Qualitative and Quantitative Studies Within Mental Health Care


This essay will look at a critical review of research of one qualitative paper and one quantitative paper (Cohen 2002) says that qualitative research study can mean the analysis of open-ended questions where

respondents are asked to write on a survey. It also can refer to what is thought of as naturalistic research. Parahoo (1997) describes quantitative research as providing hard, objective facts that can be statistically analysed and interpreted. Those who support a quantitative approach point to the value of objective, systemic observations for nursing practice.
The main aim of research is to help us gain knowledge in the field we study, in this case nursing. As Cormack (2000), explains that ‘it is done through a process of systemic enquiry governed by scientific principle’. A definition of research was offered by Macleod and Clark (1989) cited in Cormack (2000) as ‘an attempt to increase the sum of what is known, usually referred to as “ a body of knowledge”, by the discovery of new facts or relationships through a process of systemic scientific enquiry, the research process.’
The articles will be critiqued separately, with each section of the Rees (2001) critiquing framework applied (see appendices 3).

For the purpose of this essay, I will explore the related literature on schizophrenia and the associated problems involved as an aspect in mental health. There will be a written reflection on the two articles to help support findings which relate to mental health issues.

The author used the Cardiff University database web site, such as the Calmative Index of Nursing and Allied Healthcare (CINAHL), British Medical Journal, and Ovid Medline in the university Library. The author was able to find two research articles relating to Schizophrenia. The first article is of Australian origin by Rene Geanellos (2005) entitled ‘Adversity as opportunity: Living with Schizophrenia and Developing a Resilient Self’.

Article two is Barker and Trenchard (2005) which is a quantitative article of British origin entitled, ‘Positive Practice and Psychosis Care and the Role of the Community Mental Health Nurse’.
Key words were used to help assist the author in the research process such as:
• psychosis
• schizophrenia
• qualitative
• quantitative
• research
• critiquing psychosis

ARTICLE ONE QUALITATIVE CRITQUE

Heading
Adversity as Opportunity: Living with Schizophrenia and Developing a Resilient Self.

Focus
Geanellos, firstly says that living with schizophrenia develops resilience (meaning how you as a person, your personality, your character), handles the disorder and adapts this unwanted disease.

Key words used are:
• Resilience
• Adaptation
• Adversity
• Schizophrenia
• Self
It also goes on to mention words such as:
• Hermeneutically
• Wisely
• Mindfully
• Recovery

Background
The author states that this study sought to understand people’s intersubjective experience of living with schizophrenia using Gadamerian Hermeneutics for guidance. The author also states that schizophrenia is a costly disorder, which is personal, social and vocational. The costs result from disabling symptoms, medication side effects, inadequate treatment, factors relating to mental health clinicians/services.

To rationalize the research, the author considers three points. Firstly, most research on schizophrenia is biomedical, seeking to explicate cause and effect and most treatment is pharmacological, which is seeking to remedy cause and effect. Secondly, a biomedical focus marginalizes issues like poverty, unemployment, housing and health and results in a dominant bio-medical view of schizophrenia. Thirdly, research focuses on some aspects of the disorder instead of people’s experiences of it; therefore, the authors present study contribution is an attempt to bridge this gap.
It appears to this writer that the author (Geanellos) is trying to highlight that the bio medical and pharmacological model predominates with little or no psychological input. The bio-medical model stands accused of taking little or no account of a person’s strengths and resilience to overcome his or her condition.

This writer can now start to understand the reasons why the author has used Gadamerian Hermeneutics, which is to try and understand, feel, and explore these individual texts, as Phillips (2002) explains that ‘Gadermeriun Hermeneutics concentrates on expanding horizons of understanding through dialogue, between people or between researcher and text, in which taken for granted assumptions are examined and opinions willingly put at risk’.

