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Qualitative Perspectives in TranslationalResearch

Toni Tripp-Reimer, RN, PhD, FAAN, Bradley Doebbeling, MD, MS

A B S T R A C TThe 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 improvingthe quality of health care. Qualitative approaches highlight the human dimension in health care byforegrounding 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 improvinghealth 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 andtranslational 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):S65–S72. Copyright © 2004 Sigma Theta Tau International

KEYWORDS qualitative methods, naturalistic inquiry, qualitative synthesis, translational research, evidence-based practice, patient experience, provider behavior, theory construction, Cochrane Qualitative MethodsGroup

INTRODUCTION

W

hile qualitative approaches in research have

been increasingly recognized as providingdistinct and significant contributions in health research

for the past 40 years, they have received unprecedentedemphasis in the past 5 years. The rapid uptake of qualita-tive approaches in translational research can be best under-stood in the context of recent innovations in health servicesresearch, as well as an overarching concern with improv-ing the quality of health care. Qualitative approaches high-light the human dimension in health care by foregrounding

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

HealthServicesResearch, Regenstrief Institute for HealthCare; Director, HealthServicesResearch 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; [email protected]

This article was presented at the U.S. Invitational Conference “Advancing Quality

Care Through Translation Research,” October 13–14, 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 con-sumers and providers of care. As such, these methods are

particularly useful for addressing the complex issues re-lated to improving health care quality and implementingsystem 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 willtrace a brief history of the factors contributing to the recentand rapid growth of qualitative methods in health researchin general and translation research in particular; describe

the varieties of qualitative approaches employed in this re-search; and illustrate the utility of these approaches forvariable identification, instrument development, descrip-

tion/explanation of patient/provider perceptions and be-haviors, as well as individual/organizational change.

HISTORICAL OVERVIEW

Qualitative approaches in translational research need to be

understood within the broader context of the recent uptakeof qualitative methods in health services research. Qualita-tiveapproaches in health-related research were first used by

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Qualitative Perspectives in Translational Research

anthropologists conducting ethnographies in remote cul-

tures (Rivers 1924; Evans-Pritchard 1937). Later sociol-ogists adapted observational techniques to study aspectsof the biomedical health system (Becker, Geer, Hughes &Strauss 1961; Goffman 1961, 1963). Nursing was the first

health discipline to identify the importance of qualitativemethods, legitimize them, and incorporate them into re-search. Over the past decade, and particularly in the past 5years, there has been an exponential increase in the use of qualitative approaches in health services and translationalresearch.

Federal, national, and international agencies and ini-tiatives have facilitated this evolution through a varietyof mechanisms such as conferences and reports. Two fed-eral funding agencies in the United States—the NationalInstitutes of Health (NIH) and Agency for Health Re-search and Quality (AHRQ)—have promoted qualitativeapproaches through a series of developmental/training con-

ferences and calls for applications. In 1998, the Agency forHealth Care Policy and Research (now AHRQ) and TheRobert Wood Johnson Foundation co-sponsored a ground-

breaking conference titled “Qualitative Methods in HealthServices Research” in Rockville, Maryland, with 78 in-vited participants from health services research and socialscience (http://www.ahcpr.gov/about/cods/codsqual.htm).These proceedings were subsequently published in the journal Health Services Research (Devers, Sofaer & Rundall1999). In 1999, a workshop of social scientistsorganized bythe National Institute for Mental Health and the NationalInstitute on Alcohol Abuse and Alcoholism resulted in theguide “Qualitative Methods in Health Research: Opportu-

nities and Considerations in Application and Review” forinvestigators using qualitative approaches http://obssr.od.nih.gov/Publications/Qualitative.PDF. Shortly thereafter,in 2002, NIH sponsored the conference “Using Quali-tative Methods to Promote Self-Care in Diverse Popu-lations” (http://obssr.od.nih.gov/Conf Wkshp/Adherence /Qualitative Methods.htm). A final example is the 2004NIH conference “The Design and Conduct of Qualitativeand Mixed-Method Research” sponsored by the Office of

the Director, Office of Behavioral and Social Science Re-search (http://obssr.od.nih.gov/conf wkshp/sw/).

