ABSTRACT
The rapid uptake of qualitative approaches in translational research can be best understood in the
context of recent innovations in health services research, as well as an overarching concern with improving
the quality of health care. Qualitative approaches highlight the human dimension in health care by
foregrounding the perceptions, experiences, and behaviors of both consumers and providers of care.
As such, these methods are particularly useful for addressing the complex issues related to improving
health care quality and implementing system change. This overview traces a brief history of the factors
contributing to the recent and rapid growth of qualitative methods in health research in general and
translational research in particular; describes the varieties of qualitative approaches employed in this
research; and illustrates the utility of these approaches for variable identification, instrument development,
description/explanation of patient/provider perceptions and behaviors, individual/organizational change,
and theory refinement.
Worldviews on Evidence-Based Nursing 2004; 1(S1):S65S72. Copyright 2004 Sigma Theta Tau International
qualitative methods, naturalistic inquiry, qualitative synthesis, translational research, evidencebased practice, patient experience, provider behavior, theory construction, Cochrane Qualitative Methods
Group
KEYWORDS
INTRODUCTION
Toni Tripp-Reimer, Professor and Associate Dean for Research, The University of Iowa,
College of Nursing, Bradley Doebbeling, General Internal Medicine Professorship in
Health Services Research, Indiana University School of Medicine; Associate Director for
Health Services Research, Regenstrief Institute for Health Care; Director, Health Services
Research Service (11-H), Roudebush VA Medical Center, Indianapolis, IN 46202, USA.
Address correspondence to Toni Tripp-Reimer, Professor and Associate Dean for
Research, The Univercity of Iowa, College of Nursing, 50 Newton Road, Iowa City,
IA 52242, USA; toni-reimer@uiowa.edu
This article was presented at the U.S. Invitational Conference Advancing Quality
Care Through Translation Research, October 1314, 2003, at the University of
Iowa, Iowa City, Iowa.
Copyright 2004 Sigma Theta Tau International
1545-102X1/04
the perceptions, experiences, and behaviors of both consumers and providers of care. As such, these methods are
particularly useful for addressing the complex issues related to improving health care quality and implementing
system change. Qualitative research offers a variety of
methods for identifying what really matters to patients and
[providers], detecting obstacles to changing performance,
and explaining why improvement does or does not occur
(Pope, van Royen & Baker 2002, p. 148). This overview will
trace a brief history of the factors contributing to the recent
and rapid growth of qualitative methods in health research
in general and translation research in particular; describe
the varieties of qualitative approaches employed in this research; and illustrate the utility of these approaches for
variable identification, instrument development, description/explanation of patient/provider perceptions and behaviors, as well as individual/organizational change.
HISTORICAL OVERVIEW
Qualitative approaches in translational research need to be
understood within the broader context of the recent uptake
of qualitative methods in health services research. Qualitative approaches in health-related research were first used by
anthropologists conducting ethnographies in remote culfor increased use of qualitative approaches in health
tures (Rivers 1924; Evans-Pritchard 1937). Later sociolresearch:
ogists adapted observational techniques to study aspects
r Priority Areas for National Action: Transforming
of the biomedical health system (Becker, Geer, Hughes &
Health Care Quality (Adams & Corrigan 2003)
Strauss 1961; Goffman 1961, 1963). Nursing was the first
r Leadership by Example: Coordinating Government
health discipline to identify the importance of qualitative
Roles in Improving Health Care Quality (Corrigan,
methods, legitimize them, and incorporate them into reEden & Smith 2002)
search. Over the past decade, and particularly in the past 5
r Who Will Keep the Public Healthy? Educating Pubyears, there has been an exponential increase in the use of
lic Health Professionals for the 21st Century (Gebbie,
qualitative approaches in health services and translational
Rosenstock & Hernandez 2003)
research.
r Speaking of Health: Assessing Health CommunicaFederal, national, and international agencies and inition Strategies for Diverse Populations (Institute of
tiatives have facilitated this evolution through a variety
Medicine 2002)
of mechanisms such as conferences and reports. Two fedr Unequal Treatment: Confronting Racial and Ethnic
eral funding agencies in the United Statesthe National
Disparities in Health Care (Smedley, Stith & Nelson
Institutes of Health (NIH) and Agency for Health Re2003)
search and Quality (AHRQ)have promoted qualitative
r Crossing the Quality Chasm: A New Health System for
approaches through a series of developmental/training conthe 21st Century (Institute of Medicine 2001)
ferences and calls for applications. In 1998, the Agency for
r Promoting Health: Intervention Strategies from Social
Health Care Policy and Research (now AHRQ) and The
and Behavioral Research (Smedley & Syme 2000)
Robert Wood Johnson Foundation co-sponsored a groundbreaking conference titled Qualitative Methods in Health
The British-based International Cochrane CollaboraServices Research in Rockville, Maryland, with 78 intion prepares, maintains, and disseminates systematic revited participants from health services research and social
views. In 2001, the Qualitative Methods Group was ofscience (http://www.ahcpr.gov/about/cods/codsqual.htm).
