Question Number: 448

Social Science homework help Qualitative Findings And Social Work InterventionsEvidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mezzo and/or macro-levels. Kearney (2001) described ways qualitative research findings can inform practice. Qualitative findings can help social workers understand the clients’ experiences and “what it may feel like” (Kearney, 2001). Therefore, social workers can develop clinical interventions that take into account the experiences of their clients. Qualitative findings can also help social workers monitor their clients. For example, if after reading a qualitative study on how domestic violence survivors respond to stress, they can monitor for specific stress behaviors and symptoms (Kearney, 2001). In addition, they can educate their client what stress behaviors to look for and teach them specific interventions to reduce stress (Kearney, 2001). Given the increasing diversity that characterizes the landscape in the United States, social workers need to take into account culture when formulating interventions. Social workers can utilize qualitative findings to plan interventions in a culturally meaningful manner for the client.INSTRUCTIONS:To prepare for this Discussion, read (ATTACHED) Knight et al.’s (2014) study from this week’s required resources. Carefully review the findings, the photographs, and how the researchers wrote up the findings. Finally, review the specific macro-, meso-, and micro-oriented recommendations.Then read Marsigilia and Booth’s (ATTACHED) article about how to adapt interventions so that they are culturally relevant and sensitive to the population the intervention is designed for. Finally, review the chapter written by Lee et al. on conducting research in racial and ethnic minority communities. Post the following: Using one of the direct quotes and/or photos from Knight et al.’s study (ATTACHED), analyze it by drawing up a tentative meaning. Discuss how this would specifically inform one intervention recommendation you would make for social work practice with the homeless. This recommendation can be on the micro, meso, or macro level. Next, explain how you would adapt the above practice recommendation that you identified so that it is culturally sensitive and relevant for African Americans, Hispanics, or Asian immigrants. (Select only 1 group). Apply one of the cultural adaptations that Marsigilia and Booth (ATTACHED) reviewed (i.e., content adaption to include surface and/or deep culture, cognitive adaptations, affective-motivational adaptations, etc.)(pp. 424-426). Be as specific as you can, using citations and the attached reading resources to support your ideas.Focus on Research MethodsLevels and Applications ofQualitative Research EvidenceMargaret H. KearneyBoston College School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467-3812Received 8 May 2000; accepted 4 December 2000Abstract: Evaluation of qualitative ®ndings for application to nursing practice can go beyond the rigor with which the evidence was developed to thecharacteristics of the ®ndings themselves. Five categories of qualitative®ndings are described that vary in their levels of complexity and discovery:those restricted by a priori frameworks, descriptive categories, sharedpathway or meaning, depiction of experiential variation, and dense explanatory description. Four modes of clinical application of qualitative evidenceare proposedÐinsight or empathy, assessment of status or progress, anticipatory guidance, and coachingÐthat vary in their degree of visibility andpatient involvement. The greater the complexity and discovery within qualitative ®ndings, the stronger may be the potential for clinical application. ß2001 John Wiley & Sons, Inc. Res Nurs Health 24: 145±153, 2001Keywords: qualitative research; evidence-based practiceMost health care practice is based on somekind of evidence, but rarely is it based exclusivelyon outcomes of randomized controlled trials. Infact, most judgments by practitioners draw on acomplex array of formal and informal information sources, shuf¯ed and sorted based on thesalient characteristics of the situation at hand.Published research ®ndings are one formal information source, and qualitative research is animportant subset. Yet little has been written abouthow to transfer the speci®c kinds of informationproduced in qualitative research to the interactivearena of health care delivery. The goal of thisarticle is to offer for discussion two preliminaryframeworks: one for classifying and the other forusing qualitative research ®ndings.The Role of Qualitative ResearchEvidence in Nursing PracticeAlthough the use of nursing research ®ndings todirect practice decisions is as old as FlorenceNightingale's work in the Crimea, there has beena recent surge in attention to evidence-based nursing practice (Mulhall, Alexander, & le May,1998; Simpson & Knox, 1999), in which the idealis to select procedures for patient assessment andcare delivery based on experimental evidence thatone