Keynote Address: Tenth Annual QHR Conference
QUALITATIVE HEALTH RESEARCH / December 2004Sandelowski / USING QUALIT ATIVE RESEARCH
Using Qualitative Research
A renewed urgency has emerged in the qualitative health research community concerning
the utility of qualitative research. This urgency is the result of several converging trends in
health care research, including the elevation of practical over basic knowledge, proliferation
of qualitative health research studies, and the rise of evidence-based practice as a paradigm
and methodology for health care. Diverse conceptualizations of use and users exist, and
ity of qualitative research findings. Issues affecting the utilization of these findings include
the varied ways in which they are conceived, presented, synthesized, signified, and trans-
lated, and the complex repertoire ofskillsrequired to activate the knowledge transformation
cycle in qualitative health research fully.
Keywords: knowledge transformation; knowledge dissemination; qualitative research;
studies have beenconductedin thehealth care arena, researchers, front-line practi-
tioners, policy makers, and other stakeholders in the health care community are
increasingly exhorted to use the findings of these studies to improve the public
ers are pressed to produce findings that are immediately or potentially relevant for
practice and to present findings in ways that enable their use by others. Front-line
use, and evaluate how useful they actually are in effecting desired change.
The current interest in the utility of qualitative research findings raises impor-
tant questions that go to the heart of the qualitative research enterprise, including
(a) Whatdoesusemeaninthecontextofqualitative research?(b) Whoaretheusers
should qualitative research findings be used? (d) Is the evidence-based practice
imperative to exploit research findings compatible with the non-exploitative
renewed urgency has emerged in the qualitative health research community
concerning the utility of qualitative research. Now that so many qualitative
Useless: The Discourse of Use Around Qualitative Research”—at the Tenth Annual Qualitative Health
Research Conference in Banff, Alberta, May 3, 2004.
QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 10, December 2004 1366-1386
© 2004 Sage Publications
imperatives of qualitative research? and (e) Of what use—and to whom—is all the
talk about use in qualitative research? I consider these questions in this article.
SITUATING THE UTILITY DISCOURSE
health research emerged in the 1980s as a distinctive domain and mode of inquiry.
because it was not objective and could not yield generalizable findings
(Sandelowski, 1997). Although these charges, unfortunately, continue to be made
by critics with an impoverished view of objectivity, generalization, and qualitative
result of several converging trends in health care research that have served both to
basic knowledge as the highest form of knowledge and the raison d’être of inquiry,
the proliferation of qualitative health research studies, and the rise of evidence-
based practice as a paradigm and methodology for health care. These events have,
in turn, contributed to the growing interest in incorporating qualitative health
research findings into evidence-based practice and in instilling an evidence-based
practice mindset into researchers conducting qualitative health research.
The New Primacy of the Practical
A resurgence of interest in the “actionability” of research findings (Greene, 1994,
criticism of Western science (Harman, 1996) and by activism to resolve persistent
social problems and health disparities engendered by differences in gender, race/
ethnicity, and class (Greene,1994), theemphasis onactionability has movedpracti-
cal knowledge from its lowly position in, to the top of the hierarchy of knowledge.
Once viewed as contaminated by discussions of use and usefulness, practical
knowledge is now increasingly privileged over pure knowledge by virtue of its
focus on use (Dickoff & James, 1992). Even scholars in such traditionally
nonpractice disciplines as anthropology are increasingly depicting these disci-
plines as “interventions” in scientific, technological, and medical practices
nography, have emerged in response to the new call to be useful (Chambers, 2000):
to produce knowledge that discernibly matters to someone for something.
