CONTRIBUTIONS OF QUALITATIVE RESEARCH TO EVIDENCE-BASED PRACTICE IN NURSING

Aim. This article aims to identify the contributions of qualitative research to evidence-based practice in nursing. Background. Qualitative research dates back to the 1920s and 1930s, when anthropologists and sociologists used qualitative research methods to study human phenomena in naturalistic settings and from a holistic viewpoint. Afterwards, other subject matters, including nursing, adopted qualitative methods to answer their research questions. The restructuring of health care over the past decade has brought about increased accountability in nursing research. One method for increasing this accountability is evidence-based practice. Method. The method used was a search in the Cumulative Index to Nursing and Allied Health Literature database from 1999-present. The search resulted in 61 citations for evidence-based practice in nursing research; however, only 5 citations focused on evidence-based practice and qualitative research. Findings. The authors’ findings revealed six contributions of qualitative research to evidence-based practice: generation of hypotheses; development and validation of instruments; provision of context for evaluation; development of nursing interventions; development of new research questions; and application of Qualitative Outcome Analysis. Conclusion. Qualitative research makes important contributions to the quality of evidence-based practice.


DESCRIPTORES: investigación cualitativa, práctica basada en evidencias, investigación en enfermería
The aim of this article is to identify the qualitative methods to answer their research questions (1) .
Qualitative research also has received renewed attention in health care research.Recently (2) , has focused attention on qualitative methods to answer health services research and policy questions (3)   .In nursing (4)   , there are examples (4)   of evidence based on four patterns of knowing in nursing (5)   .They view 'scientific data' as associated with empirical knowing; 'standards of practice, codes of ethics, [and]   philosophies of nursing' as associated with ethical knowing; 'autobiographical stories' as associated with personal knowing; and 'aesthetic criticism and works of art' as associated with aesthetic knowing.Fawcett et al. (4)   .believe that each of the four patterns of knowing can be viewed as a theory and that 'different kinds of nursing theories provide different lenses for critiquing and interpreting the different kinds of evidence essential for theory guided, and evidencebased-holistic nursing practice' [italics added].
Evidence-based practice is a relatively new term that has evolved over the past decade; it has been driven by managed care, cost pressures, consumer awareness and information dissemination.But what is evidence-based practice?Three definitions of it follow to highlight differing perspectives.Evidence-based practice is defined in medicine as 'the integration of best research evidence with clinical expertise and patient values' (6) .Another author (7) defines evidence-based practice in nursing as 'the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences'.
Finally (8) , note that 'evidenced-based practice builds on the nursing literature of research utilization by adding other forms of evidence that can be used in making clinical decisions'.What else does the literature contain about qualitative research and evidence-based practice?

METHOD
In a search of the database Cumulative Index to Nursing and Allied Health Literature for the past three years (1999-2002), there were 61 citations for evidence-based practice in the nursing literature.However, when the search was confined to evidence-based practice and qualitative research, only five articles appeared.In the first article (9) , described a model for guiding nurses through a process for examining both quantitative and qualitative research.
The authors then described one of the steps in the process of using evidence-based practice as synthesizing the best evidence available.To accomplish this step, they used a modification of the Agency for Healthcare Research and Quality guideline, which is considered the gold standard.
Rosswurm & Larrabee (9) synthesized the quantitative studies' evidence and combined it with qualitative reports and clinical judgment.In the second article (10)   , described the use of qualitative methods in an adjunct study of a randomized trial using evidence-based protocol on incontinence.The qualitative piece revealed that the patients' perceptions of the interpersonal and technical skills of the nurse impacted on the effectiveness of the evidence-based treatment.Data from the 23 respondents indicated that the nurses with good communication skills mitigated the patients' anxiety and embarrassment about incontinence.In the third article (11)   , conducted a qualitative study of older women with osteoarthritis and noted that a greater understanding of living with osteoarthritis is necessary to improve evidence-based nursing care.In the fourth article (12) , reported that qualitative methods played an important role in changing evidence-based practice by illuminating power relationships that permeate practice.
The author noted that the agenda for evidence-based practice in nursing will remain theoretical unless practitioners can envision how it will change their clinical practice.In the last article (13) , conducted a concept analysis of the meaning of 'context' in healthcare practice as it relates to evidence-based practice or, as they call it, 'research evidence implementation'.The authors frame their analysis of context around three characteristics: strength of organizational culture; strength of leadership; and strength of evaluation.The authors conclude that the meaning of context is not clear: 'thus, the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown'.