approach is better than another. Severalcautionary voices have emerged in this discussion. Although impressive bodies of researchhave been built to guide nursing approaches tocertain clinical problems, experimental evidenceto support many common nursing care concernsis patchy at best (Mitchell, 1999). The mintingof the randomized controlled trial as the goldstandard of evidence discounts other in¯uentialknowledge sources, such as colleagues, salientexperiences, and ethical and clinical judgment(Estabrooks, 1998), that nurses and others use intheir therapeutic interactions with patients.Human caring, the central landscape of muchnursing practice, is less easily quanti®ed thanare surgical procedures or pharmacological regimens (Benner & Wrubel, 1989; Mitchell, 1999).*Associate Professor.ß 2001 John Wiley & Sons, Inc. 145However, qualitative health research producesknowledge situated in the intra- and interpersonalrealm: what health and illness feels like topatients; where interpretations of health andillness experience come from; how experienceschange under a variety of interpersonal, historical, cultural, and other conditions; and howthe subtleties of human in¯uence, includingprofessional in¯uence, can propel or derail illness adjustment and recovery (Green & Britten,1998).According to Stetler (1994), utilization ofresearch ®ndings by individuals or groups canbe instrumental (concrete applications in practiceprotocols), conceptual (cognitive applicationthrough new insights and understandings ofsituations), or symbolic (use of ®ndings tolegitimate a policy or practice approach). AsSandelowski (1997), Estabrooks (1998), andothers have observed, qualitative evidence forpractice likewise can be used in instrumentalforms in clinical assessment, protocols, andpolicies but is perhaps especially well suited toconceptual uses, in which by reading qualitative®ndings nurses gain access to the experiences andobserved actions of patients and others andthereby expand their stores of theoretical understanding, which reveal more helpful approachesto care.In order to use qualitative ®ndings as evidencefor either conceptual or instrumental purposes,nurses need frameworks for evaluation and comparison of the methods and ®ndings of qualitativestudies. Much has been written on standards foradequate conduct of qualitative research (Lincoln& Guba, 1985). To defend the systematic andthorough nature of their work against quantitativeexpectations for reliability and validity, qualitative researchers have focused more on defendingthe rigor with which the research was conductedthan on the usefulness of the ®ndings themselves.Both quantitative and qualitative ®ndings areassumed worthy if achieved systematically andwithout bias. Yet qualitative ®ndings can besystematic and unbiased but less than illuminating for human learning or clinical practice in aparticular situation. The following discussionidenti®es two characteristics of qualitative ®ndingsÐcomplexity and discoveryÐthat can befound in varying degrees across methodologicalapproaches. Although exceptions certainly doexist, the current study suggests, in agreementwith others (Swanson, Durham, & Albright,1997), that the higher the levels of complexityand discovery, the greater is the potential forclinical insight and application.Degrees of Complexity and Discoveryin Qualitative FindingsThe utility of research ®ndings in speci®c situations must be based not only on their ®t with theclinical issues at hand but also on the richness andinformativeness of the ®ndings as evidence. Attheir best, qualitative ®ndings teach the readersomething about how context, history, and individuality constitute meaning and explicatehuman action in a closely observed, highlyspeci®c unique situation. Such a research reportcan be a gold mine for clinical insights. Less wellintegrated or narratively vivid presentations mayoffer less to clinicians in search of ideas forpractice.A way of characterizing the richness of information in qualitative ®ndings is in terms ofcomplexity and discovery. Complexity is de®nedhere as the substantiated linking of discrete®ndings into a multifaceted web of interactions.Components of ®ndings that may be integrated inthis way include aspects of the context of aphenomenon, such as historical, familial, economic, social, environmental, and political in¯uences, and aspects of human individuality andexperience, such as perception, meaning, emotion, action, and interaction. Discovery is de®nedas the presentation by researchers of newperspectives on or information about the humanphenomenon under study. New perspectives orinformation may be revealed, for example, inverbatim accounts that portray the experienceunder study for the ®rst time or with previouslyuncaptured richness, or in a theoretical or interpretive framing of the phenomenon that shedslight on how it came to be and what it is like.Although newness depends on the knowledge andperspective of the reader, for this purpose itconnotes a characterization of the phenomenonunder