SCHOLARLY PAPER

Qualitative Approaches to Evaluating Quality of Service Barbara Richardson

Key Words Quality service, qwlit ive research, evaluation, interpretive para- digm.

summery This paper draws attention to changes in the ethos of health care services today as manifested in the Patient’s Charter and the move towards care in the community. It questions whether the current profile of physiotherapy research, which is based pre- dominately within a positivist paradigm, is sufficient to inform practitioners in designing and evaluating programmes of care which are focused on the needs of the individual and service delivery in the community setting. A critical analysis of naturalistic inquiry is made and it is concluded that rich data which could be released through the use of qualitative methodologies would reveal a wealth of information germane to helping practitioners in ensuring high standards of care and in achieving outcomes satis- factory to the individual needs of clients. It is suggested that more studies based within an interpretative paradigm would balance the professional profile of research and help ensure the quality of service and the effectiveness of its delivery.

Introduction Research is considered as the key to providing an effective service (Polgar and Thomas, 1991; Michels, 1982) and physiotherapists continually strive towards the development of reliable and valid research methods which allow an investi- gation of the efficacy of treatments (Wilkinson, 1986; Payton, 1988; Bohannon, 1989). Radical changes in health care policy have taken place in Britain over the last decade and there is now an emphasis on evaluation of the quality of care that health care services provide (DOH, 1990,1991a, b, c; NAHAT, 1994). Increased attention has been given to the rights and expectations of the consumer of health services, and there are raised expectations of professional accountability through the use of medical audit which analyses the quality of care. This paper questions whether a professional research profile which is based predominantly within a positivist paradigm is sufficient to enable physiotherapists to achieve a quality of care which requires the design and eval- uation of programmes of care that emphasise the autonomy and participation of individual patients and which focus on the needs of individ- uals in the community setting. Critical analysis of naturalistic inquiry in relation to the effectiveness and quality of care provided by physiotherapy

services suggests that rich data released through the use of qualitative methodologies would reveal a wealth of information germane to assisting physiotherapists in defining and achieving high standards of care. It would help to evaluate the quality of service and the effectiveness of its delivery.

Tracing the Development of Physiotherapy Research Despite several early articles which called for physiotherapists to become involved in research (Tegner, 1966; Rogers, 1976; Metters, 1978) the history of physiotherapy research in this country, as may be traced through the Journal of the Char- tered Society of Physiotherapy, is comparatively recent. Few reports of systematic investigation are documented before 1980 (Physiotherapy, 1979). Journals of the 1980s show increasing evidence of the development of physiotherapy- led research and by the late 1980s there is a noticeable trend towards two or three research papers being published each month. This devel- opment has continued into the 1990s and the tradition of physiotherapy research is clearly on the way to becoming well established. However, except for one or two notable examples (Farthing, 1973; Armour, 1977; Johnson, 1993) the Journals show a preponderance of studies based firmly on methodologies within the positivist tradition of research. The contribution this current profile of physiotherapy research can make to physio- therapy and the underlying ethos of care it supports needs to be appraised in .light of the ongoing changes in health care policy and practice and of changing information needs of physiother- apists which are consequent on that.

Researchwithha Positivist Paradigm A positivist approach to research aims to isolate and manipulate variables, to measure responses and to submit data to statistical tests. It requires that variables are isolated and manipulated away from the context in which they occur 80 that infor- mation may be gleaned in a way that allows generalisation to other situations at a certain level of probability if encountered under exactly the same conditions again. The assumption which underpins this approach is that of a single truth, a single reality (Shepard et al, 1993) in which it is possible to isolate variables, objectively describe

and measure phenomena and then make predic- tions of behaviour.

Information from research of this nature in phys- iotherapy may increase a knowledge base of the behaviour of tissues and of people in relation to pre-defined norms of health but it is a health status which is defined by people other than the recipients of care. This type of research thus supports a disease-oriented system of care with the implied ethos of care as a dispensation of treatment to an individual for illness which is regarded as a deviation from an agreed health status norm. It supports a system of health care in which expert professionals make pronounce- ments on the status of their patients, judging or predicting the level of deviation from an expected norm and prescribing treatment which aims to restore to a normality. The question is raised of how this matches the changes in provision of health care today.

