Questioning the use value of qualitative research findings

Questioning the use value of qualitative research findingsnup_514 112..125

Martin Lipscomb RN PhDSenior Lecturer, Department of Nursing and Midwifery, Faculty of Health and Social Care, University of the West of England, Gloucester, UK

Abstract In this paper the use value of qualitative research findings to nurses inpractice is questioned. More precisely it is argued that, insofar as actionfollows belief then, in all but the rarest of cases, the beliefs that nurses inpractice can justifiably derive from or form on the basis of qualitativeresearch findings do not sanction action in the world and the assumption,apparently widely held, that qualitative research can as evidence pro-ductively inform practice collapses. If qualitative research does not havea substantive action guiding potential then, in consequence, three con-clusions are permitted. First, regarding the requirement that nursesground actions on evidence, regulators should redraft methodologicallyneutral or permissive guidelines to specify the sorts of research evidencethat can serve this function. Second, qualitative methodologies shouldreceive less prominence in nurse education programmes. Third, qualita-tive researchers should make it clear that their work cannot informpractice.Alternatively, if this claim is advanced the process by which thisis to be achieved should be explicitly stated.

Keywords: applied research, nursing research, qualitative research.

Introduction

Guba & Lincoln (1998) assert, correctly in myopinion, that qualitative data can provide ‘rich insightinto human behaviour’ (p. 198). Qualitative research,prioritizing subjective witness rather than objective

measurement, generates knowledge about importantaspects of human experience. However, let it beassumed that we are looking at a qualitative researchreport of unimpeachable quality – what does theinsight or knowledge provided by that report allow?‘Insight’ is, as a truth qualifier, a woolly modal termand the status of ‘knowledge’ is no less problematic.Nevertheless, if insight or knowledge informs under-standing and if understanding alters or creates belief,then where action follows belief qualitative researchfindings can guide actions. This statement does notcommit to either causal or non-causal theories ofaction (although I am minded to assume that reasons

Correspondence: Dr Martin Lipscomb, Senior Lecturer,

Department of Nursing and Midwifery, Faculty of Health and

Social Care, University of the West of England, Gloucester

Center – Hartpury Campus, Gloucester GL19 3BE, UK.

Tel.: +44 01452 702166; e-mail: [email protected]

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112 © 2012 Blackwell Publishing Ltd

Nursing Philosophy (2012), 13, pp. 112–125

can be causes). Yet, the logic of the linkage betweenqualitative research findings, insight/knowledge,understanding, belief formation, and action is com-plex and problematic.

Smaling (2003) asks: ‘When persons, groups, orga-nizations, situations, social processes, aid programs etcetera, have been researched, do the results and con-clusions of this research also hold for other persons,groups, organizations et cetera, as with those thatwere the object of the research?’ (p. 52). Findingsfrom some forms of research are not intended to‘hold’ beyond particular cases (e.g. types of evalua-tion research; Thagard, 1993). However, if a negativeanswer to Smaling’s (2003) question is given, then itmight be argued that research findings have little orno ‘use value’ where use value is defined as usefulnessin understanding another non-study site context, situ-ation, group, or experience (or indeed the same studylocation/participants on another occasion). Researchthat lacks use value by this criterion cannot, it is hereargued, inform nursing practice and whilst under-standing the views and experiences of study partici-pants may be of interest in itself, if that understandinghas no relevance or purchase beyond that study then,regardless of the profundity of insight/knowledgegained, that understanding cannot guide action. Onthe other hand, if a positive answer to Smaling’s(2003) inquiry is forthcoming, then those findingshave use value by this standard.

Few researchers presumably want to produce find-ings that lack use value and, for example, Polit &Beck (2006) after discounting the possibility of gen-eralizing qualitative findings, nonetheless claim that‘the application of . . . [qualitative] results to othersettings and contexts must be considered’ (p. 436). Ina later work, Polit & Beck (2010) clarify their posi-tion by stating that generalizing from research is‘an act of reasoning that involves drawing broadconclusions from particular instances . . . [and] Innursing . . . generalizations are critical to the interestof applying the findings to people, situations, andtimes other than those in a study’ (p. 1451). Polit& Beck (2010) here position generalization as a‘critical’ aspect of qualitative research and, from anon-nursing perspective, Campbell & Stanley (1966)authoritatively state that the ‘goal of science

includes . . . generalization to other populations andtimes’ (p. 32). Thus, generalization or, if one prefers,transferability (these terms are described later in thepaper) is closely associated with the concept of usevalue.

The phrase ‘use value’ is however contentious whenapplied to qualitative research findings and, in thispaper, the use value of qualitative research findings tonurses in practice is questioned. In presenting theissues involved it is assumed that a nurse is reviewinga single research report. This is of course an artificialdevice. It would be most unusual and almost alwaysfoolish to read a single research report, determine it isof excellent quality, and act on its findings. That saidwhile beliefs are formed over time in relation to arange of evidence and experience, the consumers ofresearch (here nurses in practice) must, if belief for-mation over the extended period is to happen, pre-sumably be able to reach judgements about thegoodness of otherwise of the constituent parts ofwider beliefs (here particular pieces of research) aspart of this process.

Belief formation also occurs within a social context.Here it is asserted that, tenebo, nursing as a professionvalues research principally for its ability to inform ordirect practice. This function is articulated or embed-ded in the concept of evidence-based practice and it isenshrined by nurse regulators in policy documents thatprize research’s action-guiding potential. As nursingportrays itself as a practice-based discipline (see, e.g.Pearson in Gelling, 2010), claiming practice as thetelos or rationale of research activity is uncontrover-sial. However, qualitative research sits uncomfortablywithin this schema. Qualitative work lacks externalvalidity and,according to some definitions, it cannot begeneralized (David & Sutton, 2011). Its findings aretherefore of indeterminate use value to clinicallysituated nurses and although the concept of transfer-ability has been advanced in place of generalizability(Lincoln & Guba, 1985), qualitative research’s action-guiding potential remains unsettled. A justificationfor this claim is advanced in the main section of thispaper where the problematic nature of generalizabil-ity, transferability, theory-carried generalization, ana-logical generalization, and insight is addressed (i.e.problems regarding how we understand relations

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between situations are explored) and it is proposedthat, because agreed criteria regarding the determina-tion of these concepts are absent, clinically situatednurses are necessarily ill-equipped (they cannot beeducated or enabled) to use or apply qualitative find-ings in practice. Indeed qualitative findings may, tostretch the term,have a finkish disposition insofar theirassumed use value evaporates when put to the test.

Despite recent interest in the subject (e.g. Misco,2007; Groleau et al., 2009; Finfgeld-Connett, 2010;Polit & Beck, 2010), this paper examines an importantbut still underexplored aspect of research application(applied epistemology). UK examples are employedin developing sections of the argument; however, thecase being made has broad significance. And here apersonal statement is introduced. As a researcher Ihave undertaken and hope again to participate instudies with a qualitative component. It is thus not myintention to belittle or markdown qualitative work.It is my intention to better understand aspects ofresearch use and, in relation to qualitative work, bringto focus issues requiring clarification and develop-ment. I anticipate that this paper will stimulate dis-cussion and I look forward to engaging with others onthese issues.