Moreover, as fully embodied in participatory action research, knowing can be
consummatedonly in use (Heron, 1996). Indeed, practice disciplines, such as nurs-
ing, which are concerned with the doable and makeable (Johnson, 1991), are not
knowledge but, rather, sites where the utility of any knowledge can be put to the
ultimate test. And this testing function of the practice disciplines requires, in turn,
knowledge of how to put knowledge to the test, that is, in the language of research
utilization, how to transform it for use, implement it, and evaluate its implementa-
tion against specified outcomes. Knowledge in the practice disciplines entails not
just knowing that but also knowing how, when, why, whether, and for whom. As
Sandelowski / USING QUALITATIVE RESEARCH1367
Kim (1994) proposed for nursing, practice requires theories of intervention,
approach, deliberation, and enactment.
of health problems but also theories of diagnosis and treatment themselves and of
icalvalidity(Kvale,1995; Maxwell,1992) ofknowledgeinparticularsituationsisat
research procedures generating that knowledge and its putative generalizability
across situations. Research findings are expected to be accessible, relevant, signifi-
cant, and credible, and to hold the prospect of change to those who have a stake in
them (Chambers, 2000). Practitioners and patients are interested in the questions
(a) Does it work? and (b) If it works, should it be used?
The Proliferation of Qualitative Health Research
tive health research, which encompasses a diverse collection of approaches to
inquiry intended to generate knowledge actually grounded in human experience.
Thousands of reports of qualitative health studies are now available concerning a
public health, and other consumers of health research. These topics include (a) the
personal and cultural constructions of disease, prevention, treatment, and risk;
(b) living with and managing the physical, psychological, and social effects of an
array ofdiseases andtheirtreatments;(c) decision making aroundandexperiences
with beginning- and end-of-life, and assistive and life-extending, technological
ing and militating against access to quality care, the promotion of good health, the
preventionofdisease, andthereductioninhealthdisparities. Thesereportsappear
not only in exclusively qualitative research publication venues but also in venues
that once rejected qualitative studies as unscientific.
Supporting the exponential growth of reports of qualitative studies is the dra-
matic increase in qualitative methods literature, institutes, conferences, academic
now a growth industry and a research methods utilization success story, the very
success of which has engendered a renewed imperative to make better use of all of
the research findings produced from qualitative research.
The Rise of Evidence-Based Practice
of another “growth industry” in health care (Estabrooks, 1999b, p. 274): evidence-
professional jurisdictions, and the explosion of health-related information
(Timmermans & Berg, 2003; Traynor, 2002; Trinder & Reynolds, 2000)—evidence-
1368 QUALITATIVE HEALTH RESEARCH / December 2004
the turn to evidence-based practice is evident in the burgeoning literature on the
subject; the rise in several Western countries of centers and institutes of evidence-
based practice; the establishment of new journals and special features in existing
journals devoted to evidence-based practice; local, regional, national, and interna-
tional conferences on evidence-based practice; and the increasing availability of
databases housing evidence syntheses and evidence-based guidelines for practice.
basedpracticemovement,isnowaglobal enterprisesaid torival inimportancethe
Human Genome Project (Naylor, 1995).
Although variously conceived across the disciplines, evidence-based practice
generally connotes the thoughtful, explicit, conscientious, and judicious use of the
best evidence available to develop the best practices for individual patients
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sackett, Straus, Richard-
wide gap that still exists between research and practice, evidence-based practice is
retrieval of all evidence available concerning the treatment of a clearly specified
clinical problem;(b)ranking ofevidenceinanevidencehierarchy;(c)evaluation of
evidence using quality criteria; (d) synthesis of evidence using clearly specified
research techniques; (e) translation of evidence syntheses into practice guidelines;
(f) implementation of these guidelines in practice settings; (g) evaluation of this
implementation against clearly specified outcomes; and (h) the subsequent refine-
ment of practice guidelines derived from this evaluation (Stevens, 2002). Champi-
more informed use of evidence, more effective treatments, more efficient use of
scarce resources, transparency and accountability in clinical decision making, and
the empowerment of both practitioners and patients (Trinder, 2000).
