Supplement

Qualitative Perspectives in Translational

Research
Toni Tripp-Reimer, RN, PhD, FAAN, Bradley Doebbeling, MD, MS

ABSTRACT
The rapid uptake of qualitative approaches in translational research can be best understood in the
context of recent innovations in health services research, as well as an overarching concern with improving
the quality of health care. Qualitative approaches highlight the human dimension in health care by
foregrounding the perceptions, experiences, and behaviors of both consumers and providers of care.
As such, these methods are particularly useful for addressing the complex issues related to improving
health care quality and implementing system change. This overview traces a brief history of the factors
contributing to the recent and rapid growth of qualitative methods in health research in general and
translational research in particular; describes the varieties of qualitative approaches employed in this
research; and illustrates the utility of these approaches for variable identification, instrument development,
description/explanation of patient/provider perceptions and behaviors, individual/organizational change,
and theory refinement.
Worldviews on Evidence-Based Nursing 2004; 1(S1):S65S72. Copyright 2004 Sigma Theta Tau International

qualitative methods, naturalistic inquiry, qualitative synthesis, translational research, evidencebased practice, patient experience, provider behavior, theory construction, Cochrane Qualitative Methods
Group

KEYWORDS

INTRODUCTION

hile qualitative approaches in research have

been increasingly recognized as providing
distinct and significant contributions in health research
for the past 40 years, they have received unprecedented
emphasis in the past 5 years. The rapid uptake of qualitative approaches in translational research can be best understood in the context of recent innovations in health services
research, as well as an overarching concern with improving the quality of health care. Qualitative approaches highlight the human dimension in health care by foregrounding

Toni Tripp-Reimer, Professor and Associate Dean for Research, The University of Iowa,
College of Nursing, Bradley Doebbeling, General Internal Medicine Professorship in
Health Services Research, Indiana University School of Medicine; Associate Director for
Health Services Research, Regenstrief Institute for Health Care; Director, Health Services
Research Service (11-H), Roudebush VA Medical Center, Indianapolis, IN 46202, USA.
Address correspondence to Toni Tripp-Reimer, Professor and Associate Dean for
Research, The Univercity of Iowa, College of Nursing, 50 Newton Road, Iowa City,
IA 52242, USA; toni-reimer@uiowa.edu
This article was presented at the U.S. Invitational Conference Advancing Quality
Care Through Translation Research, October 1314, 2003, at the University of
Iowa, Iowa City, Iowa.
Copyright 2004 Sigma Theta Tau International
1545-102X1/04

the perceptions, experiences, and behaviors of both consumers and providers of care. As such, these methods are
particularly useful for addressing the complex issues related to improving health care quality and implementing
system change. Qualitative research offers a variety of
methods for identifying what really matters to patients and
[providers], detecting obstacles to changing performance,
and explaining why improvement does or does not occur
(Pope, van Royen & Baker 2002, p. 148). This overview will
trace a brief history of the factors contributing to the recent
and rapid growth of qualitative methods in health research
in general and translation research in particular; describe
the varieties of qualitative approaches employed in this research; and illustrate the utility of these approaches for
variable identification, instrument development, description/explanation of patient/provider perceptions and behaviors, as well as individual/organizational change.

HISTORICAL OVERVIEW
Qualitative approaches in translational research need to be
understood within the broader context of the recent uptake
of qualitative methods in health services research. Qualitative approaches in health-related research were first used by

