Shift in Research Methodology Preferences

¶ … shift in research methodology preferences in nursing towards a more qualitative rather than a quantitative approach. While the professional nurse has always been involved in the application of quantitative research designs and methods, there are indications that the nature of the profession has changed and become more independent, sophisticated and holistically inclined (ROLES IN ONCOLOGY NURSING). The emphasis on a more integrative and holistic trajectory in nursing is however not unusual. The ideal of an intimate, holistic and inclusive caring attitude and approach - which is aligned with qualitative methodologies - has always been a central concern around which nursing was established as a profession.

While quantitative methods and views are certainly accepted and used by nursing professionals, there has been a realization that more open-ended and expansive qualitative approach in research and praxis has a number of positive advantages in the nursing context. Qualitative approaches and methods also have a certain advantage in terms of the contemporary medical and nursing environment. This paper will attempt to show, through examples, the way that qualitative methods can be effective in the nursing situation and in research. The focus will be on quantitative aspects in diabetes management in older people.

2. Qualities research techniques: brief overview

A common definition of qualitative research is " & #8230;any kind of research that produces findings not arrived at by means of statistical procedures or other means of quantification" (Strauss and Corbin, 1990, p. 17). A working definition of quantifiable research is research that is aimed at "…determining the relationship between one thing (an independent variable) and another (a dependent or outcome variable) in a population" (Hopkins).

The difference between qualitative and quantities research methodologies implies in the first instance an understanding of the philosophies that support these methods. (Hussey and Hussey, 1997). The choice of a particular research design is determined by the research theories, presuppositions and the relevance of the methodology to the issue at stake.

As will be discussed, external and self-management in the case of elderly diabetes is an issue that requires insight into subjective and not only objective aspects. In other words, the nurse has to be aware not only of the clinical data but also have insight into aspects such as whether the subject or patient has acquired the necessary knowledge and understanding of the disease to manage his or her situation adequately. This implies that a qualitative and more subjective approach is in certain cases and situations a more effective method of understanding the problems and implementing interventions and management protocols than quantitative research can provide.

In brief and rather simplistically put, it can be argued that a philosophical stance that favors objectivism and scientific verifiability would choose a form of quantifiable methodology; while constructivist and subjectivist researchers would on the other hand choose qualitative methods. Vincent Pouliot ( 2007), has argued that the objectivist or "experience-distant" form of knowledge should be supported by subjective (experience-near) knowledge (Pouliot, 2007. p. 359). This would suggest the value of quantitative research in a field such as nursing where inter-subjective contact is a priority.

Common examples of qualitative methods include action research, case study research and ethnography. In general data and insight is obtained from more open -- ended techniques in comparison to the statistical and measurable data that is the norm in quantifiable research methods. Qualitative methods include interviews and questionnaires, documents and texts, as well the researcher's impressions and reactions (Haugh, and Mckee, 2007, p.377). In general, the quantitative researcher attempts to understand the situation from a holistic and contextual point-of-view.

3. Diabetes management and qualitative methodologies

Studies indicate that there is a high rate of diabetes among the elderly in the United States. As one report states, "The prevalence of type 2 diabetes, which represents roughly 90% of all diabetes, increases with age and affects 18 -- 20% of people over age 65 in the United States (with a substantial percentage of these cases being undiagnosed)" ( Wallace). Furthermore, it has been shown that people with diabetes, who have elevated blood sugar, develop senescence-associated disorders at an earlier stage than the general population. This fact would suggest that nursing and healthcare bodies should focus on research and management of this disease among older patients and that self-management interventions are priorities in terms of nursing care.

3.1. Interviews

It is significant to note that many studies indicate that there is a definite paucity of research in diabetes management - especially with regard to older people. ( Abbot and Gunnell, 2004) While quantitative research is effective in many respects with regard to the more clinical measurement of aspects of this disease, yet it fails to address the more complex issue of the problematics of management, and the way that the elderly patient perceives and understands the necessary and required processes in management responsibility.

The research question that may be asked in this regard is to what extent are elderly patients aware of self-management techniques and processes and to what extent are they cognizant of the responsibilities and requirements that are associated with the management of this disease. This also should also take into account another related factor that has a bearing on the treatment of the elderly; namely, the aspect of cognitive functioning and possible impairment and how this relates in turn to management issues.

With regard to the above questions, a qualitative methodological approach has been shown in a number of studies to be particularly effective in management interventions and understanding - especially in relation to the use of in-depth and one-ended interviewing techniques and methods. This methodology has also been shown to be more effective than quantitative methods in investigating these issues; in that it allows the subject to explore his or her own personal situation and to respond in a more open and subjective way that cannot be achieved in quantitative methodologies or through the synthesis of hard data.

An example of this methodology in practice is a study entitled Older people's experiences of diabetes care by Stephen Abbott and Caroline Gunnell (2004). This is an exploratory study which used a more structured interview format and was aimed at establishing key themes. The authors note that the central problem that was being investigated by means of the interviews was that "One of the biggest challenges for health care providers today is how to address the continued needs and demands of individuals with chronic illnesses like diabetes" (Abbott and Gunnell, 2004). The intention of the study was to ascertain to what extent the patients had the necessary skills to effectively manage their diabetes.

