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Quantity or quality?
The aim of nursing as a profession is to deliver a high quality service based on reliable and valid research findings. As a result, there is an urgent need to address the methodological issues arising from the quantitative-qualitative debate and the nature and resolution of the perceived theory-practice gap. Billy Kelly and Ann Long examines the key issues.

Nursing research has made significant strides over the last decades. Progress has been made to advance the nursing research agenda in terms of training in research skills, research awareness among students and practitioners in addition to the production, publication and dissemination of research findings. Patently, however, there remain fundamental unanswered questions within nursing. These relate to the present status of nursing research and its future direction. A central issue is the quantitative-qualitative methodological debate, relating primarily to the issue of positivistic as opposed to interpretative approaches. This is intimately intertwined with the perceived theorypractice gap that continues to generate debate and much confusion. These questions relate directly and indirectly to wider debates about nursing theory and the knowledge base of nursing. Ultimately the degree to which there is or can be agreement will confirm the research credentials of nursing.

Methodological Debates Quantitative versus Qualitative

Historically, nursing authors tended to use the concept of paradigm to categorise and dichotomise research methods into one of two paradigms qualitative and quantitative. According to Barnum (1994) and Rolf (1994) nursing literature depicts these paradigms as mutually exclusive opposites, each encompassing a different view of reality or truth. These two main traditions of enquiry form the basis of most research activity in nursing and for many nurse researchers the paradigm of the natural sciences and quantitative methodologies remain paramount (Abdellah and Levine, 1971; Polit and Hungler 1983). However Hicks and Hennessy (1997) refer to the conspicuous profile of
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randomised controlled trials within nursing having contributed to the exalted status of the experimental method. As evidence they highlight organisations such as the Cochrane Collaboration that focuses almost exclusively on randomised controlled trials and the authors consequently argue that the overriding methodological theme of previous research reviews has been experimental. This suggests that high status, valuable research is synonymous with logical positivism. Clark (1992) argues that for nurses and other non-medical professions, this approach is not comfortable, familiar or necessarily appropriate for many of the research topics that are central to their own clinical activities. Other researchers including Melia (1982) and Duffy (1985) do not accept that investigation of the social world is possible using a positivistic approach. Porter (1993) reinforces this point suggesting that the natural science paradigm is often criticised for its transparent failure to recognise the social construction of research. Alternatively, critics of qualitative research frequently dismiss it as a soft option, methodologically inferior and lacking the scientific and statistical rigor of the experimental method. These differences create tensions within nursing around the appropriateness of different theories of knowledge and methodologies (Booth et al 1997). Guba and Lincon (1994) claim that the quantitative-qualitative debate is due in part to an incompatibility of fundamental beliefs. This debate raises essential questions over how to understand societies and social behaviour. This is a profound issue for nursing given the nature of its practice and the importance of ensuring that there is shared understanding of the nature of knowledge, theory construction and methodological appropriateness. However, this is far from the current reality within nursing research. A brief review of the nature of the thinking that underpins the assumptions of quantitative and qualitative methods within the sociological discipline is useful in considering the nature of the problem. What is the most appropriate approach to be adopted in studying the social world? The most relevant approach is, to a considerable degree, determined by ones view of the nature of social reality. The character
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of the subject under investigation obviously determines the method of investigation and this is a fundamental question that must be addressed by nursing in the context of the totality of the research endeavour. This includes the dimensions of theory construction, knowledge development and in particular a clear exposition of the philosophical considerations that underpin methodological determination. Quantitative and qualitative approaches derive from positivistic and interpretative traditions respectively. These early approaches to the study of society and social phenomena have been refined over time but the key elements that influenced the founders of sociological enquiry remain apparent and relevant. Harper and Hartman (1997) report that positivistic science had a powerful impact on early research and theory generation in nursing. It was considered to be synonymous with good science and highly valued in the discovery of medicines knowledge base. It was reasonable to assume that, in order to replicate a sound knowledge base for nursing and establish the legitimacy of nursing, the same paradigm used by medicine should be adopted. Supporters of quantitative methods believe that while there are no laws of human behaviour there are patterns of human behaviour that can be identified. This position follows from the assumption that external and objective forces operating on human beings influence profoundly human behaviour. This in turn accepts that it is self evident that human beings do have consciousness and have the capacity to think and interpret. However, it does not include the fact that people exist within a very definite set of institutions and cultures and that these have major influences on behaviour. In order to understand behaviour these external, objective forces must therefore be acknowledged and identified. Qualitative sociology does not share this perception of the determinants of social behaviour. Moreover, a growing unease began to emerge within nursing in the 1970s which articulated a recognition that positivistic approaches did not reflect nursings more holistic philosophical base (Munhall 1982). As Harper and Hartman (1997) claim: Positivistic science was seen to be limited in its capacity to illuminate information of significance to the phenomena of caring.