Worldviews on Evidence-Based Nursing r Third Quarter (Suppl.) 2004 S65

Qualitative Perspectives in Translational Research

anthropologists conducting ethnographies in remote culfor increased use of qualitative approaches in health
tures (Rivers 1924; Evans-Pritchard 1937). Later sociolresearch:
ogists adapted observational techniques to study aspects
r Priority Areas for National Action: Transforming
of the biomedical health system (Becker, Geer, Hughes &
Health Care Quality (Adams & Corrigan 2003)
Strauss 1961; Goffman 1961, 1963). Nursing was the first
r Leadership by Example: Coordinating Government
health discipline to identify the importance of qualitative
Roles in Improving Health Care Quality (Corrigan,
methods, legitimize them, and incorporate them into reEden & Smith 2002)
search. Over the past decade, and particularly in the past 5
r Who Will Keep the Public Healthy? Educating Pubyears, there has been an exponential increase in the use of
lic Health Professionals for the 21st Century (Gebbie,
qualitative approaches in health services and translational
Rosenstock & Hernandez 2003)
research.
r Speaking of Health: Assessing Health CommunicaFederal, national, and international agencies and inition Strategies for Diverse Populations (Institute of
tiatives have facilitated this evolution through a variety
Medicine 2002)
of mechanisms such as conferences and reports. Two fedr Unequal Treatment: Confronting Racial and Ethnic
eral funding agencies in the United Statesthe National
Disparities in Health Care (Smedley, Stith & Nelson
Institutes of Health (NIH) and Agency for Health Re2003)
search and Quality (AHRQ)have promoted qualitative
r Crossing the Quality Chasm: A New Health System for
approaches through a series of developmental/training conthe 21st Century (Institute of Medicine 2001)
ferences and calls for applications. In 1998, the Agency for
r Promoting Health: Intervention Strategies from Social
Health Care Policy and Research (now AHRQ) and The
and Behavioral Research (Smedley & Syme 2000)
Robert Wood Johnson Foundation co-sponsored a groundbreaking conference titled Qualitative Methods in Health
The British-based International Cochrane CollaboraServices Research in Rockville, Maryland, with 78 intion prepares, maintains, and disseminates systematic revited participants from health services research and social
views. In 2001, the Qualitative Methods Group was ofscience (http://www.ahcpr.gov/about/cods/codsqual.htm).
ficially registered as an active component of the overall
These proceedings were subsequently published in the
Cochrane Collaboration in partnership with the Campjournal Health Services Research (Devers, Sofaer & Rundall
bell Process Implementation Methods Group. The goals
1999). In 1999, a workshop of social scientists organized by
of the Cochrane Qualitative Methods Group are to
the National Institute for Mental Health and the National
(a) demonstrate the value of qualitative research through
Institute on Alcohol Abuse and Alcoholism resulted in the
systematic reviews, (b) disseminate methodological stanguide Qualitative Methods in Health Research: Opportudards to aid the evaluation of qualitative research,
nities and Considerations in Application and Review for
(c) promote the synthesis and integration of qualitainvestigators using qualitative approaches http://obssr.od.
tive research within the broader literature syntheses, and
nih.gov/Publications/Qualitative.PDF. Shortly thereafter,
(d) provide some training in qualitative methods synin 2002, NIH sponsored the conference Using Qualithesis: (http://www.lancs.ac.uk/depts/ihr/research/public
tative Methods to Promote Self-Care in Diverse Popu/cochrane.htm).
lations (http://obssr.od.nih.gov/Conf Wkshp/Adherence
This recent and rapidly increasing attention and activity
/Qualitative Methods.htm). A final example is the 2004
have been triggered by several sources including increasing
NIH conference The Design and Conduct of Qualitative
health care costs, increasing health disparities, unexplained
and Mixed-Method Research sponsored by the Office of
practice variation, the increased role of the consumer voice,
the Director, Office of Behavioral and Social Science Rethe complexity of clinical decision making, and the recogsearch (http://obssr.od.nih.gov/conf wkshp/sw/).
nition that practice changes are not driven solely by sciPublications in health literature reflect these developentific knowledge (Jones 1995; Popay, Rogers & Williams
ments. While nursing science journals have published
1998; Shortell 1999; Pope, van Royen & Baker 2002). For
qualitative studies since the 1952 inaugural issue of Nursexample, the recent, but dramatic, emergence of patienting Research, medical and health research journals have
centered initiatives, such as the Picker/Commonwealth
only more recently incorporated such studies. In the
Program for Patient-Centered Care approach, mandate atpast decade, a series of editorials in prominent meditention be given to topics such as respect for patient values,
cal journals, particularly the British Journal of Medicine
preferences, and needs that are best identified and underand to a lesser extent the Journal of the American Medistood through qualitative approaches.
cal Association, have highlighted the importance of qualShortell (1999) views the growing role of qualitative apitative approaches. Similarly, the National Institute of
proaches in translation research as reflecting the need for a
Medicine issued a series of reports specifically calling
more in depth (sic) understanding of naturalistic settings,
r
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Qualitative Perspectives in Translational Research

