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Qualitative Evidence in Practice Lynam, Judith Mar 19, 2007

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Appraising Evidence Developed Using Qualitative Inquiry Judith Lynam, PhD Associate Professor, UBC Co-Director Culture, Gender & Health Research Unit  Building from… Feb 8, 2007 „  How do I know the research is any good? „  Step 1: How to appraise the literature (Qualitative articles – theory session).  Wendy Hall (Associate Professor, Nursing, UBC)  To-day….. How do I know the article is any good? „  Step 2: How to appraise the literature (Qualitative articles – practical session).  Topics we will consider during this session….. „  What are the indicators of ‘quality’ in a qualitative study? „  „  How can we recognize the indicators? „  „  A synthesis of literature Are the premises that underpin qualitative inquiry upheld in this study?  Practice appraising selected studies  Selected Resources drawn upon…. „  „  „  „  Clark, F. (1993) Occupation embedded in a real life: interweaving occupational science and occupational therapy. American Journal of Occupational Therapy. 47(12): 1067-78. Clemson, L, Cusick, A. & Fozzard, C. (1999) Managing risk and exerting control: determining follow through with falls prevention. Disability and Rehabilitation. 21(12): 531-541. Cohn, ES (2001) Patient perspectives of occupational therapy using a sensory integration approach. American Journal of Occupational Therapy, 55(3): 285-94. Cutcliffe, J.R. & McKenna, H.P. When do we know what we know? Considering the truth of research findings and the craft of qualitative research. (2002) International Journal of Nursing Studies, 39: 611-618.  Selected resources drawn upon con’t…. „  „ „  „ „  Foster, J. (1999) People with traumatic brain injuries used various strategies to deal with labels applied by society. Evidence-Based Nursing, 2: 64 Kearney, M. H. (2001) Levels and applications of qualitative research evidence. Research in Nursing & Health, 24: 145-153. Pettersson, Appelros & Ahlstrom (2007) Lifeworld perspectives utilizing assistive devices: Individuals, lived experience following stroke. Canadian Journal of Occupational Therapy, 74(1): 1526. Thorne, S. (2000) Data analysis in qualitative research. Evidence Based Nursing, 3: 68-70. Morse, J. (2004) Qualitative significance, editorial. Qualitative Health Research, 14(2): 151-52.  Premises….. Of qualitative research  Recognizes knowledge as ‘perspectival’ Assumes there are multiple perspectives ‘on’ the topic, issue or question….  1.  „  Therefore assumes that there is not one ‘truth’  Seeks to make manifest different perspectives  Knowledge is constructed 2. Assumes reality is socially constructed which means what we know and how we experience it is shaped by context and in interaction with others. Therefore the research process is an intersubjective one...the researcher engages with the ‘researched’ to produce knowledge Reflexivity is a key concept  „  3. May also consider the ways broader social structures – influence experience, shape the ways actions are undertaken  Knowledge is contextual  „  4 Qualitative research uses Inductive reasoning „  Uses data to generate the idea --’bottom up’ -- in many instances foregrounds the possibility of ‘alternative’ viewpoints  Insight on the ‘particular’ „  5 Rather than being generalizable to the broader population…qualitative research is generated to provide insights into an event or experience or phenomenon in a „ „ „  Social context Subjective experience Historical time (Thorne, 2000)  Nature of knowledge generated…… „  Generally AIMS to provide Insights into, or understanding of, processes…eg „ „  How power operates Marginalizing processes and practices „ „  „  How enacted in different contexts How taken up and communicated in discourses  How a particular event (illness etc.) is managed or viewed over time  Thorne (2003).. „  Aim is to develop an analytic structure to offer insights into why a particular phenomenon operates as it does.  Analysis is…. „ „ „  Systematic Rigorous Auditable (Thorne, 2003, p. 70).  Nature of knowledge con’t…. „  May contribute to an understanding of ways context influences or shapes peoples’ understandings or experiences „ „  How do toxic workplaces operate? Tracing the influences of patriarchy, hegemony on particular group’s (men’s, women’s, poor, etc.) experiences of…..  With Dr. Hall you…….. Reviewed Theoretical & Methodological Perspectives…in Qualitative Research….  In appraising quality… Key idea to keep in mind…internal congruence. This applies throughout the presentation of the study in the article…. „  „  Is the question congruent with the proposed method? Are there clear links between the methodology and methods used?  What if you don’t know the methodology?.... „ „  „  Look for supporting literature Is it internally congruent?  The goal is to draw upon this reading to appraise whether the ‘methods’ –what was done - is consistent with the methodological principles.  Sampling „  Principles of sampling are informed by the assumptions of the methodological perspective drawn upon….  Sampling concepts…. Sources of data…guided by purposive sampling…..participants chosen on the basis of their 1. knowledge of the phenomenon of interest and their willingness to ‘speak’ to it. 2. Position within an organization/society and/or 3. Authority or record of the topic of interest.  