Rationale and standards for the systematic review of qualitative literature in health services research

Enhancing the evidence base for health impact assessment

Health impact assessment differs from other purposes for which evidence is collated in a number of ways, including:the focus on complex interventions or policy and their diverse effects on determinants of health;the need for evidence on the reversibility of adverse factors damaging to health;the diversity of the evidence in terms of relevant disciplines, study designs, quality criteria and sources of information;the broad range of stakeholders involved;the short timescale and limited resources generally available;the pragmatic need to inform decision makers regardless of the quality of the evidence. These have implications for commissioning and conducting reviews. Methods must be developed to: facilitate comprehensive searching across a broad range of disciplines and information sources; collate appropriate quality criteria to assess a range of study designs; synthesise different kinds of evidence; and facilitate timely stakeholder involvement. Good practice standards for reviews are needed to reduce the risk of poor quality recommendations. Advice to decision makers must make explicit limitations resulting from absent, conflicting, or poor quality evidence.

A glossary for evidence based public health

This glossary seeks to define and explain some of the main concepts underpinning evidence based public health. It draws on the published literature, experience gained over several years analysis of the topic, and discussions with public health colleagues, including researchers, practitioners, policy makers, and students.

A Strategy to Identify Critical Appraisal Criteria for Primary Mixed-Method Studies

The practice of mixed-methods research has increased considerably over the last 10 years. While these studies have been criticized for violating quantitative and qualitative paradigmatic assumptions, the methodological quality of mixed-method studies has not been addressed. The purpose of this paper is to identify criteria to critically appraise the quality of mixed-method studies in the health literature. Criteria for critically appraising quantitative and qualitative studies were generated from a review of the literature. These criteria were organized according to a cross-paradigm framework. We recommend that these criteria be applied to a sample of mixed-method studies which are judged to be exemplary. With the consultation of critical appraisal experts and experienced qualitative, quantitative, and mixed-method researchers, further efforts are required to revise and prioritize the criteria according to importance.

The problem of appraising qualitative research

Qualitative research can make a valuable contribution to the study of quality and safety in health care. Sound ways of appraising qualitative research are needed, but currently there are many different proposals with few signs of an emerging consensus. One problem has been the tendency to treat qualitative research as a unified field. We distinguish universal features of quality from those specific to methodology and offer a set of minimally prescriptive prompts to assist with the assessment of generic features of qualitative research. In using these, account will need to be taken of the particular method of data collection and methodological approach being used. There may be a need for appraisal criteria suited to the different methods of qualitative data collection and to different methodological approaches. These more specific criteria would help to distinguish fatal flaws from more minor errors in the design, conduct, and reporting of qualitative research. There will be difficulties in doing this because some aspects of qualitative research, particularly those relating to quality of insight and interpretation, will remain difficult to appraise and will rely largely on subjective judgement.

The problem of appraising qualitative research

Qualitative research can make a valuable contribution to the study of quality and safety in health care. Sound ways of appraising qualitative research are needed, but currently there are many different proposals with few signs of an emerging consensus. One problem has been the tendency to treat qualitative research as a unified field. We distinguish universal features of quality from those specific to methodology and offer a set of minimally prescriptive prompts to assist with the assessment of generic features of qualitative research. In using these, account will need to be taken of the particular method of data collection and methodological approach being used. There may be a need for appraisal criteria suited to the different methods of qualitative data collection and to different methodological approaches. These more specific criteria would help to distinguish fatal flaws from more minor errors in the design, conduct, and reporting of qualitative research. There will be difficulties in doing this because some aspects of qualitative research, particularly those relating to quality of insight and interpretation, will remain difficult to appraise and will rely largely on subjective judgement.

