Research Worlds in Health Care

Transcription

1 Research Worlds in Health Care W. Ellen Raboin, Paul Uhlig, and Sheila McNamee Abstract What constitutes legitimate research is viewed differently across different communities of scholarship. This paper describes three approaches to research in health care. We refer to any distinct way of understanding and conducting research, including its unique purposes, practices, and conventions of rigor together with the beliefs, assumptions and standards of the professions and communities of scholarship within which it is situated as a research world. The Diagnostic research world is the traditional orientation to research in health care and has origins in natural sciences; Interpretive research is growing in acceptance and has origins in social sciences; Relational research is an emerging orientation that views research as having a legitimate purpose of intentional transformation. Each world is coherent and has well developed standards of rigor when viewed within world--yet may seem inconsistent and puzzling when viewed across worlds. Health care can benefit if all three worlds are understood as unique, rigorous, and valuable in their own ways; and as complementary. Introduction Health care is at a crossroads. Unsolved challenges of rising costs, uneven quality and safety, and a need for reengaging the human side of health care are global concerns. It is possible that improvements can be found within existing frameworks of practice, education and research that will take health care beyond these challenges. But it is possible that deeper transformations will be necessary, extending to foundational assumptions and standards that underlie existing approaches and upon which rigor and legitimacy have traditionally been based. 1

2 From a perspective of willingness to re-imagine health care in fundamentally new ways, in this paper we consider contemporary approaches to health care research. We utilize a well known patient safety study to illustrate three distinct approaches to health care research one familiar, one growing in acceptance, and one emerging. We discuss each approach, comparing differing assumptions, purposes, criteria for rigor, and the communities of scholarship within which each approach is accepted and has meaning. Our purposes are to show how each approach can be useful for guiding inquiry and facilitating change in health care s complex mix of science, quality and humanness; to affirm the legitimacy of each approach; and to describe a transformational trajectory in health care research. Research Worlds in Health Care In this paper we introduce the term research world to highlight the complex interdependencies that support and give scholarly rigor to a particular approach to research. We refer to any distinct way of understanding and conducting research, including its unique purposes, practices, and conventions of rigor together with the beliefs, assumptions and standards of the professions and communities of scholarship within which it is situated as a research world. A research world is a comprehensive context that guides, supports, funds, conducts and evaluates research in certain ways. A research world holds and maintains a particular approach to research based on core assumptions about the nature of reality (ontology), ways of knowing (epistemology), and ways of conducting research based on these understandings. What is acceptable in each world is constructed and held in place by many stakeholders as depicted in Figure 1. 2

3 Figure 1. Research World as Comprehensive Context This paper describes three research worlds in contemporary health care. To emphasize fresh understandings, we have named the research worlds Diagnostic, Interpretive and Relational. We prefer the names diagnostic and interpretive rather than the more familiar names quantitative and qualitative research because we want to consider the roots, purposes, and conventions of these approaches with an openness less burdened by past associations. We use the word relational to describe an emerging research world that is less familiar to many scholars working in traditional health care. To illustrate these research worlds, discuss differences, and show usefulness we utilize reports from the Keystone ICU Project, which reduced hospital acquired infections in participating intensive care units across the state of Michigan. References will be listed in later sections. 3

4 Diagnostic Research World The diagnostic research world (World One) is an assumed standard in the profession of medicine, and in nursing and other health professions although not as dominantly. The diagnostic research world is situated in communities of scholarship that place value in the beliefs, assumptions and conventions of the scientific method. The diagnostic research world has historical roots in the natural sciences for the study of natural phenomena. Research in this world is based on an assumption of a single reality that can be objectively observed and measured. 1 Diagnostic researchers develop aims and research questions related to problems to be solved, propose hypotheses that can be objectively tested, and seek objective evidence supporting generalisable truths and cause-effect relationships. Rigor in diagnostic research requires maintaining objective distance between the researcher and what is being studied, striving to minimize bias and confounding effects, evaluating data collection methods for reliability and validity, and analyzing results using appropriate statistical methods. 2 Conclusions are drawn with the intent of establishing or contributing to an evidence base, and disseminating generalisable knowledge. Case in Point [Box]. A frequently cited account of the Keystone ICU Project was published in the New England Journal of Medicine. 3 This report has a strong diagnostic orientation. From this perspective, the Keystone ICU Project is evidence that central line infections can be reduced by the use of five evidence based procedures. 4