Sampling adequacy…. Guided by… „ Depth „  „  Duration „  „  Quality and detail of the data gathered. May need to gather data (observe/interview/review documents etc.) over time.  Analytic complexity „  „  May need to extend sampling to satisfy emerging analysis – terms you may see are… theoretical sampling, negative case etc. You may also see terms such as ‘saturation of categories’  Theoretical sample….term used in particular methodology – grounded theory – where as the theory is being developed the researcher seeks out participants who may be able to speak to different aspects of the theory. „ „  the ‘negative case’ explore different dimensions of the experience for example - gendered or generational perspectives  Analysis… „ „  Explicitly described and illustrated. Internally consistent…steps taken are compatible with the methodological perspective being used.  Approaches to analysis…. Analyses of quality are systematic and involve.. „ Comprehending the phenomenon under study „ Synthesizing a portrait of the phenomenon that accounts for relations & linkages „ Theorising about how & why these relations appear as they do „ Recontextualising or putting the new knowledge about the phenomena back into the context of how others have articulated the evolving knowledge (Thorne, 2003)  Appraising approaches to analysis Is the process systematic & made explicit? Is the context of the research clearly delineated? „ „ „  „  Who is involved? Why they are involved? Nature of their ‘credentials’ for speaking to the question If appropriate to the question (& methodological perspective) are multiple perspectives (people with different points of view on the topic, other sources of data, texts, etc. sought?  Analysis….con’t - auditability „  Are the researchers’ decisions evident? „  „  „  Do they describe & illustrate the decisions made through the analytic process? Do they explain their role (position) with respect to the research? Do they explain and illustrate the way(s) they involved the participants in appraising the adequacy of the analysis?  Qualitative ‘pyramid’ of evidence? „  Determining Quality…. „  Significance…(Morse, 2004) „  „  Establishing the place for this kind of knowledge in practice & theory development  Levels of complexity and discovery….(Kearney, 2001)  Kearney (2001) „  Complexity – “substantiated linking of  discrete findings into a multifaceted web of interactions” (p. 146) „  „  „  Context of a phenomenon – historical, familial, socio-economic, environmental, political and Aspects of human individuality such as meaning, perception, emotion, action, and interaction.  „  Discovery “ presentation by researchers of new perspectives on or information about the human phenomenon under study” (p. 146). „ „  With previously uncaptured richness or In a new theoretical or interpretive framing of the phenomenon that sheds light on how it came to be and what it is like  „  „  Descriptive methods…lower levels of complexity Intepretive & theorizing methods…(hermeneutic phenomenology, grounded theory, critical interpretive inquiry etc.)…higher levels of complexity  The Qualitative ‘pyramid’…….. „  „  „  „  „  ``````````````````Dense explanatory description – traces  the ways a number of influences impact the situation of interest – ‘thick description’ (highest complexity & discovery)  ````````````Description of experiential variation – the main  pathway is described but also variations on pathway or of process – needs depth & breadth of data and variation in sampling  ```````Shared pathway or meaning – synthesis of shared  experience or process – higher level of complexity – with an integration of categories or clusters  ````Descriptive categories – clusters of data – inventory of  categories – content analysis- no linking of categories to one another – can be high level of discovery but often low level of complexity ‘a priori’ frameworks - (new data into ‘old’ bottles)  - Practice….. Assigned reading: „ Pettersson, I, Appelros, P. & Ahlstrom, G. (2007) Lifeworld perspectives utilizing assistive devices: Individuals, lived experience following a stroke. Canadian Journal of Occupational Therapy. 74(1): 1526.  Critiquing quality….(1) „  Is the problem contextualised?  „  Question or aims articulated?  „  Methodological perspective noted?  Critiquing quality……(2) „  Are Methods used „  Compatible with the methodology? „  Hermeneutic Phenomenology „ „ „  Sample ‘experts’ with the experience? Able to ‘speak to’ the experience? Does researcher engage ‘with’ to explore dimensions of experience – sensory, emotional etc?  Critiquing quality (3) „  Analysis „  Depth & detail evident? „ „ „  Seeking experience of… Account for variations in the experience? Dimensions illustrated with data? „  „  Central concept…Lived Body … „ Meanings of assistive devices in relation to different aspects of one’s life  Considered in relation to broader literature or conceptualizations?  „  Auditable? „  „  Steps of analysis made visible?  Systematic? „  „  Rigorous? „  Insights this study offers… On reading this study what were your thoughts? How did it align with what you observe or experience in your practice? Any surprises or new insights?  Critique of quality…. „  Complexity? „  „  Levels  Discovery? „  Levels  Additional examples….. „  See handout…..  To keep in mind..….. „  When taking up qualitative evidence. „ „  Ensure you are using it as it is intended. Recall the AIMS of qualitative inquiry. „  If not generalizability then what?   