Journal of Nursing Education

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EDUCATIONAL INNOVATIONS 

Integrating Qualitative Research Into the Curriculum

Michele J Upvall, PhD, FNP

Abstract

Applying anthropological methods to nursing studies, especially when uncovering cultural concepts, has become increasingly common with the acceptance of qualitative research. Nursing research courses in the university typically include qualitative methods in their topical outlines. However, qualitative methods such as ethnography, phenomenology, and grounded theory require an in-depth understanding of the process and are often time consuming. For example, ethnographic researchers may be in the field for at least a year before completing a study (Kulig, 1990; Upvall, 1992; Wolf, 1988). Such constraints make it difficult, if not impossible, to include extensive practice in qualitative data collection in a nursing research course. In addition, nursing students often have difficulty in applying research results, quantitative and qualitative, to practice.

Rapid assessment procedures (RAP) is a positive alternative to traditional qualitative methods. Data can be collected by students in a rapid, efficient manner and be applied to practice within 1 to 2 months (Scrimshaw & Hurtado, 1987) after initiation of data collection. By using the RAP approach, nurse educators will view qualitative data as more accessible and useful for developing, implementing, and evaluating clinical courses (Vlassoff & Tanner, 1992).

Historical Perspective

Rapid assessment procedures, also known as rapid ethnographic assessment (Bentley, et al., 1988), was developed in 1981 when anthropologists Scrimshaw and Hurtado implemented methodological guides for a study of infant feeding practices in Honduras. The guides were revised in 1983 (Scrimshaw & Hurtado, 1984), and after intensive research of their use in other Central American countries and Italy, a manual of field guides was published in 1987 (Scrimshaw & Hurtado, 1987).

The goal of RAP is to determine, "...health-seeking behavior, behavior involved in overcoming illness, including the use of both traditional and modern health services" (Scrimshaw & Hurtado, 1987, p. 1). Thus far, RAP has been successfully implemented in a dietary management diarrheal program in Peru and Nigeria (Bentley et al., 1988). Also, the World Health Organization's (WHO) Global Program in AIDS has developed RAP guidelines to collect data related to HIV/AIDS beliefs and behaviors across cultures (Scrimshaw, Carballo, Ramos, & Blair, 1991). Both the dietary management diarrheal program and the WHO HIV/AIDS guidelines emphasize the success of using RAP to uncover attitudes and specific cultural practices that cannot be obtained by using quantitative approaches.

The RAP as a method for identifying cultural variables related to health and illness incorporates the following techniques:

* Formal and informal interviewing.

* Participant observation.

* Focus groups.

Interviewing guidelines have been specified by Scrimshaw and Hurtado (1987) with an emphasis on depth of answers given by participants. Overlap exists between formal and informal interviews but each has its own particular strengths. At the beginning of an interview, demographic questions should be asked as a "nonthreatening icebreaker" (Fetterman, 1989). If only one chance will be given for interviewing a participant the more formal, semistructured interview with open-ended questions will be useful (Bernard, 1989).

Spradley (1980) identified five types of participation inherent to ethnography, which also applies to RAP data collection.

1) Nonparticipation is at one end of the continuum, as no involvement occurs with the people being studied or thenactivities. The researcher acts only as an observer.

2) The next stage is passive participation, with a low degree of involvement. Here, the ethnographer acts as a spectator at a scene of action but, again, does not interact with the people or in the situation.

3) Moderate participation, preferred by RAP researchers, occurs when "...the ethnographer seeks to maintain a balance between being an insider and an outsider, between participation and observation" (Spradley, 1980, p. 55).

4) Active participation begins with observation, and the ethnographer emulates…

Applying anthropological methods to nursing studies, especially when uncovering cultural concepts, has become increasingly common with the acceptance of qualitative research. Nursing research courses in the university typically include qualitative methods in their topical outlines. However, qualitative methods such as ethnography, phenomenology, and grounded theory require an in-depth understanding of the process and are often time consuming. For example, ethnographic researchers may be in the field for at least a year before completing a study (Kulig, 1990; Upvall, 1992; Wolf, 1988). Such constraints make it difficult, if not impossible, to include extensive practice in qualitative data collection in a nursing research course. In addition, nursing students often have difficulty in applying research results, quantitative and qualitative, to practice.

Rapid assessment procedures (RAP) is a positive alternative to traditional qualitative methods. Data can be collected by students in a rapid, efficient manner and be applied to practice within 1 to 2 months (Scrimshaw & Hurtado, 1987) after initiation of data collection. By using the RAP approach, nurse educators will view qualitative data as more accessible and useful for developing, implementing, and evaluating clinical courses (Vlassoff & Tanner, 1992).