5 Notice that from this perspective, the intervention is described as precisely specified actions and behaviors; analysis centers on cause and effect associations between the intervention and outcomes; and conclusions are assumed to be generalisable. Interpretive Research World The Interpretive Research World (World Two) is situated in communities of scholarship that accept or attempt to reconcile many of the conventions of the scientific method, but apply these in ways intended to achieve rich, often theory-based understandings of phenomena being studied, recognizing and accounting for complexities of human interactions and the contexts in which they occur. 4 The historical roots of interpretive research are in the social sciences for the study of human and social interactions. Interpretive research has a relativist orientation, allowing for multiple realities and acknowledging complex rather than complicated shaping factors that cannot necessarily be fully understood or predicted by simple cause-effect relationships. 5

6 Communities of scholarship within which the interpretive research world is situated, including the profession of nursing as an exemplar and many social science disciplines, value the importance of context and the significance of what is felt and experienced as well as what is observed. 5 In contrast to maintaining objective distance, interpretive researchers are comfortable interacting with respondents. They focus attention on the environments and social milieu that surround and shape the phenomena of interest, and how meaning is ascribed and evolves. 6 Whereas the stance of diagnostic research is standing apart from, the orientation of interpretive research is standing beside. Rigor in Interpretive research is established in relation to the methods and analyses used, emphasizing transparency and explication of intentional choices made by the researcher. 7,8 Whereas diagnostic research is designed from the outset to test a certain hypothesis, interpretive research accepts the legitimacy of developing theory from emerging data (induction). 9 Interpretive researchers do not expect that findings will always be strictly generalisable from one setting to another, although they intend for their work to be helpful or transferable in contextually relevant ways. Case in Point [Box]. After the publication of their diagnostic report, researchers involved in the Keystone ICU study felt that important details of the study were misunderstood or missing. 10 They worked with social science researchers to revisit their experiences and clarify what they 10, 11 felt was important. Notice that the interpretive orientation allows the authors to consider additional dimensions of the study not apparent or accessible from the diagnostic perspective. The interpretive reports 6

7 tell a different story about the Keystone ICU Project, richer with theory-based human insights and useful in complementary ways for applying research findings in practice. Relational Research World Relational research (World Three) is an emerging orientation situated in communities of scholarship that find value in beliefs, assumptions and standards centered in relationships and co-participatory engagement. Relational research is a useful descriptor for approaches with participatory, generative, reflexive orientations with a purpose of transformation. These include Relational Constructionist Research, 12 Appreciative Inquiry, 13 Community Based Participatory Research, 14 and other approaches where inquiry and intervention are viewed as inseparable and co-produced between researchers and participants. 7

8 Relational research has roots in diverse disciplines including social construction, certain areas of public health, critical theory and other fields sharing an emphasis on engagement, giving voice, 15 emergence, and social and organizational transformation. A hallmark of relational research is legitimacy of research designs intended to catalyze as well as inform transformational change. This is quite different from maintaining objective distance in diagnostic research; and is related to but extends beyond efforts to understand and describe experiences with contextual sensitivity in interpretive research. McNamee and Hosking emphasize that relational research focuses on transformation mediated through linkages between meaning and interactions in local contexts. 12 Relational research starts with an assumption that meaning is produced by what people do together. Researchers ask, How are we coming to this particular understanding, and what are we doing together that generates this meaning? The emphasis is on how interactions unfold and meaning shifts in evolving relationships, and how new possibilities arise as this happens. 8