study not previously commonly describedor not accepted as known within the publicdiscourse in the discipline.The qualitative methods commonly applied bynurse researchersÐcontent analysis, phenomenology, ethnography, and grounded theoryÐproduce differing degrees of complexity whenapplied to their full potential. In general, descriptive methods, such as qualitative description (Sandelowski, 2000) and certain forms ofdescriptive phenomenology, are designed to produce a lower level of complexity, and interpretiveand theorizing methods, such as hermeneuticphenomenology and grounded theory, aim fora higher level. Nonetheless, a high degree ofdiscovery is possible with all these methods. For146 RESEARCH IN NURSING & HEALTHexample, qualitative description is intended toportray subjective experience of a phenomenonwithout complex interpretations or theoreticallinkages by the researcher, but it can achievediscovery in bringing to light fresh perspectivesfrom participants. On the other hand, a visiblycomplex ``grounded'' theory may not discovernew knowledge about a phenomenon if the theoryin fact replicates other published work on thetopic in similar samples and settings.For this discussion ®ve categories of complexity and discovery in qualitative evidence aresuggested, four of which have clinical utility (the®rst category lacks discovery and hence providesno new clinical guidance). These groupings canapply both to original work and to syntheses ofqualitative ®ndings. Although some may questionthe use of hierarchical evaluation systems asdevaluing more basic and exploratory forms ofinquiry, that is not the intention here. As suggested above, simply structured ®ndings are notinherently of lower quality than more complex®ndings, but they are descriptively different.Either may be arrived at using strong and rigorousmethods and be useful for a given clinicalsituation. Examples cited here were drawn fromseveral volumes of a convenient and reputablesource, Qualitative Health Research, in order toreduce the confusion of methodological rigorÐwell monitored by the peer reviewers of thisjournalÐwith complexity and discovery. Theintent here is to elucidate the differences instructure in ®ve types of qualitative ®ndings anddiscuss the impact of these differences when®ndings are considered as evidence for practice.Findings restricted by a priori frameworks.Findings that are produced by applying anexisting set of ideas to qualitative data withoutidentifying new insights or enriching, extending,or revising existing theory may offer a certaindegree of complexity but little discovery, andconsequently they provide little or no evidencefor practice. This restriction occurs when aresearcher has claimed to have described aphenomenon using inductive techniques, but the®ndings have been visibly constrained by adominant predetermined framework. In effect,data are collected and then ®tted to an externallyimposed model without close attention to newevidence that these data might contain.Restriction of supposedly inductive ®ndings byinappropriately applied theoretical frameworksmust be distinguished from extension and enrichment of existing theory. Indeed, Sandelowski(1993) has noted that although the role of theoryvaries across qualitative approaches, atheoreticalqualitative work is impossible and undesirable.Disciplinary and philosophical worldviews unavoidably shape the goals of research and how®ndings are interpreted by nurses, sociologists,educators, and others. If qualitative ®ndings areset loose in the research literature withoutintegration into the matrix of knowledge in the®eld, little is gained for clinical application.By contrast, discovery is aborted when aresearcher sets out to analyze data with the goalof inductive discovery, sees a resemblance to apopular theory, and abandons the inductiveprocess in favor of categorizing new data in oldbottles, so to speak. Although such reports arerarely found in major research journals thathave qualitative-methods experts on their reviewpanels, in other venues in the nursing literaturethey are more common. For example, well-knownworks on women's ``relatedness'' and ``connections'' (Gilligan, 1982; Miller & Stiver, 1997)have inspired many a reiteration of these conceptsin manuscripts and dissertations without clearsubstantiation in the data, preventing the discovery of instances where relatedness is notcentral, or other insights might be offered. Likewise, a popular concept from nursing scholarship(uncertainty, transition, coping, or the like) maybe identi®ed as the major descriptor of a phenomenon under study, but the careful reader ®ndsthat verbatim data provided in support of thisclaim reveal alternative views that have not cating that all categories of data are componentsof a central idea, but the speci®c nature of theserelationships is not detailed.A high level of discovery may be achieved indescriptive categories when a phenomenon isportrayed from a new perspective through thepresentation of vivid and informative data in aclear