the importance of understanding context, and the complexity of implementing social change (p. 1083). Correspondingly, the greater appreciation of qualitative methods
can be traced to the growing recognition that many health
problems and processes of care do not fit easily into experimental research designs (Popay, Rogers & Williams 1998,
p. 341).

NATURE OF QUALITATIVE APPROACHES

While in a literal sense, qualitative methods include all
modes of inquiry that do not use statistical methods; the
term is actually a misnomer. The terms qualitative and
quantitative actually refer to forms of data, not to forms of
design. More accurately, qualitative and quantitative data
are generally collected through naturalistic and positivistic designs, respectively. Further, both forms of data come
from empirical sources.
Naturalistic inquiry encompasses a wide array of both
primary and secondary research modes, which differ in
their depth of focus and degree of interpretation. Primary
modes have greater depth and interpretative level and are
represented most commonly by ethnography, grounded
theory, and phenomenology, but also include ethology,
ethnomethodology, hermeneutics, oral/life histories, discourse analysis, and critical and historical approaches to
inquiry. Each primary tradition has a distinct set of foundational philosophical and theoretical orientations, strategies for data collection and analysis, and forms of research
products. Secondary modes of naturalistic inquiry generally elicit more superficial-level data for categoric (descriptive rather than interpretive) analysis; common types include focus groups, critical incident technique, case study
methodology, ethnoscience, and open, free-text responses.
The selection of a particular naturalistic approach depends on the purpose of the research. For example, phenomenology is the method of choice when the purpose is to
understand the meaning of the lived experience of a given
phenomenon for informants; grounded theory is selected
to uncover/understand basic social processes; and ethnography is selected to understand patterns and/or processes
grounded in culture.
In most forms of naturalistic inquiry, investigators typically use one or a combination of strategies including
participant observation, informant interviews, and document analysis. However, the extent to which the investigator relies on any one strategy will vary; for example,
phenomenology relies primarily on informant interviews,
ethnography has a more even balance between participant
observation and interviewing, and ethology relies primarily
on observations (Tripp-Reimer & Kelley 1998).
In summary, naturalistic inquiry most commonly occurs
in field settings with investigators collecting data through

participant observation and unstructured interviews, and

analyzing data through thematic content analysis.