BC Rehabilitation Sciences Research Network (BC RSRnet) Workshop Series How to Make the Most of your Therapy: Putting Research into Practice! Annotated Bibliography – to inform the workshop on Appraising the Quality of Qualitative Research Prepared by M. Judith Lynam, PhD - March 2007 Clark, Florence (1993) Occupation embedded in a real life: Interweaving occupational science and occupational therapy. The American Journal of Occupational Therapy, 47(12): 1067-1079. The author describes this article as research she undertook with a young, active, educated and healthy acquaintance recovering from a stroke secondary to a ruptured aneurysm at the age of 47. Methodology She indicates that the narrative discourse presented in this article "emerged through our collaboration as life history ethnographers (Frank, 1979, 1984, 1986), interpreting her experience of disability over time from an occupational science standpoint, and as ethnomethodologists (Garfinkel, 1967) identifying the therapeutic process that emerged as I unexpectedly functioned as her occupational therapist, while engage in the research process." (p. 1068). 'Findings' This article illustrates the ways a narrative can create a means for practitioners to understand the process of recovery as rooted in the individual's own life story (a story with a beginning, middle and end) while also challenging professionals' views of their role and providing a means for positioning themselves in the process of recovery. It illustrates the principles of reflexivity – researcher engagement 'with' the research but also reflections 'on', the researcher's own views or conceptions of practice, recovery etc. It clearly writes the person into the story with great depth, detail and variation over time. This is an example of the ways the 'particular' can be drawn upon to inform practitioners' views of practice. Notes:  Clemson, L. Cusick, A. & Fozzard, C. (1999) Managing risk and exerting control: Determining follow through with falls prevention. Disability and rehabilitation. 21(12): 531-41. Abstract Purpose/Method: This study used in-depth interviews to explore the perspectives of nine older women who had not followed through with environmental modification recommendations to reduce the risk of falls in their own home. Results: It was found that the core concept of 'exerting control' provided an understanding of their experience following an occupational therapy home visit. Exerting control was a behavioral, cognitive and affective process whereby the women made decisions about whether or not to follow thought with environmental modification recommendations based on their knowledge of environmental risks, perceptions of degree of risk, perceived ability to mediate these risks through behavior and the degree of freedom she had in decision making. Exerting control meant that the women made daily choices about their home environment which increased or decreased the risk of falls with identified home hazards. Conclusion: The findings suggest that, for some women, health professionals need to work with the phenomenonon of exerting control, in order to work with clients to reduce environmental hazards. Notes:  Lynam, lynam@interchange.ubc.ca  March 2007  1  Cohn, Ellen S. (2001) Parent perspectives of Occupational Therapy using a sensory integration approach. The American Journal of Occupational Therapy. 55(3): 285-93. Background to the research The author locates the study in the literature within Occupational Therapy practice related to the identified value of 'sensory integration approaches' in "increasing children's motor, sensory processing, and academic skills" (p. 285). The observes however the evidence related to efficacy is not definitive. She argues that parents play a key role in identifying the need for therapy and in achieving and sustaining outcomes of therapy. Moreover, the author positions the study in her observations in practice and in relation to her experience as a parent of young children. The study builds from earlier research identifying themes related to desired changes in the "parenting occupation" and the "occupation of children" (p. 286) and seeks to make manifest parents' perceptions of this particular form of therapy for their children. Methodology The investigator used 'naturalistic program evaluation methods' (Lincoln & Guba, 1985) to undertake the research. The design was a 'collective case study approach' (Stake, 1994). Sampling was purposive in that it involved parents whose children had received OT using the sensory integration approach for a minimum period of time (at least 32 - 1 hr sessions). Children with a positive diagnosis of Autism, pervasive developmental disorder or fragile X syndrome were excluded because they may not respond in a similar way to the therapy. Parents were interviewed in their own home, interviews were audio-taped and transcribed and submitted to analysis using 'grounded theory methods' (Strauss & Corbin, 1998). Findings Parents' perspectives of therapy outcomes are described as a process that is shaped by parents' expectations, their perceptions of 'successful' parenting and influenced by their views of their children's challenges and responses to therapy. (See Figure 1, p. 288). Categories and processes are illustrated using quotes and data excerpts and considered in relation to the broader literature on parenting, literature on child focused outcomes of therapy. Notes:  Moules, NJ, Simonson, K, Prins, M., Angus, Pl & Bell, J.M. (2004) Making room for