In this issue, McAllister and Rowe argue in their article that skillful teaching is essential to help students learn not only how to conduct qualitative research, but also how to be committed researchers. Citing several other authors, they state that being
. . .a qualitative researcher involves attributes such as compassion, passion, integrity, tolerance of ambiguity, willingness to play with ideas, knowledge and inquiry, committed to viewing the social world from the viewpoints of people being studied, valuing of detail and a willingness to inject something of themselves into the research process and hence into the outcomes.
McAllister and Rowe correctly indicate these are the very qualities we are trying to cultivate in our basic students, not only those pursuing advanced education. Are there lessons to be learned from the craft of teaching qualitative research that may be applied to teaching basic nursing practice? I think so.
I am currently immersed in leading curriculum reform for our undergraduate nursing program. In virtually every discussion among faculty we are confronted with questions such as:
* "What is essential nursing knowledge?"
* "What must be included in the curriculum, and what can be left out?"
* "How can we encourage 'deep learning1 when so much breadth is important?"
* "What is the role of clinical education in our curriculum?''
* "How do we build scientific advances in nursing into our curriculum?"
McAllister and Rowe's article reminds me of another important question in any curriculum effort, "How can we cultivate the compassionate and inquisitive nurse within each student?"
Faculty who teach principles of basic nursing practice often feel the pressure of covering all of the content - the vast array of knowledge about health and disease states and nursing processes and the cognitive, technical, and interpersonal skills necessary to apply scientific knowledge to practice. All important content, to be sure. But there are aspects of skilled nursing practice that can be obscured by reliance on this technical-rational model, aspects that parallel those of skillful qualitative research. Like McAllister and Rowe, I think it is important to plant the seeds for this kind of practice early and cultivate them throughout students' educational experiences.
Interpretive skills are at the heart of clinical interviews. Nursing students learn basic health history by collecting data about their clients' usual health patterns and practices, family health history, and history of the current illness. However, skillful nursing practice requires nurses to hear clients* stories - the personal, social, and cultural meanings of health and illness, clients' understanding of their symptoms and illnesses, their ways of coping, and their worries and hopes for the future. Clients' stories must be interpreted because the raw data seldom guide nursing responses. These interpretive skills develop through experience and willingness to authentically engage with clients and to be open to their stories. These are potential traits of novice students that can be coached by skillful clinical teachers.
Practical knowledge is knowledge gained from experience, the skillful know-how gained from engaged practice, reflection on practice, and noticing, attending to, and responding to nuances in each client situation. Through such practice, nurses gain skill in recognizing and responding to familiar patterns. Teaching strategies, such as those described by McAllister and Rowe, may help students notice qualitative distinctions and commonalities, see fine detail in particular situations, and link the commonalities among their clients.
Qualitative researchers enter the field with the goal of learning from the field (i.e., interviewing informants and observing and recording actions in everyday life) and then analyzing for common themes and shared meanings. Nursing students, with coaching from their teachers, enter the clinical field with the aim of applying theoretical constructs to practice. Although practice settings clearly create opportunities for application of theory, they also create opportunities for fleshing out theories with sights, smells, and sounds that escape theoretical description and for seeing patterns of client responses that have not yet been described theoretically. This is the stuff of practical knowledge, and skillful teachers can help plant the seeds for its growth by helping students approach the field like qualitative researchers.
Evidence-based practice has become the buzz phrase of early 21st century health care. As commonly represented, evidence is assumed to have a hierarchy of strength, from randomized clinical trial to expert opinion. Best practices are derived from the strongest available evidence. There has been little analysis of the place of qualitative research in the hierarchy of evidence, perhaps because qualitative research often is viewed as a precursor to the more rigorous and eventually applicable quantitative research. However, as McAllister and Rowe imply, the methods of qualitative research are useful in practice, and the findings are a form of evidence. If one considers practice to be only the instrumental application of scientifically based research to the solution of problems in practice, then it is difficult to see how qualitative research may provide any kind of evidence. However, when practice is viewed, in part, as an interpretive activity, then qualitative research as evidence is more meaningful. A good qualitative study provides insights into client and family experiences that otherwise may be unavailable to inexperienced clinicians. A good qualitative study sensitizes clinicians to possible concerns and worries of clients in particular situations and to possible ways of coping. It may help clinicians see what otherwise may go unnoticed.
So what are the lessons here? What can you take back to your curriculum reform teams? As we develop our curricula, let us not pack it so tightly with scientific content to be applied in clinical practice. Let us make space for students to approach the field as scientists who are open to new learning and ready to have their theories challenged by the evidence in practice. Let us make space for students to listen and interpret clients* stories, not simply walk through the steps of the routine nursing history. Let us create learning activities that promote active engagement and that plant the seeds for deep understanding of what it means to be nurses.