Publications in health literature reflect these develop-ments. While nursing science journals have published

qualitative studies since the 1952 inaugural issue of Nurs-ing Research, medical and health research journals haveonly more recently incorporated such studies. In thepast decade, a series of editorials in prominent medi-cal journals, particularly the British Journal of Medicineand to a lesser extent the Journal of the American Medi-cal Association, have highlighted the importance of qual-itative approaches. Similarly, the National Institute of Medicine issued a series of reports specifically calling

for increased use of qualitative approaches in health

research:

Priority Areas for National Action: TransformingHealth Care Quality (Adams & Corrigan 2003)

Leadership by Example: Coordinating Government

Roles in Improving Health Care Quality (Corrigan,Eden & Smith 2002)

Who Will Keep the Public Healthy? Educating Pub-lic Health Professionals for the 21st Century (Gebbie,Rosenstock & Hernandez 2003)

Speaking of Health: Assessing Health Communica-tion Strategies for Diverse Populations (Institute of Medicine 2002)

Unequal Treatment: Confronting Racial and EthnicDisparities in Health Care (Smedley, Stith & Nelson2003)

Crossing the Quality Chasm: A New Health System forthe 21st Century (Institute of Medicine 2001)

Promoting Health: Intervention Strategies from Socialand Behavioral Research (Smedley & Syme 2000)

The British-based International Cochrane Collabora-tion prepares, maintains, and disseminates systematic re-views. In 2001, the Qualitative Methods Group was of-ficially registered as an active component of the overallCochrane Collaboration in partnership with the Camp-bell Process Implementation Methods Group. The goalsof the Cochrane Qualitative Methods Group are to(a) demonstrate the value of qualitative research throughsystematic reviews, (b) disseminate methodological stan-

dards to aid the evaluation of qualitative research,

(c) promote the synthesis and integration of qualita-tive research within the broader literature syntheses, and(d) provide some training in qualitative methods syn-thesis: (http://www.lancs.ac.uk/depts/ihr/research/public /cochrane.htm).

This recent and rapidly increasing attention and activityhave been triggered by several sources including increasinghealth carecosts, increasinghealth disparities, unexplainedpractice variation, the increased role of the consumer voice,

the complexity of clinical decision making, and the recog-nition that practice changes are not driven solely by sci-entific knowledge (Jones 1995; Popay, Rogers & Williams1998; Shortell 1999; Pope, van Royen & Baker 2002). For

example, the recent, but dramatic, emergence of patient-centered initiatives, such as the Picker/CommonwealthProgram for Patient-Centered Care approach, mandate at-tentionbe given to topics such as respect for patient values,preferences, and needs that are best identified and under-stood through qualitative approaches.

Shortell (1999) views the growing role of qualitative ap-proaches in translation research as “reflecting the need for amore in depth (sic) understanding of naturalistic settings,

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the importance of understanding context, and the com-

plexity of implementing social change” (p. 1083). Corre-spondingly, the greater appreciation of qualitative methodscan be traced to the growing recognition that many healthproblems and processes of care do not fit easily into exper-

imental research designs (Popay, Rogers & Williams 1998,p. 341).

NATURE OF QUALITATIVE APPROACHES

While in a literal sense, qualitative methods include all

modes of inquiry that do not use statistical methods; theterm is actually a misnomer. The terms qualitative andquantitative actually refer to forms of data, not to forms of design. More accurately, qualitative and quantitative dataare generally collected through naturalistic and positivis-tic designs, respectively. Further, both forms of data comefrom empirical sources.

Naturalistic inquiry encompasses a wide array of bothprimary and secondary research modes, which differ intheir depth of focus and degree of interpretation. Primary

modes have greater depth and interpretative level and arerepresented most commonly by ethnography, groundedtheory, and phenomenology, but also include ethology,ethnomethodology, hermeneutics, oral/life histories, dis-course analysis, and critical and historical approaches toinquiry. Each primary tradition has a distinct set of foun-dational philosophical and theoretical orientations, strate-gies for data collection and analysis, and forms of researchproducts. Secondary modes of naturalistic inquiry gener-ally elicit more superficial-level data for categoric (descrip-

tive rather than interpretive) analysis; common types in-clude focus groups, critical incident technique, case studymethodology, ethnoscience, and open, free-text responses.

