The use of qualitative research methodologies within musculoskeletal physiotherapy practice
Article Outline
- 1. Introduction
- 2. What is qualitative research?
- 3. Qualitative research and evidence-based healthcare
- 4. How qualitative research might benefit and enrich musculoskeletal physiotherapy practice
- References
- Copyright
1. Introduction
Qualitative research has long been associated with the academic disciplines of anthropology and sociology, and with images of lone researchers travelling to distant and exotic lands to investigate and later write about these cultures. However, the last two decades have witnessed a growing awareness of the relevance of qualitative research for healthcare. The discipline most thoroughly sold on the approach is nursing, since the demonstration of its usefulness in the mid-1980s by a group of American nurse qualitative researchers (Field and Morse, 1985; Leininger, 1985; Chenitz and Swanson, 1986). A decade later, medicine and psychology acknowledged that qualitative methodologies were useful for their respective disciplines (Britten, 1995; Henwood and Nicolson, 1995). More recently, as a result of lobbying by the Mental Health Qualitative Research Network, the British Journal of Psychiatry has this year amended its instructions to authors by including detailed advice on the submission of qualitative research articles (Quirk, 2004).
2. What is qualitative research?
Qualitative research is an umbrella term for a collection of methodologies (general approaches) that have in common the desire to uncover and explore how people experience particular events and the meanings they attach to those experiences (Denzin and Lincoln, 2000; Holliday, 2002). Compared with quantitative experimental research, contemporary, sometimes labelled ‘progressive’, qualitative research (Holliday, 2002) proceeds from a different set of assumptions and philosophical beliefs.
In healthcare, quantitative researchers seek to test hypotheses to identify cause and effect, while the aim of qualitative researchers is to answer questions, such as ‘how do this group of people experience X’? Quantitative researchers seek to find out about cause and effect through increasingly refined experimental conditions, within which researcher bias is controlled for. In contrast, progressive qualitative researchers argue that such a distanced and controlling approach is inappropriate for the study of human experiences and meanings, asserting that knowledge is inevitably co-constructed between researchers and their participants in qualitative fieldwork.
Given this, qualitative researchers are charged with celebrating their inscription within the experiences and meanings of the people, events and issues they investigate, rather than seeing this as troublesome. From this perspective, qualitative researchers have a moral duty to make explicit how they interact with their participants, to explore rather than shy away from issues of power and influence, and to give equal respect in their accounts to their mistakes, as well as moments of epiphany (Denzin and Lincoln 2000; Duncan-Grant, 2001; Sparkes 2002; Holliday 2002).
Quantitative researchers seek to increase the accumulated general stock of knowledge in relation to circumscribed causes and effects, independent of time and geographical location. In contrast, qualitative researchers argue that, as far as human experiences and meanings are concerned, knowledge is always provisional, and conceptualized within a particular group of people at a particular time in a particular place.
All of the above contrasts can of course be traced to fundamental differences at the level of the philosophy of science. Whereas quantitative experimental researchers rest their case on the positivist/post-positivist paradigm or worldview, within which it makes sense to seek to make robust and global truth claims, progressive qualitative researchers argue than human meaning and experience can only ever at best be interpreted. Because meanings and experiences are socially constructed, an infinite number of stories can be told, so knowledge is never ‘exhausted’. Given this, it is argued that the kinds of ‘grand narratives’ valued by quantitative researches should be treated with a healthy scepticism, at least in the area of human meaning making.
3. Qualitative research and evidence-based healthcare
Recent years have seen turf wars emerging in particular healthcare disciplines over the relative merits of quantitative or qualitative approaches for the development of knowledge. From time to time in nursing, for example, writers from both camps take issue with each other, and the debate often takes a moral ‘one-upmanship’ turn in the direction of which approach supposedly best serves the interests of client groups. Clearly, this kind of ‘either-or’ thinking does little else than further polarize already entrenched positions. A more balanced view is that equal respect should be given to all communities of knowledge production, and that no one paradigm should dominate (Gergen, 1999).
Unfortunately, paradigm dominance characterizes the current British healthcare research agenda. The practice of evidence-based health healthcare is promoted on the basis of an established hierarchy of strength of evidence described below, where (1) is assumed to be the source of evidence upon which clinicians can place most confidence (Muir Gray, 1997):
Whereas the randomized control trial is lauded as the ‘gold standard’ of healthcare research, ‘non-experimental’ and ‘descriptive’ qualitative research is relegated to the bottom of the confidence hierarchy.