A definition of hermeneutics is explained by Oxford dictionary (1988) ‘as the interpretation of scripture’. Gadermerian Hermeneutics is the brainchild of philosopher Hans- Georg Gadamer’s personal theory of interpretation. Gadamer saw the work of hermeneutics not as ‘developing a procedure of understanding, but to clarify further the conditions in which understanding itself takes place’ (Laverty 2006).

The author chose Gadamerian Hermeneutics as his choice of interpreting people’s lived experience. This helps give structure to the phenomenological meaning and to help categorise these people’s meanings of words.

Terms of Reference
The aim of the study is to understand people’s intersubjective experience of living with schizophrenia (the phenomena). The phenomenological research method is unlike most other research methods in that it has no scientific framework. It places sole credibility on a persons own lived experience and his or her own perceptions of events, emotions, outcomes etc. The person can be the only expert on him or herself.

Study Design
The author uses Gadamerian Hermeneutics to guide the study and the stories were hermeneutically interpreted, seeking to understand the individual meaning (single stories) and collective meaning (all the stories). This is his representation of the phenomenon. Wilson and Hutchinson (1991) cited in (Laverty 2003) hermeneutic phenomenology as being ‘concerned with the life, world or human experience as it is lived’. This would be classed as phenomenological.

This research uses the ability and willingness of people who suffer with schizophrenia to write their stories and have them published, and then reflect on the written experience. Therefore, this is the phenomenological, qualitative specific approach,

Tool of Data Collection
The author’s data was collected from The Schizophrenia Bulletin, between 1990 and 2003. They are published articles which consist of nineteen personal accounts, some of them were anonymous. There were also carers, family members, and health professionals published. The author’s tool of collecting data was to understand each story told and its individual meaning, and then read all the stories to give a collective meaning. There appears to be no factual evidence to suggest that these published articles are convincing enough to give any imaginable depth to the reader. The writer feels that these words could simply be from a book, which anyone could have written. This writer feels that this is a main weakness of trying to research using an intersubjective approach, as trust is paramount from the client and clinician if this particular study is going to work. Also another area to consider is that the articles are from numerous resources, which accumulates to the potential of being past through a numerous amounts of hands before they were published. It has the potential to be diluted. Even so, the beauty of this type of research is it would allow the individual researcher to investigate what ever was written resulting in an individual outcome. As Geanellos says, ‘Because of interpreter misunderstandings and the plurality of language, however, my understanding and representation of the phenomenon is one of many.’

However, Rees says that, ‘to contribute to the credibility in the data collected, areas such as the environment, the period of time and any other details that allows us to visualize the conduct of data are helpful and often necessary’ (Rees 2001).’

The author has used a bracketing type system in order to clarify his role in the process of meaning and give a constructed approach. Bracketing is a mathematical metaphor that involves putting ones attitude to the world in brackets in order to place it temporarily out of the question, which helps the reader / researcher assistants to arrive at a more adequate knowledge of reality (Spinelli 1992).

The research article takes Meta themes of the client’s experiences to explore the development of resilience.

For example:
• The façade of normalcy: desperately trying to appear normal.
• Considerable anguish: the pain of suffering and enduring alone.

The researcher has classed these under the theme one of fragmentation.
This may be contrary to the correct usage of phenomenology in research, because the basis of this philosophy is about a better understanding of individual experience and not group perceptions. Although it is worth noting, that the author in describing his methodology does state his ‘representation of the phenomena’s are one of many’. In other words it’s the individual’s perceptual understanding of context.

Ethical Consideration
What the writer appears to have noticed is the lack of ethical consideration towards the use of people’s names and their words, with no written evidence of permission from them. It also doesn’t mention at what stage of illness or recovery they are in, as the writer feels this would alter the interpretation of people’s expression of words. Even though this study was conducted in Australia and not in the UK, the writer would assume that similar confidentiality rights would apply.

Sample
The researcher used nineteen people’s stories randomly from The Schizophrenia Bulletin. It is a journal, which publishes first person accounts of people’s experiences of mental illness. At first reading, the subjects appeared to have the required background, i.e. all have schizophrenia and describe their experiences and living with it. As already discussed, it is then difficult to see that the subjects aren’t biased, as the author states at the outset, it is a subjective study and that the author is interpreting their stories in script (hermeneutics).