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Indeed Clark (1998) argues that positivistic conceptions of truth and enquiry have philosophically been widely dismissed as incompatible with nursing research. Nursing authors highlight the inadequacies to nursing of an approach that denies the importance of subjective, social, spiritual and interpretative aspects of people, their relationships and psychosomatics. Instead of an emphasis on external, objective forces qualitative researchers are concerned to stress the internal and subjective dimensions of human consciousness. Individuals are therefore thinking, reasoning creatures constantly evaluating and interpreting the world of their existence. In addition they react to that world as a consequence of interpretations made. Within this approach study is directed toward gaining insight into the subjective level of the internal processes of the human mind. Qualitative research simply could not perceive human beings as robots responding to the computer software of objective social forces over which they have no control. No more can nurses perceive patients as objects. This division over the nature of social reality and the determinants of behaviour rest at the heart of the quantitative/qualitative debate. The differing philosophical positions lead in turn to different views concerning the methods that are most appropriate to the study of the particular social phenomena under scrutiny. Quantitative researchers believe that the social world has parallels with the natural world and in order to study the social world the scientific approach provides the appropriate methodology. This positivistic approach emphasises objectivity and impartiality. Research data must be reliable, verifiable and representative in order to achieve generalisability. According to Hammersley (1993) there are probably few social researchers today who would call themselves positivists, but the influence of positivism persists. It certainly does in quantitative research which adopts a reductionist approach. Quantitative research is also deterministic, seeking cause and effect relationships as exemplified in experimental research. Quantitative research may also be deductive as in the use of hypothesis testing. Within the context of nursing it is worth emphasising that quantitative research adopts a modified form of
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empiricism for the quantification of data. In this regard survey research continues to make a significant contribution to the study of nursing. It is capable of not just description but also of hypothesis testing. Qualitative research with its different worldview rejects the positivistic stance and the methodological approaches adopted by quantitative researchers. Where the subject matter is human beings rather than, for example, the study of chemistry or physics, it is essential for the researcher to get close to the subject of study in order to achieve an understanding of behaviour. This is achieved essentially through the approaches of phenomenology, ethnography and grounded theory, which focus on subjectivity and on eliminating the distance between the subject and researcher. The aim is to discover meaning and to promote understanding. The natural scientific approach is simply unable to achieve this and is therefore inappropriate in the context of much nursing research. While quantitative research emphasises hard data which is capable of re-testing, qualitative approaches stress the importance of quality data that provides insights into the interpretations and motivations, which underpin human behaviour. Hard data is viewed by the qualitative school as superficial since what goes on in peoples minds is not quantifiable. Many quantitative researchers seize on this point as evidence of the absence of reliability in qualitative studies and the consequent lack of verification together with absence of the potential to generalise the results of such enquiry. But for qualitative research the data, while not quantifiable, is nonetheless very valid data. Proponents of quantitative methods would also challenge the data emanating from unstructured interviews, participant observation and ethnographic approaches claiming that the methods are unscientific. Moreover, the researchers values are perceived to be very much part of the unscientific process because they must interpret the phenomena under scrutiny. In addition, because of the frequently small-scale nature of qualitative studies it is argued that they are unrepresentative and cannot be replicated. Qualitative researchers do not however see these issues as important since it is not their aim to pursue replication of studies, nor their objective that there should be generalisability of the
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research design. Within the nucleus of this debate there is little doubt that an understanding of meaning is important in the study of nursing practice. So too is the need to emphasise the importance of the biological and cultural dimensions of illness as well as its management by patients and carers (Radley 1993). Harper and Hartman (1997) suggest that there is an increased understanding of the meaning of life and death issues such as illness, loss and disability and this new found knowledge owes much to interpretative studies carried out for example in the sociology of health and illness. Hicks and Hennessy (1997), accept that the experimental method is appropriate to use in given circumstances. However, they also emphasise the need for methodological choice being fit for its purpose and assert that hitherto experimentation has reigned supreme. The authors conclude by claiming that the time is ripe for the qualitative paradigm to receive its due recognition. This is not only because of the special nature of the information it can offer health care, but also because of its goodness of fit for both nursing research and the underlying ideology of the profession. Clearly tension remains regarding the debate on the appropriateness of methodological approaches and the continuation of the argument has the potential to limit the value and credibility of nursing research legitimacy. Indeed it is argued that an over emphasis on quantitative approaches has more to do with the desire of the nursing profession to be accepted within the mainstream of medical research culture. However, this stance is counter productive as it weakens the position of nursing within the wider research arena (Hicks and Hennessy 1997). It also imperils the unique professional identity of nursing and the special contribution nursing research can make in improving patient/client care. In an effort to move the debate forward and advance the case of nursing research Clark (1998) claims that the concepts of positivism and confrontation should be replaced with post-positivism and reconciliation. He suggests that post-positivism research need not exclude either qualitative (i.e. non-numerical) data or truths found outside the quantitative method. Acceptance of this is crucial to
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rejecting the strict dichotomy often drawn between the qualitative and quantitative paradigms. Examination of this discourse implies that nursing research studies in both traditional qualitative and quantitative camps have been consistently notorious for lack of articulation about their philosophical underpinnings. This assumes that many researchers are committed to a methodological approach for reasons other than a clear understanding of the philosophical issues involved or, because of a lack of awareness of the implications of post-positive philosophy for nursing research. However as an example of the reality of postpositivism, Clark (1998) points to the triangulation of qualitative and quantitative methods in the same research studies. He argues that this movement is an indication of tacit acceptance of post-positivism philosophy. In addition, it acknowledges that are diverse truths that can be viewed through the lenses of either qualitative or quantitative approaches or a combination of both approaches. Hence there is recognition that truth can be reached through different forms of enquiry. The ultimate result of adopting this mind-set would result in valuing each approach for the contribution they make to the development of nursing knowledge and practice. Synthesis of this debate demonstrates that the empirical methods of quantitative research and those of the qualitative approach are not as diametrically opposed as is frequently suggested.

