Critical Appraisal of Qualitative Evidence in Healthcare
One of the key steps of evidence-based practice is to critically appraise evidence to best answer a clinical question. Mental health clinicians need to understand the importance of qualitative evidence to their practice, including levels of qualitative evidence, qualitative inquiry methods, and criteria used to appraise qualitative evidence to determine how implementing the best qualitative evidence into their practice will influence mental health outcomes. The goal of qualitative research is to develop a complete understanding of reality as it is perceived by the individual and to uncover the truths that exist. These important aspects of mental health require clinicians to engage this evidence. J Am Psychiatr Nurses Assoc, 2009; 15(3), 202-207. DOI: 10.1177/1078390309338733 Critical Appraisal of Qualitative Evidence in Healthcare
Keywords: evidence-based practice; qualitative inquiry; qualitative designs; critical appraisal of qualitative evidence; mental health
Evidence-based practice (EBP) is an approach that enables psychiatric mental health care practitioners as well as all clinicians to provide the highest quality of care using the best evidence available (Melnyk & Fineout-Overholt, 2005). One of the key steps of EBP is to critically appraise evidence to best answer a clinical question. For many mental health questions, understanding levels of evidence, qualitative inquiry methods, and questions used to appraise the evidence are necessary to implement the best qualitative evi- dence into practice. Drawing conclusions and making judgments about the evidence are imperative to the EBP process and clinical decision making (Melnyk & Fineout-Overholt, 2005; Polit & Beck, 2008). The over- all purpose of this article is to familiarize clinicians with qualitative research as an important source of evidence to guide practice decisions. In this article, an overview of the goals, methods and types of qualita- tive research, and the criteria used to appraise the quality of this type of evidence will be presented. Critical Appraisal of Qualitative Evidence in Healthcare
Qualitative research aims to generate insight, describe, and understand the nature of reality in
human experiences (Ayers, 2007; Milne & Oberle, 2005; Polit & Beck, 2008; Saddler, 2006; Sandelowski, 2004; Speziale & Carpenter, 2003; Thorne, 2000). Qualitative researchers are inquisitive and seek to understand knowledge about how people think and feel, about the circumstances in which they find themselves, and use methods to uncover and decon- struct the meaning of a phenomenon (Saddler, 2006; Thorne, 2000). Qualitative data are collected in a natural setting. These data are not numerical; rather, they are full and rich descriptions from participants who are experiencing the phenomenon under study. The goal of qualitative research is to uncover the truths that exist and develop a complete understand- ing of reality and the individual’s perception of what is real. This method of inquiry is deeply rooted in descriptive modes of research. “The idea that multiple realties exist and create meaning for the individuals studied is a fundamental belief of qualitative research- ers” (Speziale & Carpenter, 2003, p. 17). Qualitative research is the studying, collecting, and understand- ing the meaning of individuals’ lives using a variety of materials and methods (Denzin & Lincoln, 2005). Critical Appraisal of Qualitative Evidence in Healthcare
WHAT IS A QUALITATIVE RESEARCHER?
Qualitative researchers commonly believe that indi- viduals come to know and understand their reality in
Kathleen M. Williamson, PhD, RN, associate director, Center for the Advancement of Evidence-Based Practice, Arizona State University, College of Nursing & Healthcare Innovation, Phoenix, Arizona; Kathleen.Williamson@asu.edu.
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Critical Appraisal of Qualitative Evidence
different ways. It is through the lived experience and the interactions that take place in the natural setting that the researcher is able to discover and understand the phenomenon under study (Miles & Huberman, 1994; Patton, 2002; Speziale & Carpenter, 2003). To ensure the least disruption to the environ- ment/natural setting, qualitative researchers care- fully consider the best research method to answer the research question (Speziale & Carpenter, 2003). These researchers are intensely involved in all aspects of the research process and are considered participants and observers in setting or field (Patton, 2002; Polit & Beck, 2008; Speziale & Carpenter, 2003). Flexibility is required to obtain data from the richest possible sources of information. Using a holistic approach, the researcher attempts to cap- ture the perceptions of the participants from an “emic” approach (i.e., from an insider’s viewpoint; Miles & Huberman, 1994; Speziale & Carpenter, 2003). Often, this is accomplished through the use of a variety of data collection methods, such as inter- views, observations, and written documents (Patton, 2002). As the data are collected, the researcher simultaneously analyzes it, which includes identi- fying emerging themes, patterns, and insights within the data. According to Patton (2002), quali- tative analysis engages exploration, discovery, and inductive logic. The researcher uses a rich literary account of the setting, actions, feelings, and mean- ing of the phenomenon to report the findings (Patton, 2002). Critical Appraisal of Qualitative Evidence in Healthcare
COMMONLY USED QUALITATIVE DESIGNS
According to Patton (2002), “Qualitative methods are first and foremost research methods. They are ways of finding out what people do, know, think, and
feel by observing, interviewing, and analyzing docu- ments” (p. 145). Qualitative research designs vary by type and purpose: data collection strategies used and the type of question or phenomenon under study. To critically appraise qualitative evidence for its valid- ity and use in practice, an understanding of the types of qualitative methods as well as how they are employed and reported is necessary.
Many of the methods are routed in the anthropol- ogy, psychological, and sociology disciplines. Many commonly used methods in the health sciences research are ethnography, phenomenology, and grounded theory (see Table 1). Critical Appraisal of Qualitative Evidence in Healthcare
Ethnography has its traditions in cultural anthropology, which describe the values, beliefs, and practice of cultural groups (Ploeg, 1999; Polit & Beck, 2008). According to Speziale and Carpenter (2003), the characteristics that are central to eth- nography are that (a) the research is focused on culture, (b) the researcher is totally immersed in the culture, and (c) the researcher is aware of her/ his own perspective as well as those in the study. Ethnographic researchers strive to study cultures from an emic approach. The researcher as a par- ticipant observer becomes involved in the culture to collect data, learn from participants, and report on the way participants see their world (Patton, 2002). Data are primarily collected through obser- vations and interviews. Analysis of ethnographic results involves identifying the meanings attrib- uted to objects and events by members of the cul- ture. These meanings are often validated by members of the culture before finalizing the results (called member checks). This is a labor-intensive method that requires extensive fieldwork Critical Appraisal of Qualitative Evidence in Healthcare
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