The author or the writer has no knowledge of who they are, or their characteristics. This vague information on such a diverse group, may then limit the research being utilised in practice, i.e. its fittingness to be applied elsewhere Rees (2001). However, this could be a good thing, as it helps eliminate a biased or prejudiced approach.

Data Presentation
The data presented were split up into eighteen sub-themes and these are categorised into four themes.
• Theme 1 Fragmentation
• Theme 2 Disintegration
• Table 3 Reintegration
• Table 4 Reconstruction

The sub themes cover the interpretation of words used by the people’s letters that have been published. The researcher has then broken down the meaning of each sentence and has then categorised them into a Meta theme which incorporates all the themes and is named – Adversity as Opportunity, Living with Schizophrenia and Developing a Resilient Self.

In each story told, the person is explaining what it is like to live with schizophrenia in his or her own words. The researcher has then subjectively categorised these words into what they perceive the person is saying. This reader finds the dialogue and description heavy with terminology and definitions, which lead’s the reader to look for background definition and detail of terminology. Accuracy of data presented may be flawed as it is based on a previous article and a diverse group of subjects whose stories were told subjectively.

However, we don’t necessarily consider this a problem in phenomenology. One individual’s account of an event or an illness for the phenomenologist. It is not about masses of data, that’s quantitative. So what is true for qualitative research is as important as many people’s accounts need not necessarily be true for the phenomenological approach because it focuses on the individual.

Main Findings
The core effect of the main findings is the level of resilience, as Geanellos divides the sufferer’s resilience into high and low. Resilience as explained, (Oxford dictionary 1984) as ‘readily recovering from something like depression’.

Have they got used to their difficulties and just live with them and not cope? Or have they become more resilient through developing self found skills and abilities that provide coping strategies? The Meta theme does not illustrate this.
We all might have to live with a disability, but it is our own personal resilience to cope is the core fundamental issue.

The Meta theme incorporates all the themes and is named – Adversity as opportunity: Living with Schizophrenia and Developing a Resilient Self. This appears to cover the entire data finding. The author uses Gadamerian Hermeneutics to interpret the main findings; the writer finds it a complex methodological way to interpret data. There appears to be no evidence of any content check by the people who wrote the stories, which decreases validity in the way this study was conducted. As Rees (2001) asks in his critiquing model, were their findings checked by the respondents (members check) or examined by other experts in the field? This writer asks experts in the field of what?
Can someone be an expert in how someone else feels?

There appears to be no evidence check, only the author’s interpretation. The writer feels that it is biased towards the author’s interpretation and not the participants. So, therefore its claim to be phenomenological in its approach must be treated with caution, because if the focus is the researchers and not the subjects (meaning the client’s), then it has broken a cardinal rule in phenomenology.

Conclusion
Sub themes are focused on these words, which are integral to the author’s research methodology, i.e. Meta themes, 19 persons with schizophrenia and their individual stories. In conclusion, this reader is unconvinced that the article clearly identifies the development of resilience to their illness simply by utilising collected patient experience and stories. Then uses Meta themes to highlight this increased ability to live with schizophrenia. This clearly does not pin point the development of resilience. There is no explanation of the achieved resilience by the author in the context of the article, i.e. the patient’s stories.

Geanellos in his conclusion identifies resilience as ‘the ability to mediate adaptation, indeed this resilience is mindfulness, prudent and purposeful action built on foundations of tenacity and courage’. He further goes on to state that ‘they have the capacity to withstand the unexpected and to prosper despite adversity’.

To finalise the conclusion, this different and non-scientific research methodology, uncertain evidence of developing resilience, do not ultimately illustrate that the story tellers have gained these laudable abilities and determinations that enhance their life and capacity to live with schizophrenia.