A question of place: medical power in rural Australia

In Australia, like many countries, government, medicine and the community have maintained an interdependent and symbiotic relationship based on mutual resource dependency and reciprocity. The services of medicine have been indispensable to government and the community and in return medicine has achieved power, elitism and financial gain. Traditionally, doctors have controlled and directed medical knowledge in an absolute manner and this has been the basis of increasing power and dominance. There are, however, claims that medicine's power and dominance over the health care system is being eroded by the emergence of major social trends. The corporatization of medicine, manageralism and proletarianization are touted as factors that are increasingly countervailing medical dominance and power. Whilst it could be suggested that as these trends become more firmly established government and the community gain greater discretionary control over how the resources of medicine can be allocated and utilized, this article argues that the geographic and social dimensions of the community in which doctors practice must be considered. Using a qualitative descriptive approach research was conducted in rural Victoria, Australia. The overall aim of the study was to identify the issues that impact upon service delivery in rural hospitals. The most significant issue that emerged related to medical relationships. The results of this research indicate that in this rural area the power of medicine is strengthened and institutionalized by geographically determined resource control. The sustainability of rural communities is linked to the ability of the town to attract and retain the services of a doctor. Crucial shortages of rural doctors provide medicine with a mandate to dictate the way in which medical resources will be allocated and used by hospitals and the community. Organizations that control critical resources are in an extremely powerful position to control others. Doctors in rural Victoria maintain a position of strength and use their power to exert control over the state, the community and the hospital. Although medical power and dominance may be declining in some areas, in rural Victoria it remains firmly entrenched.

Clinical guidelines and care protocols

Clinical guidelines and care protocols are intended to provide information, based on an appraisal of the current best evidence of clinical and cost-effectiveness, regarding therapeutic interventions for given conditions. With the establishment of the National Collaborating Centre for Nursing as a part of National Institute for Clinical Excellence (NICE), it is anticipated that an increasing number of clinical guidelines that focus on aspects of nursing care will be developed at a national level. The Department of Health also aims to introduce nationally agreed multidisciplinary care protocols which will dictate how certain conditions are to be managed. These developments have the potential to enhance healthcare provision and nursing practice. However, they also introduce potential dilemmas for nurses. This paper discusses some of the issues involved in the development and implementation of clinical guidelines and care protocols in intensive care nursing.

A qualitative evaluation of an adolescent cancer unit

MULHALL A., KELLY D. & PEARCE S. (2004) European Journal of Cancer Care13, 16-22 A qualitative evaluation of an adolescent cancer unit The Expert Advisory Group on Cancer (1995) recommended that cancer centres in the UK should make provision for adolescents with cancer. However, although their number is growing, only a small number of specialist adolescent cancer units currently exist, and teenagers may often be treated in more general settings. To date, no formal evaluation of adolescent cancer units has taken place. This study adopted a qualitative approach to evaluate the first specialist adolescent oncology unit, which was established in the UK 10 years ago. The aim was to provide insight into: the culture of the unit; the experiences of patients and parents on the unit and the staff who worked there; and how the unit was valued by these groups. Semi-structured interviews were conducted with 10 teenagers with cancer, 10 parents and 14 professionals. Systematic non-participant observation of routine activities in the unit was undertaken also. Interview transcripts and observational data were analysed to identify key themes and categories. Six categories emerged from the data: (1) cancer and the cancer unit: although the word cancer had negative connotations, it provided a common supportive bond for adolescents and families on the unit; (2) what it feels like over time: key points in the adolescent cancer experience were emphasized as significant. These included diagnosis, end of treatment and recurrence of cancer; (3) physical structures and facilities: these were focused around the needs of adolescents with cancer and helped to provide a suitable environment of care; (4) the social context: approaches to care were relaxed in nature and suited the needs of adolescents and their families; (5) the family: there was an emphasis on maintaining normal routines whilst managing the impact of cancer on family relationships; and (6) specialism and expertise: the availability of an expert team of professionals with specialized insight into adolescents' needs was pivotal to creating an appropriate environment of care. In conclusion, the complex care and treatment needs of adolescents with cancer may best be met by specialist units.

Educating for rural nursing practice

BACKGROUND

Rural hospitals in Australia, as in many countries, face challenges in ensuring that appropriate, quality services are provided.