Regulation and education

Nurse regulation in the UK is the preserve of theNursing and Midwifery Council (NMC) and whilstany number of individuals and groups assert claimsabout what nursing is or should be, the pre-eminentposition of the NMC in defining nursing’s UKprofessional agenda and responsibilities cannot beoverstated.

With regard to research NMC (2010) standards forpre-registration education state that: ‘All nurses mustappreciate the value of evidence in practice, be able tounderstand and appraise research, apply relevanttheory and research findings to their work, and iden-tify areas for further investigation’ (p. 14). This stan-dard forms the basis of UK nurse educationalprogrammes and, as if to emphasize its importance,the above requirement is repeated four times withinthe document (pp. 14, 23, 32, 41). The same standardalso proclaims that nurses operate ‘within a statutory

framework and code of ethics delivering nursing prac-tice (care) that is appropriately based on research,evidence and critical thinking’ (NMC, 2010, p. 11,repeated p. 148). The code referred to here is theNMC (2008) Standards of conduct, performance and

ethics for nurses and midwives and, more specifically,the claim therein that ‘You must deliver care based onthe best available evidence or best practice’ (p. 7).Nursing and Midwifery Council strictures it will benoted are prefaced with the declamatory ‘must’ and,regarding the code, failure to meet this requirementcan result in removal from the register of nurses, thatis, removal of the right to work as a nurse and lossof employment. These documents might be accusedof erroneously eliding evidence with research (as ifthe two descriptors were necessarily synonymous).Yet, that aside, on the basis of these NMC publica-tions, UK nurses are introduced to research as evi-dence in order that its findings can be applied in or topractice.

Here three caveats or clarifications are necessary.First, if qualitative research findings generate beliefsthat guide actions in the world, then this does requirethat nurses act or behave by commission or omis-sion in ways that differ from those they would haveundertaken had that belief not been formed.However, beliefs generated or changed on the basisof such findings can influence behaviour subtly andqualitative findings may simply direct nurses to be‘mindful of’ or ‘interested in’ phenomena in waysthey would not have done had that research not beenencountered. Thus the expectation that researchmust, if it is to have use value, find application inpractice is not synonymous with the requirementthat dramatic behavioural change always be evi-denced. Responses can include awareness raising(Patton, 1990; Popkewitz, 1990) where this influenceschoice taking and still be action-guiding. (Choicescan of course be forms of action; Campbell, 2011.)

Second, although the descriptors ‘scholar’, ‘aca-demic’ and ‘clinically situated nurse’ need not desig-nate separate or distinct groups (practitioners canengage in scholarly and academic pursuits and visaversa), it is feasible that the interests of nurse scholarsand academics may differ from clinically situatednurses and, where this occurs, scholars and academics

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might generate, read, and value qualitative or quanti-tative research for reasons other than those placedupon all nurses.

Recognizing the heterogeneous nature of nursing isimportant. Statements in the nursing literature, a lit-erature produced by a small subset of nurses, suggestthat research serves multiple functions and researchis, for example, associated with a variety of intellec-tual virtues (Cutcliffe et al., 2005). Moreover, scholar/academics may undertake research without expect-ing that its findings necessarily have immediate orconcrete use value. However, while it is possible tosympathize with these broader or more generousrationales for engaging with research, it is also thecase that, insofar as no other purpose or merit ismeaningfully acknowledged, regulatory pronounce-ments by the NMC require that the generality ofnurses interest themselves in research principally andsimply for instrumental reasons (that is, researchprovides evidence for practice). Acknowledging theoversimplification involved this paper henceforthjuxtaposes or contrasts nurses in practice againstresearcher–scholar–academics.

Third, it might be objected that because NMC pro-nouncements do not overtly favour any particularresearch design, qualitative, quantitative and mixedmethod approaches (and others that do not easily fitunder these headings) are all for the NMC equivalentsince, as nothing is excluded, everything is permitted.However, insofar as research is promoted for itsaction-guiding potential (i.e. it has worth because itprovides an evidence base), then by implication it canimplicitly be assumed that research that is not action-guiding lacks value. This conclusion could be consid-ered overly exacting. Yet, even if the interpretation ofNMC documentation offered above is rejected, theassumption that research should guide, influence, orinform action by providing an evidence base is widelyestablished in the nursing literature (e.g. see: Pearsonet al., 2007; Balakas & Sparks, 2010; Koivula et al.,2011; Moule & Hek, 2011) and, as Polit & Beck (2010)assert: ‘Without generalization there would be noevidence-based practice’ (p. 1452). It is therefore thelink between research and practice that is here prob-lematized for, if this link is granted, then the signifi-cance of qualitative research for clinically situated

nurses must be questioned. To explain why this isso the purpose and practice of nurse education ishereafter considered.

Although pre-registration education includes aresearch component, whether this education is at alevel or depth commensurate with NMC require-ments is a moot point and it is perhaps debateablewhether NMC claims on educators and students areor can be substantively met. It might here be arguedthat educators ‘pass’ student work on researchmodules, learning outcomes for these modules meetprogramme requirements, programmes are ‘signedoff’ by the NMC and, hence, research education issuccessful (NMC requirements are met). However,the circular and limited nature of this argumentshould be obvious.

More realistically, although all UK nurses willhenceforth be educated to level III (first degree),research reports generally appear in academic jour-nals and, furthermore, these reports are mostlywritten by researchers operating at Master’s level orabove. If academic ‘levels’ capture or describe varyingdegrees of knowledge and/or conceptual sophistica-tion, then it might be supposed that some potentiallyuseful research findings will be incomprehensible tosome nurses simply because the manner in which theyare written and presented outstrips the ‘preparedness’of those nurses to evaluate them. This statement doesnot denigrate or cast aspersions on the intellectualcapability of nurses. It merely recognizes that, in theirwritings, researcher-scientists demonstrate special-ized and advanced skills, they employ technicallydemanding nomenclatures and their outputs are fre-quently aimed at other researcher-scientists ratherthan students or practice-based nurses.

Similarly, regulatory injunctions (e.g. NMC, 2008,2010) make no allowance for the complex and variednature of research forms.Research methodologies andmethods are highly diverse and it is questionablewhether professional researchers, let alone busy prac-tising nurses, can, regardless of educational attain-ment, ‘understand and appraise’ with equal abilityor insightfulness multi-arm experimental studiesemploying assorted statistical tests, densely descrip-tive phenomenological reports, and sophisticatedmixed method research that assumes familiarity with



contrasting methodologies and their interplay. Indeed,few people are equally adept or at home amidst allresearch forms.