9 The primary vehicle for relational research is collaborative inquiry. The nature of the research inquiry is intentionally participatory and generative, and is understood as being continuously reshaped through cycles of action and reflection between researchers and participants, i.e., taking on new meaning and new forms as ongoing interactions unfold. For these reasons, relational research moves with the emergent rather than adhering to a predetermined protocol. Whereas diagnostic researchers stand apart from what they are studying and interpretive researchers stand with participants in varied contexts, relational researchers change with others through participatory engagement, learning together and creating new possibilities as coparticipants in evolving local relationships. Rigor in relational research is achieved when researchers and participants agree they have engaged in respectful, generative activities as co-researchers. Respect and generativity are considered part of the work, which means that creating the contexts within which relational research takes place requires attention to how participants are invited into the research activity. What is important is the local utility of the research, and how new meaning and capabilities are achieved as relational accomplishments. Relational researchers do not expect that experiences in a particular local context can be generalized. Relational research is about becoming or accomplishing something new together in a specific context. What is generalisable is growing awareness, stories, and experiences that invite others to recognize and explore how relational co-inquiry can generate new meaning, new actions, and new possibilities in the unique contexts in which they unfold. 16, 10, 11 Case in Point [Box]. Although not conceived of as a relational research study, reports show that the Keystone ICU Project was implemented in ways closely aligned with relational 9

10 premises. Notice how researchers and participants engaged together to implement the study; and how perspectives, meanings, actions, and relationships evolved over time, expanding what was possible in the local environments. Understanding Approaches across Research Worlds Each research world is coherent and has well developed standards of rigor when viewed within world--yet may seem inconsistent and puzzling when viewed across worlds from the perspective of one world looking out at another. This consistency/ inconsistency is illustrated in Table 1 which summarizes the research worlds. 10

11 Table 1. Understanding Consistency and Inconsistency across Research Worlds Note first the consistency with each world by reading down each column. Each world is internally consistent and coherent within a certain philosophical framework. Then, note the differences between worlds by reading across each row. A trajectory is apparent moving left to right; from a stable diagnostic research world of cause and effect, to a dynamic interpretive research world of contextualized experience, to an intentionally generative relational research world supporting the intentional co-creation of new possibilities. 11

12 Potential for Misunderstanding Confusion occurs when standards and expectations from one research world are applied to another. Evaluating one world by the criteria of another world creates an unnecessary sense of lower quality work. It is important and necessary to evaluate research by the criteria of the research world in which it was generated, and to appreciate that purposes, conventions and criteria for rigor are different for each world. Take a moment to locate your own beliefs and approach to research using this table. As researchers interested in collaborative practice with active engagement of patients and families, the authors research approach has steadily shifted toward the relational research world. The more we utilize and understand these approaches the more we appreciate their usefulness for inquiry addressing the kinds of challenges that health care faces. The relational approaches themselves match the kind of new practice that we are attempting to create, with participation and active engagement of patients and families as co-producers of care. Yet the more our research moves in this direction, the harder it becomes to describe our work in ways that are meaningful for colleagues who approach research from other perspectives, especially from a diagnostic perspective. This is true at many levels, from what is taught to students about evidence, to funding available, peer support, IRB oversight, and likelihood of publication. Conclusion The larger universe of health care research can benefit if all three research worlds are understood as unique, rigorous and valuable in their own ways; and as complementary. For many years a divide has existed between quantitative and qualitative research in health care. Increasing understanding and growing acceptance of qualitative research has occurred as 12

13 health professions such as nursing have assumed a more equal place in health care and as the benefits of qualitative approaches have become evident. 17 This progress and the emergence of relational research makes it possible to restructure this classical debate. Rather than attempting to position qualitative research in relation to standards and conventions of quantitative research, it is useful to consider qualitative research for what it is, part of the interpretive research world; a unique perspective complete in its own right and drawing from different core philosophies and methods. The emerging relational research world takes these distinctions and special capabilities even farther. From within worlds these differences are confusing, but viewed across worlds the legitimacy and importance of each world can be appreciated and the value of each research world for health care at this transformational moment is increasingly evident. Many of the challenges health care faces will benefit from, in fact may require, the kinds of research made possible by these approaches. When all three research worlds are considered together, the relative position of each research world shifts. The diagnostic research world remains important, but its central position as a gold standard is less necessary. The interpretive research world is recognized as a coherent body of independent scholarship distinct from diagnostic research--a more profound departure than at first it may have seemed. And a trajectory of transformation, a true paradigm shift inclusive of interpretive and moving toward relational research, seems apparent and useful. We believe the richness and benefits of working across research worlds will increasingly be recognized. The comprehensive context of each research world, which often now constrains efforts to work outside of accepted norms and creates barriers to be navigated, can be utilized instead to promote and catalyze inter-world interactions. Changes could include commitments by journals to invite and publish inter-world research, commitments by funding entities to solicit 13