AIMS

The overall aim of this study was to explore the issues that impact on the ability of rural hospitals to provide effective health care.

METHODS

We used a qualitative descriptive method and purposive sampling, and conducted interviews in hospitals in rural Victoria, Australia. The data collected enabled major issues that impact on hospital service delivery to be identified. Using thematic analysis, global themes were extracted and organized around a thematic network.

FINDINGS

The workforce was an important theme. Whilst the impact of medical shortages on hospital function has been considered in other studies, little consideration has been given to the rural nursing workforce. The need to maintain an appropriately educated rural nursing workforce emerged as one of the major issues that impact on rural hospital service delivery. In Australia, there has been a great deal of discussion about the educational preparation required for rural nursing practice, with the emphasis on postgraduate study. However, the majority of rural nurses do not have postgraduate qualifications and face significant barriers in obtaining them. Although the vast majority of literature claims that postgraduate preparation is vital for rural nursing practice, this research suggests that the future rural nursing workforce will be recruited from undergraduate courses in regional universities. However, there is a need to include specific theoretical and operational preparation in undergraduate education, to enable nurses to make the transition to rural practice more readily.

CONCLUSIONS

Rural nurses are central to the delivery of health services in rural hospitals. Future rural nursing recruitment and retention hinges on ensuring that they have the confidence, knowledge and skills to deliver safe, appropriate and effective care.

Involvement and detachment in researching sexuality: reflections on the process of semistructured interviewing

In this article, the authors reflect on the utility of the concept of involvement-detachment for researchers involved in a study of the lifeworlds of gay, lesbian, and bisexual young people where one of the researchers was lesbian. They focus in particular on the process of semistructured interviewing in qualitative research and the analysis of material generated by the interviews, noting that complete detachment from the subject of study is neither achievable nor desirable. They discuss the benefit of teamwork in supporting researchers and enhancing the integrity of the research, particularly when the subject is sensitive, the importance of researchers' active management of their own ideological leanings, and the understanding of project management as a conceptual and cognitive process that is fundamental to enhancing research rigor.

Praiseworthy pragmatism? Validity and action research

BACKGROUND

Action research has been promoted as a suitable methodology for nursing, but is located in a discourse that challenges its claims of validity. This discourse, influenced by positivism, is similar to that which qualitative researchers have faced.

AIM

This article contributes to theoretical discussion of the validity of action research.

FINDINGS

Because of similarities, the emergent debates around the reconceptualization of validity in qualitative research are outlined, prior to a consideration of the relative arguments in relation to action research. Three avenues of thought are discerned: that no criteria are required; that parallels with other schools are appropriate; and that new concepts specific to one school of thought should be developed.

CONCLUSIONS

Because of its ethical and action-oriented principles, action research offers the potential to address validity issues that remain problematic to 'pure' qualitative researchers, and it can be claimed that its pragmatic approach is validity-enhancing. We argue for the rejection of naïve rule-based formulae and for recognition of the impact of contextual and pragmatic concerns, so that the potential for the added value of action research might be realized.

The newfound credibility of qualitative research? Tales of technical essentialism and co-option

Qualitative research is no longer the "poor relation" to quantitative research that it has been in the past. However, it is important to monitor the manner in which it is becoming incorporated into the mainstream. In this article, the author examines current dangers and challenges by critically reviewing current developments affecting our own research practice. It is argued that technical essentialism (including the co-option of grounded theory) characterizes many responses to qualitative research. The author concludes by suggesting that our own everyday research practice, involving teaching and supervision, provides an opportunity to advance debates about rigor by allowing us to formulate a considered response that respects both the complexities and the unique contribution that qualitative research can make.

Communicating and judging the quality of qualitative research: the need for a new language

BACKGROUND

Traditionally UK dietitians have tended to take a more quantitative approach to research. Qualitative research which gives an in-depth view of people's experiences and beliefs is also now being used to help answer some important dietetic research questions.