Readability
One is tempted to make assumptions about the readability of this article. Its fluency is affected by the complex use of terminology. However, this writer takes into account that complex terminology is unavoidable, but certain areas could be made simpler for the more common lay person, such as this writer.
The reader could be distracted by continued movement between reading story excerpts and then examining research to better understand the article. Minimal background knowledge of the storytellers means we have no knowledge of their circumstances, i.e. elderly, young, acutely ill, chronically ill, religious or ethnic backgrounds; hence, there are no parameters in which to assess their stories, against the research themes and the evidence in practice. One could even query if evidence practice occurred, i.e. the stories do not indicate that there is any input from professional mental health workers (Mental Health Community Nurses) CMHN‘s, or even semi voluntary support. However, one or two stories mention relative care input.

There also seems to be no time line of events. This makes it difficult, particularly to read the main findings. Do the storytellers relapse quickly? And gain resilience quickly? Or do they spend years chronically ill? As in losing years. As one subject describe as losing track of time by not gaining enough insight or resilience. This back and forth within the article occurs when describing patients stories where one moment the author describes an individuals experience or conditions and in the next sentence makes global statements on schizophrenia such as:
‘Schizophrenia alters life and self in such all encompassing and fundamental ways that it shatters preciously held understandings’ (Geanellos 2005).
And yet, this writer feels Geanellos is showing that who ever reads peoples understanding in text, can take their own view on that interpretation. This writer concludes that there appears to be no right or wrong as many different views can be taken on what someone is trying to communicate.

Relevance to Practice
This qualitative study, with all its flaws gives this writer clearer insight. There appears to be no clear, straight forward answers to the understanding of others, as individual’s interpretation appears to not allow it. This qualitative paper could not be any further from a quantitative paper, as there are no statistical figures with clear percentages to follow. The author used a Meta theme to categorise the text, which gives some structure to the paper for the reader to follow, but no graphs or any other structured models used. Phenomenology is concerned with life world experience and not statistical figures with only logical explanations to hand. This article has tried to illuminate details in the account of others which may seem in the lives of ordinary people (Laverty 2003).
However, I feel that it does humanise the experience of schizophrenia for the lay reader and helps to provide both the reader of this research and the subjects themselves with a greater understanding of this tragic condition in a way that quantitative research may not.

ARTICLE TWO
QUANTITATIVE CRITIQUE

Heading
’Positive Practice in Psychosis Care’.
Barker D. Trenchard S (2005).

Focus
The focus of this quantitative paper is the study of how Community Mental Health Nurse’s (CMHNs) become aware of their role within the Community Mental Health Team’s (CMHTs), and how community teams fit into mental health team care delivery.
Key words of focus are:
• Caseload composition,
• Clinical interventions,
• Staff attitudes,
• Preparation and supervision.

Background
The author has justified his research on the introduction of the National Service Framework (NSF 2002) for Mental Health, with further backing by the (NICE guidelines 2002) explaining how these guidelines develop further by good underpinned practice guidelines (NICE 2002). Its focus is to examine their knowledge of CMHN’s within CMHT’s and see if they are capable of using old and newly developed knowledge, while changing with the times.
Compared to the qualitative paper in appendix one, this paper has given clear and direct instructions to the reader in the area of research the author has taken. It is also explained in simple language that the novice can understand. Perhaps if the qualitative paper had taken a similar approach, it may have been easier to understand.

Terms of Reference
Two key words were used i.e., ‘explore and describe’.
The purpose of this research is to explore CMHN’s knowledge of working with people who suffer with schizophrenia. To explore attitudes towards change and policy proposals. Also to describe CMHN’s clinical practice and confidences skills. The role of the community mental team members can be defined and understood within the changing needs of the service user and the resultant service provision required.

Study Design
The author used a quantitative study approach using a self – completion questionnaire, the author states that it ‘would allow for collection of large volumes of information in a systemic and standard way.’ The researchers also say that questionnaires promote honest answers, but this writer argues that completed questionnaires are only as honest as the person who completes it. Trust issues appear to be just as important in this quantitative paper as the qualitative paper, which prove to be a common denominator in both papers.