and helpful set of categories. In this formthe data speak for themselves. For example, ina study entitled, ``My Hurts,'' Woodgate andKristjanson (1996) categorized children's descriptions of pain, producing a comprehensive list ofpain descriptors, attributed causes, and children'sviews on good care during painful episodes.These data, logically organized, provide a vividimmersion in the children's views. In a secondexample, Engebretson (1996) analyzed observations and interviews of clients and healers whoused healing touch therapy. Experiential descriptions were categorized into physical sensations,emotional experience, and visual experience, thelabels of which were simple but whose contentwas informative. Steinberg, Davila, Collazo,Loew and Fischgrund (1997) described attitudes,perceptions, and beliefs of Hispanic familieswith deaf children and presented clinically usefulportraits of the families' views on causality, theirresponses and that of their community, ways ofcommunicating with the child, and adequacy ofservices.Discovery of previously undescribed aspects ofexperience is demonstrated in these examples,although the structure of these ®ndings is simple.This level of complexity ®ts well with initialexploratory work when the goal is to begin todescribe an experience, and it can providestimulus for future research. Descriptive categorizations can suggest the breadth of patients'worries or the scope of their learning needs,information that can have great clinical utility.They can serve as maps of previously unchartedlandscapes in human experience.Shared pathway or meaning. The third category shows an increase in complexity. Here, theinvestigator's interpretation produces a synthesisof a shared experience or process. It is distinguished from the previous grouping by theinvestigator's integration of concepts or themesinto a linked and logical portrayal. The commonality, core, or essence of the experience iscaptured by the analyst. This synthesis has thepotential to reveal something previously undescribed about the phenomenon that would notbe readily apparent in a series of unlinked categories. The increased complexity enables greaterdiscovery.Shared pathways or meanings can be seen in®ndings achieved with a variety of qualitativeapproaches. For example, in a qualitative description, data clusters are linked in a holistic pictureof the experience. In a grounded-theory study,concepts are connected in a model of in¯uencesand strategies or actions, with each relationshipsubstantiated by data. In a phenomenologicalstudy, themes are experiential components integrated into a narrative depiction of a multifacetedphenomenon. The analyst has moved from describing parts of a data set to explaining how theseare components of a larger social or experientialwhole.Examples here include Schreiber's (1996)description of women's process of recovery fromdepression. Women were shown to move throughsix phases, and the conditions for progression areclearly described. Each phase was fully ¯eshedout with evidence of its origins in the precedingphase. Bott, Cobb, Scheibmeir, and O'Connell(1997) described the salient themes in the experience of quitting smoking, including the intensity of the struggle, the personi®cation of thecigarette, the planning process and how thistime was different, and how it was necessary toreplace the old habit with a new habit as a transitional measure. Marcus (1998) portrayed a fourstage process by which women moved towardaddiction recovery in a therapeutic community,each stage entailing several kinds of work on theself, moving toward preparation for a new worldview and life role. Barroso (1997) developed fourdimensions of reconstructing one's life as a longterm survivor of AIDS, the dimensions forming a``web of meaning; if one were to pull a strandfrom the web, the whole structure is likely tocollapse'' (p. 63).Those perusing these research reports movebeyond reading the quotes to reading the analyst'sideas. The investigator's interpretation has shownhow discrete data bits come together in a meaningful whole, allowing re¯ection on the largerpicture and what it means for human experienceand health care clients.Depiction of experiential variation. An evengreater degree of qualitative complexity isachieved in ®ndings that not only describe themain pathway or essence of an experience butalso portray how that experience or pathwayvaries depending on individuality and context.Portraying or explaining variation in a humanexperience requires considerable breadth anddepth of sampling and data collection and ahigh level of analytic expertise, which can produce a high degree of discovery of new insights148 RESEARCH IN NURSING & HEALTHor perspectives on human phenomena. Althoughgrounded theories are the type of ®ndings mostcommonly thought of as portraying variation,this level of complexity can be seen in otherapproaches as well. The rich detail in a fullyrealized phenomenology or ethnography can capture a variety of viewpoints and realizations of ahuman