REVIEW

A review of the limited number of qualitative research papers in the Journal of Human Nutrition and Dietetics 1990-2002 (nine papers in all), revealed a lack of specific discussion of the quality strategies commonly used in qualitative research. This could indicate a less than robust approach, but might also reflect a different perspective on quality, or simply the difficulties associated with disseminating qualitative research to a profession whose members lack familiarity with the language. The fact that qualitative research seems to be used rarely may also indicate a poor understanding of its role.

PURPOSE OF THIS PAPER

This paper seeks to clarify the potential role of qualitative research and draws on previously published guidelines for demonstrating quality. It is hoped that this will offer dietitians a framework for carrying out qualitative research and a language for reporting it, as well acting as a stimulus for discussion.

Evaluating and synthesizing qualitative research: the need to develop a distinctive approach

The growing popularity of qualitative research has led to calls for it to be incorporated into the evidence base. It is argued that, in seeking to respond to this challenge, it is important that we recognize the important differences between qualitative and quantitative research and that we take this into account in developing a distinctive approach. This paper outlines the distinctive contribution made by qualitative research with regard to the nature of the curiosity involved, the iterative research process and its treatment of data, analysis and findings. We caution against simply importing templates developed for systematic review of quantitative work, and make suggestions with regard to developing a new model for evaluating and synthesizing qualitative work. The proposed new model takes a critical look at some of the assumptions underpinning systematic review, such as the process of literature searching and selection of relevant material. Although there is potential for checklist items--such as purposive sampling, respondent validation, multiple coding, triangulation and grounded theory--to be used over-prescriptively in evaluating qualitative papers, it is argued that a more creative engagement with these concepts could yield a distinctive approach more appropriate for this type of work. Moreover, we speculate that some of the questions thereby raised might be usefully applied to consideration of established procedures for reviewing quantitative work.

Reframing the evaluation of qualitative health research: reflections on a review of appraisal guidelines in the health sciences

In this article, we explore the form of evaluation put forward by guidelines used in the health sciences for appraising qualitative research and we begin to articulate an alternative posture. Most guidelines are derivative of the modes of assessment developed by clinical epidemiologists as part of the promotion of evidence-based medicine (EBM). They are predominantly proceduralist in orientation, equating quality with the proper execution of research techniques. We argue that this form of judgment assumes a fixed relationship between research practice and knowledge generated, and tends to over-simplify and standardize the complex and non-formulaic nature of qualitative inquiry. A concern with methods as objects of judgment in and of themselves restricts the reader's field of vision to the research process and diverts attention away from the analytic content of the research. We propose an alternative 'substantive' perspective that focuses on the analysis put forward, and regards methods as resources for engaging with and understanding the substantive findings and topic of inquiry. An important challenge is to find a way to embody such a form of judgment in practical assessment tools.

An investigation into the perceptions of primary care practitioners of their education and development needs for communicating with patients who may not be fluent in English

This paper reports on an empirical research project that assessed educational needs of primary care practitioners for communicating with minority ethnic patients who are not fluent in English. The qualitative study was carried out in general practice settings in a northern inner city locality. Discrepancies are highlighted between patient and practitioner understandings, and between educational models and practitioner views. Educational needs are identified to enhance practitioners' specific skills, knowledge of patient perspectives, and self-awareness. Organisational influences on communication are explored. Key arguments are that "transcultural" educational models should be used critically, and education should enable practitioners to integrate their personal coping strategies with structured practice development planning.

Qualitative research in palliative care 1990-1999: a descriptive review

A collaborative, evaluative review of qualitative research in palliative care published between 1990 and 1999 has been conducted. Nearly 30,000 articles in 48 journals from specialist palliative care, oncology, death studies, medicine, nursing, gerontology, health and the social sciences were examined. From these journals, 138 articles (0.5%) reporting qualitative research with a focus on palliative care in the context of death, dying or bereavement were identified. These articles were reviewed using a proforma designed by the group. This article describes the review process, and the following findings: the distribution of different forms of qualitative research in palliative care; the location of such papers; the focus of the research; and the research methodology and methods adopted.