Health Care Policy and Practice Today Until the late 1970s it may be said that a policy of paternalistic medicine existed in which doctors were regarded as the experts, the healers in possession of special powers (Richardson and Bray, 1987; Scambler, 1991) and the patients merely mechanistic recipients of care. But during the 1970s there was a move towards mutual collaboration and patient participation (Richardson and Bray, 1987) with a growing emphasis on the need to consider the patients’ ideas and concerns. Today, three government initiatives have furthered the move towards a philosophy of care which focuses on promoting health, creating patient autonomy and empow- ering patients in self care.

The National Health Service and Community Care Act (DOH, 1990) aims to ‘enable people to live an independent and dignified Life at home and elsewhere in the community for as long as they are able and wish to do so’. The objectives of care management particularly promote client-centred care and consumer choice. The Citizen’s Charter (DSS, 1991) also shows an awareness of con- sumer rights with its four themes of choice, quality, standards and value. The subsequent Patient’s Charter (DOH, 1991a) has emphasised the right of patients, as consumers of health care, to full and open information about their medical condition and alternative approaches to their treatment; the right to receive care without long waiting periods, and the right to be treated with respect and dignity with an expectation of non- discrimination and accessibility of service. The Health of the Nation (DOH, 1991b) gives health authorities explicit responsibility to ‘ensure that

everybody has the best possible information they need to understand the influences on their health, especially the influence of their own behaviour and the necessary support to improve their health’. Government initiatives such as these give evidence of major changes in health policy within the last decade which show a move towards more democracy in health care and more concern for patient participation. They herald a move away from a disease-oriented health care system towards one which will ‘focus as much on the promotion of good health and prevention of disease’ (DOH, 1991b). As Pringle (1993) states: ‘Now the aim is to show not to protect, to collabo- rate not to isolate, and to be pro-active to health needs.’

Empowerment of patients, autonomy of patients, and patient participation are the predominant issues in health care today. To promote healthy lifestyles in client-focused care, the information needs of practitioners clearly include both an understanding of the experience of health and disease of their clients in their own home context and also of their own professional responses to disease. It may be expected that any audit of outcomes of physiotherapy services will attempt to monitor the quality of the ways in which the needs of the individual client are identified and met.

Research Needs to Inform Professional Responsibilities in Health Care Today The role of research within the health care service is to inform and support the ethos and provision of care of the service. Currently there is a general thrust towards developing quantitative outcome measures which satisfy purchasers who operate within a positivist paradigm encouraged by the medical model of disease, and research towards that end is considered favourably by funders. However, Donabedian (1988), an advocate of management of quality of care through setting standards of quality, particularly recognises the elements of both technical judgement and interpersonal effectiveness in professional performance. He emphasises the importance of the management of the interpersonal process, and the art of medicine which is shown in the ways practitioners grasp a situation, make decisions and process information. In this context he frankly admits that ‘profundities still elude us’ and he is concerned that the ‘nature of quality is to ensure that concepts are socially relevant and scientifically valid’. Maxwell (1984) also warns of creating a new Frankenstein’s monster in the shape of a quality assurance and quality control scheme which is insensitive to

Phy.latkmpy, sepmgmr 1995, volB1, no 9

the variation, autonomy and trust implicit in health care. The demands for quality assurance in the efficacy and provision of health care services along with the demand for recognition of the primacy of the clients - the consumers of health care - has created a need for research which supports and provides information to help clinicians in meeting those demands.

A focus on care which aims to empower patients in providing their own health care and to facilitate patient autonomy implies a need to consider people within their own experiences of health and illness (see Kretlow, 1989) and to look at indi- vidual responses to treatment approaches in relation to particular needs rather than measured against a norm. It also implies a need to take a fresh look at ourselves as professionals and to consider how we respond to the health care needs of individuals. Studies within a positivist research paradigm assume a single reality and use methodologies which look only at phenomena that can be objectively described, measured and quan- tified as a basis for prediction of behaviour of other people and other events. Information from such studies will thus increase a sense of authority and power over clients and an expecta- tion for them to respond passively to health care administrations. Delitto (1989) particularly admits to a fear that medical care is becoming increasingly dehumanised in this way and that ‘there is little regard for the patients’ description of illness when making clinical decisions’.