experience and the contextual sources ofthat variety, whether political, cultural, familial,or intrapersonal.For example, in a grounded-theory studyWilson, Hutchinson, and Holzemer (1997) described how men with AIDS salvaged their qualityof life in a context of cultural, sexual, andlinguistic diversity, depicted in a multivariatemodel. For each stage of the basic psychosocialprocess, details were given on the variations inits expression and in the conditions necessaryfor progression, explaining why some movedtoward satisfactory life quality, whereas otherscould not. These ®ndings are at a higher level ofcomplexity than those of Barroso (1997), introduced above, in which family reaction to HIVwas the only variation described. Likewise, incontrast to the portrayal by Marcus (1998) of addicted women's shared pathway toward recovery,Pursley±Crotteau and Stern (1996) describedhow pregnant women recovering from cocaineaddiction might or might not move forward tocreate a new life depending on how much structure they imposed on their behavior and howmuch they desired to give up drugs and changetheir lives. The researchers diagrammed thisrelationship in a four-quadrant model. Conditional models (in which several ``variables'' varyand thereby produce different consequences) arehallmarks of this level of fully realized groundedtheory.Experiential variation also can be demonstrated in narrative descriptions such as that ofHarris (2000), a recounting of young women'sself-harmÐof ``cutting the bad out of me''Ðwhich vividly evokes the situations under whichthis painful experience worsened or was relievedand how the responses of others could in¯uenceits progression or remission. Studies of structuresand organizations also can portray and explainvariation, as exempli®ed by the analysis of King,Stewart, King, and Law (2000) of the organizational characteristics and issues affecting thelongevity of self-help groups for parents of specialneeds children. By observing six groups andspeaking with a range of parents, they were ableto identify the qualities of groups that succeededversus those that were not able to sustain themselves over time. If the answer to the researchquestion is ``It depends,'' the ®ndings havereached this level.Dense explanatory description. The ®fth andhighest level of complexity and discovery mightbe termed the qualitative gold standard. These®ndings may be seen as representing the characteristics of the ``experiential variation'' categorywhen achieved to the highest degree, but in doingso, these ®ndings appear qualitatively different.Clifford Geertz (1973) exempli®ed this level of®ndings in his de®nition of ``thick description,''but this level of explanatory detail can be seenoutside ethnography as well. These ®ndings are arich evocation of a situated understanding of amultifaceted and varied human phenomenon ina unique situation. With dense factual and descriptive detail, they portray the full depth andrange of complex in¯uences that propel personsto make one choice over another, to speak oneway versus another, and to view life one wayrather than another. Physical and social context iscolorfully conveyed, and the experience of timeis captured at the levels of social, cultural, andpolitical history as well as at the level of personalprogress. The role of the researcher in thisparticular context and interaction also is clearlyapparent.Dense explanatory description may be achievedusing a number of qualitative methods including ethnography, phenomenology, and groundedtheory. The researcher provides excursion intothe participants' evolving lives as shaped by aconstellation of historical and cultural in¯uencesas well as by the life experience of the researcher.In addition to feeling a feeling or gaining a deepgrasp of the forces leading to a decision, thereader learns previously unrevealed unique qualities of a particular set of events in a particularhistorical and cultural milieu. These ®ndingscontribute to or extend the theory, whether explicitly or by demonstration, in portraying adynamic by which a phenomenon can be framedacross situations.Most dense explanatory descriptions are booklength, and, indeed, qualitative studies realizedat this level may be portrayed less fully whenconstrained by journal format (Sandelowski,1997). In journal article form they focus on asmall piece of a highly particular experienceand illuminate it exquisitely. For example, Davisand Joakimson (1997) examined the folk illness of ``nerves'' in two different yet similarcultural contexts: ®shing villages in Norway andNewfoundland. Despite many parallels in culture,access to medical care, and social construction ofillness, the researchers demonstrated that theQUALITATIVE EVIDENCE / KEARNEY 149social milieu and social consequences of havingnerves differed greatly in these two communitiesbased on differences in the longevity and livelihood of the ®shing industry and in the strengthand cohesion of women's social networks. Theseconditions produced contrasting social views ofnerves as