Clinical scenario

A team of general practitioners, nurses, physiotherapists, occupational therapists, dieticians and medical receptionists working in a government-funded health centre have invested a great deal of energy and resources to develop a team-based approach to client care. Overall, they are pleased with the progress made and are anxious to consider the degree to which their efforts relate to improving clients’ experiences. They have agreed that, given the growing size of the team and the increase in the number of different members of the team interacting with clients with chronic illnesses, their most urgent need is to find out what, from the clients’ perspective, continuity really means.

This chapter focuses on questions that relate to the experiences of clients and health professionals and the meaning that clients and health professionals associate with these experiences. In general terms, evidence-based health care has tended to focus on the search for objective evidence to establish the degree to which a particular intervention or activity results in defined outcomes. The importance of basing practice on the best available evidence is now well accepted and ways of finding, appraising and applying evidence related to diagnosis, prognosis or the effects of an intervention are becoming increasingly well understood. Thus, evidence-based practice is generally conceptualised as searching for, appraising and synthesising the results of experimental or quantitative research and transferring the findings to practice and policy domains to improve health outcomes.

Health professionals, however, seek evidence to substantiate the worth of a very wide range of activities and interventions and thus the type of evidence needed depends on the nature of the activity and its purpose. Pearson and colleagues ¹ have described a model of evidence-based health care in which they assert that, if evidence is needed to address the multiple questions, concerns or interests of health professionals or the users of health services, it must come from a wide range of research traditions. Evidence that arises out of qualitative inquiry is frequently sought and utilised in clinical practice.² Qualitative research seeks to make sense of phenomena in terms of the meanings that people bring to them.³ Evidence from qualitative studies that explore the experience of clients and health professionals has an important role in ensuring that the particularities associated with individual clients, families and communities are just as important as information that arises out of quantitative research.

Qualitative researchers attempt to increase our understandings of:

• how individuals and communities perceive health, manage their own health, and make decisions related to health service usage

• the culture of communities and of organisations in relation to implementing change and overcoming barriers to the use of new knowledge and techniques

• how clients experience health and illness and the health system

• the usefulness, or otherwise, of components and activities of health services that cannot be measured in quantitative outcomes (such as health promotion and community development)

• the behaviours/experiences of health professionals and the contexts of health care.

Qualitative research generates evidence that informs clinical decision making on matters related to feasibility, appropriateness or meaningfulness. Pearson et al ² describe feasibility as the extent to which an activity is practical and practicable. Clinical feasibility is about whether or not an activity or intervention is physically, culturally or financially practical or possible within a given context. They define appropriateness as the extent to which an intervention or activity fits with or is apt in a situation. Clinical appropriateness is about how an activity or intervention relates to the context in which care is given. Meaningfulness refers to how an intervention or activity is experienced by the client. Meaningfulness relates to the personal experience, opinions, values, thoughts, beliefs and interpretations of clients. Evidence-based practice in its fullest sense is about making decisions about feasibility, appropriateness, meaningfulness and effectiveness—and quantitative and qualitative evidence are of equal importance in this endeavour.

This chapter explores the development of qualitative clinical questions and the role and methods of qualitative research. It will also explain how to appraise and apply qualitative evidence. Throughout the chapter, a clinical scenario and relevant qualitative article will be referred to as an example as we consider how to appraise a qualitative article and how the findings of qualitative research can be applied in practice.

Qualitative research: its role in researching clients’ experiences and concerns

Qualitative research that focuses on clients’ (and health professionals’) experiences and concerns assists people to tell their stories about what it is like to be a certain person, living in a particular time and place, in relation to a set of circumstances, and analyses the data generated to describe human experience and meaning. The ‘data’ that are collected and analysed in qualitative research are words because they are the media through which people express themselves and their relationships to other people and their world. This means that, if researchers want to know what the experience of care is like, they will ask the people receiving that care to describe their experience in order to capture the rich meaning.