The results from this exploratory study and interviews indicates that in most the cases, "…respondents did not generally report finding self-care difficult, as the requisite procedures were easily explained, whether this had been done orally by healthcare staff or in written form" (Abbott and Gunnell, 2004). However, a central area of concern was the management of dietary concerns that are so significant in these patients.

Almost all respondents said that they should avoid sugar, and some said that they should avoid fat or oil. Most reported that they had seen a dietitian at some point, often when first diagnosed, but some were uncertain about what to do

(Abbott and Gunnell, 2004).

Therefore, the qualitative methods employed in this case were useful in isolating areas of concern in the management of the disease. This is information that the nurse can use in dealing with management protocols for these patients and in future scenarios

Another study that uses the interview technique examines self- monitoring of blood glucose in patients with type 2 diabetes. This study, entitled Self-care coping strategies in people with diabetes: a qualitative exploratory study (2008), found that the "…role of the health professional is crucial to patient understanding of their blood glucose fluctuations and whether or not the patient responds to the high blood glucose reading with an appropriate self-care action" (Collins M. et al. 2009) This study made use of in-depth interviews, which were tape-recorded and transcribed. The study also found that the perceptions of self-care varied among those interviewed. This led the authors to describe three types of patients according to the level of management knowledge. This finding served to increase understanding and provided a framework for more effective management and nursing intervention

Qualitative in-depth interviews have also been successfully implemented in many other diabetic studies, and have shown positive results in terms of improving patient care and management of this disease. It is therefore clear that in situations where self-help and care are problems the interview as a qualitative technique or methodology is capable of revealing issues and problems that possibly may not have been evident if a more quantitative methodology had been employed.

3.3. The case study approach

While the interview is effective as a qualitative technique, a more in-depth and detailed technique is the case study. One of the most effective qualitative approaches that have been implemented successfully in elderly patients is the case study. A case study is generally defined as a form of empirical inquiry that "…investigates a contemporary phenomenon within its real-life context, especially when & #8230;the boundaries between phenomenon and context are not clearly evident" (Myers M.D.)

Case studies are in essence external detailed investigations of an individual, group or an institution. (MODULE R14.QUALITATIVE RESEARCH) As a method it enables the researcher to uncover and explore variables and factors that each individual case study reveals -- and this in turn adds to the overall perception and understanding of the topic or issue under investigation. Case studies also differ from more statistical and quantifiable methods of inquiry in that "…the focus of attention is the individual case and not the whole population of cases" (MODULE R14.QUALITATIVE RESEARCH).

From a more philosophical viewpoint, the case study is more open-ended and less dependent on a research methodology that focus on a limited or "bounded system." A central aspect of this method is that content and case studies have the particular advantage of focusing on any system or issue in its natural context or habitat. (MODULE R14.QUALITATIVE RESEARCH)

The case study method can be effectively employed in the following scenario. An elderly diabetic has problems with his diet and this is related to a lack of knowledge and information. These issues are also linked to the problem of an inadequate support system. As has been referred to, diet is an important aspect of self-management. "Diet and exercise are the cornerstones of diabetic treatment at all ages" ( Wallace).

The research question that might be posited in this case is to what extent are a patient's dietary and management problems related to a number of other social and external issues and variables, such as the interaction between the support system and an adequate knowledge base? These and other factors are all interrelated and impinge on the understanding of the problems that the elderly patient may be experiencing.

In this case a quantitative research methodology would only be able to reveal some the variables and their interrelationships and would probably not expose the more subtle linkages between them. On the other hand, a case study approach would be a more effective and appropriate methodology to implement in the attempt to understand the interaction of variables that could effect the management of the problem in terms of understanding the individual situation in all its detail. As one study using this methodology found, "…some patients felt undersupported." The study also suggests that by using the case study method one is able to "… assess in more detail the relationships between people's appetite for knowledge, their actual knowledge, and their satisfaction with knowledge levels" (Abbott and Gunnell, 2004).

3. 4. Ethnographic and postmodern approaches

A modern trend is the "postmodern "interpretation of healthcare. The term postmodern is a complex and much debated term, a discussion of which is outside the parameters of this paper. Simplistically stated, the postmodern approach refers most commonly to a wide-ranging 'deconstruction' or radical analytic interrogation of the way those social norms, values and 'master narratives' construct the world in which we live. The deconstructive aspect of postmodernism is the attempt to unravel the layers of bias and prejudice that obscure a clear view of reality.

In terms of the present discussion on management and the elderly diabetic person, the most appropriate qualitative method to use is the ethnographic method. In a postmodern context the management of the diabetic patient should be examined from the point-of-view of the hidden biases and presuppositions that might be active and which may impede adequate management methods and procedures. The question that could be asked in this research situation is as follows: is the view of the elderly diabetic patient affected in any negative sense by presuppositions and biases that are not blatantly obvious? In other words, the broadest context should be taken into account.

The ethnographic method refers to a from of intensive and participatory research that focuses on "…the sociology of meaning through close field observation of sociocultural phenomena" ( Young, 2004). Typical ethnographic research deals with an investigation of the community and often the researcher enters into the community as a participant in order to gain an understanding of the social factors and variables in play.