The current research profile of the physiotherapy profession as demonstrated to date by the majority of research papers in the Journal of the Chartered Society of Physiotherapy sits firmly within the positivist paradigm. It would seem insufficient to help physiotherapists explore the best ways to enable and facilitate health and to understand individuals. Inrine (1990) considers that the ‘goodness’ of interpersonal relationships as depicted by Donabedian (1988) requires a sensitivity and understanding of patients’ needs and a commitment to protecting their autonomy, privacy and other interests. The positivist approach to research is not valid for promoting 8n understanding of individual needs through investigation of the important events, phenomena and interactions which may occur within a single context of health care. Rather, methodologies are required which will uncover, fully explore and look deeply at the meaning and understanding individuals make of a particular context of health care. To help in gaining as much insight as possible to a situation (Stone, 19911, research within an interpretive (humanistic) paradigm may therefore be more appropriate.

Research within the Interpretive Paradigm Research within an interpretive paradigm doe8 not aim to predict and control. It acknowledgea that truth depends on shared values and ie deter- mined by the interaction and the context. This approach therefore involves the study of the empirical world from the perspective of the subjects under investigation (Robertson, 1988). Integral to the approach is the belief that meaning depends on context and that a complex mutual shaping of meaning for individuals oecure in each individual situation or activity. The reality of a health care context is seen as a whole related to the time, the person and the place, and one which cannot be understood through the study of isolated bits of it (Bogdan and Biklen, 1992). Subjects are studied in the context of their natural setting, and not laboratory conditions. This ‘naturalistic inquiry‘ (Lincoln and Guba, 1985) may take place in the home, hospital, work or leisure setting.

Data are collected through interviews, observ- ation, document analysis or collation of un- obtrusive clues (Patton, 1990). They are rich in detail of ‘thick‘ description (Geertz, 1973) and is in-depth and inclusive. Qualitative methodologies are used because they are able to adapt to the indeterminate situations which will be encoun- tered. The researcher is regarded as the prime data-gathering tool since only a human person ie sensitive to complexities and nuances in interac- tions and activities of other people and can make decisions to explore some avenues of inquiry further while perhaps discarding others. In this way data are successively integrated into a process of purposive sampling, inductive analpie and development of theory which capture the core of the meaning in the data (Glesne and Peshkin, 1992). The research design is said to emerge through a process of exploration which aims to identify the multiple perspectives which converge in the reality of a setting and to allow that setting to be fully described and values to be exposed (Lincoln and Guba, 1985).

The interpretive approach to research does not exploit or manipulate people or exclude them from the formation of knowledge that purports to be about them (Lincoln and Guba, 1985). It serves rather to capture the reality of clinical interac- tions (Schmoll, 1987) and to keep the autonomy of the clients central. Constant checks are made with the subjecta under study to ensure that the meanings they communicate, through their descriptions of events, and those of the m a r c h e r s coincide. The validity of the research is based on a negotiation of meanings, which ensures that the construction of reality by the

inquirer is agreed by those under study. This is then followed by a rigorous analysis of findings which looks for divergent cases and uses trian- gulation of analysis to confirm findings (Jensen, 1989).

Discussion There is now the beginning of a concerted effort to explore fully the needs of health care research. It has been rekognised that patients have little say in what should be audited and are rarely asked to participate in studies of the quality of care they receive. As Rigge (1994) declares: Too many audits are based on patients as cases, as members of diagnostic groups, as the subjects of medical records.’ She carried out a study of the quality of life of people before and after hip and knee replacements using the qualitative interview method and points out that ‘owing to the way the system operates there was no way in which the consultants concerned would have known of the disappointment and concern of these patients’ over lack of progress and lack of information. Davies (1994) goes further to suggest that research which evaluates ‘patient defined outcomes’ of care can ‘inform health policy reform agenda at all levels of government’.