status or stigma, as public or private, asoriginating in the psyche or the soma, and asexpression of belonging or of alienation.In a second example Tourigny (1998) capturedthe unique cultural conditions and familial breakdown and hopelessness in a decaying inner city inthe Midwest that led to ``some new dying trick:African-American youths `choosing' HIV/AIDS''(p. 149). Physical violence, gang membership,loss of social structure and purpose, and thedemands of caretaking in families where becauseof disease or drugs the parents were unable tofunction as adults led several young people todeliberately expose themselves to HIV as a graspfor meaning and purpose in life.In a third study Wilson, Morse, and Penrod(1998) looked intensively at how caregivingrelationships were built over the course of asingle week in a summer camp for ventilatordependent children. They used photography andthorough observations, the latter of which produced ®eld notes with many action examplesalthough only a few verbatim comments. Theinvestigators recognized the unique context oftheir study, in which there was abatement of theparental contingencies resulting from illness suchas worry about the future and the rest of thefamily, thus allowing caregiving to ¯ourish ina normalized atmosphere. The progression ofphysical, verbal, and affective communicationbetween a primary professional caregiver and achild was mapped in exquisite detail. The actionsthat enabled a dyad to progress from a tentativerelationship to a connected relationship weredepicted in ®eld notes, in which the role ofthe observer in the scene as well as the context ofthe interaction was described. There was exploration of variations such as whether a particularcamper was new or returning and whether a caregiver was new or known. The ®t of this processwithin a larger body of theory-building work oncaregiving was discussed at length.Although they arose from different disciplinarycontexts and describe a range of human phenomena, the densely woven structure of these ®ndingsenabled them to have in common the discovery ofa rich fund of clinically and theoretically usefulevidence, in which layers of detail work togetherto increase understanding of human choices andresponses in particular contexts. Not all qualitative analysis achieves this level, and not allqualitative work needs to do so to meet its goals.Nonetheless, appreciation of the distinct natureof such extraordinary contributions is warranted.They provide a wealth of evidence of humanexperience that can be mined to enrich health carepractice.Applying Qualitative Evidence inHealth Care EncountersQualitative ®ndings, both complex and simple,that portray newly discovered concepts or explanations of human experience can be applieddirectly in certain clinical situations withoutintervening steps of replication or transformationinto quantitative tools. The following is an exploration of ways of using qualitative evidence inclinical encounters and of the role of complexityand discovery in this application, offered in thehope of advancing dialogue between research andpractice.Qualitative evidence can be applied in at leastfour ways of increasing degrees of visibility andpatients' involvement. Qualitative ®ndings in arange of complexity levels can serve as evidencefor practice if discovery is presentÐthat is, ifnew information about a phenomenon has beenrevealed. The higher the complexity level of thequalitative evidence, the more information can begleaned on how and when to apply it (Swansonet al., 1997). When ®ndings portray a worldviewwith great vividness and explain how differentcontexts affect a health experience, their relevance and ®t with a given situation are better ableto be judged than if given only a list of quotes orconcepts without contextual settings or insightfulinterpretation. The mode of application dependson the complexity level of the evidence; theparticularities of the patient situation, whichdetermine the ®t and utility of the evidence;and, most important, the clinician's judgmentabout what that patient needs.Insight or empathy. The simplest mode ofapplying qualitative evidence is using the information to better understand the health experience,as suggested in the conceptual mode of researchutilization referred to by Stetler (1994) andSandelowski (1997). Clinicians can learn fromqualitative ®ndings such things as what it feelslike to be in a given illness situation, the commonfactors affecting individuals as they considerhealth care options, and the different ways oflooking at a particular illness. They can use thisexperience and to offer support in a more sensitive way. This insight can be gained from anylevel of qualitative ®ndings that have quotationsor description vivid enough to evoke vicariousexperience.Using this understanding, the clinician paysattention to new cues from the patient, recognizestypical or atypical responses, makes sense ofcomments or behaviors previously consideredinconsistent, and is empowered to reach out withsupport in a more informed