grief': walking backwards and living forwards. Nursing Inquiry, 11(2): 99-107. Background to the research The authors position this study in the broader theoretical and practice perspectives on grief therapy. They undertook the study because their practice experience was that peoples' experiences did not 'fit' the traditional perspectives on grief as 'separation' or loss. Methodology  Lynam, lynam@interchange.ubc.ca  March 2007  2  The methodology is described as a 'hermeneutic interpretive study'. The authors position their perspectives on practice as aligning with this philosophical position. The strategies for 'sampling' and data gathering are compatible with the tenets of this perspective. Analysis The preliminary analysis sought to extract "beliefs that seemed linked to grief, and which may have been potentially diminishing or contributing to the suffering associated with grief" (p. 101). The researchers then engaged in an interpretation of these beliefs to emphasize "practical applications of the findings". 'Findings' The findings are presented first as an exploration of a series of beliefs. The participants' explanations or experiences are considered in light of the prevailing literature on grief, to highlight points of tension or compatibility. The analysts then proceed to propose an alternative interpretation of the grief experience. This interpretation creates a way for persons living with loss to engage with their grief and introduces new metaphors – that capture different experiences and dimensions of grief. Such metaphors the authors argue create a means for people (and therapists) to engage with grief that is at times experienced as "walking backwards and living forward". The authors propose a second phase of research to explore the impact of interventions to diminish the suffering associated with grief. Notes:  Wicks, Al, & Whiteford (2003) Value of life stories in occupation-based research. Australian Occupational Therapy Journal, 50: 86-91. Positions the narrative approach to research in occupational therapy. Illustrates ways this method can be enacted and the forms of insights it offers. A methods paper. Additional Examples of Qualitative Research – with applications to OT/PT: Anderson, J.M., Dyck, I. & Lynam, M.J. (1997) Health care professionals and women speaking: Constraints in everyday life and the management of chronic illness. Health 1(1): 57-80. Angus, Jan, Kontos, P., Dyck, I., McKeever, P. & Poland, B. (2005) The personal significance of home: habitus and the experience of receiving long term home care. Sociology of Health and Illness, 27(2): 161-87. Abstract The physical, symbolic and experiential aspects of receiving long-term care are examined in this paper using Bourdieu’s concepts of habitus and field. We draw on data from an ethnographic study of home care in 16 homes in urban, rural and remote locations in Ontario, Canada. Across all cases, data about domestic and caregiving routines were gathered through observation, interviews with clients and/or the primary family caregiver, interviews with service providers and videotaped tours of the home. Based on the analysis of these data, we argue that a transposition of logics and practices occurred when the domestic and health care fields were superimposed within the spaces of the home. Although all  Lynam, lynam@interchange.ubc.ca  March 2007  3  of the care recipients and their family caregivers indicated a strong preference for home care over institutional care, their experiences and practices within their homes were disrupted and reconfigured by the insertion of logics emanating from the healthcare field. These changes were manifested in three main themes: the politics of aesthetics; the maintenance of order and cleanliness; and transcending the limitations of the home. In each of these dimensions, it became apparent that care recipients engaged in improvisatory social practices that reflected their ambiguous and changing habitus or social location. The material spaces of their homes signified, or prompted, altered or changing social placement. Keywords: home care, ethnography, chronic illness, Bourdieu  In addition to the ideas presented in the ppt component of the workshop the following are Articles that address – the appraisal of Quality in Qualitative Research Horsburgh, D. (2003) Evaluation of qualitative research. Journal of Clinical Nursing, 12: 307-12. (While important points are made, all points are not necessarily applicable to all types of qualitative research. Does not always distinguish between different methods within the qualitative paradigm). ****Kearney, M. H. (2001) Levels and applications of qualitative research evidence. Research in Nursing and Health, 24: 145-53. (Focus is on the analysis of the quality of the analysis. Introduces the criteria of complexity and discovery as indicators of quality. Provides a description of levels of analysis that reflect increasing complexity and discovery and illustrates these with examples. Useful for focusing attention on the nuances of detailed analysis.)  Thorne, S. (2000) Data analysis in qualitative research. Evidence Based Nursing, 3: 68-70. (Articulates the aims of qualitative inquiry and illustrates, for different methods within the paradigm, how these aims are accomplished in the analysis. Distinguishes criteria to be applied to different types of studies.)  Lynam, lynam@interchange.ubc.ca  March 2007  4  


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