Research carried out within an interpretive para- digm acknowledges that each patient has a unique set of past experiences, values, norms and expectations which may affect the outcomes of treatment (Austin and Clarke, 1993) and influ- ence attempts to establish healthy, independent lifestyles. An increased understanding of clients, carers and health professionals on matters regarding health and disease will provide infor- mation which can promote the quality of health

Working within an interpretive paradigm using qualitative methods shifts the metaphor of man fiom a mechanistic being who is acted upon by the events of a single predictable reality to a human being who perceives, responds, is shaped and who shapes a fluid, dynamic reality (Lincoln and Guba, 1985). Research which supports this view of man seems to be a better fit to the study of contextual sociobehavioural processes which will inform the process of enabling individual people to live healthy lives in the real world of an ever- changing, interactive community setting. If no attempt is made to increase an understanding of the client as an individual, rather than merely a recipient of care, standards of care may become b i d towards professional aspirations. Knowl- edge of the effects of professional interpersonal skills on individual clients and of the ways in which professionals interact with the experience of health and illness of the client may facilitate

care.

setting standards of care which are more socially relevant to individuals.

The Research and Development Strategy for the National Health Service (DOH, 1991~1, currently directed by Professor William Peckham, has led to directorates of research and development in Regional Health Authorities and programmes which are being set up to support researchers who may operate in a number of ways in order to eval- uate the quality of care in the health service. Qualitative research is on the agenda and funding is available for qualitative studies. However i t has to be acknowledged that at present there is a dearth of expertise both to put forward and to judge proposals which are robust, rigorous and valid. Physiotherapists should be in a good posi- tion to redress the situation and to confirm the importance of the use of qualitative methodology in evaluating care.

Conclusion A more focused and co-ordinated approach to physiotherapy research is required (Sackley, 1994). Use of qualitative methodologies within an interpretive paradigm will help to illuminate not only the outcomes of physiotherapy care but also the processes of interaction which are conducive towards quality outcomes (Colquhoun and Kelle- hear, 1993). Shepard (1987) proposes that the combined use of qualitative and quantitative research methods may be the single most impor- tant breakthrough in defining a body of knowledge that is unique to the practice of phys- ical therapy. Jette (1993) suggests the ultimate goal of physiotherapy service provision is improve- ment of function and the overall quality of life, but the ‘systematic study of quality of life as a health care outcome is a relatively recent phenomenon’ and he states there is a ‘paucity of evidence of the known effectiveness of many health care practices’.

Research which utilises qualitative methodology supports the concept of patient satisfaction as a multi-dimensional construct and the ability of patients to make ‘refined and distinctive judge- ments’ about different aspects of their care (Fitzpatrick and Hopkins, 1993). Qualitative and quantitative research is necessary to acknowledge both the technical judgement and the interper- sonal management of treatment and to develop both the science and art of physiotherapy practice. More studies based within an interpretive para- digm would balance the professional profile of research and help to assure the quality of the physiotherapy service and the effectiveness of its delivery.

Author and Address for Correspondence Barbara Richardson MSc MCSP DipTP is a lecturer in physio- therapy at the School of Occupational Therapy and Physiotherapy, University of East Anglia, Norwich NR4 7TJ.

This article was received on December 12,1994. and accepted on March 9, 1995. It is adapted from a paper presentation at the CSP Annual Congress, September 1994 in Birmingham.

References Armour. C (1977). ‘A patient’s view of spina bifida’, Physio- therapy, 63, 7,221-222. Austin, C and Clarke, C R (1993). ‘Measures of outcome for whom?’ British Journal of Occupational Therapy, 56, 1,21-23. Bogdan, R C and Biklen. S K (1992). Qualitative Research for Education: An introduction to theory and methods. Allyn and Bacon, Needham HeigMs. Bohannon, R W (1989). ‘Objective measures’, Physical Therapy, 69, 7,590-593. Colquhoun, D and Kellehear. A (1993). Health Research in Prac- tice, Chapman Hall, London. Davies, A R (1994). ‘Patient defined outcomes’, Quality in HeaM Care 3, supplement S6S9. Delitto, A (1989). ‘Subjective measure and clinical decision making’, Physical merapy, 69, 7, 585589. Department of Health (1990). National Health Service and Community Care Act. HMSO. Department of Health (1991a). The Patient‘s Charter, HMSO.. Department of Health (1991 b). The Health of the Nation. HMSO. Department of Health (1991~). Research for Health, HMSO. Department of Social Security ( I 991) The Citizen’s Charter: Raising the standard, HMSO. Donabedian. A (1988). ’The quality of care - How can it be assessed?’, Journal of the American Management Association, 260,12,1743-48. Farthing. D (1973). ‘My thoughts as a patient‘, Physiotherapy, 59, 12,393-394. Fitzpatrick, R and Hopkins, A (1993). Measurement of Patient Satisfaction With Their Care, Royal College of Physicians, London. Geertz, C (1 973). The lntetpretation of Cultures, Basic Books. New Yo&. Glesne, C and Peshkin, A (1992). Becoming Qualitative Researchers: an introduction. Longman. New York. twine. D (1990). Managing For Uuafity in General Practice, King’s Fund. London. Jensen, G (1989). ‘Qualitative methods in physical therapy research: A form of disciplined inquiry’, Physical Therapy. 69, 6,492-499. Jette, A (1 993). ‘Using health-related quality of life measures in physical therapy outcomes research’, Physicar Thempy, 73,8. 528-537.