FINDINGS
The findings, which are based on nursing and on personal research, revealed six contributions of qualitative research to evidence-based practice.Each contribution is supported with nursing research examples from over the past five years.
First, a major contribution of qualitative research is that of generating hypotheses.When a qualitative study is being conducted, the findings often suggest hypotheses that can be tested in future research.In a recent study on symptom management of chronic heart failure that included shortness of breath (14) , employed a qualitative design to identify numerous self-care strategies used by patients (e.g., resting between physical activities).An example of a hypothesis that could be tested from this study is: patients using resting between physical activities as a self-care strategy show greater decrease in the symptom of shortness of breath than patients who do not use this selfcare strategy.Paterson et al. (15) took the hypothesis testing a step further in their meta-ethnographic synthesis of qualitative studies of the lived experience of people with diabetes.They found that 'balance emerged as the predominant metaphor of the lived experience of diabetes' and that nurses need to value the expertise that patients have gained in living with diabetes.
Second, the development and validation of instruments have long evolved out of the qualitative tradition.
The researcher collects qualitative information on a topic and then translates that information into a quantifiable instrument.Sitzia & Wood (16)   , for example, reported on the development of an instrument to assess patient satisfaction with chemotherapy treatment.They analyzed quantitative and qualitative data from 173 completed questionnaires to develop the Worthing Chemotherapy Satisfaction Questionnaire.Their qualitative data helped to establish content validity of the instrument.A second example is the development of the Facts on Osteoporosis Quiz, which was based on a review of the qualitative report of the National Institutes of Health consensus conference on osteoporosis (17) .Finally (18) , reported both quantitative and qualitative data that measured students' perceived writing outcomes.The qualitative data were translated later into a quantitative instrument that measured students' self assessment of their writing skills.The preceding studies demonstrate how qualitative research can be translated into quantifiable instruments that support evidence-based practice.These instruments are then used as outcome measures in studies that assess the implementation of evidence-based practice.
Qualitative research also can be used to validate quantitative instruments.Merkouris et al. (19) developed an instrument to measure patient satisfaction with nursing care.They collected qualitative data from 103 hospital patient interviews and reported that the qualitative data augmented the validity of the Patient Satisfaction Scale and provided important information for upgrading the instrument they had developed.In addition, the percentages of patients who were satisfied were different using quantitative and qualitative measures.The qualitative measure showed less satisfaction than the quantitative measure.Was reported (20) that family concerns in critical care had been examined using the Critical Care Family Needs Inventory but that family members never were asked about their needs during the instrument's development.
Burr then conducted a methodological triangulated study to assess the level of agreement between the quantitative instrument and family members' responses to a qualitative interview.The findings indicated that the qualitative data helped to contextualize and clarify the needs of family members.
Third, qualitative research can provide the context for evaluating evidence-based practice in nursing.For example, when evidence-based practice is implemented, an evaluation of the practice is needed.Usually this evaluation is done in anticipation of adopting the practice change.The evaluation should include process as well as outcome.The outcome may be described both quantitatively and qualitatively; however, the process is usually described qualitatively.For example, was investigated pregnant women's experiences of nuchal translucency screening using a qualitative design.She found that women's understanding of the screening varied considerably and suggested that evidence-based midwifery practice needs to examine these routine screenings more critically.In another study, was (22) examined transcriptions from tape recorded qualitative interviews with diabetic patients and providers and used evaluation as one of the categories.They found that patients evaluated how they felt, whereas practitioners evaluated blood glucose concentrations as the control standard in evidence-based practice.Finally, Rosswurm & Larrabee (9)  Clinicians, researchers, educators, and administrators can make valuable contributions to qualitative research in evidence-based practice by understanding the importance of it and by implementing it in nursing wherever possible.This goal is important for two reasons.First, evidence-based practice is an important and timely standard in addressing nursing quality.That standard may be diminished if nurses fail to understand the many contributions that qualitative research plays in evidence-based practice.Second, nurses have and are creating a substantial body of qualitative research in nursing and this trend will continue.However, qualitative research in evidence-based practice will be hampered unless sound and significant qualitative research is conducted by nurses who are committed to it and to its application in nursing practice.When this commitment and application conjoin, evidence-based practice in qualitative nursing research will have reached its full potential.
contributions of qualitative research to evidence-based practice.To place this aim within a broader context, a brief history of qualitative research and of nursing research related to evidence-based practice are presented.Qualitative research dates back to the 1920s and 1930s when anthropologists and sociologists made inquiries into human groups.As part of their inquiries, social science researchers developed various research methods to study human phenomena, usually in a naturalistic setting and from a holistic viewpoint.Later, other disciplines, including nursing, political science and education, adopted research makes important contributions to the quality of evidence-based practice.Because evidencebased practice is a growing phenomenon in nursing, qualitative research, alone or in combination with quantitative research, helps make visible nurses' goals to provide the best health care within an often fiscally constrained environment.
described their implementation of a protocol for patients with acute confusion in which they included nursing interventions that qualitative