The selection of a particular naturalistic approach de-pends on the purpose of the research. For example, phe-nomenology is the method of choice when the purpose is tounderstand the meaning of the lived experience of a givenphenomenon for informants; grounded theory is selectedto uncover/understand basic social processes; and ethnog-raphy is selected to understand patterns and/or processes

grounded in culture.In most forms of naturalistic inquiry, investigators typ-

ically use one or a combination of strategies including

participant observation, informant interviews, and docu-ment analysis. However, the extent to which the inves-tigator relies on any one strategy will vary; for example,phenomenology relies primarily on informant interviews,ethnography has a more even balance between participantobservation and interviewing, and ethology relies primarilyon observations (Tripp-Reimer & Kelley 1998).

In summary, naturalistic inquiry most commonly occursin field settings with investigators collecting data through

participant observation and unstructured interviews, and

analyzing data through thematic content analysis.

USES OF QUALITATIVE APPROACHES

IN HEALTH RESEARCHQualitative approaches may be employed for a wide va-riety of purposes related to health services and transla-tional research. Five specific topics are addressed belowranging from variable identification to instrumentation, de-

scription/understanding of lay and provider behaviors, the-ory construction/refinement, and synthesis for developingpractice guidelines.

Variable Identification

At the most foundational level, qualitative approaches areoften used to clarify concepts and constructs, and to or-

der them vertically and horizontally in the form of tax-onomies. These standardized languages and classification

systems commonly form the basis for effective research us-ing large datasets. Two nursing standardized languages, theNursing Interventions Classification (NIC; Dochterman &Bulechek 2004) and the Nursing Outcomes Classification(NOC; Moorhead, Johnson & Maas 2004) were developedat the University of Iowa using the ethnoscience approach.Further, Kuzel et al. (2003) demonstrated the utility of thisapproach for constructing typologies of errors experiencedby patients and contrasting them with that of physicians;they found that most technical definitions fail to capture

many types of errors of greatest concern to patients.

Instrumentation

Qualitative approaches are often used to develop or refinedata collection instruments. Prior to instrument construc-tion, interviews (either individual or group) are commonlyused to establish content domains and generate specificitems. After instrument construction, these same methods,as well as formal cognitive interviews, may be used to as-sess the adequacy of the instruments or to understand re-

sponse difficulties and variations. For example, while qual-itative approaches were used in the initial development of the Picker (adapted from the Picker-Commonwealth Sur-

vey of Patient-Centered Care) and Consumer Assessmentof Health Plans Survey (Adult) (CAHPS 2.0) instruments,they were also employed in later evaluations of their suit-ability for different populations. Ngo-Metzger et al. (2003)identified important aspects of the quality of care for Chi-nese and Vietnamese immigrants not included in these in-struments. Important missing domains in the Picker and

CAHPS instruments included (a) provider respect for tradi-tionalhealthbeliefs andpractices, (b) access to professional



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interpreters (and quality of interpreters), and (c) assistance

in obtaining social services.

Description/Understanding PhenomenaPerhaps the most frequent use of qualitative approaches isfor understanding the phenomena that are context depen-dent. Broad domains include understanding patient andprovider perceptions and behaviors, as well as the processof individual and organizational change.

Patient Experiences and BehaviorsHundreds of qualitative studies have been conducted todescribe and understand patient experiences, preferences,needs, and satisfaction. Projects have described what it islike to live with a specific illness such as headache (Peters,Abu-Saad, Vydelingum & Murphy 2002) or cystic fibro-sis (Gjengedal, Rustoen, Wahl & Hanestad 2003); how thecontext of care affects experiences such as dying (Mur-ray, Grant, Grant & Kendall 2003) or self-reliance with

sickle cell disease (Maxwell, Streetly & Bevan 1999); howperceived needs (Detaille, Haafkens & van Dijk 2003) orquality-of-care domains (Curtis et al. 2002) differ acrossdifferent groups of chronically ill patients. Evans (2002,p. 290) points out how these studies provide a strategy togive consumers a voice in clinical decision making throughdocumenting their experiences,preferences, and priorities.

Studies of patient behaviors have provided importantinsights regarding the basis for specific patient behaviorsincluding patterns of service utilization (Kelly & Groff 2000), the logic of noncompliance (Trostle 1997), and vari-

ation in triggers and barriers to change for various health-related behaviors (Currie, Amos & Hung 1991). Power(2002) points out how qualitative approaches have demon-strated utility in areas where the social phenomena may behighly personal, sensitive, and sometimes illicit, as withmuch of HIV/AIDS research where these methods havegreatly increased our understanding of cultural influenceson lifestyles, risk negotiation around sex and drug inject-ing, and health or identity disclosures.