Johnson, R (1 993). ‘”Attihtdes don’t just hacg in the air‘: MBebled people‘s perceptions of physiotherapists’, Physbfhempy, 19.9, 619-627.

Kretlow. F (1989). ‘A phenomenologicel view of Uhess’. AusinJlnn Journal of Advanced Nucdng, 7,2,8-10. Lincoln, Y S and Guba, S G (1985). Naturalisffc Inpulcy, Sage PuMications, Bevedy Hilts, CA. Maxwell, R J (1984). ‘Quality assessment in health’, Rrltish MedicalJournaI, 268,1470-71.

Metters, J S (1978). ‘Research in physiotherapy: The way forward‘, Physiotherapy, 64,364-367. Michels, E (1 982). ’Evaluation and research in physcal !hempy‘, Physical Therapy. 62,6,828-834. National Association of Health Authorities and Trusts (1994). Managing the New NHS - NAHArs response, NAHAT. Birm- ingham. Patton, M Q (1990). Qualitative Evaluation and Research Methods, 2nd edn, Sage Publications, Nervkrry Park, CA. Payton, 0 D (1988). ‘Documenting quality one case at a time’ (editorial), Physiotherapy Practice, 4,187-188. Physiotherapy (1979). ‘A research column’, Special Interest Group report, Physiotherapy, (16,10,312. Polgar, S and Thomas. S A (1991). lntroduclion to Research in

Pringle, M (1993). Change and Teamwork in Primacy Care, BMJ Publishing Group. London. Richardson, A and Bray, C (1987). ‘Promoting health through participation’, Policy Studies Institute Report 659. 100 Park Village East, London NW1 3SR. Rigge, M (1994). ‘Putting patients at the heart of raising quahi, Qualify of Health Care 3, supplement S2-S5. Robertson, L (1988). ‘Qualitative research methods in occupa- tional therapy’, Bribsh Journal ofoCnrpational m y , Odober 1988, pages 344-346.

Rogers, S (1976). ‘A role for physiotherapists in research‘, phys- iotherapy, 62,4.127-128. Sackley, C (1994). ‘Developing a knowWge base: Progress so far‘, Physiotherapy. BOA. 24A-28A. Scambler,G(1991). ~ a s A p p l i e d t o M e d i d m , W e d n . Bailliere Tindall, London. Schmdl, B J (1987). ‘Ethnographic inquiry in clinical settings’, Physical Thempy, 67,12,1895-97. Shepard, K F (1987). ‘Qualiative and quantitative research in clinical practice’, Physical Therapy. 67,12,1891-@4. Shepard, K F, Jensen. G M. Schmdl, B S, Hack, L M and Gwyer. J (1993). ‘Alternative approachas to research in phvsicai therapy: Positivism and phenanenology’. Physicaf Thefapy, 73.2,88-101. Stone, S (1991). ‘Qualitative research methods for physiothera- pists’, Physiotherapy, TI. 7,449451. Tegner, W S (1966). ‘The importance of research’, Physio- merapy, 52,4,230-231. Wilkinson. J (1966). ‘Don’t get your k n i i in a W. The Heallh Servia, Journal. March 27.

the Health Sdences (2nd edn), Churchill uvingstone , Edinburgh.