Evaluation of qualitative research

It is necessary to subject published research to critical scrutiny, in order to evaluate the robustness of the findings. The criteria used in evaluation require to be appropriate for the research paradigm, i.e. quantitative or qualitative. Quantitative conceptualizations of reliability and validity are unsuitable for evaluation of qualitative research as they were not devised for this purpose. The use of quantitative criteria to evaluate qualitative research may create the impression that the latter is not academically rigorous. Evaluation criteria which are specific to qualitative research require identification and application, in order to provide a formalized and rigorous approach to critical appraisal. A formalized framework for evaluation will help to ensure that the contribution of qualitative studies, with specific reference to health services research, receives optimum recognition. The work of a number of writers is used in this paper to examine the features which distinguish qualitative research and the following are discussed: the need for researcher reflexivity; the use of the 'first person' in academic work; the context in which research takes place; the selection of research participants; the interpretation of participants' accounts; the active acknowledgement of 'lay' knowledge; researcher flexibility within the research process; the generalizability of findings. It is concluded that academically rigorous criteria, which are appropriate for evaluation of qualitative research, exist and are available for use by practitioners and researchers.

The psycho-social impact of infertility on young male cancer survivors: a qualitative investigation

Intensive treatment regimes that are known to have a potential risk of infertility sometimes have to be given to boys who have aggressive malignant disease. Long-term care must therefore include further discussion of these patients' impaired fertility. This study describes the results of a series of semi-structured interviews with 15 young male cancer survivors regarding their experience of receiving feedback on their probable fertility status. All the interviews were conducted by a psychologist formerly uninvolved with their treatment. The interviews were analysed qualitatively using a grounded theory approach. The findings of the study are organised under four headings: (a) Emotional reaction to news of probable infertility. (b) Coping style adopted. (c) Response to the offer of semen analysis. (d) Implications for clinical practice.The results of this thematic analysis are compared to the wider research literature in oncology and health psychology.

Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care

Interest in how qualitative health research might be used more widely to inform health policy and medical practice is growing. Synthesising findings from individual qualitative studies may be one method but application of conventional systematic review methodology to qualitative research presents significant philosophical and practical challenges. The aim here was to examine the feasibility of synthesising qualitative research using qualitative methodology including a formative evaluation of criteria for assessing the research to be synthesised. Ten qualitative studies of adult patients' perspectives of diabetes were purposefully selected and questions proposed by the critical appraisal skills programme (CASP) adapted and used to assess papers prior to synthesis. Each study was reviewed independently by two experienced social scientists. The level of agreement between reviewers was determined. Three papers were excluded: one because it turned out not to be qualitative research, one because the quality of the empirical work was poor and one because the qualitative findings reported were also recorded in another paper already included. The synthesis, which had two distinct elements, was conducted using the meta-ethnographic method. Firstly, four papers containing typologies of patient responses to diabetes were synthesised. Secondly, six key concepts were identified from all seven papers as being important in enabling a person with diabetes to achieve a balance in their lives and to attain a sense of well-being and control. These included: time and experience, trust in self, a less subservient approach to care providers, strategic non-compliance with medication, effective support from care providers and an acknowledgement that diabetes is serious. None of the studies included in the synthesis referenced any of the early papers nor did they appear to have taken account of or built upon previous findings. This evaluation confirmed that meta-ethnography can lead to a synthesis and extension of qualitative research in a defined field of study. In addition, from it a practical method of qualitative research assessment evolved. This process is promising but requires further testing and evaluation before it could be recommended for more widespread adoption.

Multi-agency training for quality: reflections and recommendations

Clinical governance within the National Health Service (NHS) and best value across local authorities in England have emphasised the need for decisions and actions being demonstrably evidence based. In an attempt to progress these related initiatives and facilitate a closer working relationship between NHS Trusts and local government departments, a multi-agency and interprofessional training event on evidence-based practice (EBP) was organised across three boroughs within Tyne and Wear. While there are advantages to different agencies learning and working in partnership to develop quality systems for health improvement, the reality of introducing EBP concepts and creating an evaluative culture within and across public sector organisations represents a major challenge. This article has adopted a case study approach to describe the key lessons learnt through critically reflecting on the planning and delivery of this training event, and it is hoped that it will be of value to other attempting similar projects in the future.