The theory-practice gap

Mulhall (1997) claims that research based practices have been extolled within nursing in the UK since the 1960s. More recently strong political and professional emphasis has been placed on establishing evidencebased practice among all health care professionals. In the past health care practices were associated with ritualistic traditions, precedent and a resistance to change within a conservative culture. Current ideology is more concerned with co-operation, accountability, cost effectiveness, efficiency, audit and values for money. Past methods used for the delivery of nursing care can, therefore, no longer be justified. This has led to the development of a research-based or evidence-based health care culture. If this proposition is true then a marriage should be
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arranged between research and practice wherein the often-perceived gap between theory and practice might disappear or at least become blurred. The reality is somewhat different. Both cultures remain estranged therefore, a theory-practice gap continues to form the bedrock of a significant problem for nursing generally and for nursing research in particular. For example Porter and Ryan (1996) used a case study approach to investigate if the documentation relating to the nursing process that was embraced within a specified model of nursing was operationalised in the practical care observed. They concluded that there was a large gap between contemporary nursing theory concerning the appropriate organisation of care and the actual organisation of care. Hicks and Hennessy (1997) refer to the reality of clinical practice continuing to be ritualistic and point to a corpus of evidence suggesting that care has remained unaltered fundamentally despite the efforts of government and the professional bodies to sell the concept of evidencebased practice. By way of explanation Timpson (1996) suggests bluntly that nursing theory has a reputation for abstraction, even irrelevance, in the minds of many practitioners. These attitudes result in a less than enthusiastic commitment to research-based activities at ward level. According to Rolfe (1996) since nursings existence, the problem of the theory-practice gap is the most important and fundamental issue facing the profession. This gap remains today and it calls into question the very foundation on which nursing is based. Rolfe contends that concepts of nursing practice have changed significantly over the past 30 years. However, he also argues that nursing theory as well as the way that theory and knowledge are generated and disseminated have not kept pace with practice. It is argued that current models of nursing practice no longer fit the dominant theoretical paradigm. In contrast the hard sciences, where the theory-practice gap is scarcely perceptible, it is reasonable to assume that there is a close relationship between theory and reality. This is the axiom of the problem in nursing. A close relationship does not exist between the theories being generated and the reality of nursing practice. Here Rolfe (1996) differentiates between
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theory and reality matching at two levels the macro, statistical level and the micro, individual level. The scientific, hypothetico-deductive model of research that creates laws for physics and chemistry is of little use when describing or investigating what happens when an individual patient encounters an individual nurse! Rolfe concludes that nurses are not technicians applying laws based on scientific method. Nurses and nursing are concerned with therapeutic interventions, holistic care and relationship building rather than technical, physical care giving, task-orientated activities. Moreover, it is argued that a new conception of what nursing theory and knowledge actually are should be designed (Rolfe 1996). The practitioner is emphasised as pivotal in Rolfes proposed new nursing praxis, which is underpinned by the notion of informal knowledge and hypothetico-abductivism. It is not intended within the constraints of this paper to expand on the detail of Rolfes work. It is important however to emphasise the fundamental challenges that the theory-practice gap pose to nursing as a profession and in terms of the legitimacy of its knowledge base and research credentials. McKenna (1997) in an authoritative analysis of nursing theories and models does much to clarify the often-criticised diversity of terminology attributed to theorists and researchers by Timpson (1996), among others. McKenna examines the meaning of knowledge in relation to the theory-practice gap. He refers to the problem in terms of the rift between the know how knowledge of clinical practice and the know that knowledge with its foundation in theory and empirical research. Acknowledgement of the rift between the two is well documented by McKenna who concludes that the know how knowledge of clinical practice is perceived as less important than the know that knowledge because of the heavy impact of empiricism. Implicit in this analysis is the recognition that if theory was based upon know how knowledge (as opposed to know that knowledge) then nursing practitioners might find it more comfortable to accept the knowledge base as being more appropriate to their practice. Addressing solutions to the theory-practice gap McKenna suggests that qualitative approaches such as phenomenological approaches might encourage the