Equipping nurses to engage at a meaningful depthor level with the vast array of research types thatcould potentially inform their practice would be aremarkable accomplishment. More likely, and morecynically, in reality educators probably introducepre-registration students to relatively basic ideasabout quantitative and qualitative methodologiesillustrated perhaps with a few carefully drawnexamples from the easier-to-read papers. This processmay occur at level III (first degree). However, evengifted students are, at level III, still operating as neo-phytes when it comes to research awareness and thisshould be acknowledged since, presumably, thiscannot but affect the ability of post-registrationnurses to meet regulatory demands.

With specific regard to qualitative research, anotable but underexplored gap in nurse educationexists. Agreement regarding the use value of qualita-tive work remains uncertain and this uncertaintyhampers nurse education as students cannot beenabled to evaluate the action-guiding potential ofsuch work in the absence of some form of agreement(assuming this is in principle possible). Specifically,while difficulties and barriers to generalizing or trans-ferring qualitative findings across locations areacknowledged in nursing and other research texts, theimplication of this difficulty for research consumers,here students and practising nurses, remains under-theorized (Polit & Beck, 2010).

If qualitative research findings are to inform nursingpractice (i.e. influence acts) in settings or at times or inrespect of patients that differ from participantsinvolved in the original research then, among muchelse,attention needs to be given to how clinically basednurses can understand and justify this ‘conveyance’.Thus,nurses need not only to appraise research againstmethodological criteria regarding the goodness or oth-erwise of that research type, they also need to compe-tently recognize how, if at all, qualitative reportsdescribe similar or analogous situations to those inwhich they are located if those reports are to functionas evidence.This paper focuses on the second of theseneeds and, to develop the argument, generalizability

and transferability are described and problematized,difficulties with theory-carried and analogical gener-alization are recognized and, lastly, the concept ofinsight is explored. It is not necessary to accept theinterpretation of regulatory statements outlinedabove on use value or the practical difficulty ofmeeting those requirements in practice to acknowl-edge the significance of the issues identified here.However, if it is allowed that research is valued innursing primarily for its action-guiding potential (i.e.it is valued insofar as it provides an evidence base),then the problem of qualitative research’s ‘use value’assumes heightened importance.

Generalizability

Sweepingly put, naturalistic nomothetic (Erklären)quantitative researchers seek to reductively fashiongeneralizable law-like statements with broad applica-bility, whereas anti-naturalistic ideographic qualita-tive researchers attempt to describe (Verstehen) theunique or local non-generalizable aspects of phenom-ena, concepts, or objects (Archer, 1995; Bhaskar, 1997,1998; David & Sutton, 2011). This distinction, vari-ously phrased, is widely accepted (e.g. see, Seale, 1999;Freshwater & Bishop, 2004; Freeman, 2006; Newell &Burnard, 2006; Gilmartin, 2007; Bowling, 2009), albeitthat the diverse nature of specific quantitative andqualitative research forms must be acknowledged ifglib oversimplification is to be avoided (Devetaket al., 2010).

Thus, although the descriptor ‘qualitative research’covers a broad and disputive spectrum of investigativeactivity (Creswell, 1998; Freeman, 2006; Newell &Burnard, 2006) – so it is a weakness of this paper that‘qualitative research’ is portrayed as an homogenousentity – commonality between qualitative researchforms can be found in their use of non-representativesampling/recruitment, non-repeatable forms of datacollection, non-uniform ‘personal’ or ‘subjective’ pro-cesses of data interpretation, and non-probabilisticlogic (non-causal reasoning). These factors inhibit orundercut established (nomothetic) constructions ofinternal and external validity (Hammersley, 1993; sug-gests that the assessment of internal and externalvalidity cannot be meaningfully disaggregated) and

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this constellation of features, taken together, produceswidespread agreement amongst theorist/researcherson the non-generalizability of qualitative work (e.g.see, Keenan & Teijlingen, 2004; Newell & Burnard,2006; Parahoo, 2006; Gilmartin, 2007; Devetak et al.,2010; David & Sutton, 2011; Moule & Hek, 2011)(although the term‘generalization’ continues to attachto qualitative work – see, e.g. Polit & Beck, 2010;Thomas, 2011; or, less recently, Miles & Huberman,1994. See also developments in qualitative teamworking/synthesis; Rogers-Dillon, 2005).

Despite this, Newell & Burnard (2006) argue thatqualitative findings are generalized when, in thenursing literature, they become linked with recom-mendations for practice.This is illogical for:‘If it is truethat findings from such [qualitative] studies are limitedto a particular time, place and sample, then it followsthat such findings should not generate recommenda-tions for other times, places and populations’ (Newell& Burnard, 2006, p. 111). Generalizing in this manneris a mistake. However, respected nursing journals suchas The Journal of Advanced Nursing (JAN) encourageresearchers to identify ‘implications for practice’ witharticles submitted for publication. This requirementassumes that research findings must have relevance forpractice and this assumption appears to mirror orreiterate important elements of the argument pre-sented earlier in relation to the NMC (i.e. research hasvalue insofar as it can inform practice). Yet contraaccepted understandings when ‘implications for prac-tice’ accompany qualitative findings, it is likely thatnurses in practice who lack advanced (post level III)research awareness skills will be confused by thisimplicit generalization.

Thus, for example, Bauer & Nay (2011) make adetailed series of claims regarding ‘Low level carefacilities’ (p. 1232) on the basis of 12 interviews andTruesdale-Kennedy et al. (2011) determine that ‘multi-format information’ (p. 1301) is required for womenwith intellectual disabilities who require mammogra-phy following four focus groups with 19 women. Bothstudies are of high quality, both studies are well worthreading and both studies identify ‘needs’ that, to bemet, make resource demands. Reading these andsimilar works can, of course, teach us much about thelives and experiences of participants. However, when

qualitative findings are phrased as ‘implications forpractice’ that apply in other locations and with peopleother than those studied, then readers might reason-ably suppose that generalized claims are being madeand that these are, more importantly, permitted.

Newell & Burnard (2006) also note that qualita-tive research findings are generalized, or rather theappearance of generalizability is given, when reportsare titled in a manner suggesting wide applicability.And, for example, Bauer & Nay’s (2011) study isheaded – Improving family–staff relationships in

assisted living facilities: the views of family and notTwelve carers from Victoria Australia’s views on . . .

etcetera. And Truesdale-Kennedy et al.’s (2011)paper is titled – Breast cancer knowledge among

women with intellectual disabilities and their experi-

ences of receiving breast mammography and notNineteen women’s views on . . . etcetera. In neitherinstance do the authors of these papers do anythingunusual (they are merely following standard conven-tions regarding titles). However, generalizing claimsare nevertheless implicitly manifest in these titles.