Provider Perspectives and Behaviors While provider behaviors have been a relatively recent fo-cus on inquiry, this is a rapidlydevelopingareaand includesdomains related to interaction/communication, providerbehavior, and the process of clinical decision making. Stud-

ies of interaction/communication have contributed to ourunderstanding of the ways providers strategically estab-lish and maintain unequal power relations (Rapp 1988)and how the different realities of providers and patients re-sult in miscommunication and misunderstandings (Cohen,

Tripp-Reimer, Smith, Sorofman & Lively 1994; Green &Britten 1998; Gjengedal et al. 2003).

Several descriptive studies have investigated provider-prescribing behavior related to pain management (Rogers

2002) or antibiotic use (Walker, McGeer, Simor,

Armstrong-Evans & Loeb 2000; Radyowijati & Haak2003). These have clear implications for planning interven-tions to alter provider behavior in translational research.

Changing Provider Behavior and Health SystemsA number of studies have investigated the phenomena of practice change, particularly noting barriers to change.Many barriers are based on providers’ perceptions of pa-tient views, preferences, or characteristics. Patients’ views

of their own illness may affect their compliance (Green &Britten 1998) or their preferences for treatment. For ex-ample, an investigation of unnecessary antibiotic prescrib-ing indicated that providers’ actions relied more heavilyon their views of patient preferences for antibiotics thanon their own knowledge of scientific recommendations(Butler, Rollnick, Pill, Maggs-Rapport & Stott 1998); theysuggested that greater practice change would result from

interventions targeting clinical interactions rather thaneducation. Patient characteristics also may influence ap-

plication of practice guidelines. An investigation of lowadherence to hypertension practice protocols for geri-atric patients found that providers viewed their patients’other problems as more significant and were also con-cerned about the greater likelihood of adverse effects of medications in elders (Cranney, Warren, Barton, Gardner& Walley 2001).

Other studies have targeted the ways in which organiza-tional context and professional environment affect use of practice protocols. For example, available time and level

of expertise affected how residents obtained evidence for

clinical decision making (Montori, Tabini & Ebbert 2002).Similarly, local provider culture was shown to create a localconsensus of practice knowledge that strongly influencedthe interpretation and weighting of new scientific evidence(Fairhurst & Huby 1998).

A few studies have specifically focused on strategiesfor guideline implementation, such as use of ward rounds(Deshpande, Publicover, Gee & Khan 2003). Other ap-proaches have examined how different groups of stake-

holders vary in their uptake of practice guidelines. Allery,Owen, and Robling (1997) used critical incident techniqueto explore how general practitioners and specialists dif-fer in triggers and sources of evidence underlying prac-

tice changes. Using Giorgi’s phenomenological method,Andersen (2002) examined important differences in bar-riers to implementing a medication tracking system as ex-perienced by nurse managers and physicians.

In perhaps the most comprehensive study of barriersand facilitators to guideline implementation, Doebbeling et

al. (2002)conducted 50 focus groups with three categoriesof stakeholders (administrators, primary care providers,and clinicians) at 20 Veterans Affairs Medical Centers in



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the United States. Annually, the Veterans Health Adminis-

tration rolls out different clinical practice guidelines andmonitors compliance with them, making this an excellentenvironment for translational science. Perceived major fa-cilitators to guideline implementation included admin-

istrative commitment, electronic patient records, workreorganization, and audit with feedback. Major barriersincluded time and workload issues, lack of technologi-cal support, and lack of guideline credibility. Providers(primarily physicians) and clinicians (primarily nurses)emphasized barriers and problems with clinical prac-

tice guidelines, while administrators emphasized guidelinebenefits andfacilitators to implementation. Thegroups alsodiffered in the major concerns expressed: Administratorsemphasized guideline compliance; providers emphasizedcontinuity of care; and clinicians emphasized benefits forpatients (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 organi-zational change requires attention to the issues of each keystakeholder group.

Theory Construction/RefinementQualitative approaches are not only useful for generat-ing hypotheses, but also for theory development and re-finement. An illustration of this point was made by theDoebbeling et al. (2002) team investigating barriers and

facilitators to clinical practice guideline implementationin the VHA. After completing the qualitative data analysisfrom the 50 focus groups, they mapped the codes to theframework developed by Kitson, Harvey, and McCormack

(1998) to depict implementation of clinical practiceguidelines. The model by Kitson et al. contains threemajor domains: evidence (research, clinical experience,and patient preferences), context (culture, leadership,and measurement), and facilitation (characteristics, role,and style). Recommendations for refinement of the Kit-

son model included adding “guideline characteristics” tothe evidence domain, deleting measurement from andadding organizational characteristics to the context do-main, and adding implementation strategies/processesto the facilitation domain (Tripp-Reimer & Doebbeling2003).