But critics (i.e., both critical inquirers and frank opponents) of evidence-based
practice view it as itself problematic and even as a potentially retrograde step
(Clarke, 1999) in the advancement of the public health and for the establishment of
professional identity and autonomy (Gupta, 2003; Timmermans & Berg, 2003;
Trinder&Reynolds,2000; Walker,2003). Focusingonthecasuistryinclinicalmedi-
prevails over nomothetic knowledge (or knowledge of the general) (Hunter, 1989),
and on the importance of the practical knowledge embedded in clinical expertise
(Benner, 1984), critics have decried the scientific aesthetic of averages and dispas-
sionate objectivity promoted by evidence-based practice (Colyer & Kamath, 1999;
White, 1997). For these critics, evidence-based practice appears to devalue the per-
sonal knowledge (Benner, 1984) and knowledge of persons (Liaschenko & Fisher,
1999) critical to excellent patient care that is drawn from and produced in irreplic-
able interactions between practitioners and their patients. Although proponents of
values in treatment decisions, critics argue that these have yet to be discernibly
included in the evidence-based practice process.
Advocates of qualitative research are especially incensed by the use of hierar-
chies of evidence that assume the randomized clinical trial as the gold standard in
inquiry, which thereby devalues or frankly excludes qualitative research (Evans,
2003; Mitchell, 1999). Instead of ensuring best practices that truly reflect the judi-
cious consideration of all of the evidence available, the evidence-based practice
Sandelowski / USING QUALITATIVE RESEARCH1369
paradigm—as actually put into practice—reinforces well-worn prejudices against
certain forms and sources of evidence (McKenna, Cutcliffe, & McKenna, 1999).
Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Forbes et al., 1999;
Hampton, 2002; Madjar & Walton, 2001; Upshur, 2001a, 2001b).
Qualitative Health Research and Evidence-Based Practice
Thesheerproliferation ofqualitative healthresearchhasmadequalitative findings
difficult to dismiss and has generated urgent calls to incorporate them into the evi-
dence-based practice process. Scholars across the health-related disciplines have
increasingly recognizedtheerrorinexcludingqualitative researchfromsystematic
ria that automatically exclude qualitative studies from any consideration at all, let
alone consideration as best evidence (Barbour, 2000; Dixon-Woods, Fitzpatrick, &
Roberts, 2001; Giacomini, 2001; Green & Britten, 1998; Greenhalgh, 2002; Popay &
One manifestation of this new demand to incorporate qualitative research into
the evidence-based practice process is the recent upsurge of interest in conducting
variously referredtoasqualitative metasynthesis,qualitative meta-analysis, quali-
tative meta–data analysis, and meta-ethnography is evident in the burgeoning
methodological literature on the subject (e.g., Campbell et al., 2003; Finfgeld, 2003;
Jensen & Allen, 1996; Noblit & Hare, 1988; Paterson, Thorne, Canam, & Jillings,
2001; Sandelowski & Barroso, 2003a, 2003b, 2003c), in the growing number of
reports of studies designated as qualitative metasyntheses or the like (e.g., Barroso
& Powell-Cope, 2000; Kearney, 2001a; Thorne & Paterson, 1998), and in the forma-
tion of the Cochrane Qualitative Methods Group (http://mysite.freeserve.com/
Cochrane_Qual_Method/index.htm). Although they differ in their views of what
qualitative metasynthesis is as method and how metasynthesis studies should be
conducted, scholars engaged in qualitative metasynthesis agree that it represents
an advancement in making qualitative research findings more useful and in
moving them to the center of the evidence-based practice process.
The flip side to the call to incorporate qualitative research into evidence-based
practice is to instill an evidence-based practice mindset into qualitative research.
discourse around qualitative research and, therefore, to this article. Having briefly
reviewed the complex origins of the new discourse on use in qualitative research, I
turn now to the varied uses of use at its center.
Whether something is deemed to be usable or useful depends on what usable and
useful are deemed to be. As Baker, Norton, Young, and Ward (1998) proposed, use-
1370 QUALITATIVE HEALTH RESEARCH / December 2004