Qualitative research as evidence: criteria for rigour and relevance

This paper is about the nature and construct of evidence and its relation to qualitative research. Using a post-modern lens, we begin by defining evidence, signifying the importance of context, and use discourse as a vehicle for looking at the ways in which qualitative research evidence struggles to achieve the equivalent standing of its quantitative counterpart. In outlining the role of discourse in the creation of research paradigms, we offer a conceptual map that enables a repositioning of qualitative research in the evidence-based genre. In order to best illustrate our standpoint, we then provide two examples of qualitative, transformational research approaches and relate these to the criteria of rigour and relevance, criteria which we would argue when met are examples of high-quality evidence. Having used the examples of discourse analysis and auto-ethnography, we then conclude by exposing and decentralising the myth that surrounds the discourse of evidence-based practice, which continues, albeit unintentionally, to discredit any evidence that falls outside of its parameters.

The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system

This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings

OBJECTIVES

To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures.

DATA SOURCES

Major electronic databases (including PsycINFO) were searched from inception to 2002.

REVIEW METHODS

A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated.

RESULTS

The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard.

CONCLUSIONS

The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Introduction of a child and adolescent mental health link worker: education and health staff focus group findings

Policy guidance suggests that outcomes for adolescents with mental health problems can be improved by secondary education services (SES) and child and adolescent mental health services (CAMHS) working more closely. This study reports on staff experiences of the introduction of a mental health link worker (MHLW). The findings of two focus groups are presented, conducted with staff from CAMHS and SES. These focus groups formed part of the overall wider evaluation of the MHLW role. The groups explored staff perceptions and experiences following the introduction of the MHLW, and elicited their views on the effectiveness of this innovative role. Qualitative methods were employed, and analysis was conducted using the principles of grounded theory and the constant comparative method. The findings revealed that the MHLW was well received by both groups, despite the identification of potential barriers. A number of key themes emerged, which included the ability of the link worker to improve communication and to encourage mutual understanding between services. The issues raised by these themes are discussed and recommendations are made for future practice and research.

Inhibition of c-Jun N-terminal kinase pathway attenuates cerebral vasospasm after experimental subarachnoid hemorrhage through the suppression of apoptosis

BACKGROUND

Recent studies have demonstrated that apoptosis in cerebral arteries could play an essential role in cerebral vasospasm after subarachnoid hemorrhage (SAH) and that SP600125, an inhibitor of c-Jun N-terminal kinase (JNK) could suppress apoptosis. The present study examined whether SP600125 could reduce cerebral vasospasm through the suppression of apoptosis.

METHOD

Fifteen dogs were assigned to 3 groups: control, SAH, and SAH + SP600125 (30 micromol/l). SAH was induced by the injection of autologous blood into the cisterna magna on day 0 and day 2. Angiograms were evaluated on day 0 and day 7. The activation of the JNK pathway and caspase-3 were also evaluated using Western blot. To determine the distribution, TUNEL staining and immunohistochemistry for phosphorylated c-jun and cleaved caspase-3 were performed.

FINDINGS

Severe vasospasm was observed in the basilar artery of the SAH dogs. SP600125 reduced angiographic and morphological vasospasm and reduced the expression of cleaved caspase-3, thereby suppressing apoptosis.

CONCLUSIONS

These results demonstrate that SP600125 attenuates cerebral vasospasm through the suppression of apoptosis, which may provide a novel therapeutic target for cerebral vasospasm.

Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure: a marker of diastolic dysfunction and clinical risk

BACKGROUND

B-type natriuretic peptide (BNP) is widely accepted in the evaluation of left ventricular systolic dysfunction and heart failure. However, little is known of the implications of elevated BNP levels in individuals with preserved systolic function (PSF).

AIMS

To investigate the drivers and clinical implications of elevated BNP levels in asymptomatic individuals with established PSF.

METHODS

We enrolled 154 individuals who all underwent physical examination, BNP evaluation and Doppler-echocardiographic studies. They were divided into those above and below the median BNP level (50 pg/ml).

RESULTS

Independent predictors of higher BNP were older age, more severe left ventricular hypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival and multivariable analysis demonstrated more death and/or admission in those above the median BNP (HR: 4.79, p=0.007).

CONCLUSIONS

Elevated BNP is the strongest, independent predictor of serious adverse cardiovascular outcomes in this population and requires closer clinical follow-up.

Dynamics of coherent and incoherent spin polarizations in ensembles of quantum dots

The temperature dependence of spin coherence in InGaAs quantum dots is obtained from quantum beats observed in polarization-resolved pump-probe experiments. Within the same sample we clearly distinguish between coherent spin dynamics leading to quantum beats and incoherent long-lived spin-memory effects. Analysis of the coherent data using a theoretical model reveals approximately 10 times greater stability of the spin coherence at high temperature compared to that found previously for exciton states in four-wave-mixing experiments by Borri et al. [Phys. Rev. Lett. 87, 157401 (2001)]]. The data on incoherent polarization reveal a new form of spin memory based on charged quantum dots.