USES OF QUALITATIVE APPROACHES

IN HEALTH RESEARCH
Qualitative approaches may be employed for a wide variety of purposes related to health services and translational research. Five specific topics are addressed below
ranging from variable identification to instrumentation, description/understanding of lay and provider behaviors, theory construction/refinement, and synthesis for developing
practice guidelines.
Variable Identification
At the most foundational level, qualitative approaches are
often used to clarify concepts and constructs, and to order them vertically and horizontally in the form of taxonomies. These standardized languages and classification
systems commonly form the basis for effective research using large datasets. Two nursing standardized languages, the
Nursing Interventions Classification (NIC; Dochterman &
Bulechek 2004) and the Nursing Outcomes Classification
(NOC; Moorhead, Johnson & Maas 2004) were developed
at the University of Iowa using the ethnoscience approach.
Further, Kuzel et al. (2003) demonstrated the utility of this
approach for constructing typologies of errors experienced
by patients and contrasting them with that of physicians;
they found that most technical definitions fail to capture
many types of errors of greatest concern to patients.
Instrumentation
Qualitative approaches are often used to develop or refine
data collection instruments. Prior to instrument construction, interviews (either individual or group) are commonly
used to establish content domains and generate specific
items. After instrument construction, these same methods,
as well as formal cognitive interviews, may be used to assess the adequacy of the instruments or to understand response difficulties and variations. For example, while qualitative approaches were used in the initial development of
the Picker (adapted from the Picker-Commonwealth Survey of Patient-Centered Care) and Consumer Assessment
of Health Plans Survey (Adult) (CAHPS 2.0) instruments,
they were also employed in later evaluations of their suitability for different populations. Ngo-Metzger et al. (2003)
identified important aspects of the quality of care for Chinese and Vietnamese immigrants not included in these instruments. Important missing domains in the Picker and
CAHPS instruments included (a) provider respect for traditional health beliefs and practices, (b) access to professional

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Qualitative Perspectives in Translational Research

interpreters (and quality of interpreters), and (c) assistance

in obtaining social services.
Description/Understanding Phenomena
Perhaps the most frequent use of qualitative approaches is
for understanding the phenomena that are context dependent. Broad domains include understanding patient and
provider perceptions and behaviors, as well as the process
of individual and organizational change.
Patient Experiences and Behaviors
Hundreds of qualitative studies have been conducted to
describe and understand patient experiences, preferences,
needs, and satisfaction. Projects have described what it is
like to live with a specific illness such as headache (Peters,
Abu-Saad, Vydelingum & Murphy 2002) or cystic fibrosis (Gjengedal, Rustoen, Wahl & Hanestad 2003); how the
context of care affects experiences such as dying (Murray, Grant, Grant & Kendall 2003) or self-reliance with
sickle cell disease (Maxwell, Streetly & Bevan 1999); how
perceived needs (Detaille, Haafkens & van Dijk 2003) or
quality-of-care domains (Curtis et al. 2002) differ across
different groups of chronically ill patients. Evans (2002,
p. 290) points out how these studies provide a strategy to
give consumers a voice in clinical decision making through
documenting their experiences, preferences, and priorities.
Studies of patient behaviors have provided important
insights regarding the basis for specific patient behaviors
including patterns of service utilization (Kelly & Groff
2000), the logic of noncompliance (Trostle 1997), and variation in triggers and barriers to change for various healthrelated behaviors (Currie, Amos & Hung 1991). Power
(2002) points out how qualitative approaches have demonstrated utility in areas where the social phenomena may be
highly personal, sensitive, and sometimes illicit, as with
much of HIV/AIDS research where these methods have
greatly increased our understanding of cultural influences
on lifestyles, risk negotiation around sex and drug injecting, and health or identity disclosures.