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generation of new theories based on an exploration of meaning and experience. These new theories would have their foundations in the know how knowledge used by practitioners. There is therefore considerable meeting of minds on the need to focus theory generation on the reality of practitioner experiences and also on their relationships with patients and clients. In addition there is a clear recognition of the limitations of hypothetico-deductivism in resolving the problem of the theory-practice gap. However the position adopted by government inspired reports (DoH 1989; 1993; 1995) tends to reinforce the scientific approach to nursing research together with an expectation that research is a highly professional enterprise therefore, not within the competence of all nurses. By implication this suggests that an elite of nurse researchers should be formed, which would include few if any nurse practitioners. This thinking is at odds with that outlined above. Clearly the Department of Health is advocating the development of generalisable knowledge and that this is derived mainly from the statistical model of research proposed by many social scientists, psychologists and medical researchers (Rolfe 1998). There is no doubt that while statistical research is adequate for generating theory, difficulties emerge when attempts are made to apply that theory to practice settings with individual patients (Rolfe 1996). Moreover, in todays intellectual climate of research-based practice the only way that professional judgement can compete with the technical rationality paradigm is through practitioner-based research (Rolfe 1998). The large-scale, statistically generalisable studies that the gatekeepers to the nursing profession, (research funding committees, journal review panels and the DoH) favour might well be adequate for the construction and testing of theory but they tell us little about the individualised nursing care that remains the crux of effective practice (Rolfe 1998). In striving to eliminate the theory-practice gap reality must lie in shifting the focus of research from research-based practice to practice-based research. Clearly, there exist two different cultures whereby academic
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researchers and practitioners have different foci and work under different imperatives. This axiom contributes to some of the difficulties associated with the effectiveness of evidence-based practice initiatives (Mulhall 1997). This situation must exacerbate the gap between theory and practice by virtue of the communication problems that result from the two groups literally speaking different languages. Improvement can occur however through the reformulation of the way in which researchers present and write about their work (Mulhall 1997). This presents a challenge for nurse scientists who might require to explore the way they conceive and tackle nursing problems as well as the way they report them (Mulhall 1997). This is yet a further indication of the significance of the relationship between ideological and methodological considerations and the generation of theory when addressing the reality of a theory-practice gap in nursing. Hicks and Hennessy (1997), describe this dilemma as a persisting hiatus between evidence and practice. The authors enumerate a number of issues related to the cause of the problem. The first issue cited is so basic it warrants careful consideration. It relates to a possible lack of a common understanding of the definition of research within non-medical groups such as nursing, midwifery and health visiting. It is suggested that this naivete may be a legacy of vocational rather than academic traditions. There are large numbers of professionals today who fall into this category. Only a small proportion of professionals have been educated within the academic and research orientated culture of a university. Given that nursing education has only recently been integrated with the higher education field, it will take some time to assess the degree to which this innovation will impact upon research activities ultimately diminishing the theory-practice gap. If there is a serious lack of knowledge of what research actually is, little wonder that research dissemination and practice based on research findings predominate as major problems to be overcome. In addition, nursing already suffers from information overload, a fragmented occupational role structure and considerable work pressure (Hicks and Hennessy 1997). It seem evident that any further fundamental ideological or practical changes of the sort demanded by
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the new evidence based culture must be clearly, explicitly and unequivocally laid out. Until then, two key questions remain unanswered. First, is a substantive proportion of the nursing workforce patently unclear about the nature and definition of research? Second, does this large proportion of the profession support Timpsons (1996) proposition that nursing theory is irrelevant? This argument leads us to an extremely depressive and negative scenario. However the very fact that questions such as these are even formulated provides an indication of the fundamental nature of the practice-theory gap debate and the degree to which the very foundations of nursing depend on an interrogation of the issues. The outcomes of such debates might lead to achieving an agreed ideological position.