Understanding and evaluating qualitative research

Qualitative research aims to address questions concerned with developing an understanding of the meaning and experience dimensions of humans' lives and social worlds. Central to good qualitative research is whether the research participants' subjective meanings, actions and social contexts, as understood by them, are illuminated. This paper aims to provide beginning researchers, and those unfamiliar with qualitative research, with an orientation to the principles that inform the evaluation of the design, conduct, findings and interpretation of qualitative research. It orients the reader to two philosophical perspectives, the interpretive and critical research paradigms, which underpin both the qualitative research methodologies most often used in mental health research, and how qualitative research is evaluated. Criteria for evaluating quality are interconnected with standards for ethics in qualitative research. They include principles for good practice in the conduct of qualitative research, and for trustworthiness in the interpretation of qualitative data. The paper reviews these criteria, and discusses how they may be used to evaluate qualitative research presented in research reports. These principles also offer some guidance about the conduct of sound qualitative research for the beginner qualitative researcher.

Appraising the evidence: reviewing disparate data systematically

The authors describe a method of systematically reviewing research from different paradigms. They draw on the methods adapted, developed, and designed during a study concerned with the delivery of care across professional boundaries. Informed by the established method of systematic review, the authors undertook the review in distinct stages. They describe the methods developed for each stage and outline the difficulties encountered, the solutions devised, and the appraisal tools developed. Although many of the problems encountered were related to the critical assessment of qualitative research, the authors argue that the method of systematic review can be adapted for use with different data andacross disciplines.

The nursing contribution to qualitative research in palliative care 1990-1999: a critical evaluation

BACKGROUND

Qualitative research plays an important part in providing evidence for practice in nursing, and is gaining greater acceptance within medicine. However, questions remain about what criteria are most appropriate for evaluating qualitative research. To date, little systematic evaluation of qualitative research in palliative care has been conducted.

AIMS

This paper is based on a larger study in which we conducted a critical review of qualitative research in palliative care from nursing, medicine, specialist palliative care, sociology, death studies, medical anthropology, and gerontology journals published between 1990 and 1999. The aim of this paper is to present an account of the strengths and weaknesses of qualitative palliative care research in nursing, using data from this review.

METHODS

In the larger study, 138 papers from 50 journals were reviewed critically using a tool developed to assess both content and quality; in one part of this tool reviewers recorded open-ended comments on the strengths and weaknesses of each paper. In this paper, we present a thematic analysis of reviewers' comments on a subgroup of 67 nursing papers from the main review, together with an analysis of comments on 29 papers from a comparison group of death studies, medical anthropology, and sociology journals. Patterns of positive and negative evaluation are identified and used to generate an account of strengths and weaknesses in qualitative palliative care research in nursing.

FINDINGS

Over 40% of the subgroup of papers from nursing journals received positive comments on topic and quality of writing; around 30% received positive comments on contribution to understanding, practical value, and conceptual or theoretical issues. Less than 20% received positive comments on other critical dimensions. Over 40% of nursing papers received negative comments on the link between data, analysis, and findings, other aspects of method and theoretical and conceptual issues. A higher proportion of papers in the comparison group received positive comments on conceptual and theoretical issues and contribution to understanding.

CONCLUSIONS

Nearly half the nursing papers reviewed were judged to be well written or to have a well-chosen topic. However, more than 40% of papers drew negative comments about key methods-related issues. Arguably therefore efforts to improve the quality of research evidence should focus on this area.