Gut mucosal response to food antigens in Crohn's disease

BACKGROUND

Food antigens may contribute to gut inflammation in Crohn's disease.

AIM

To assess in vivo sensitization to food antigens, ascertain whether sensitivity is gut specific, assess food sensitization in vitro, and correlate in vivo changes with histological and blood changes.

METHODS

Skin testing and rectal exposure to six food antigens (cereal, cabbage, citrus, milk, yeast and peanut) and control saline were assessed double-blind by immediate and 3.5-h laser Doppler blood flowmetry, and rectal biopsies were taken. Peripheral blood lymphocyte proliferation was measured in response to the same antigens.

RESULTS

Ten patients with Crohn's disease and 10 healthy controls were studied. Blood flow increased in 24 of 60 antigen sites in Crohn's disease patients and six of 60 antigen sites in controls (P < 0.0001) after 3.5 h. The Crohn's disease group demonstrated higher rectal blood flow than controls in response to all food antigens, and this was significantly different for the responses to yeast (P = 0.036) and citrus fruits (P = 0.038). Lymphocyte proliferation occurred in 32 of 60 tests in Crohn's disease patients and eight of 60 tests in controls (P < 0.0001). There were no skin responses. Submucosal oedema corresponded to increased mucosal flow.

CONCLUSIONS

Crohn's disease patients demonstrate in vivo and in vitro sensitization to food antigens, which is gut specific. Mucosal flowmetry allows the identification of sensitization to gut antigens.

Self-rated quality of life measures: effect of change to a low-fat, high-fiber, fruit and vegetable enriched diet

The Polyp Prevention Trial (PPT) was a multicenter, randomized clinical trial to determine the effect of a low-fat (20% of energy from fat), high-fiber (18 g/1,000 kcal/day), high-fruit/vegetable (3.5 servings/1,000 kcal/day) eatingplan on the recurrence of large bowel adenomatous polyps. The PPT provided an opportunity to examine the impact of dietary changes on quality of life. At baseline and annuallyfor 4 years, participants in the Quality of Life Substudy of PPT completed a Quality of Life Factors (QF) Questionnaire, a modified Block-National Cancer Institute Food Frequency Questionnaire, and a Health and Lifestyle Questionnaire. The 51-item QF Questionnaire assessed changes in nine domains: taste, convenience, cost, self-care, social, health assessment, health belief health action, and life satisfaction. The analysis compared annual changes in domain scores for intervention (n = 194) and control (n = 200) participants. At Year 1, 363 (92%) completed a questionnaire, and 325 (82%) participants completed a Year 4 questionnaire. There were no statistically significant differences between treatment groups in the change from baseline to Year 1 for the convenience, cost, taste, health assessment, and life satisfaction domains. At Year 1, intervention participants rated the self-care (p < .001), health belief (p = .021), and health action (p < .001) domains significantly higher and the social domain significantly lower (p <.001) than control participants. These changes were consistent through Years 2, 3, and 4. This study

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance.

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance.

Severe intellectual disability and transition to adulthood

Institutional and psychological aspects of transition were explored with parents and staff involved with five young adults with severe intellectual disability whose challenging behaviour diminished after they made the transition, and five whose challenging behaviour remained high. They were selected from a previously surveyed cohort. Grounded theory analysis of interviews suggested little connection between the perspectives of parents and staff. The impact these differences have on communication about challenging behaviour was explored, and recommendations for service changes are made.

Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge

BACKGROUND

Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented.

AIMS

As part of an ongoing randomized study on the value of multidisciplinary care in a high risk (NYHA Class IV), elderly (mean age 69 years) heart failure population, we examined the effects of this intervention on previously high (20%) 1-month readmission rates.

METHODS

Unlike previous studies of this approach, both multidisciplinary (MC) and routine care (RC) populations were cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge (100% of patients) and received at least target dose angiotensin-converting enzyme (ACE) inhibition with perindopril prior to discharge (94% of indicated patients). We analysed death and unplanned readmission for heart failure at 1 month.

RESULTS

This early report from the first 70 patients (67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0+/-6.7%) enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result represents a dramatic improvement both for this patient cohort (20% 30-day readmission rate prior to enrollment reduced to 0% following the index admission in both care groups) and in comparison with available data.

CONCLUSIONS

Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition.

Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group

BACKGROUND

We tested the hypothesis that dietary intervention can inhibit the development of recurrent colorectal adenomas, which are precursors of most large-bowel cancers.

METHODS

We randomly assigned 2079 men and women who were 35 years of age or older and who had had one or more histologically confirmed colorectal adenomas removed within six months before randomization to one of two groups: an intervention group given intensive counseling and assigned to follow a diet that was low in fat (20 percent of total calories) and high in fiber (18 g of dietary fiber per 1000 kcal) and fruits and vegetables (3.5 servings per 1000 kcal), and a control group given a standard brochure on healthy eating and assigned to follow their usual diet. Subjects entered the study after undergoing complete colonoscopy and removal of adenomatous polyps; they remained in the study for approximately four years, undergoing colonoscopy one and four years after randomization.