Through these approaches the enduring realities of people’s experiences are not over-simplified and subsumed into a number or a statistic. Because qualitative researchers draw relationships between sets of data and interpret the material, qualitative research is flexible in design and adaptive. For example, it is possible to use multiple methods for any one study. Qualitative approaches in health services research represent a relatively new disciplinary approach and there is still much debate concerning the rigour of analysis ⁴^–⁶ and the benefits of one method over another: for instance, the benefits of an ethnographic approach over a phenomenological or a grounded theory approach. Each of these approaches is briefly explained later in this chapter. Different qualitative research approaches set out to achieve different things and, when differing perspectives are put together, they provide a multifaceted view of the subject of inquiry that deepens our understanding of it. In this sense they are not substitutes for each other due to some essential superiority of one method over another, but rather they represent a theoretical ‘tool kit’ of devices. Depending on the task at hand, one methodology on one occasion may be a more useful tool than another.

How to structure a qualitative question

The team that was described in the clinical scenario at the beginning of this chapter want to find out what receiving care from a large primary healthcare team is like for people who have a chronic illness. The PICO format that was described in Chapter 2 can be used to structure a qualitative question, but generally there is no ‘comparison’ in a qualitative question and the ‘I’ refers to ‘interest’ or ‘issue’ rather than intervention.

Clinical scenario (continued): Structuring the question

From this scenario, a suitable qualitative question would be: In adults with any chronic condition that requires frequent primary health care (Population), what is their experience of continuity and of receiving that care from different members of the primary healthcare team (Issue) and how does this experience help or hinder their daily lives (Outcomes)?

Because the question for our clinical scenario explicitly seeks qualitative information, clearly, the team will need to search for qualitative research articles. Using the term ‘qualitative research’ is, however, in itself problematic. The word ‘qualitative’ is frequently used to describe a singular, specific methodology (for example ‘… in this study a qualitative methodology was pursued’) when in its broadest sense it is an umbrella term that encompasses a wide range of methodologies stemming from a number of diverse traditions.

Although we can be clear in saying that there are easy-to-describe qualitative data (that is, data that consist of words and the meaning they convey) and that there are easy-to-describe ways to approach qualitative data analysis (that is, manual and electronic approaches to analysing words and their meanings), to design and conduct qualitative research requires the identification of a well understood methodology that is appropriate to the question and the use of methods of data collection and analysis that are congruent with the chosen methodology. There are many different qualitative methodologies and we will outline six commonly used approaches in the following section. Although they are discussed separately, qualitative researchers often combine elements from different methodologies when undertaking their research.

Qualitative methodologies used in health research

Phenomenology

A phenomenological research approach values human perception and subjectivity and seeks to explore what an experience is like for the individual concerned.⁷ The basis of this approach is a concept called ‘lived experience’, which means that people who are living presently, or have lived an experience previously, are in the best position to speak of it, to inform others of what the experience is like or what it means to them. Phenomenology is concerned with discovering the ‘essence’ of experience. It asks the question: ‘What was it like to have that experience?’

Data are collected using a focussed, but non-structured, interview technique to elicit descriptions of the participant’s experiences. This style of interview supports the role of the researcher as one who does not presume to know what the important aspects of the experience to be revealed are. Several steps are involved in thematic data analysis.⁷ The interviews are transcribed verbatim and are then read by researchers who attempt to totally submerge themselves in the text in order to identify the implicit or essential themes of the experience, thus seeking the fundamental meaning of the experience.

The strength of the phenomenological method is that it seeks to derive meaning and knowledge from the phenomena themselves and, although it is generally conceded that unmediated access to a phenomenon is never a possibility (that is, the exclusion of all prior perceptions and research bias), the emphasis on the experience of the participants ensures that this model represents as closely as possible the participants’ perspective.^5,⁶ In this sense the perspectives that arise from the phenomenological approach help to shape the categories of concern in terms of the issues that the participants themselves identify. Through the phenomenological method, participants contribute substantially to informing and describing the field of inquiry that future policy needs to address.

Clinical scenario (continued): Potential contribution of evidence from phenomenological research

The findings of phenomenological research studies could usefully provide evidence to the primary healthcare team related to the lived experience of being a patient/client and the meanings that clients associate with this experience.

Grounded theory

Grounded theory is a term chosen by sociologists Glaser and Strauss ⁸ to express their ideas of generating theory from the ‘ground’ using an ‘iterative’ (or cyclical/circular) approach whereby data are gathered using an ongoing collection process from a variety of sources. They developed this approach in their ground-breaking work on death and dying in hospitals.⁸ Strauss and Corbin⁹ have developed an approach that begins with open coding of data that requires the researcher to take the data apart and ask, ‘What is going on here?’