Qualitative research in evidence-based rehabilitation.

Hammell KW, Carpenter C, eds. Philadelphia, PA 19106, Churchill Livingstone Inc, 2004, paperback, 148 pp, illus, ISBN 0-443-07231-0, $32.95.

This book is an excellent resource for physical therapists and occupational therapists who want to learn about the use of qualitative methods for clinical research and how to derive evidence for guiding clinical practice through the use of qualitative research. All the contributing authors emphasize that their research questions led them to select qualitative methods, and they describe why a quantitative approach would have been inappropriate to address their questions. Many of the authors demonstrate the effectiveness of qualitative approaches in promoting evidence-based, client-centered practice. Each contributing author demonstrates the efficacy and necessity of using qualitative methods, and provides readers with unique approaches used to address a variety of areas of inquiry. Each chapter describes a different research project and includes the research question (or questions), a rationale for using a qualitative method, description of the method, study findings, and their relevance to practice.

In Chapter 2, Hammell examines quality of life following high spinal cord injury and makes a strong case for conducting life histories to set the stage for a biographical orientation to rehabilitation. According to Hammell, our evidence needs to include this type of data to inform our interventions so that they are "meaningful, useful, and relevant to the individuals (clients) in the context of their environment, and are focused on fostering control and a view of the self as able and competent."

Melinda Suto, a contributing author, used an ethnographic approach and semi-structured interviews in chapter 3 to address the role of leisure for women who immigrate to Canada in the contexts of sex, race, and class relations. Her findings illustrate the importance of seeking evidence from clients to determine what they regard as leisure. A client's activities may appear to be leisure, such as TV viewing, when in fact it is a person's way to learn a new language. We must gain insight from those we serve and not impose our views or personal experiences of leisure. According to Hammell, this evidence also is critical for building theory in our practices; that is to say, we build theory when we systematically collect data from our clients and consider the data from the context of the client's perspective or frame of reference, instead of our own.

In chapter 4, another contributing author, Mary Law, described the use of participatory research to identify environmental factors that affect the daily activities of children with physical disabilities. I found this chapter to be of particular interest. She showed how involving parents as integral members of the research team result in evidence that is relevant and more readily incorporated into practice. In this study, parents established policy recommendations for the community, schools, and recreational programs. The findings revealed that limitations in physical environments, though prevalent, were not the major environmental barriers for children with disabilities.

Christine Carpenter, in chapter 5, used qualitative focus groups to evaluate a spinal cord injury advocacy organization. Few studies, in my experience, have used focus groups as a qualitative method. She outlined focus group research design and identified issues that researchers using this design should address. Of particular interest was the author's focus on ethical issues related to recruitment of participants, the relationship of the researcher with contracting organizations, and the accountability of the researcher to participants.

Deborah Corring, in chapter 6, explored clients' definitions of client-centered care and their quality-of-life issues. The term "client-centered care" has been used for more than 20 years, but has not been defined from the perspective of the client. Focus groups composed of clients with mental illness were used to define this concept. In my opinion, this clarity is required to engage in evidence-based practice.

In chapter 7, contributing authors Schachter, Teran, and Stalker used grounded theory and action research to develop guidelines for sensitive practice for women who have been sexually abused as a child. Interviews were conducted with the women to form a substantive theory that emerged from their experiences and their suggestions for sensitive practice. The inclusionary and participatory processes used to translate findings from interviews into a Handbook on Sensitive Practice was of particular interest to me. The written and verbal feedback from women who are survivors of childhood sexual abuse, women who had not been interviewed, other health care professionals, and related agencies on drafts of the Handbook was a novel approach and worthy of duplication.

Karen Rebeiro used a variety of qualitative methods in a series of studies in chapter 8 to glean evidence to support the use and applications of occupation as a therapy in mental health. She used a combination of in-depth interviews, participant observation, and observation to work with a women's group. She conducted a single case study and used in-depth interviews and nonparticipant observations to study voluntarism as occupation. In a third study, she studied the mental health system from contexts of mental health consumers.

She engaged in participant observation, conducted in-depth interviews, surveyed community health programs, and reviewed documents. The studies are excellent examples of the use of multi-pronged qualitative methods to obtain evidence regarding the practice of occupational therapy in mental health.

In chapter 9, Gwyer and colleagues used a multiple case study approach to describe expert clinicians and their practices. The case studies were conducted by the use of nonparticipant observations, in-depth interviews, videotapes of patient evaluations and treatment sessions, and a review of documents such as patient records and patient teaching materials. The professional development interview guide and debriefing interviews of videotapes were unique elements of this research. They provide an excellent description of how they addressed reliability (dependability) and validity (credibility).

Lastly, Curtin and Jaramozovic explored the perceptions of occupational therapists in southern England about evidence-based practice. They provide an excellent description of the use of multi-triangulation. Triangulation is a means of addressing reliability and validity and of capturing a holistic view of a phenomenon. They used focus groups and questionnaires to learn about views of evidence-based practice. They followed up with a free, one-day conference to discuss findings.

One cannot read this book without realizing the value of qualitative research to enable us to derive evidence to guide our practice and to develop truly client-centered practice. Our success in helping our clients achieve an optimal quality of life and in using strategies to promote compliance and self-efficacy in our patients will be achieved only if we conduct qualitative research that is relevant and meaningful to those we serve.

Beverly J Schmoll, PT, PhD, FAPTA 

Wayne State University 

Detroit, Mich

Dr Schmoll is Dean of the Eugene Applebaum College of Pharmacy and Health Science. She has written and lectured on qualitative research.