ficially registered as an active component of the overall
These proceedings were subsequently published in the
Cochrane Collaboration in partnership with the Campjournal Health Services Research (Devers, Sofaer & Rundall
bell Process Implementation Methods Group. The goals
1999). In 1999, a workshop of social scientists organized by
of the Cochrane Qualitative Methods Group are to
the National Institute for Mental Health and the National
(a) demonstrate the value of qualitative research through
Institute on Alcohol Abuse and Alcoholism resulted in the
systematic reviews, (b) disseminate methodological stanguide Qualitative Methods in Health Research: Opportudards to aid the evaluation of qualitative research,
nities and Considerations in Application and Review for
(c) promote the synthesis and integration of qualitainvestigators using qualitative approaches http://obssr.od.
tive research within the broader literature syntheses, and
nih.gov/Publications/Qualitative.PDF. Shortly thereafter,
(d) provide some training in qualitative methods synin 2002, NIH sponsored the conference Using Qualithesis: (http://www.lancs.ac.uk/depts/ihr/research/public
tative Methods to Promote Self-Care in Diverse Popu/cochrane.htm).
lations (http://obssr.od.nih.gov/Conf Wkshp/Adherence
This recent and rapidly increasing attention and activity
/Qualitative Methods.htm). A final example is the 2004
have been triggered by several sources including increasing
NIH conference The Design and Conduct of Qualitative
health care costs, increasing health disparities, unexplained
and Mixed-Method Research sponsored by the Office of
practice variation, the increased role of the consumer voice,
the Director, Office of Behavioral and Social Science Rethe complexity of clinical decision making, and the recogsearch (http://obssr.od.nih.gov/conf wkshp/sw/).
nition that practice changes are not driven solely by sciPublications in health literature reflect these developentific knowledge (Jones 1995; Popay, Rogers & Williams
ments. While nursing science journals have published
1998; Shortell 1999; Pope, van Royen & Baker 2002). For
qualitative studies since the 1952 inaugural issue of Nursexample, the recent, but dramatic, emergence of patienting Research, medical and health research journals have
centered initiatives, such as the Picker/Commonwealth
only more recently incorporated such studies. In the
Program for Patient-Centered Care approach, mandate atpast decade, a series of editorials in prominent meditention be given to topics such as respect for patient values,
cal journals, particularly the British Journal of Medicine
preferences, and needs that are best identified and underand to a lesser extent the Journal of the American Medistood through qualitative approaches.
cal Association, have highlighted the importance of qualShortell (1999) views the growing role of qualitative apitative approaches. Similarly, the National Institute of
proaches in translation research as reflecting the need for a
Medicine issued a series of reports specifically calling
more in depth (sic) understanding of naturalistic settings,
r
S66 Third Quarter (Suppl.) 2004 Worldviews on Evidence-Based Nursing
the importance of understanding context, and the complexity of implementing social change (p. 1083). Correspondingly, the greater appreciation of qualitative methods
can be traced to the growing recognition that many health
problems and processes of care do not fit easily into experimental research designs (Popay, Rogers & Williams 1998,
p. 341).
the United States. Annually, the Veterans Health Administration rolls out different clinical practice guidelines and
monitors compliance with them, making this an excellent
environment for translational science. Perceived major facilitators to guideline implementation included administrative commitment, electronic patient records, work
reorganization, and audit with feedback. Major barriers
included time and workload issues, lack of technological support, and lack of guideline credibility. Providers
(primarily physicians) and clinicians (primarily nurses)
emphasized barriers and problems with clinical practice guidelines, while administrators emphasized guideline
benefits and facilitators to implementation. The groups also
differed in the major concerns expressed: Administrators
emphasized guideline compliance; providers emphasized
continuity of care; and clinicians emphasized benefits for
patients (Doebbeling et al. 2002; Sorofman et al. 2002;
Vaughn et al. 2002; Lyons et al. 2003). Taken as a whole,
these studies illustrate that implementing effective organizational change requires attention to the issues of each key
stakeholder group.
SUMMARY
The unprecedented proliferation of qualitative research in
health sciences can be attributed to an increased emphasis on the components of quality of care and a mandate
to ensure that health care decisions are made on the best
available evidence. In the context of health research in
general, and translational research in particular, qualitative approaches are making distinct and important contributions through the illuminating and explanatory power
of these forms of evidence.
Acknowledgments
This research was supported in part by the National Institutes of Health grant P30 NR03979 awarded to Dr. TrippReimer and by the Department of Veterans Affairs, Veterans
Health Administration, Health Services Research and Development Service, Quality Enhancement Research Initiative (QUERI), Investigator Initiated Research Grants CPI
99-126 and CPI 01-141, awarded to Dr. Doebbeling.
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