2002) or antibiotic use (Walker, McGeer, Simor,

Armstrong-Evans & Loeb 2000; Radyowijati & Haak
2003). These have clear implications for planning interventions to alter provider behavior in translational research.
Changing Provider Behavior and Health Systems
A number of studies have investigated the phenomena of
practice change, particularly noting barriers to change.
Many barriers are based on providers perceptions of patient views, preferences, or characteristics. Patients views
of their own illness may affect their compliance (Green &
Britten 1998) or their preferences for treatment. For example, an investigation of unnecessary antibiotic prescribing indicated that providers actions relied more heavily
on their views of patient preferences for antibiotics than
on their own knowledge of scientific recommendations
(Butler, Rollnick, Pill, Maggs-Rapport & Stott 1998); they
suggested that greater practice change would result from
interventions targeting clinical interactions rather than
education. Patient characteristics also may influence application of practice guidelines. An investigation of low
adherence to hypertension practice protocols for geriatric patients found that providers viewed their patients
other problems as more significant and were also concerned about the greater likelihood of adverse effects of
medications in elders (Cranney, Warren, Barton, Gardner
& Walley 2001).
Other studies have targeted the ways in which organizational context and professional environment affect use of
practice protocols. For example, available time and level
of expertise affected how residents obtained evidence for
clinical decision making (Montori, Tabini & Ebbert 2002).
Similarly, local provider culture was shown to create a local
consensus of practice knowledge that strongly influenced
the interpretation and weighting of new scientific evidence
(Fairhurst & Huby 1998).
A few studies have specifically focused on strategies
for guideline implementation, such as use of ward rounds
(Deshpande, Publicover, Gee & Khan 2003). Other approaches have examined how different groups of stakeholders vary in their uptake of practice guidelines. Allery,
Owen, and Robling (1997) used critical incident technique
to explore how general practitioners and specialists differ in triggers and sources of evidence underlying practice changes. Using Giorgis phenomenological method,
Andersen (2002) examined important differences in barriers to implementing a medication tracking system as experienced by nurse managers and physicians.
In perhaps the most comprehensive study of barriers
and facilitators to guideline implementation, Doebbeling et
al. (2002)conducted 50 focus groups with three categories
of stakeholders (administrators, primary care providers,
and clinicians) at 20 Veterans Affairs Medical Centers in

Provider Perspectives and Behaviors

While provider behaviors have been a relatively recent focus on inquiry, this is a rapidly developing area and includes
domains related to interaction/communication, provider
behavior, and the process of clinical decision making. Studies of interaction/communication have contributed to our
understanding of the ways providers strategically establish and maintain unequal power relations (Rapp 1988)
and how the different realities of providers and patients result in miscommunication and misunderstandings (Cohen,
Tripp-Reimer, Smith, Sorofman & Lively 1994; Green &
Britten 1998; Gjengedal et al. 2003).
Several descriptive studies have investigated providerprescribing behavior related to pain management (Rogers
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Qualitative Perspectives in Translational Research

the United States. Annually, the Veterans Health Administration rolls out different clinical practice guidelines and
monitors compliance with them, making this an excellent
environment for translational science. Perceived major facilitators to guideline implementation included administrative commitment, electronic patient records, work
reorganization, and audit with feedback. Major barriers
included time and workload issues, lack of technological support, and lack of guideline credibility. Providers
(primarily physicians) and clinicians (primarily nurses)
emphasized barriers and problems with clinical practice guidelines, while administrators emphasized guideline
benefits and facilitators to implementation. The groups also
differed in the major concerns expressed: Administrators
emphasized guideline compliance; providers emphasized
continuity of care; and clinicians emphasized benefits for
patients (Doebbeling et al. 2002; Sorofman et al. 2002;
Vaughn et al. 2002; Lyons et al. 2003). Taken as a whole,
these studies illustrate that implementing effective organizational change requires attention to the issues of each key
stakeholder group.