Historical Perspective

Rapid assessment procedures, also known as rapid ethnographic assessment (Bentley, et al., 1988), was developed in 1981 when anthropologists Scrimshaw and Hurtado implemented methodological guides for a study of infant feeding practices in Honduras. The guides were revised in 1983 (Scrimshaw & Hurtado, 1984), and after intensive research of their use in other Central American countries and Italy, a manual of field guides was published in 1987 (Scrimshaw & Hurtado, 1987).

The goal of RAP is to determine, "...health-seeking behavior, behavior involved in overcoming illness, including the use of both traditional and modern health services" (Scrimshaw & Hurtado, 1987, p. 1). Thus far, RAP has been successfully implemented in a dietary management diarrheal program in Peru and Nigeria (Bentley et al., 1988). Also, the World Health Organization's (WHO) Global Program in AIDS has developed RAP guidelines to collect data related to HIV/AIDS beliefs and behaviors across cultures (Scrimshaw, Carballo, Ramos, & Blair, 1991). Both the dietary management diarrheal program and the WHO HIV/AIDS guidelines emphasize the success of using RAP to uncover attitudes and specific cultural practices that cannot be obtained by using quantitative approaches.

The RAP as a method for identifying cultural variables related to health and illness incorporates the following techniques:

* Formal and informal interviewing.

* Participant observation.

* Focus groups.

Interviewing guidelines have been specified by Scrimshaw and Hurtado (1987) with an emphasis on depth of answers given by participants. Overlap exists between formal and informal interviews but each has its own particular strengths. At the beginning of an interview, demographic questions should be asked as a "nonthreatening icebreaker" (Fetterman, 1989). If only one chance will be given for interviewing a participant the more formal, semistructured interview with open-ended questions will be useful (Bernard, 1989).

Spradley (1980) identified five types of participation inherent to ethnography, which also applies to RAP data collection.

1) Nonparticipation is at one end of the continuum, as no involvement occurs with the people being studied or thenactivities. The researcher acts only as an observer.

2) The next stage is passive participation, with a low degree of involvement. Here, the ethnographer acts as a spectator at a scene of action but, again, does not interact with the people or in the situation.

3) Moderate participation, preferred by RAP researchers, occurs when "...the ethnographer seeks to maintain a balance between being an insider and an outsider, between participation and observation" (Spradley, 1980, p. 55).

4) Active participation begins with observation, and the ethnographer emulates the participant's activities as new behaviors are learned.

5) The highest level of participation described by Spradley (1980) is complete participation. This occurs when the researcher is already part of the setting under study.

Focus groups are interviews with small groups of individuals (usually 6 to 12) who are guided by a facilitator or the researcher to discuss the topic under study. In RAP, focus groups can be used to develop interview questions for the field guide, provide depth of information regarding the community's health care system, and assist with developing hypotheses for future studies (Scrimshaw & Hurtado, 1987).

Advantages to using focus groups with RAP are many. Most important, the researcher can obtain data quickly and at a low cost. During the session, the researcher can observe interactions among group members and ask for clarifications or expansion of responses. The "give and take" format of the focus group promotes a synergistic response among the group members, as individuals react to others' comments (Stewart & Shamdasan, 1990). This synergistic effect is an advantage to interviewing on an individual basis to obtain depth of information. However, focus groups may not be preferred when a topic is sensitive or considered to be private by the participants, such as HW/AIDS. Also, focus groups may not be as useful as participant observation when the researcher requires observation in a natural setting (Morgan, 1988).

The RAP manual by Scrimshaw and Hurtado (1987) contains field guides to study characteristics of a community, household, or primary health care providers. Each of these guides specify appropriate techniques for data collection. For example, eliciting treatment of common illness in children may include interviews with the child's primary care provider, observation of a household with a sick child, and focus groups with local school teachers.

Brief and expanded field notes, as well as tape recorders, have been used successfully to record data from interviewing, participant observation, and focus groups. Data analysis is similar to other types of qualitative studies, as the researcher derives themes or conceptual categories appropriate from the data. Flow charts, taxonomies, and cognitive maps are useful for structuring the data and helpful in creating a logical chain of evidence for developing conclusions (Scrimshaw & Hurtado, 1987).

Application

Currently RAP is being incorporated into a community health postgraduate program for muses in Zanzibar. Nurses selected for the program will have, as a minimum, a certificate in nursing and at least 3 years experience in primary health care (PHC). At the end of the year-long curriculum, a diploma will be awarded to those successfully completing a final examination set by the Nursing Council of Zanzibar and external examiners working in community health nursing.

In the example of the Zanzibar community health nursing (CHN) program, active participation will be achieved through program location. A rural location, a considerable distance from the urban College of Health Sciences, has been chosen as the field site where students and instructors will live and study. By living in the community, students will not only collect data using RAP field guides but will also have the opportunity to apply findings to health programs and evaluate their success. This will facilitate the goal of developing a true communitybased CHN program responsive to community needs and congruent with health and illness beliefs.