Such an arguably unfair over-investment in quantitative approaches can be criticized on inter-related moral and epistemological grounds. From a moral point of view, because quantitative experimental research focuses on clinical outcomes with research done to rather than with patients, the views and experiences of people are accorded insufficient attention. While a randomized control trial can provide valuable health care information, it does not on its own provide a sufficiently rich or holistic picture of the often distressing meanings associated with the experience of ill health. To paraphrase Gergen (1999), we are left with a picture of ‘misery with the tears wiped off’.
Equally, the homogenizing nature of quantitative experimental research means that variations in experiences and meanings are not identified. Writing on the Cochrane consumer website, Hilda Bastion (1994, p. 8) asserted that:
People's views in pluralistic communities cannot, and should not, be squeezed into unidimensional frameworks to meet demands for mathematical order. Values cannot be measured with a ruler, and the pain of people's struggles with ill-health should not be homogenised till it is no longer recognisable. That something is useful, does not necessarily make it right. It should not be forgotten that utility does not equate with value, and that utilitarian decisions – “the greatest good for the greatest number”, by definition discriminate against minorities.
Epistemologically, the kinds of evidence-based healthcare assumptions described above clearly influence what is seen to count as quality knowledge in many healthcare disciplines. Such assumptions fuel a form of circular reasoning where clinical outcomes only are seen as worthwhile. Atkinson et al. (2001) described this as ‘paradigm entrapment’, arguing that it contributes to the social construction of patients and the experiences in particular ways. At worst, this can for example lead to clinicians being dismissive of their patients’ experience of ill-health and the distress associated with sometimes painful treatments.
4. How qualitative research might benefit and enrich musculoskeletal physiotherapy practice
At a very general level, physiotherapy researchers might use qualitative approaches to explore how patients experience physiotherapy treatments. More specifically, there are lots of exciting research questions that could be asked in relation to the varieties of qualitative research methodologies available. For instance, researchers might want to investigate the lived experience of a patient, or group of patients, with chronic ill-health requiring long-term physiotherapy treatment. A focus on the personal meaning or meanings of the experience of treatment in relation to ill-health would make a phenomenological qualitative approach appropriate. The answers to the research questions posed might well aid in the development and refinement of physiotherapy interventions to the benefit of future patients.
A different research focus on the social laws governing the shared and divergent experiences of groups of patients with specific illnesses requiring musculoskeletal physiotherapy interventions might indicate the need for a grounded theory approach. This essentially sociological form of qualitative research seeks to identify patterns in the trajectory of patients’ illnesses. An improved knowledge of such patterns might help the profession better understand the value of physiotherapy intervention for specific groups of patients at specific times in the course of their illnesses.
A discourse analytic research approach would enable researchers to focus more on the language used by patients in relation to their illnesses. From this perspective, language is not understood as a neutral vehicle to describe experiences but as constitutive of these experiences. Discourse analytic researchers could, for example, use non-participant observational methods to study the verbal interaction between physiotherapists and their patients. This might yield interesting data on what characterizes helpful and unhelpful dialogue, which may in turn inform curriculum development in physiotherapy education.
While the above has a focus on, and assumed benefit for, patient treatment, qualitative approaches could equally be used to study the lived experiences of physiotherapy practitioners, and the meanings they attribute to such experiences. A qualitative focus on training and education might lead to an improved curriculum. Equally, studies which addressed questions around particular kinds of post-qualifying experience might uncover important but ‘hidden’ experiences around, for example, bullying, job stress or practitioner burnout.
Finally, and perhaps most importantly, the broadening of the research agenda in musculoskeletal physiotherapy in according more respect for, and recognition of, qualitative approaches can only benefit the physiotherapy profession. As Atkinson and his colleagues argued (2001, p. 6), ‘It is singularly unhelpful to all concerned if disciplines become too tightly classified and circumscribed according to styles of research’. As well as the benefits to patients and staff described above, the profession would be following a paradigm shift already well established in other healthcare disciplines and would be seen to be responding appropriately to the epistemological and moral difficulties long associated with ‘paradigm entrapment’.
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PII: S1356-689X(04)00063-3
doi:10.1016/j.math.2004.07.001
© 2004 Elsevier Ltd. All rights reserved.