Conclusion
Nursing research does not have the same chronological history as other science and social science disciplines. Nonetheless it has come a long way in a relatively short time and throughout its development has been active in challenging the ideological issues that have confronted it as a discipline. The debates within nursing research as outlined in this paper signal the health and confidence of nursing research. The first issue relates primarily to the interface between academic research and nursing practice and this is a reflection of the real problems confronting nursing research. The second issue relates to the continued debate and indeed to the degree of frustration that exists regarding the theoretical basis of nursing practice. The third issue relates to identifying the appropriateness of research methodologies. This debate symbolises the maturity of a profession. It demonstrates the confidence the profession has of its own intellectual capacity; its ideological diversity and its ability to investigate uncharted territories hence challenge the boundaries of research thinking and practice. The great sociological and scientific thinkers in the past adopted such strategies, often with less formality and demands for ideological purity than expected from
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current nurse researchers. Given the changes that have occurred over the last decade in the management and delivery of health care in the UK and the impact these have had on the nursing profession it is clear that nursing is undergoing yet another transition in its life journey. The social and political forces that moved these changes along have challenged the reformation lobby within the profession and placed increasing demands on the skills of practitioners. In particular a response to the demand for evidence-based practice has been required. Findings that have been produced from years of research have been considered useful at individual or local levels however the cumulative effect of the broad spectrum of research has not been easily recognisable. Limitations on the use of that research and failure to influence effectively the reality of advancing nursing practice through research have also been evident. As a consequence of nursing education being placed in a potentially rich culture of academia and research practice, there is the potential to benefit not only from the initial change but also from the multidisciplinary opportunities that exist in an academic culture. However, nursing research must be recognised for its unique contribution to the research endeavour by virtue of the quality of its practice and its intellectual contribution to the wider research community. The insular perspective adopted by nurse researchers in the past has done little to ensure its acceptance as a legitimate researchbased discipline and there is a need to break away from this narrow professional perspective. In so doing, nursing research can argue and counter-argue its debates confidently hence indicating mature responses to the changing nature of its place in health care. Other research-based disciplines are faced with ideological differences and challenges to their knowledge base. This happened as the result of acknowledging the changing nature of the generation of knowledge and theory construction in all fields of scientific endeavour. Moreover, as initiatives such as multidisciplinary research and research and development strategies advance within health care, nursing as a profession should become confident regarding its own research base. Otherwise there is a danger that it might well become subsumed
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within the more powerful medical research machine. This must not happen. Nor must nursing research engage in research and development in the NHS without a clear acceptance of equality of roles, status and funding opportunities. In the past, nursing research has been prone to accept the limitations of its research enterprise as postulated by representatives of other disciplines. Currently, however, it has achieved eminent success and advanced remarkably in the last few decades. Nursing has reached the stage where it should be confident enough to engage in initiatives with other disciplines and also formulate new thinking that will inform future research strategies within the NHS. Undoubtedly other disciplines will question the legitimacy of the role that nursing research can contribute to the wider health care research agenda. In return, however, nursing must feel free to pose the same questions to other disciplines on an equal basis. Equally important are the management and political skills needed to ensure that a market philosophy for educational services now imposed on universities is not enabled to undermine the funding arrangements for nursing research. A further issue of ethical proportions is the impact of the research assessment exercise that has the potential for determining the type and nature of research to be supported. Nursing research has an agenda that is concerned with the quality of its research as this in turn impacts on the quality of care. This agenda recognises the reality of the nature of the nursing enterprise and cannot be driven primarily by the policies and the politics of university education and government short term strategies. Nor is nursing research naive in its approach to these matters. Fundamentally it is guided by a caring ethos which takes a pivotal place when determining the best way forward to achieve acceptable outcomes that should ultimately be related to interests of quality patient care. It is now opportune for nursing to assert the vital and important role it will continue to play in ensuring the health of the nation through effective research strategies. Clearly debates will continue on issues relevant to the advancement of nursing research. Finally, it should be recognised that nursing practice is neither mechanistic nor static but a unique human enterprise best
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References

understood by nurses and nurse researchers.

Authors: Billy Kelly, MSSc, M.Research, RMN, RGN, RCNT, RNT. Ann Long, DPhil, RGN, RMN, MSc, PG Cert.Research, HV, RNT, HVT.

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