way than before.Simply knowing what a health experience has feltlike to a particular group of study participantscan be extremely instructive. One can keep suchevidence in mind, compare it to patients' descriptions and behaviors, and enrich one's stock ofknowledge over time without mentioning it to thepatient if the clinician judges this would not behelpful. The usual toolbox of clinical judgmentskills must be used here and in all applications inorder to gauge whether the information from astudy report really does make sense for anindividual patient in her or his stage of illnessand cultural and social context. Fittingness (Beck,1993) in a given clinical setting does not originatein the ®ndings themselves but only within theprofessional's carefully considered clinical judgment of all the evidence at hand.Assessment of status or progress. Manyqualitative ®ndings, from descriptive categoriesto higher levels of complexity, suggest a trajectory of illness experience or describe differentperspectives on a particular health condition.Formal clinical assessment tools can be developed from qualitative ®ndings and tested inlarger samples, but using qualitative ®ndings toconsider a range of possible responses or pointson a trajectory for an individual patient also isworthy of consideration. If one has read, forexample, that there may be three ways of reactingto the diagnosis of diabetes or of behaving asfathers-to-be during labor, one can use clinicalcues and skilled questions to determine the ®t of acategory to a particular client or family, with itsprobable orientation and associated responses. Inthis way a clinician gains a set of possibilitiesfor clinical exploration, problems to watch outfor, and emotions and behaviors to understand.Likewise, if it is believed there is a clinical ®t of aclient's situation with study ®ndings that includea trajectory, such as stages of recovery fromcardiac events or steps to reach adjustment after atraumatic loss, it is possible to mentally locateone's patient on that progression and based onthat comparison to make judgments as to possibleproblems with or the speed of recovery forthat patient. These observations are silent and, asalways, ®ltered among many other clinicaljudgments, but they have the potential to speedthe recognition of exemplary recovery or theknowledge of when a client is ``stuck.''Anticipatory guidance. This mode includesopen sharing of qualitative ®ndings with clients.As such, it can be considered more interventionist,yet perhaps more cautious while still empowering, in the sense the patient is brought into thediscussion of ®t and relevance of qualitative ®ndings to her or his situation. In this approachclinicians share openly with patients what qualitative ®ndings suggest that the patients may ®ndthemselves experiencing or the stages that may beahead. Patients are offered a research-basedperspective on what they may be going through,based on how other people (that is, studyparticipants) have described it. This usuallyrequires evidence at the level of shared pathwayor meaning or on higher degrees of complexity.The purpose of sharing ®ndings in a clinicaldialogue is to help clients anticipate such factorsas what resources may be needed to deal withobstacles ahead or what markers are linked tofeeling better. It also provides patients an opportunity to feel less alone in an illness experienceor, if the ®t is not apparent, to offer previouslyundisclosed but clinically relevant informationabout their own experience.Qualitative research offers much to patients inits systematic depiction of human experience. Itsscope surpasses the personal sagas of celebritiesfound in paperback bookstores or the advice ofpeers in self-help groups. Clinicians are obligedto describe the sources of qualitative healthinformation and their limitations and to serve aseditors and translators of methods and ®ndings,just as when discussing results of randomizedtrials. Nonetheless, clients deserve exposure topeer-reviewed qualitative research informationjust as they deserve access to health informationsources on the Internet and in the popular press,although they may be more limited or misleading.Coaching. In this most active mode of applying qualitative evidence, clinicians share qualitative ®ndings and advise patients of steps theymight take to reduce distress or improve adjustment based on that evidence. If qualitativeevidence has shown that diabetics were best ableto make peace with blood-sugar-control regimenswhen those prescribed regimens were adapted totheir own lifestyles, when they worked cooperatively with clinicians in a team approach, andwhen they paid attention to both biochemical andembodied signs of changes or imbalances, thenQUALITATIVE EVIDENCE / KEARNEY 151based on this evidence, one might advise selectedpatients that doing these things might make themfare better. Coaching patients based on qualitative evidence is most secure when a topic hasavailable a body of qualitative ®ndings with amoderate- to high degree of