14 and provide resources for inter-world research, and support for and recognition of the significance of inter-world research by professional organizations. Many of the challenges facing health care involve complexities of human interactions, meaning, and transformation rather than the predictability of natural phenomena. Approaches to research are needed that specifically allow inquiry in these dimensions of health care. In the same way that collaborative practice is opening new possibilities for clinical care, and interprofessional education is reshaping what and how students think and learn together, inter-world research is poised to generate transformational understandings of health and health care and how these can be intentionally achieved in complex human systems. References [1] Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: Social science matters. PLoS Medicine. 2011;8(8). [2] Neuman WL. Social research methods: Qualitative and quantitative approaches. 5th ed. Boston: Allyn & Bacon [3] Pronovost P, Needham DM, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006; December;355(26): [4] Turner JH. In defense of positivism. Sociological Theory. 1985;3(2): [5] Lopez KA, Willis DG. Descriptive versus interpretive phenomenology: Their contributions to nursing knowledge. Qualitative Health Research. 2004;14(726). [6] Ricoeur P. Interpretation theory: Discourse and the surplus of meaning. Fort Worth, Texas: Texas Christian University Press

15 [7] Rolfe G. Validity, trustworthiness and rigour: quality and the idea of qualitative research. Journal of Advanced Nursing. 2006;53(3): [8] Davies D, Dodd J. Qualitative research and the question of rigor. Qualitative Health Research. 2002;12:279. [9] Thomas DR. A general inductive approach for qualitative data analysis. New Zealand: University of Auckland School of Population Health [10] Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost P. The art of medicine: Reality check for checklists. The Lancet. 2009;374(9688): [11] Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost P. Explaining Michigan: Developing an ex post theory of a quality improvement program. The Milbank Quarterly. 2011;89(2): [12] McNamee S, Hosking DM. Research and Social Change: A Relational Constructionist Approach: Routledge [13] Cooperrider DL. Appreciative Inquiry: Towards a methodology for understanding and enhancing organizational innovation: Case Western Reserve University; [14] Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity American Journal of Public Health. 2010;100(S1):S40-S6. [15] Lather P. Against empathy, voice and authenticity. In: Jackson AY, Mazzei LA, eds. Voice in qualitative inquiry: Challenging conventional, interpretive, and critical conceptions in qualitative research. London: Routledge 2009: [16] Gawande A. The Checklist. New Yorker. December 10, [17] Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: Social science matters. PLoS Medicine. 2011;8(8). 15

16 Contributors and Sources W. Ellen Raboin, PhD, is a researcher and consultant with special interest in collaborative practices in health care. She conducted literature reviews, contributed central ideas including the concept of research worlds, made final decisions about content, provided writing and coedited the manuscript and revision. Paul N. Uhlig, MD, is a cardiothoracic surgeon and researcher with a special interest in interprofessional practice with active participation of patients and families in care. He received a King James IV professorship from the Royal College of Surgeons of Edinburgh in patient safety. He contributed much of the writing, helped develop central concepts, co-edited, and revised the manuscript. Sheila McNamee, PhD, professor of communication at University of New Hampshire, is a scholar practitioner with special interest in relational constructionist research. She contributed guiding concepts and special expertise about relational research. She helped to review and coedit the manuscript and revision. Sources used to prepare the paper include cited references and the authors experiences as practitioner-researchers. W. Ellen Raboin is guarantor for the paper. No Competing interests All authors have completed the Unified Competing Interest form at and declare: 16

17 The authors received reimbursement from non-profit organizations as declared in their disclosure forms to attend the 2012 International Meeting for Simulation in Healthcare where they co-presented a workshop related to development of the manuscript ; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. Copyright The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors. Contact Ellen at ellen@carequestconsulting.com 17