Recognising relationships: reflections on evidence-based practice

This paper argues for a broadening of the way evidence is developed and used in health-care. It contends that the current political and policy imperatives and the evidence-based practice movement are in direct tension with the other major ideological movements that promote patient-centred healthcare services. Nursing is affected by this tension because it is more naturally focused on relationships with clients to achieve health outcomes. The unresolved and mounting tension could be alleviated by embracing a broader definition of what counts as evidence and by focusing more on patient-centred healthcare methodologies and acknowledging the interdependency of distinct ways of generating new knowledge. A number of case studies are used to illustrate how research focusing on patient perspectives and nurses' response to patient experiences can improve the evidence base for nursing.

Methodological strategies for the identification and synthesis of 'evidence' to support decision-making in relation to complex healthcare systems and practices

This paper addresses the limitations of current methods supporting 'evidence-based health-care' in relation to complex aspects of care, including those questions that are best supported by descriptive or non-empirical evidence. The paper identifies some new methods, which may be useful in aiding the synthesis of data in these areas. The methods detailed are broadly divided into those that facilitate the identification of evidence and those that enable the interpretation of the data retrieved. To illustrate some of the issues involved, reference is made to a multimethod review recently completed by the authors, which aimed to identify factors that promote continuity in the transition from child to adult health and social care. It is argued that as healthcare organisations are becoming increasingly preoccupied with the evidence base of practice, such methods may help ensure that aspects of care and approaches that are outside the dominant pharmaco-medical domain maintain a prominent position on the healthcare agenda while remaining open to external scrutiny. Healthcare professionals who use such approaches need to know their relative utility and benefits to inform clinical decisions, so as to ensure that best practice is observed.

Reasons for physically restraining patients and residents: a systematic review and content analysis

OBJECTIVE

The purpose of this systematic review was to determine why people are physically restrained in the acute and residential care settings.

METHOD

A comprehensive search was undertaken of electronic databases to identify studies addressing the reasons for using physical restraint. Findings were synthesised using content analysis.

RESULTS

Twenty-three studies were identified. The most common reason for using restraints related to patient-oriented issues such as ensuring the safety of people. However, they are also commonly used to facilitate treatment, maintain the social environment and because of issues such as understaffing.

Research in black and white

The authors consider the methodological, interpretative, and practical issues that arise when there is a difference in ethnicity between researcher and informant in qualitative research by drawing on the academic literature and their fieldwork experiences as White researchers undertaking studies with individuals of African/Caribbean and South Asian descent. Some contemporary issues raised by "researching the other" in the context of pragmatic health services research are highlighted, including access to same-ethnicity researchers, the involvement of interpreters, and the potential for ethnocentric interpretation. The authors believe that qualitative research should be judged by the plausibility of the findings and by a critical evaluation of the way in which the research was conducted and the reflexivity of the researcher.

How do directors of public health perceive leadership?

This study examines how directors of public health (DsPH) perceive effective leadership. Kelly's repertory grid technique is used. A total of 13 out of a possible 14 DsPH in one NHS region of England were interviewed. Qualitative and quantitative analysis were carried out. The findings show that male DsPH (n = 8) rate their leadership ability more highly than do female DsPH (n = 5). Qualitative analysis produced a number of categories of constructs, some of which are perceived to be indicative of effective leadership, these being "working for others", "personal attributes", "vision and innovation" and "courage and integrity" Some categories appear to be applicable only to the UK (or to public health) and not to the existing dominant US models of leadership. In general, DsPH perceptions of effective leadership converge with current theories; most specifically the UK-based theories. This study therefore refutes any simple extrapolation of US theories of leadership to UK health organisations.

Criteria for evaluating evidence on public health interventions

Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.

Nursing research and nursing practice: an exploration of two different cultures

Despite increasing efforts by both the government and the professions to institute evidence-based practice, there still remains a significant research practice gap in UK nursing. This paper explores the two worlds of practice and research and the factors that may affect them. It suggests that academic researchers and practitioners often have different perspectives and are working under different imperatives. These different cultures need to be recognized and made more explicit. Consideration will be given as to what sort of evidence is required by practitioners to nurse effectively, how we should identify this evidence and the role which research plays. The disharmony between the worlds of research and practice extends the discussion to consider the ways in which research is produced and disseminated. The question is raised as to why researchers fail to identify the contingencies, adaptations and social biases that affect their work. Strategies that might facilitate a franker discussion of research and the way in which it is produced will be illustrated by examples of research work undertaken by the author.