Transferability

Acknowledging the non-generalizability of qualita-tive findings, Lincoln & Guba (1985) suggest thatqualitative studies outperform quantitative researchinsofar as they are more naturalistic and ecologicallyvalid and, on this basis, they propose that transferabil-ity if not generalizability can be achieved (see alsoStake, 1978, 1995; Guba & Lincoln, 1989). Transfer-ability offers the possibility that qualitative findingshave, supposedly, use value or applicability beyondthose ‘persons, groups [and] organizations’ (Smaling,2003, p. 52) who participated in the primary researchand as such it is a concept nurse theorists andresearchers appear to be willing to endorse (e.g. see,Im & Chee, 2006; Koch, 2006; Parahoo, 2006).

For Lincoln & Guba (1985), transferability occurswhen qualitative research findings,as working or semi-formal hypotheses, ‘hold’ (p. 316) or demonstrate ‘fit-tingness’ (p. 124) with the same or other contexts tothose in which they were formed and, to facilitatetransference, researchers must provide readers with‘the thick description necessary to enable someone



interested in making a transfer to reach a conclusionabout whether the transfer can be contemplated as apossibility’ (Lincoln & Guba, 1985, p. 316). Thickdescription is, in this account, the primary method bywhich some ‘degree of similarity between sending andreceiving (or earlier and later) contexts’ (Lincoln& Guba, 1985, p. 316) is communicated to readers(Misco, 2007) and, although the problem of discerningsimilarity or analogy is discussed below,here it is notedthat, to reiterate, thick description is merely a form ofcommunication. It does not in itself solve the problemof how, in transference, similarity or analogy is to beassessed.

Yet if transferability relies upon thick description, itcan be argued that Lincoln & Guba (1985) style trans-ferability is infrequently realized by nurse reportwriters.To explain why this is so it might be noted that:‘Classically, thick description is achieved in participantobservation, where long periods of fieldwork and theresultant “immersion” of the researcher in the settingare likely to provide an adequate level of detail’ (Seale,1999, p. 108). Thus described thick description com-municates through ‘rich, thorough descriptive infor-mation’ (Polit & Beck, 2010, p. 1453) the experience ofresearchers who have engaged with participant/subjects over protracted timescales and while thisdescription can theoretically be of any length it isperhaps most obviously found, for example, inextended (possibly book-length) ethnographic andanthropological monographs.

However, qualitative research reports in thenursing literature rarely evidence prolonged and sus-tained researcher–participant engagement. Interac-tion can be limited to a small number of shortinterview meetings (often one meeting only) and,moreover, regardless of the quality of researcher–participant interaction, it is improbable that meaning-ful or substantive thick description can be conveyedin the short (e.g. 5000 word maximum) researchreports commonly found in nursing journals (e.g.JAN). This is not a criticism of the skill or ability ofnurse researchers and the worth of qualitativeresearch performed by nurses is not being scorned.The statement simply acknowledges that ‘immersive’levels of description cannot easily be shoehorned intoa few paragraphs and it recognizes that this in turn

impacts upon the use value of such work for, if quali-tative nursing research reports do not contain thickdescription and if thick description is required asa preliminary step in the transference of findingsbetween groups or settings, then transference cannotoccur.

From the perspective of a nurse in practice, ambi-guity regarding transference is problematic. TheNMC (and others) want evidence to inform practice.Many aspects of practice generate questions that,theorists claim, are best approached by qualitativemethodologies/methods (Parahoo, 2006). Yet, asnoted earlier, qualitative research findings cannot begeneralized on theoretical grounds and, because themajority of research reports lack thick description(as defined by Seale, 1999) it appears that transfer-ence is disallowed on practical grounds. On the face ofit, qualitative research has little to offer clinical prac-titioners and important nursing questions cannot beanswered.

Theory-carried generalization

Perhaps then some other version of transferability orgeneralization exists which might assist nurses in prac-tice? Smaling (2003) argues that, in addition to sta-tistical (quantitative) generalization, theory-carriedgeneralization may occur when a theory generated atone study site is taken or carried as a hypothesis fortesting into another situation/context. Smaling (2003)claims Znaniecki (1934) as an early advocate oftheory-carried generalization (see also Mitchell, 1983on case study generalization and Firestone, 1993 onanalytical generalization) and some versions of, forexample, grounded theory might be associated withthis concept. Thus, grounded theorists generate theo-ries and ideas about particular study sites and/orunique groups and, if these theories and ideas areconsidered ‘plausible’ by research report readers(e.g. nurses in practice) then, following evaluation/assessment (testing), it might be shown that they‘apply’ or can be transferred to other contexts orpeople. This process is however problematic. Ques-tions about how theory can or should be evaluated atthe receiving location remain unresolved and, asSmaling (2003) points out in relation to report writing:

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Some research is more descriptive than it is theory forming

or theory testing. Even research aimed at theory forming or

theory testing does not in every case lead to a good, solid

theory.The result is sometimes merely a typology. Moreover,

a point of theoretical saturation often fails to be reached.

Even if the result is a theory, that theory hardly ever indi-

cates precisely in which cases and under what circumstances

the theory holds. Furthermore, existing theories are all too

often not strong enough, not precise enough, nor sufficiently

supported, to serve as a vehicle for generalization.

(Smaling, 2003, p. 54)

This quotation emphasizes the suboptimal nature oftheory presentation in research reports. It would beimpolite to list examples from the nursing literaturethat claim typology as theory or which fail to clarify,substantiate, or support the theory being advanced(and I am not sure my own work would survive suchscrutiny). However, just as brevity may not be condu-cive to communicating thick description so, likewise,there might simply not be space in 5000-word papersto adequately engage with the strengths and weak-nesses of theory formation.

In addition to those forms of inductive generaliza-tion noted above (statistical and theory-carried),Smaling (2003) also identifies variation-based gener-alization. This is more applicable in quantitativeinquiry and it is not discussed here. However, forSmaling (2003), all of these forms of generalizationsuffer a fatal flaw as, ultimately, they are incapable of:‘determining whether or not the results of theresearch can be generalized to other situations’ (p. 55)and, in response, Smaling (2003) introduces theconcept of analogical generalization.

Analogy and analogicalgeneralization

Analogy and analogical generalization are significantconcepts. Smaling (2003) notes that, particularly inrelation to cases and case studies, analogical generali-zation does not need to be of or about a particulartheory but that, rather, ‘analogical argumentation canplay a role when statements are made concerning anew case that has not yet been researched, based on acase that has’ (p. 56) (see also Thomas, 2011). More-

over, while: ‘Theory-carried generalization impliesthat the researcher knows in which sorts of cases thetheory will probably hold. These cases that have notbeen studied must possess a certain analogy withthose that have been researched’ (Smaling, 2003, p.56). This statement and the argument in which it islocated can be interpreted as rebalancing or refo-cusing debate on the nature of generalization/transferability. For if we assume that a primaryresearch report of interest (the thing we seek togeneralize/transfer) is indeed a good example of itstype (and this is currently what nurse educators trainstudents to assess), then for that research report to betaken up and used the research reader (nurse in prac-tice) must be able to discern analogies between, toinvoke Lincoln & Guba (1985), sending and receivingsituations (where ‘situations’ is broadly defined toinclude patient experiences, groups, contexts etcet-era). This may involve something very like thickdescription but it is not, importantly, necessarilyreliant on it. What then is analogy?