Community health nurses will fulfill a variety of roles after graduation. To prepare them, a comprehensive curriculum has been developed. There are five major components to the curriculum:

* Community health nursing for individuals and families.

* Emergency midwifery.

* Community psychiatric nursing.

* Management of PHC services.

* Promoting community empowerment.

Communication, health education, health assessment, and leadership are topical strands woven throughout each of the major components. The RAP field guides and techniques then are used within each of the strands to gain an understanding of the community's health care system. This begins on the very first day of the program when CHN students will ask community members (medical assistants; midwives; psychiatric nurses; maternal child health aides; laboratory assistante; traditional birth attendants; traditional healers, herbalists, and diviners; local politicians; police; teachers; and other individuals) to define the role of a CHN. The profile will include personal and professional characteristics, specific activities of a CHN, and ways to collaborate with other PHC providers in the community. This CHN profile will serve as the foundation for developing rapport with the community, especially as the CHN program is new, and Zanzibar has not previously employed CHNs.

The RAP field guide for the CHN profile is more loosely structured than other field guides students will be using. For example, during the introduction to health assessment skills students will observe the status of PHC provider and patient relationships by using the "ProviderPatient Interaction" field guide developed by Scrimshaw and Hurtado (1987). Areas of assessment include: other members with the patient; waiting time before being seen; amount of time provider spent with the patient; questions asked by provider, patient, and any others present during the exam (including nonverbal interactions); providers response to patient questions; provider's unsolicited response; patient's reactions to provider's comments; and provider's final remarks to the patient. Students using this observational field guide can incorporate their findings into their own practice to improve their care. Also, when students graduate they can use this guide to evaluate interactions of those they may supervise and again, work toward improvement.

At least 17 of the 31 field guides developed by Scrimshaw and Hurtado (1987) will be used throughout the CHN curriculum. Students will outline the geographic, demographic, epidemiologic, and socioeconomic characteristics of the community. They will also review the status of households in the community including definitions of health and illness, morbidity history of children and adults, and community use and experience with health resources. Finally, as the previous example illustrates, PHC providers and resources will be evaluated. Results of the field guides will be distributed through the local school committee, women's groups, and religious organizations. The CHN students will then work with these community groups to improve health care services in a collaborative manner.

Conclusion

Rapid assessment procedures can be used in any nursing clinical or research course where either health status, health impact, health service, or health behavior information is the focus (Vlassoff & Tanner, 1992). Because of the quality of information, findings can be used to evaluate current health services and provide recommendations for improvement. This is vital as health care reform is receiving so much attention in the United States. Nurse educators and their students can contribute to health care reform by conducting applied qualitative research studies with RAP and implementing findings into current practice.

References

  • Bentley, M.E., Petto, G.H., Strauss, W.L., Schumann, D.A., Adegbola, C, LaPena, E., ???, G., Brown, K., & Huffman, SX. (1988). Rapid ethnographie assessment: Applications in a diarrhea management programs. Social Science and Medicine, 27, 107-116.
  • Bernard, H.B.(1989). Research methods in cultural anthropology. Newbury Park, CA: Sage.
  • Fetterman, D.M. (1989). Ethnography: Step by step. Newbury Park, CA: Sage.
  • Kulig, J.C. (1990). Childbearing beliefs among Cambodian refugee women. Western Journal of Nursing Research, 12< 1), 108-118.
  • Morgan, DL. (1988). Focus groups as qualitative research. Newbury Park, CA: Sage.
  • Scrimshaw, S.. & Hurtado, E. (1984). Field guide on the study of health seeking behavior at the household level. Food and Nutrition Bulletin. 6, 27-45.
  • Scrimshaw, S., & Hurtado, E. (1987). Rapid assessment procedures for nutrition and primary health care. Los Angeles: UCLA Latin American Center Publications.
  • Scrimshaw, S., Carballo, M., Ramos. L., & Blair, B.A. (1991). The AIDS rapid anthropological assessment procedures: A too} for health education planning and evaluation. Health Education Quarterly, 18(1), 111-123.
  • Spradley, JP. (1980). Participant observation. New York: Holt, Rinehart Winaton.
  • Stewart, D.W., & Shamdasan, P.N. (1990J. Focus groups: theory and practice. Newbury Park, CA Sage.
  • Upvall, M.J. (1992). Nursing perceptions of collaboration with indigenous healers in Swaziland. International Journal of Nursing, 29(1), 27-36.
  • Vlassoff, C, & Tanner, M. (1992). The relevance of rapid assessment to health research and interventions. Health Policy and Planning, ?(1), 1-9.
  • Wolf, Z.R., (1988). Nurses' work: The sacred and the profane. Philadelphia: University of Pennsylvania Press.

10.3928/0148-4834-19980201-08

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