complexity. Evidencethat portrays or explains variation is invaluablehere because the higher the level of complexity ofthe qualitative evidence, the more clearly will onebe able to portray the contingencies that mayaffect outcomes and the range of possibilities inthe experience at hand.There will be no odds ratios or relative risksto offer a client in support of the recommendationÐonly the power of a diligent systematicstudy of human experience in a particular context. Although sharing qualitative ®ndings withpatients in the process of anticipatory guidanceand coaching may seem like new and treacherousterritory in the increasingly outcomes-driven practice arena, it is little different from the continualapplication of the experiential storehouse ofexemplars of former patients (and colleagues'stories about their former patients), which drivesmany clinical assessments and conclusions.Involving the patient in making a connectionwith reported health-related experiences enablesvalidation of the clinician's hunches; demonstrates to clients the privileging of subjectiveaccounts (Popay et al., 1998) like their own; andincreases the likelihood of open communication,mutual goal setting, and true collaboration.DISCUSSIONThis exploration has been intended as a ®rst steptoward continued dialogue on the role ofqualitative ®ndings in improving nursing care. Itis hoped that the concepts of complexity anddiscovery, the categories of ®ndings, and themodes of clinical application described here willsoon be expanded, revised, or challenged by otherwriters. Certainly, there are qualitative ®ndingsthat straddle levels or have qualities of more thanone level. Others who use these groupings toassess the studies cited as examples may arriveat different conclusions. In not addressing rigoror the faithful conduct of qualitative methods,this article lets stand the extant approachesto determining whether qualitative evidence iscredible. In addition, no delving has been doneinto how critics should most constructivelyrespond to the body of published work thatclaims to have reached a higher level of complexity than it actually has. Nor has this articleaddressed whether these kinds of qualitativeevidence apply to historical research, actionresearch, discourse analysis, or a number of otherqualitative approaches. Further dialogue on thesetopics is anticipated.Clinical acumen rooted in much thought andexperience is needed to use qualitative evidence(and any evidence) in practice. Barriers to clinicalapplication include mistrust of qualitative methods by practitioners and standard-setters (but notnecessarily patients); lack of time or motivationto seek out and learn ®ndings of qualitative studiesin one's area of practice; fatigue from decodingthe awkward and unnatural language of somequalitative researchers; and pressure within thepractice context to limit time with the patient andlimit care to standardized assessments and technical and pharmacological interventions.Qualitative researchers can facilitate clinicalapplication by conducting qualitative data collection and analysis that is as deep and rich asneeded to answer the research question and thatmakes the best possible use of participants' timeand energy. To maximize discovery, data collectors must enable participants to tell their stories orshow their lives in detail and in their own frameworks and according to their own priorities, andthey use methods to their full potential: in phenomenology, making time and space for repeatediterations of experience from different perspectives and engaging in deep levels of immersion;in grounded theory, doing intensive analysisbetween interviews or observations so that newquestions are asked and the theory moves forwardwith each contact; in ethnography, staying in the®eld long enough and with enough participationto be able to describe the border crossing of one'sown acculturated, situated body into a newhistory, culture, and worldview. In data analysisand writing, researchers can maximize the utilityof ®ndings by striving for the highest possiblelevel of complexity and discovery. Portrayingor explaining experiential variation and ®ndingevocative language seem to be the most dif®cultsteps for novices. Shaping ®ndings into narrativecan be helped by studying writers of all kinds,including journalists, playwrights, and ®ctionwriters. Reading ®ction can be a good courseof study to learn how to balance detail withsweep, action with dialogue, and description withinterpretation.In discussing their ®ndings, researchers canprovide detailed and contextually speci®c suggestions as to how a clinician might use them(Johnson, 1997), with guidance for identifyingappropriate patients and settings. Researchers152 RESEARCH IN NURSING & HEALTHmight identify important types of experiencesnot represented in their studies that might beexpected to differ, or they might suggest questions clinicians could ask to determine the ®tof the evidence with a patient's situation. 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