Thagard (1993) argues that analogy performs asignificant role in many scientific arguments and theo-ries; for example, Darwinian evolution rests on analo-gies between artificial and natural selection, and theproponents of wave theories of light employed analo-gies derived from kindred theories of sound. Yet howanalogy performs this instructive function remainsunclear and, in attempting to resolve this puzzle,Thagard (1993) proposes that ‘analogies support. . . theories by improving the explanations that thetheories are used to give’ (p. 92). Before this idea isdeveloped further however, it must be noted that, inlogic, analogy can be represented (following Thagard,1993, p. 93) as:

A is P, Q, R, S.B is P, Q, R.So: B is S.

Thus it is concluded that B has property S on the basis,on the assumption, that it shares other properties incommon with A and A is S.This form of reasoning canseem unduly abstract. However, it becomes more con-crete if (cognisant of the above notation) we imagine anurse in practice (at ‘B’) reading a qualitative researchreport (at ‘A’) and thinking: ‘I recognize that these



(“P”) subjects are like my (“P”) patients and the (“Q”)problems they face are like the (“Q”) problems mypatients face and the sorts of (“R”) things they say arelike the things my (“R”) patients say and therefore“yes”, I accept that the (“S”) findings in this (“A”)report “hold” here’ (‘At B – So: B is S’).

It is not unusual for qualitative papers to evoke orarouse strong psychological responses in readers.However, affect does not evidence anything otherthan itself and psychology and logic should not beconflated (Hempel, 1945).Thus whilst research reportwriters can wittingly or unwittingly excite emotionalresponses in readers – and the ‘yes’ response abovemay be in part emotional – the arousal of sentiment(positive or negative) has no necessary bearing on theaccuracy, validity, or use value of findings. Steppingback from uncritical confirmation (of the sort possiblydemonstrated above), the nurse in practice must,before analogy is accepted, consider a wider rangeof similarities and differences between sending(researched) and receiving (report reading) sites andstudy populations and, to this end, Smaling (2003)identifies a variety of overlapping factors requiringevaluation.

For example, we might recognize that A is not onlyP, Q, R, and S. It is also T, U, and V. Likewise, B is notonly P, Q, and R. It is also W, X, and Y. The ‘relativedegree of similarity’ (Smaling, 2003, p. 58) is there-fore important and when similarities and differencesare ceteris paribus in key respects ‘balanced’, thenanalogy is more plausible when similarities numeri-cally outweigh differences. On the other hand it maybe the case that, relevant to the conclusion beingdrawn (relative to the research question or problem),some properties or factors can be more or less impor-tant than others. Thus, if it transpires that sending andreceiving sites are similar in trivial ways (P, Q, and R)and dissimilar in more important ways (T, U, V etcet-era), then analogy collapses. To complicate mattersfurther analogical reasoning (the case for analogy) isstronger, to develop the example above, when A andC and D and E are P, Q, R, and S and B is P, Q, and R.In this instance the conclusion that ‘B is S’ is strength-ened by support from ‘similar cases’ (Smaling, 2003, p.58). And, in addition, when the points of differencebetween cases A, B, C, D, and E are both wide (defi-

nitional problems notwithstanding) and numerousand the points of similarity (relative to the researchquestion or problem) are agreed, then there exists‘support by means of variation’ (Smaling, 2003, p. 58).

Once more this may seen unduly abstract; however,the nurse in practice is, in essence, merely being askedto ascertain the plausibility or level of analogy presentbetween sending and receiving sites according to thevariety, range, and importance of similarities and dif-ferences existing between sites. However, whilst this iseasy to state it is – no surprise – more difficult to do.How, for instance, are these properties or factors to beassessed?

Qualitative champions such as Lincoln & Guba(1985) or Stake (1978) allow that similarity betweensettings rests on congruence. This seems undeniable.Yet Lincoln & Guba (1985) do not say how congru-ence is to be meaningfully assessed and Stake (1978)is notoriously enigmatic on this issue. Thus, naturalis-tic generalization or transference is to be ‘arrived atby recognizing the similarities of objects and issues inand out of context and by sensing the natural cova-riations of happenings’ (Stake, 1978, p. 6). Evocativelanguage of this sort is interesting but unhelpful as theepistemological status of ‘sensing . . . covariations’remains unclear.

Although Lincoln & Guba (1985) acknowledge that‘what constitutes “proper” thick description is . . . stillnot completely resolved’ (p. 316), it is perhaps tempt-ing to imagine that if enough background informationis transmitted from sending to receiving sites thenevaluative or judgemental problems can be dissolvedand analogy of the sort outlined above may be carried.A contrary position is however taken by Rodon &Sesé (2008). They propose that too much descriptioncan be counterproductive since the ‘more we breakdown each dimension, the closer description to a spe-cific phenomenon we get [and] In the limit we wouldhave a pure ideographic study that treats the phenom-enon as being unique and not transferable’ (p. 15).Here detailed description illuminates the uniquenessof study sites; this emphasizes dissimilarities betweensending and receiving locations and transference isthereby hampered rather than enabled. Yet, puttingRodon & Sesé (2008) aside, it is surely the case thatunless description is at a level and depth capable of

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being ordered and ‘translated’ into objective data, itcannot help practitioners decide whether analogoussituations exist. Thus it might be argued that if assess-ment is to be done effectively, that is with any degree ofrobustness (moving beyond the mere assertion ofanalogy), then each property or factor requires clarifi-cation and, problematically, enumeration.

For example, suppose a nurse in practice reads aqualitative research report that suggests analogiesbetween sending and receiving sites which stimulateher interest. Before forming beliefs capable of allow-ing her to justifiably act on the basis of its findings(and the term ‘justifiably’ here is problematic), sheneeds to assess the degree of similitude between sites.Assessment here requires, among other things, thatshe identifies points of difference and correspondencebetween sites and she needs to weight and quantifyall relevant similar and dissimilar properties/factors.At a minimum she will need to assess how similar/dissimilar study participants are compared to patientsor clients at the receiving site. But what in thisinstance does similarity mean (similar in what ways)?The study population was not chosen for its repre-sentativeness and many qualitative reports do notprovide substantive demographic or contextualizingdata.