of naturalistic studies into synthesized evidence reports

(e.g., clinical practice guidelines). In Britain, the National Health Service Center for Reviews and Dissemination called for the inclusion of qualitative data in
its syntheses, and the Cochrane Qualitative Group has
been responsive to this mandate. The University of Essex established a qualitative dataset of patient responses
that is now a part of the Economic and Social Data
Services (ESDS) Qualidata that is in the public domain
(http://www.esds.ac.uk/qualidata/online); a second established resource, DIPEx, contains a large set of interviews
describing patient experiences that may be used by clinicians, instructors, or investigators (http://www.dipex.org).
The utility of qualitative data in systematic reviews can
be demonstrated through a delineation of the several roles
it can play including (a) clarifying the focus of the review;
(b) identifying the relevant types of participants, interventions, and outcomes; (c) providing data for a qualitative
synthesis; (d) explaining unexpected findings of quantitative studies; (e) interpreting the significance and applicability of the review; and (f) suggesting both clinical and policy recommendations for implementation (Dixon-Woods,
Fitzpatrick & Roberts 2001).
Theory Construction/Refinement
Four major approaches have been proposed for the
Qualitative approaches are not only useful for generatsystematic synthesis of qualitative data. The first two
ing hypotheses, but also for theory development and reapproachesthe Case Survey Method (Yin & Heald 1975)
finement. An illustration of this point was made by the
and the Qualitative Comparative Method (Ragin 1987)
Doebbeling et al. (2002) team investigating barriers and
translate the qualitative data into numerical data, and then
facilitators to clinical practice guideline implementation
analyze those data using statistics. The two newer apin the VHA. After completing the qualitative data analysis
proaches retain the qualitative character of the data and are
from the 50 focus groups, they mapped the codes to the
termed meta-ethnography (Noblit & Hare 1988) and metaframework developed by Kitson, Harvey, and McCormack
synthesis (Sandelowski, Docherty & Emden 1997; Thorne
(1998) to depict implementation of clinical practice
et al. 2002; Finfgeld 2003; Sandelowski & Barroso 2003)
guidelines. The model by Kitson et al. contains three
and were developed by anthropologists and nurse scienmajor domains: evidence (research, clinical experience,
tists, respectively.
and patient preferences), context (culture, leadership,
Despite the recognized utility of qualitative data for synand measurement), and facilitation (characteristics, role,
thesis in practice guidelines, there are several problems
and style). Recommendations for refinement of the Kitwith the operationalization of this plan. Not the least of
son model included adding guideline characteristics to
the concerns involves difficulties in conducting literature
the evidence domain, deleting measurement from and
searches for the qualitative studies, including the frequent
adding organizational characteristics to the context douse of witty or obscure titles, lack of standardized terms
main, and adding implementation strategies/processes
in abstracts, and variation in indexing across the wide range
to the facilitation domain (Tripp-Reimer & Doebbeling
of journals (Cesario, Morin & Santa-Donato 2002; Evans
2003).
2002; Hawker, Payne, Kerr, Hardey & Powell 2002; BarIn summary, the naturalistic and qualitative approaches
roso et al. 2003). Furthermore, there is variation in evalare escalating in use and importance in all health research
uating both the quality (rigor) and the level of evidence
and are increasingly important in translational
of the results, although several recent strategies have been
put forth (Popay, Rogers & Williams 1998; Giacomini &
INTEGRATING QUALITATIVE RESEARCH
Cook 2000a, 2000b; Cesario, Morin & Santa-Donato 2002;
INTO SYNTHESIZED EVIDENCE REPORTS
Fossey, Harvey, McDermott & Davidson 2002; Hawker,
In translational research, there have been several rePayne, Kerr, Hardey & Powell 2002). While there is yet
cent, but highly significant, events and activities prono consensus regarding the best approach for qualitative
moting and facilitating the incorporation of the results
data synthesis, the Cochrane Qualitative Group is making
Worldviews on Evidence-Based Nursing r Third Quarter (Suppl.) 2004 S69

Qualitative Perspectives in Translational Research

excellent progress in formulating such recommendations,

as are individual scientists such as Greenhalgh (2002).

SUMMARY
The unprecedented proliferation of qualitative research in
health sciences can be attributed to an increased emphasis on the components of quality of care and a mandate
to ensure that health care decisions are made on the best
available evidence. In the context of health research in
general, and translational research in particular, qualitative approaches are making distinct and important contributions through the illuminating and explanatory power
of these forms of evidence.
Acknowledgments
This research was supported in part by the National Institutes of Health grant P30 NR03979 awarded to Dr. TrippReimer and by the Department of Veterans Affairs, Veterans
Health Administration, Health Services Research and Development Service, Quality Enhancement Research Initiative (QUERI), Investigator Initiated Research Grants CPI
99-126 and CPI 01-141, awarded to Dr. Doebbeling.

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