Appraising and Incorporating Qualitative Research in Evidence-Based Practice

Journal of Physical Therapy Education, Winter 2004 by Henderson, Roberta, Rheault, Wendy

Background and Purpose. Evidence-based practice (EBP) is widely acknowledged to be critical in the clinical practice of physical therapy. Clinicians must be able to evaluate and synthesize all available evidence to make sound clinical decisions. Current EBP theory provides specific criteria to evaluate quantitative research; however, this current theory lacks provisions for consideration and inclusion of qualitative research. Incorporating qualitative research in EBP is important as quantitative and qualitative perspectives have unique contributions to understanding phenomena in rehabilitation and informing physical therapy practice. There is no methodology commonly available or used to include qualitative research in JEBP. The purposes of this research are to: 1) review the theoretical basis and methods of EBP, 2) argue the case for including qualitative research in EBP, 3) introduce Decision Rules for including qualitative research in EBP, 4) introduce an appraisal instrument to evaluate the methodological rigor of qualitative research papers, and 5) present an example of clinical use of this methodology. Method/Model Description and Evaluation. To address this issue, we developed an instrument, suggested by Cuba's Model of Trustworthiness of Qualitative Research, to evaluate the methodological rigor of qualitative papers; we expanded Sackett's Rules of Evidence Model to provide for representation of qualitative studies; and physical therapy students used the instrument and the expanded model in clinical decision making. Outcomes. Students and physical therapists found the appraisal instrument and the methodology straightforward, simple to use, and helpful in clinical decision making. Discussion and Conclusion. Opportunities are virtually unlimited in rehabilitation to describe and interpret phenomena with qualitative research designs. Qualitative evidence deserves consideration and inclusion in EBP. The Decision Rule methodology and the appraisal instrument presented in this paper provide a means to appraise and incorporate qualitative research in EBP.

Key Words: Qualitative, Research, Appraisal, Evidence- based practice.

INTRODUCTION

Research...(should become) an integral part of health care so that practitioners.. .find it natural to rely on the results of research in their day-to-day decision making and longer term strategic planning.... Strongly held views based on belief rather than sound information still exert too much influence in health care.

Sir Michael Peckham, 1991(1)(p3)

Practice guided by belief, rather than practice informed by evidence, persists in health care professions in spite of the evolution of evidence-based medicine over the past two decades. Evidence-based medicine, pioneered at McMaster University in Canada in the 1980s, recognized and acknowledged the importance of research to practice and medical outcomes. Other terms have been used to refer to this process, including evidence-based health care, evidence-based decision making, evidence-based rehabilitation, and evidence-based practice (EBP). All these terms imply the "conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients," suggesting that EBP integrates "individual clinical expertise with the best available external clinical evidence from systematic research."2 Historically, best evidence from research has included results from studies using quantitative methodologies. Although qualitative research studies have a unique perspective and promise to contribute to clinical decisions, there is no methodology commonly available or used to include qualitative research in EBP.

Evidence-based practice is based upon a self-directed learning model in which the practitioner must continue to learn, and to evaluate their techniques and practice in light of their learning, to see what can be improved.3 Law succinctly states, "The argument for EBP is simple, if there is a better way to practice, therapists should find it."3(P5) We assert that both the quantitative and qualitative perspectives are needed for EBP. This paper provides clinicians with the means to appraise qualitative research and incorporate results of qualitative research in a familiar EBP framework.

The five specific purposes of this paper are to:

1) Review the theoretical basis and methods of EBP.

2) Argue the case for including qualitative research in EBP.

3) Introduce Decision Rules for including qualitative research in EBP.

4) Introduce the Rosalind Franklin-Qualitative Research Appraisal Instrument (RF-QRA).

5) Present an example of clinical use of this methodology to illustrate how our Decision Rules and the RF-QRA can be used in the clinical setting.

THEORETICAL BASIS AND METHODS OF EBP

The traditional five components of EBP include questioning (discerning a clinical question), searching (for research reports), evaluating (appraising this research and making recommendations for practice), implementing (recommendations in practice),4 and assessing the performance of evidence, that is, assessing the impact evidence has on practice and adjusting practice accordingly (Figure 1). The focus of our endeavor is the third component, evaluating.