Suggesting that description must, if it is to commu-nicate analogy, be capable of quantification mightseem overly challenging and, as David & Sutton(2011) note:‘What qualitative research is interested inis meaning as something holistic from which elementscannot merely be broken off and measured out ofcontext’ (p. 87). However, as Lincoln & Guba (1985)recognize, ‘it is entirely reasonable to expect aninquirer to provide sufficient information about thecontext in which an inquiry is carried out so thatanyone interested in transferability has a base ofinformation appropriate to the judgement’ (pp. 124–125). And, moreover, whether the working hypoth-eses developed by naturalistic inquirers ‘hold in someother context, or even in the same context at someother time, is an empirical issue’ (Lincoln & Guba,1985, p. 316). Thus, even if the required data arepresent, the apparent need to meet questions ofanalogy through empirical means (here empiricalquantification) suggests that the use value of qualita-

tive work for nurses in practice again crumples since,to be of use, some form of quantification is nowrequired.

A way through such tangles is perhaps offered byThagard (1993). He suggests that, in contrast to whatmight be described as the passive logic outlined above,analogy’s explanatory power derives, as previouslystated, from its active problem-solving potential.Thusin Fig. 1 we see that T1 can explain phenomena P1 andP2 and this is taken to indicate thatT1 has pragmaticallyproven its worth. If this is granted and if analogies canbe drawn or ‘mapped’ between T1 and T2 and P2 and P3

then:

a richer understanding of the objects posited by T2 is made

possible, since some of the information and procedural

knowledge of T1 can be carried over. Some of the techniques

that T1 employs to solve problems about P1 and P2 can be

carried over to help T2 solve problems about P3. (Thagard,

1993, p. 94)

Superficially Thagard’s (1993) model (Fig. 1) is notdissimilar to Smaling’s (2003) theory-carried gener-alization. Yet whereas Smaling (2003) carries theoryfrom sending to receiving sites, for Thagard (1993),only analogy is carried and this transport relies uponanalogy’s pragmatic problem-solving ability and notquantifiable similarities. Thagard (1993) thus appearsto overcome the requirement that nurses in practicefind some metric capable of weighting similarities anddifferences between identified properties. But, again,there is a catch. Thagard’s (1993) model may be pro-ductive in situations where problems have been or arecapable of articulation. It is inapplicable when prob-lems have yet to be identified and it is redundantwhen theories are absent. Qualitative research oftenexplores areas or topics where formal hypotheses

Fig. 1. The criterion of analogy – adapted from Thagard (1993, p. 93)



are absent – i.e. situations where problems remainunclear or ill defined (Miles & Huberman, 1994).And, as Smaling (2003) argues (above), even whenhypothesis generation is a stated goal, researchreports often fail to present theories as rigorouslyexplicit testable propositional statements. This situa-tion is frequently encountered in qualitative studiesand, thus, bar some few exceptions, because Thagard’s(1993) model of analogical transport is rarely appli-cable; nurses in practice are again left without helpfulguidance on how to ‘use’ qualitative findings.

Insight

This paper began by accepting Guba & Lincoln’s(1998) assertion that qualitative data can provide ‘richinsight into human behaviour’ (p. 198) and, if gener-alization and transferability are unable on theoreticalor practical grounds to provide mechanisms capableof articulating how qualitative research can be used orapplied in practice, and if theory-carried and analogi-cal generalizations also prove unhelpful, then perhapsthe concept of insight can be enlisted for this purpose– i.e. as a means to an end.

Nursing and non-nursing theorists assert that quali-tative reports may generate insight in readers (e.g.Guba & Lincoln, 1998; Parahoo, 2006; Rusinová et al.,2009; Thomas, 2011). However, whilst insight derivedfrom qualitative studies may be of value in itself, it isnot necessarily the case that this insight can informpractice. That is, it is not clear that insight, from quali-tative findings, can justify (be evidence for) actions inthe world. Indeed, what insight means or involves orallows remains ill-defined.

An unlimited e-search performed (21 May 2011)using the databases Cumulative Index of Nursing and

Allied Health Literature and the British Nursing Index

and the search term ‘insight’ generated 9024 hits. Theterm is thus widely employed within nursing texts(see, e.g. Schoppmann & Lüthi, 2009; Jackson et al.,2010; Serber & Rosen, 2010) and, yet, a non-rigorousreview of a small subset of located literature revealedthat the descriptor is rarely clarified or deployed withany degree of precision or consistency. More often theconcept appears as a synonym for meaning or under-standing (and it may have been used thus in this

essay).That said Sapara et al. (2007) note in one of themore informative papers that whereas insight wasonce seen as a binary phenomenon (being eitherpresent or absent) today there is an: ‘emerging con-sensus that insight is a multidimensional constructconsisting of several continua’ (p. 22). This statementreferences use of the concept in relation to quantita-tive research with schizophrenic patients and it isuntypical of use in non-mental health qualitativework. Nevertheless, by acknowledging the complexityof the term Sapara et al. (2007) avoid trivializing it.

Problematically perhaps insight feels phenomeno-logically ‘real’ and at a psychological level we easilyimagine that insight is correct or true (the idea ofincorrect or untrue insight seems absurd albeit thatwhat we strongly believe to be correct/true often isnot). However, as stated the strength of an emotionalexperience, the certitude of belief, says nothing aboutthe accuracy or validity of anything other than thataffect. Nor does it indicate that belief is rationallyderived. Reason should not be fetishized. Yet ifinsight can be generated or prejudiced on non-rational grounds – if the content of insight can, forexample, be influenced by arbitrary caprice or whimsy– then assumptions favouring insight’s ability toinform practice must be questioned. And, as Pasnau(2011) notes, we must consider: ‘how deeply puzzlingthe phenomenon of rational insight actually is’.

Reason and insight can be awkward bedfellowsand: ‘A recent biography of the Nobel-prize winningmathematician John Nash describes his long period ofmental illness, during which time he held various oddbeliefs such as that extraterrestrials were recruitinghim to save the world. How could he believe this, afriend asked during a hospital visit, given his devotionto reason and logic? “Because,” Nash said . . . “theideas I had about supernatural beings came to me thesame way that my mathematical ideas did. So I tookthem seriously”.’ (Nasar, 1998, p. 11 in Pasnau, 2011).

Insight thus describes a cognitive event or statethat we take ‘seriously’. It is also one that can besparked by multiple sources or stimuli. I argue else-where (Lipscomb, 2011) that qualitative researchincorporates and may rely upon abductively insightfulforms of inference and that, in consequence, its find-ings are peculiarly vulnerable to challenge. Insight

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derived from reading research can therefore be bothrationally obtained and inferentially weak. In addi-tion, insight is a somewhat mystical or solipsistic phe-nomenon as different people, or the same person ondifferent occasions, may obtain or fail to obtain differ-ent insights from the same source or similar insightsfrom different sources. It is also not obvious that thenature or profundity of insight obtained from non-research sources (e.g. from watching a TV hospitaldrama/soap opera) is necessarily worse or inferior tothat obtainable from reading research and, moreover,even when stimuli (e.g. from research findings ora fictional narrative’s intended meaning) are misin-terpreted, equally ‘beneficial’ (helpful) or ‘non-beneficial’ (unhelpful) insights might be obtained.