RESULTS

A total of 1905 of the randomized subjects (91.6 percent) completed the study. Of the 958 subjects in the intervention group and the 947 in the control group who completed the study, 39.7 percent and 39.5 percent, respectively, had at least one recurrent adenoma; the unadjusted risk ratio was 1.00 (95 percent confidence interval, 0.90 to 1.12). Among subjects with recurrent adenomas, the mean (+/-SE) number of such lesions was 1.85+/-0.08 in the intervention group and 1.84+/-0.07 in the control group. The rate of recurrence of large adenomas (with a maximal diameter of at least 1 cm) and advanced adenomas (defined as lesions that had a maximal diameter of at least 1 cm or at least 25 percent villous elements or evidence of high-grade dysplasia, including carcinoma) did not differ significantly between the two groups.

CONCLUSIONS

Adopting a diet that is low in fat and high in fiber, fruits, and vegetables does not influence the risk of recurrence of colorectal adenomas.

The impact of lean production and related new systems of work organization on worker health

New systems of work organization, such as lean production and total quality management, have been introduced by employers throughout the industrialized world to improve productivity, quality, and profitability. However, few studies have examined the impact of such systems on occupational injuries or illnesses or on job characteristics related to job strain, which has been linked to hypertension and cardiovascular disease. The studies reviewed provide little evidence to support the hypothesis that lean production "empowers" auto workers. In fact, auto industry studies suggest that lean production creates intensified work pace and demands. Increases in decision authority and skill levels are modest or temporary, whereas decision latitude typically remains low. Thus, such work can be considered to have job strain. In jobs with ergonomic stressors, intensification of labor appears to lead to increases in musculoskeletal disorders. The evidence for adverse health effects remains inconclusive for related new work systems in other industries, such as modular manufacturing or patient-focused care.

Quantitation and mapping of aflatoxin B1-induced DNA damage in genomic DNA using aflatoxin B1-8,9-epoxide and microsomal activation systems

Aflatoxin B1 (AFB1) is a mutagenic and carcinogenic mycotoxin which may play a role in the etiology of human liver cancer. In vitro studies have shown that AFB1 adducts form primarily at the N7 position of guanine. Using quantitative PCR (QPCR) and ligation-mediated PCR (LMPCR), we have mapped total AFB1 adducts in genomic DNA treated with AFB1-8,9-epoxide and in hepatocytes exposed to AFB1 activated by rat liver microsomes or human liver and enterocyte microsomal preparations. The p53 gene-specific adduct frequencies in DNA, modified in cells with 40-400 microM AFB1, were 0.07-0.74 adducts per kilobase (kb). In vitro modification with 0. 1-4 ng AFB1-8,9-epoxide per microgram DNA produced 0.03-0.58 lesions per kb. The adduct patterns obtained with the epoxide and the different microsomal systems were virtually identical indicating that adducts form with a similar sequence-specificity in vitro and in vivo. The lesions were detected exclusively at guanines with a preference towards GpG and methylated CpG sequences. The methods utilizing QPCR and LMPCR thus provide means to assess gene-specific and sequence-specific AFB1 damage. The results also prove that microsomally-mediated damage is a suitable method for avoiding manipulations with very unstable DNA-reactive metabolites and that this damage can be detected by QPCR and LMPCR.

The impact of lean production and related new systems of work organization on worker health

New systems of work organization, such as lean production and total quality management, have been introduced by employers throughout the industrialized world to improve productivity, quality, and profitability. However, few studies have examined the impact of such systems on occupational injuries or illnesses or on job characteristics related to job strain, which has been linked to hypertension and cardiovascular disease. The studies reviewed provide little evidence to support the hypothesis that lean production "empowers" auto workers. In fact, auto industry studies suggest that lean production creates intensified work pace and demands. Increases in decision authority and skill levels are modest or temporary, whereas decision latitude typically remains low. Thus, such work can be considered to have job strain. In jobs with ergonomic stressors, intensification of labor appears to lead to increases in musculoskeletal disorders. The evidence for adverse health effects remains inconclusive for related new work systems in other industries, such as modular manufacturing or patient-focused care.

Patient's perceptions of bedside handovers

The bedside handover is a universal phenomenon in nearly every type of care setting. It has become the chief arena for the intershift handover in contemporary nursing practice. Published literature investigating patients' viewpoints on the location of the bedside handover is sparse. The overall aim of this study is to describe and provide an analysis of patients' perceptions of the bedside handover. A grounded theory approach to data collection and data analysis was employed to capture surgical patients' views about the bedside handover. The analysis tentatively suggests the existence of three categories that describe the patients' perceptions of the bedside handover. 'Maintaining a Professional Distance', 'Establishing Professional Sharing' and 'Maintaining Patient Safety.'