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.

Bridging the research-practice gap: breaking new ground in health care

Many theorists have discussed the existence of a gap between nursing research and practice. Consequently much time and effort has been expended in trying to devise strategies to bridge this divide. This article explores what the research-practice gap is and discusses five important reasons for it. The issue is then raised as to whether or not there is a gap between evidence and practice, despite the existence of the gap between research and practice. This is explored in relation to the potential conflict between the 'know how' knowledge important in practice and the 'know that' knowledge important in academia. Finally, the concept of practitioner-centred research is described as one strategy that would effectively obliterate the research-practice gap as it is currently conceived.

Validity in qualitative research

Much contemporary dialogue has centered on the difficulty of establishing validity criteria in qualitative research. Developing validity standards in qualitative research is challenging because of the necessity to incorporate rigor and subjectivity as well as creativity into the scientific process. This article explores the extant issues related to the science and art of qualitative research and proposes a synthesis of contemporary viewpoints. A distinction between primary and secondary validity criteria in qualitative research is made with credibility, authenticity, criticality, and integrity identified as primary validity criteria and explicitness, vividness, creativity, thoroughness, congruence, and sensitivity identified as secondary validity criteria.

Methodologies analysing individual practice in health care: a systematic review

AIM OF THE REVIEW

The aim of the systematic review was to identify, explore and evaluate the current level of knowledge of methodologies used in comparative analyses of the individual practice of doctors, nurses and midwives.

RATIONALE

The question of how roles and responsibilities might be shared differently between professional groups in order to promote improved, cost-effective health care requires a systematic analysis of existing roles and practice. To do this effectively, knowledge of the methodologies available for such an analysis is essential.

METHODS

A systematic review of the literature published since 1989 comparing the practice of doctors, nurses and midwives was undertaken.

FINDINGS

The findings are presented in tabular format and include the following categories of published methodologies: experimental/quasi-experimental; descriptive/nonexperimental and qualitative studies. The discussion centres on a critique of quantitative methodologies used to analyse individual practice in relation to role substitution and diversification. The potential contribution of qualitative methodologies in the analysis of individual practice is discussed.

CONCLUSIONS

The authors conclude that the current level of knowledge is biased towards quantitative research. It is argued that the assessment of health care roles and responsibilities would be well served by a more balanced approach that recognizes the strengths of both quantitative and qualitative work.

Levels and applications of qualitative research evidence

Evaluation of qualitative findings for application to nursing practice can go beyond the rigor with which the evidence was developed to the characteristics of the findings themselves. Five categories of qualitative findings are described that vary in their levels of complexity and discovery: those restricted by a priori frameworks, descriptive categories, shared pathway or meaning, depiction of experiential variation, and dense explanatory description. Four modes of clinical application of qualitative evidence are proposed-insight or empathy, assessment of status or progress, anticipatory guidance, and coaching-that vary in their degree of visibility and patient involvement. The greater the complexity and discovery within qualitative findings, the stronger may be the potential for clinical application.

Nursing research and nursing practice: an exploration of two different cultures

Despite increasing efforts by both the government and the professions to institute evidence-based practice, there still remains a significant research practice gap in UK nursing. This paper explores the two worlds of practice and research and the factors that may affect them. It suggests that academic researchers and practitioners often have different perspectives and are working under different imperatives. These different cultures need to be recognized and made more explicit. Consideration will be given as to what sort of evidence is required by practitioners to nurse effectively, how we should identify this evidence and the role which research plays. The disharmony between the worlds of research and practice extends the discussion to consider the ways in which research is produced and disseminated. The question is raised as to why researchers fail to identify the contingencies, adaptations and social biases that affect their work. Strategies that might facilitate a franker discussion of research and the way in which it is produced will be illustrated by examples of research work undertaken by the author.