These issues raise questions about, for example, thetruth directive or epistemic nature of research find-ings and, in consequence, if qualitative researcherswish to claim that their findings have use valuebecause they generate insight in readers then theymust, I suggest, support this association in at least twoways. First, they ought to be clear about the types ofinsight they expect readers to gain or take from theirfindings (at which point they run the risk of makinggeneralizing claims). Second, they should be preparedto indicate why insights generated from their findingsare superior to (i.e. are more interesting or profound)the insights non-research sources can supply. That isthey must explain why their findings provide insightscapable of providing a defendable evidence base forpractice and insights generated by last night’s TVsoap cannot.

Post Gettier knowledge can no longer be defined asjustified true belief (Duncan, 2011). However, recog-nizing difficulties in belief justification does not permitlaissez-faire in belief formation.Although it might feelas if insight supplies true or genuine knowledge (and itis difficult not to accord insight-justificatory belief-forming ‘powers’), as with generalization, transferabil-ity, theory-carried and analogical generalization, thelogic involved in moving from insight generation tobelief formation to action in the world remains to bedeveloped and explained. Insight comes from manysources including qualitative research and insight mayoften be a necessary element or component in under-standing. However, unless qualitative researchers are

prepared to explore and engage with the concept morefully, they should be wary about invoking insight insupport of the use value of their work. Simply claim-ing insight does not sanction the generalization ofqualitative findings.

Concluding remarks

Lackey’s (2006) statement that: ‘Were we to refrainfrom accepting the testimony of others, our liveswould be impoverished in startling and debilitatingways’ (p. 1) is here endorsed. Qualitative researchfindings provide vital testimony on important aspectsof human existence and prissy logical fussiness shouldnot lead to such findings being ignored. That said incaring for others nurses cannot overlook regulatoryand ethical injunctions (e.g. NMC, 2008, 2010) thatrequire that actions have a defensible and reasonedevidence base (a base research aims to provide).And,as Cioffi (2002) notes: ‘the very least that a patientshould be able to expect, from a legal and ethicalperspective, is an adequate description by nurses ofthe judgements that lead to decisions’ (p. 48).

Therefore, if clinically situated nurses are to act onthe basis of beliefs generated by qualitative findings, ifqualitative research is to provide a trustworthy evi-dence base, then despite accepting Lackey’s (2006)comments on testimony, the logic linking findingswith insight/understanding, belief formation, andaction must be understood. This is important. Whenresearch findings are used to provide an evidencebase for nursing actions then, as care matters, thoseactions have ‘high stakes’ (Lackey, 2010, p. 364) andqualitative researchers who wish to claim that theirfindings can inform activity at times and locations andwith study populations that differ from those in theoriginal study must, I submit, engage with questions of‘epistemic support’ (Lackey, 2010, p. 373).

Problematically however, widespread agreementexists to the effect that qualitative research does notproduce nomothetically generalizable findings. Trans-ferability is advanced in place of generalization, yetthe ‘immersive’ levels of data required for transfer-ence are difficult to locate in nursing texts. Theory-carried and analogical generalizations do not appearto greatly ease the conveyance of findings between



locations and despite intuitive appeal the concept ofinsight is simply too fuzzy to validate action. From thisthree conclusions follow. First, to assist practitioners,regulators such as the NMC should review their guid-ance on evidence-based practice to explicitly identifythe sorts of research that can inform and supportactions. Second, to assist students, educators shouldemphasize qualitative research’s unsettled use valueand, third, where qualitative researchers overtlyclaim or implicitly suggest that their work can informpractice, they ought to state how this is to occur and,if this claim cannot be substantiated, it should bewithdrawn.

Acknowledgements

I would like to thank Professor Margaret Miers and P.C. Snelling for their encouragement and advice in thewriting of this paper.

References

Archer M.S. (1995) Realist Social Theory: The Morphoge-netic Approach. Cambridge University Press, Cambridge.

Balakas K. & Sparks L. (2010) Teaching research andevidence-based practice using a service-learning approach.Journal of Nursing Education, 49(12), 691–695.

Bauer M. & Nay R. (2011) Improving family-staff relation-ships in assisted living facilities: the views of family.Journal of Advanced Nursing, 67(6), 1232–1241.

Bhaskar R. (1997) A Realist Theory of Science, 2nd edn.Verso, London.

Bhaskar R. (1998) The Possibility of Naturalism: A Philo-sophical Critique of the Contemporary Human Sciences,3rd edn. Routledge, London.

Bowling A. (2009) Research Methods in Health: InvestigatingHealth and Health Services, 3rd edn. McGraw-Hill, OpenUniversity Press, Maidenhead.

Campbell D.T. & Stanley J.C. (1966) Experimental andQuasi-Experimental Designs for Research. HoughtonMifflin (Academic), Boston.

Campbell K.K. (2011) Free Will. Polity, Cambridge.Cioffi J. (2002) What are clinical judgements? In: Clinical

Decision Making and Judgement in Nursing (eds C.Thompson & D. Dowding), pp. 47–65. Churchill Living-stone, London.

Creswell J.W. (1998) Qualitative Inquiry and ResearchDesign: Choosing Among Five Traditions. Sage, London.

Cutcliffe J.R., Uys L. & Lee E.-O. (2005) The doctoralprocess: from idea to award. In: Doctoral Education in

Nursing: International Perspectives (eds S. Ketefian & H.P.McKenna), pp. 115–128. Routledge, Oxon.

David M. & Sutton C.D. (2011) Social Research: An Intro-duction, 2nd edn. Sage, London.

Devetak I., Glažar S.A. & Vogrinc J. (2010) The role ofqualitative research in science education. Eurasia Journalof Mathematics, Science and Technology Education, 6(1),77–84.

Duncan P. (2011) The value of knowledge. In: The StanfordEncyclopedia of Philosophy,Fall 2008 edn (ed.E.N.Zalta).Available at: http://plato.stanford.edu/archives/fall2008/entries/knowledge-value/ [accessed 21 May 2011].

Finfgeld-Connett D. (2010) Generalizability and transfer-ability of meta-synthesis research findings. Journal ofAdvanced Nursing, 66(2), 246–254.

Firestone W.A. (1993) Alternative arguments for generaliz-ing from data as applied to qualitative research. Educa-tional Researcher, 16(7), 16–21.

Freeman T. (2006) ‘Best practice’ in focus group research:making sense of different views. Journal of AdvancedNursing, 56(5), 491–497.

Freshwater D. & Bishop V. (2004) Nursing Research inContext: Appreciation, Application and ProfessionalDevelopment. Palgrave-Macmillan, Hampshire.

Gelling L. (2010) Attention to the fundamentals of nursingcare – interview with Alan Pearson. Nurse Researcher,17(4), 92–94.

Gilmartin J. (2007) Contemporary day surgery: patients’experiences of discharge and recovery. Journal of ClinicalNursing, 16, 1109–1117.