In summary, the naturalistic and qualitative approaches

are escalating in use and importance in all health researchand are increasingly important in translational

INTEGRATING QUALITATIVE RESEARCHINTO SYNTHESIZED EVIDENCE REPORTS

In translational research, there have been several re-cent, but highly significant, events and activities pro-moting and facilitating the incorporation of the results

of naturalistic studies into synthesized evidence reports

(e.g., clinical practice guidelines). In Britain, the Na-tional Health Service Center for Reviews and Dissem-ination called for the inclusion of qualitative data inits syntheses, and the Cochrane Qualitative Group has

been responsive to this mandate. The University of Es-sex established a qualitative dataset of patient responsesthat is now a part of the Economic and Social DataServices (ESDS) Qualidata that is in the public domain(http://www.esds.ac.uk/qualidata/online); a second estab-lished resource, DIPEx, contains a large set of interviews

describing patient experiences that may be used by clini-cians, instructors, or investigators (http://www.dipex.org).

The utility of qualitative data in systematic reviews canbe demonstrated through a delineation of the several rolesit can play including (a) clarifying the focus of the review;(b) identifying the relevant types of participants, interven-tions, and outcomes; (c) providing data for a qualitative

synthesis; (d) explaining unexpected findings of quantita-tive studies; (e) interpreting the significance and applica-

bility of thereview; and (f) suggesting both clinical and pol-icy recommendations for implementation (Dixon-Woods,Fitzpatrick & Roberts 2001).

Four major approaches have been proposed for thesystematic synthesis of qualitative data. The first twoapproaches—the Case Survey Method (Yin & Heald 1975)and the Qualitative Comparative Method (Ragin 1987)—translate the qualitative data into numerical data, and thenanalyze those data using statistics. The two newer ap-proaches retain the qualitative character of the data and are

termed meta-ethnography (Noblit & Hare 1988) and meta-

synthesis (Sandelowski, Docherty & Emden 1997; Thorneet al. 2002; Finfgeld 2003; Sandelowski & Barroso 2003)and were developed by anthropologists and nurse scien-tists, respectively.

Despite the recognized utility of qualitative data for syn-thesis in practice guidelines, there are several problemswith the operationalization of this plan. Not the least of the concerns involves difficulties in conducting literaturesearches for the qualitative studies, including the frequent

use of “witty” or obscure titles, lack of standardized termsin abstracts, and variation in indexingacross thewide rangeof journals (Cesario, Morin & Santa-Donato 2002; Evans2002; Hawker, Payne, Kerr, Hardey & Powell 2002; Bar-

roso et al. 2003). Furthermore, there is variation in eval-uating both the quality (rigor) and the level of evidenceof the results, although several recent strategies have beenput forth (Popay, Rogers & Williams 1998; Giacomini &Cook 2000a, 2000b; Cesario, Morin & Santa-Donato 2002;Fossey, Harvey, McDermott & Davidson 2002; Hawker,

Payne, Kerr, Hardey & Powell 2002). While there is yetno consensus regarding the best approach for qualitativedata synthesis, the Cochrane Qualitative Group is making



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excellent progress in formulating such recommendations,

as are individual scientists such as Greenhalgh (2002).

SUMMARY

The unprecedented proliferation of qualitative research inhealth sciences can be attributed to an increased empha-sis on the components of quality of care and a mandateto ensure that health care decisions are made on the bestavailable evidence. In the context of health research ingeneral, and translational research in particular, qualita-tive approaches are making distinct and important contri-butions through the illuminating and explanatory powerof these forms of evidence.

AcknowledgmentsThis research was supported in part by the National Insti-tutes of Health grant P30 NR03979 awarded to Dr. Tripp-

Reimer and by the Department of Veterans Affairs, VeteransHealth Administration, Health Services Research and De-velopment Service, Quality Enhancement Research Initia-

tive (QUERI), Investigator Initiated Research Grants CPI99-126 and CPI 01-141, awarded to Dr. Doebbeling.

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