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Research Reports |
 | Introduction |
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We would like to address the question of what impact qualitative studies can have on the evidence base of the profession when used as "stand-alone" methods. In particular, we consider the "problem of induction," as Fritz describes it, where without a control group it is not possible to determine whether what is observed (and its subsequent explanation) is actually superior to some alternative. We do not see inductive learning or problem solving as a "problem" even within a climate that demands that knowledge derived from research should provide better evidence for practice.
We believe it is worth reiterating, albeit briefly, that qualitative research does not pretend to determine absolute truths such as which hypothesis, explanation, or theory is right and which is wrong or which is more true or superior than another, at least not in an absolute sense. Does this mean that qualitative studies remain at the purely descriptive level, with little or no potential to actually have an impact on clinical practice? We do not think so. Were controlled studies really the only way or possible catalyst by which the regimen of bed rest for patients with acute pain could be replaced with a better alternative? We think not. Interestingly, the prescription of bed rest for acute back pain harks back, in our opinion, to an era where the importance of understanding and valuing the patient's experience was perhaps less understood. Adherence to medical or therapist directives rather than collaborative decision making was the order of the day. It is quite possible that these patients could have informed us themselves, either through formal qualitative studies or through the processes of decision making in clinical practice (if we had at that time a framework for understanding and integrating these experiences as a source of clinical knowledge) of the anxieties, sense of helplessness, and deconditioning that they may have experienced lying in bed for weeks on end.
The most basic premise underlying qualitative research is that reality or truth is not singular or unchanging for all people at all times. Consider for example, a bright sunny day. This same reality is experienced differently by the person who is intending to spend the day at the beach and by the farmer perhaps 50 miles inland who is experiencing a drought. So too, our patients may experience aspects of a condition (eg, a fractured neck of femur) that are generalizable and experienced by others, but much else of what they experience will be unique and will be shaped by many personal and social factors. We therefore argue that in evidence-based practice we do not move from one set of patient "directives" to another set of "directives" as one proven theory displaces another. Rather, we argue our mandate is to present the levels of evidence for particular courses of management in therapy and assist our patients to make decisions based on the choices available.
The further skill in collaborative decision making is to facilitate our patients' ability to work through the implications of the various management options. There may be a strong preferred direction or even a particular treatment imperative based on evidence, but the overall sets of management strategies, in our view, will necessarily vary (perhaps considerably) according to the needs and context of the patient. Research on expertise1–3 reminds us that experts do not have recipes, and they also tend to acknowledge that, in broad terms, there is often no one "right" path for a course of therapy to proceed. Theory generated from qualitative research, we believe, does not have to be right or best in an absolute manner in order for it to have an impact on clinical practice. Instead, its role is to bring to light the multiple realities of a particular experience, situation, or phenomenon.
Fritz, however, raises an important question regarding qualitative research. Stated another way, it is whether theories generated by qualitative research have necessarily to remain as localized sets of observations and conclusions. Do such theories remain tied to a specific situation or context without any kind of broader implication or applicability than the specific or unique situation from which they were derived? After all, there can be no doubt that such research is not either statistically generalizable or predictive.
The recent research, cited by Fritz, on identifying experts1 provides an opportunity to further discuss the nature of theory in qualitative research. Both our study and that of Resnik and Jensen1 are grounded theory studies, which build on previous grounded theory (that is, particular theory generated inductively from the data). Resnik and Jensen used retrospective analysis of outcome measures for the management of low back pain as a basis for identifying experts. This allowed for the possibility of "ordinary" therapists to be involved in the study and not just those of long experience and seniority. Apart from mentioning that our study, based on the research experience of others,2,3 did not use the traditional method (ie, choosing therapists based on years of experience) as our method for identifying experts, we believe it is worth noting that Resnik and Jensen1 found that the experts they identified exhibited the same multidimensional knowledge base and patient-centered values as those Jensen et al2 found in their grounded theory work on the nature of expertise in physical therapy.
Our study, as Hack suggests, also supports many of Jensen and colleagues'2 findings such as the multidimensionality of the therapists' knowledge base, the pre-eminence of collaborative decision making in their clinical reasoning, and the centrality of movement not only "as an instrument of patient care" but "as a source of information and communication." The findings of our study and those of Resnik and Jensen1 and Jensen et al2 represent a form of triangulation.4 That is, although each study sampled their "expert therapists" differently, the methodological tools of observation and interview were rigorous enough to point to similar findings with respect to the behaviors, values, and qualities of expert therapists that distinguish them from average practitioners. Each of the 2 subsequent studies extended the previous work, ours by proposing a model of clinical reasoning somewhat different from but not inconsistent with Resnik and Jensen1 and Jensen et al2 by carrying out a new and more inclusive sampling approach to the grounded theory work on expertise.
Based on the discussion of the relationship of theory among our study and the studies by Resnik and Jensen1 and Jensen et al2 and on our examination of the literature, we conclude that there can be theory resonance or dissonance between qualitative studies, each either lending support to previous findings or raising new explanations or theory. Substantive theory, which is grounded theory derived from particular instances or contexts, not only can be compared with and contrasted to other grounded theories regarding similar phenomena for its fit and completeness as an explanation or theory, it also can be related to other "middle" or "formal" theory for its applicability to other situations and phenomena.5,6 Mezirow's theory of transformative learning7 in the field of adult education is an example of this in our study. This theory both helped us interpret what we were finding, and, in a modest way, our findings add some credence to what Mezirow proposes concerning adult learning. We argue, therefore, that the findings (eg, theories) generated by qualitative studies, especially when they build upon each other, while not statistically generalizable, can be theoretically generalizable8 (or transferable9) where their "groundedness" in the particular does not necessarily limit their potential application to broader situations and contexts.
In summary, we concluded that experts move easily between deductive and inductive forms of reasoning in clinical practice. We believe that the several interesting research possibilities suggested by Hack offer a challenge to the further building of theory regarding both the nature of expertise and clinical reasoning in physical therapy. In pursuing these research ideas, or any others for that matter, the challenge, we argue, remains for researchers in physical therapy to move as easily between deductive and inductive paradigms of research.
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