Groleau D., Zelkowitz P. & Cabral I. (2009) Enhancing gen-eralizability: moving from an intimate to a political voice.Qualitative Health Research, 19(3), 416–426.

Guba E.G. & Lincoln Y.S. (1989) Fourth Generation Evalu-ation. Sage, London.

Guba E.G. & Lincoln Y.S. (1998) Competing paradigms inqualitative research. In: The Landscape of QualitativeResearch: Theories and Issues (eds Q. Research, N.K.Denzin & Y.S. Lincoln), pp. 195–220. Sage, London.

Hammersley M. (ed.) (1993) Social Research: Philosophy,Politics and Practice. Sage Publications Ltd in associationwith The Open University, London.

Hempel C.G. (1945) Studies in the logic of confirmation (I).Mind: A Quarterly Review of Psychology and Philosophy,213, 1–26.

Im E.-O. & Chee W. (2006) An online forum as a qualitativeresearch method. Nursing Research, 55(4), 267–273.

Jackson D., Peters K., Andrew S. et al. (2010) Understandingwhistleblowing: qualitative insights from nurse whistle-blowers. Journal of Advanced Nursing, 66(10), 2194–2201.

Keenan K.F. & Teijlingen E. (2004) The quality of qualita-tive research in family planning and reproductive healthcare. Journal of Family Planning and Reproductive HealthCare, 30(4), 257–259.

Martin Lipscomb124


Koch T. (2006) Establishing rigour in qualitative research:the decision trail. Journal of Advanced Nursing, 53(1),91–100.

Koivula M., Tarkka M.-T., Simonen M., Katajisto J. &Salminen L. (2011) Research utilisation among nursingteachers in Finland: a national survey. Nurse EducationToday, 31(1), 24–30.

Lackey J. (2006) Introduction. In: The Epistemology of Tes-timony (eds J. Lackey & E. Sosa), pp. 1–21. ClarendonPress, Oxford.

Lackey J. (2010) Acting on knowledge. Philosophical Per-spectives, 24(1), 361–382.

Lincoln Y.S. & Guba E.G. (1985) Naturalistic Inquiry. Sage,London.

Lipscomb M. (2011) Conference Presentation: Abductiveinference the research process and mixed method studies.In 7th Mixed Methods International Conference. Univer-sity of Leeds. 29 June to 2 July 2011.

Miles B.M. & Huberman A.M. (1994) Qualitative DataAnalysis, 2nd edn. Sage, London.

Misco T. (2007) The frustrations of reader generalizabilityand grounded theory: alternative considerations for trans-ferability. Journal of Research Practice, (M10) 3(1), 1–11.

Mitchell J. (1983) Case and situational analysis. SociologicalReview, 31(2), 187–211.

Moule P. & Hek G. (2011) Making Sense of Research: AnIntroduction for Health and Social Care Practitioners, 4thedn. Sage, London.

Nasar S. (1998) A Beautiful Mind. Simon and Schuster, NewYork.

Newell R. & Burnard P. (2006) Research for Evidence-BasedPractice. Vital Notes For Nurses. Blackwell Publishing,Oxford.

Nursing and Midwifery Council (NMC) (2008) The Code:Standards of conduct, performance and ethics for nursesand midwifes. Available at: http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf[accessed 28 February 2011].

Nursing and Midwifery Council (NMC) (2010) Standards forpre-registration nursing education. Available at: http://standards.nmc-uk.org/PublishedDocuments/Standards%20for%20pre-registration%20nursing%20education%2016082010.pdf [accessed 28 February 2011].

Parahoo K. (2006) Nursing Research: Principles, Process andIssues, 2nd edn. Palgrave-Macmillan, Basingstoke.

Pasnau R. (2011) Divine illumination. In: The StanfordEncyclopedia of Philosophy, Summer 2011 edn (ed. E.N.Zalta),forthcoming.Available at:http://plato.stanford.edu/archives/sum2011/entries/illumination/ [accessed 10 May2011].

Patton M.Q. (1990) Qualitative Evaluation and ResearchMethods, 2nd edn. Sage, Newbury Park, CA.

Pearson A., Field J. & Jordan Z. (2007) Evidence-BasedClinical Practice in Nursing and Health Care. BlackwellPublishing, Oxford.

Polit D.F. & Beck C.T. (2006) Essentials of Nursing Research:Methods, Appraisal, and Utilization, 6th edn. LippincottWilliams and Wilkins, London.

Polit D.F. & Beck C.T. (2010) Generalization in quantitativeand qualitative research: myths and strategies. Interna-tional Journal of Nursing Studies, 47, 1451–1458.

Popkewitz T.S. (1990) Whose future? Whose past? Notes oncritical theory and methodology. In: The Paradigm Dialog(ed. E.G. Guba), pp. 46–66. Sage, Newbury Park, CA.

Rodon J. & Sesé F. (2008) Towards a framework for thetransferability of results in IS qualitative research. Sprouts:Working Papers on Information Systems,8(17),1–41.http://sprouts.aisnet.org/8-17

Rogers-Dillon R.H. (2005) Hierarchical qualitative researchteams: refining the methodology. Qualitative Research,5(4), 437–454.

Rusinová K., Pochard F., Kentish-Barnes N., Chaize M. &Azoulay É. (2009) Qualitative research: adding drive anddimension to clinical research. Critical Care Medicine,37(Suppl. 1), S140–S146.

Sapara A., Cooke M., Fannon D. et al. (2007) Prefrontalcortex and insight in schizophrenia: a volumetric MRIstudy. Schizophrenia Research, 89(1), 22–34.

Schoppmann S. & Lüthi R. (2009) Insights from inside: theduties and activities of nurses at the psychiatric clinicMünsterlingen (CH). A qualitative study. Journal ofPsychiatric and Mental Health Nursing, 16(7), 606–620.

Seale C. (1999) The Quality of Qualitative Research. Sage,London.

Serber E.R. & Rosen R.K. (2010) Editorial: qualitativeresearch provides insight into quantitative quality of lifemeasurement. Pacing and Clinical Electrophysiology,33(3), 253–255.

Smaling A. (2003) Inductive, analogical, and communica-tive generalization. International Journal of QualitativeMethods, 2(1), 52–67.

Stake R.E. (1978) The case study method in social inquiry.Educational Researcher, 7(2), 5–8.

Stake R.E. (1995) The Art of Case Study Research. Sage,London.

Thagard P. (1993) Computational Philosophy of Science.MIT Press, Bradford, Cambridge, MA.

Thomas G. (2011) How to Do Your Case Study: A Guide forStudents and Researchers. Sage, London.

Truesdale-Kennedy M., Taggart L. & McIlfatrick S. (2011)Breast cancer knowledge among women with intellectualdisabilities and their experiences of receiving breast mam-mography. Journal of Advanced Nursing, 67(6), 1294–1304.

Znaniecki F. (1934) The Method of Sociology. Farrar andRhinehart, New York.

