient care. For example, clinical trials provide the valuable data on oncology treatments and interventions. Approaches and methods should be used pragmatically depending on the question and then the knowledge can be evaluated based on methodological clarity and transparency (Cutcliffe and McKenna, 1999). Nurses also need to pragmatically judge research then apply it if it enhances their practice.
In terms of practice knowledge created by qualitative research, it helps ensure patients are viewed as individual patients rather than medical conditions. In healthcare research this is an important perspective when trying to make effective policy and practice decisions (Bowling and Ebrahim, 2005). It is clear that qualitative research continues to evolve and increase its contribution but it is based on a number of relevant assumptions that add an important perspective to its suitability for many nursing questions.
The underpinning ideas and principles increase the value of knowledge created for nursing by qualitative research. This is because it acknowledges the multidimensional nature of knowledge and that perceptions vary for each individual, which implies that many different meanings are possible (Burns and Grove, 2002).
Some see qualitative research as weak and claim quantitative research methodologies are needed to ‘validate’ the knowledge provided by qualitative studies - claiming this adds to robustness. Their view is that this validation is the only way for findings to ever become part of professional knowledge.
Qualitative research can be complementary to a more statistically-orientated approach. It can illuminate issues and contribute to theory development or new ‘Gestalts’ (Ihde, 1977). Certainly, from my own experience of practice in oncology qualitative research, it does contribute significantly in terms of helping to explain large quantitative studies in detail to provide completeness. They are useful methods that can perhaps look at issues in more depth from the patient perspective.
It is a general interpretive and inductive approach that can develop knowledge, in particular about human health and the illness experience within an integral approach. The subjects of qualitative approaches provide descriptions of how they see phenomena. The researcher immersed in the data tries to understand this within the background of the possible discourses within the knowledge domain. The relationship between subject and context is a key focus to the knowledge developed. The emphasis is on the social character of knowledge as opposed to viewing knowledge as a mirror of ‘reality’ that can be quantified.
It can be useful for helping to develop knowledge in relation to communication and about roles and relationships. Some authors suggest it can empower the researcher because of its distinct characteristics (Flick et al, 2004).
Quantitative research has traditionally been referred to as the ‘gold standard’. However, Foss and Ellefsen (2002) do not recognise this hierarchical order and do not place different values on research methodologies. This links directly with knowledge since types of knowledge that result from different research sources are actually offering different contributions to knowledge. Rather than a value based on theoretical underpinning or hierarchical philosophical values, the worth should be assessed on the quality of the research - if it is applied and used by practitioners. A major strength is that as a strategy that can provide an important insight into the whole process of knowledge production (Barbour, 1999). The ‘benefits’ of qualitative studies in terms of patient care are being acknowledged.
This type of research may lead to the development of ‘nursing specific’ research methods in the future. This is somewhat ironic as the profession is increasingly multidisciplinary and collaboration is being encouraged, yet at the same time the profession is seeking its own professional status and identity. Now more than ever, the knowledge needed to care for patients is borrowed from other professions and research needs to be collaborative. It is important to add that qualitative research contributes to the knowledge of other professions.
In terms of contribution, rigour is usually assessed with regard to ‘trustworthiness’ and ‘transferability’ rather than ‘validity’ and ‘reliability’, which are means to assess quantitative research. A key issue is that in order to assess its contribution, qualitative research should be assessed in relation to its own terms, rather than ‘generalisability’, which is one of the elements used to assess quantitative research. Qualitative studies need to demonstrate their rigour in terms of a systematic study design and analysis. For example, by means of an audit trial (Holloway, 2005).
While it can be seen that underlying ideas and principles significantly influence the contribution, the second major issue identified from the literature is ‘applicability’. This is because the importance of the suitability of the research in terms of using it as evidence to inform practice is vital in relation to assessing its worth.
Varying approaches examine different issues and concerns. But the contribution of qualitative research to that knowledge is particularly useful to patient care as it is enlightening for nurses. It can answer relevant questions and has applicability for practice.
Qualitative research is especially relevant to practice knowledge. This is perhaps an oversimplification. Its interpretation and application of this knowledge in practice is not without difficulties, as sometimes ideas conflict and competing views are often produced. The context-bound nature of the research means care is needed when considering the implications for patients generally because their unique context or situation will inevitably be different from those who have been researched.
There are other problems with the knowledge produced, as qualitative research may generate knowledge that is abstract in nature. As it is often conducted in a natural setting, the researcher is involved in and may be part of the data collection process and has to be open to the subject’s perceptions rather than attach her or his own meanings.
Data needs to create general conclusions but this also leaves the knowledge from qualitative research open to criticism as being just ‘a story’. Conversely, from experience on a practical level, nurses can see the relevance of data and there are usually some implications that will help improve practice. For example, the direct quotes of participants are presented and many practitioners find this easier to interpret rather than statistics.
Qualitative knowledge generated will never be totally precise as human beings do not always act in a logical or predictable manner. Experience means people’s views and perceptions vary over time. In addition, as new knowledge constantly develops this will cause nurses to question what was thought previously. The qualitative research process is relevant to these issues as it is a methodology that is developmental and dynamic and often there is no rigid protocol. Sometimes what is found during the process guides the research.
Nursing is interpretive. Nurses have an interest in the day-to-day experiences of patients and much qualitative research makes nurses think about and question their practice. These are important factors in advancing knowledge. Patients have a variety of perspectives on an issue that do not always fit into often numerical quantitative-type approaches.
Qualitative research is better equipped to provide information on the meaning of illness for patients and how it has affected patients’ lives. It is also frequently richer in terms of the knowledge regarding social and personal experience.
Nurses in practice cannot be effective if they do not understand the patient’s viewpoint. They need to be able to consider the whole range of circumstances that affect the individual. Therefore, nurses can see the relevance of this research and the interest in this type of research is growing partly as a result. From experience of practice ‘action research’ is becoming popular among practitioners, many see it as emancipatory and it can include topical issues for those in practice.
There is an affinity between the knowledge needed to care for patients and qualitative research that tries to encompass the complexity of practice when establishing nursing knowledge. Despite it being a relatively new approach, nurses need to evaluate the contribution of qualitative research to advancing nursing knowledge.
Nursing is unique in terms of the knowledge used and it appears many things are better served by the qualitative rather than traditional methods. Traditional so-called scientific methods of investigation generally have their foundations in different philosophies and methods and some argue these do not always fit the dynamic and complicated world of the human sciences.
It is evident that some aspects of knowledge of care have been significantly advanced by qualitative research, especially suited to beliefs about health and illness, attitudes and behaviours.
It is also relevant that qualitative research is especially suited to when little is known about a subject. As nursing is a constantly changing profession, there are certainly many aspects that affect care about which relatively little is known. From experience of practice, nurses often see the relevance of the research.
Nurses are beginning to research in their own clinical settings especially ‘action research’ although this is not without difficulties. Qualitative research cannot be replicated but it can be audited and its worth assessed. There needs to be excellence in the design process and reporting.
As with any knowledge from any source, the knowledge is always provisional and subject to revision as new data may refute it and this is the case regardless of methodology. It makes more general conclusions using reflection and evaluation by employing a critical, rigorous stance.
Research findings must be communicated and applied if they can be considered ‘nursing knowledge’. Despite being a newer strategy and although it has its critics, it appears the contribution to nursing knowledge is significant for a number of reasons. It advances nursing knowledge considerably and, importantly, it is valuable, as good qualitative research can be used to enhance patient care.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net