Some of the areas covered to help establish a structured report was to describe the function of their team. To identify the personal attributes CMHN’s considered important with diagnosis of schizophrenia. In addition, the article identifies the consolidation and ongoing development of specific theme of knowledge and skill, engagement and relationship building communication skills, and attitudes of nurse’s towards approaches to specific patients with psychosis. The utilisation of current and recent evidence based intervention are highlighted to underpin these interventions.

Date Collection Method
Thoroughness appears in this area, as the researchers used this quantitative article as the pilot study ‘to identify any potential weaknesses that may be replicated at a later date’ (Trenchard and Barker 2005).
Face value was also checked prior to distributing the questionnaires, by a small number of applicants for face and construct validity. However, the author’s have failed to explain the meaning of face and construct validity, i.e. face of what?
Also the researchers don’t mention who has checked it (other nurses, the public etc) and what was the outcome from their point of view? Even though this writer feels that this paper appears to be ahead in its rigour compared to the previous qualitative paper. Yet it would appear ahead when any paper is guided with figures (quantitative method) to a paper that is dealing with single figures (qualitative method). So the question this writer asks, is it really a better paper? As numbers don’t count to the phenomenologist, it’s the personal experiences that count.

Ethical Consideration
The essay appears to retain objectivity towards their team and honesty towards the whole research study. Results were specific in their use, but as previously mentioned, the whole research paper does rely on the honesty of the questionnaires returned. Is this a major flaw in the whole of the paper? Apparently not, as Barker (1996) cited in (Barker and Trenchard 2005) suggest that when exploring sensitive topics, questionnaires are most appropriate, sparing embarrassment and promoting honest responses.

Sample
The inclusion and exclusion reflects the aim to develop a sample, which consists of 71 identified CMHN’s who work with people diagnosed with schizophrenia, with ages between 16 and 65 years.
Of the 71 questionnaires distributed 48% responded, indicating this was a sufficient number of applicants to carry on with the research, but this writer feels that the percentage 48% - 35 questionnaires is quite small to provide definitive results. However, the author acknowledges this is a small scale study ‘that offers a snapshot of CMHN practice’ though is supported by earlier and subsequent studies. The writer feels the validity is sufficient for this article content.
So, at least, in terms of numbers it would appear that the quantitative research is more valid. However, one might be able to argue that this paper is more researchers centred. The researcher sets the questions. At least in the first paper the sufferers were writing their own accounts rather than just responding to questions by researchers and it is always possible that the questionnaire is pursuing an agenda set by the researchers, or even following an agenda that he or she may not be conscious of.

Data Presentation
The data presented is in basic layout using numbers and percentages in text. It clearly discusses the analysis and then uses a concise graph chart, pie chart and rating scales to clarify its findings. There is a clear explanation of the results obtained, enabling easy understanding of the paper and easy to read unlike the qualitative paper. The writer feels that if Geanellos had taken a simpler approach to writing, it may have made more sense to the reader.

Main Findings
The researchers main findings are that most of the CMHN’s (54.5%) have no specific training at all in the management of schizophrenia. However 45.5% are receiving additional supervision in additional skills, i.e.
• Psychosocial Intervention (PSI)
• Cognitive Behavioural Therapy (CBT)
• Family Intervention (FI)
• Creative Therapy (CT)
One of the main findings in this research paper is that 97.1% agreed on further training, as a necessity to provide successful service. 95% preferred smaller case loads which appear to be one of the main subjects in providing a quality care to those with schizophrenia and the expectations for recovery – focused interventions.

Conclusion
Even though the author’s say that it is a small scale study, the findings offer a snap shot of current CMHN practice in psychosis care. The author’s mention many of the findings support earlier and subsequent studies into the dissemination of evidence based practice. They conclude that 75% felt that they could not meet all the needs of clients. Nearly all 97% agreed to further requirements to provide more effective service.
They recognise recovery approaches are becoming identified but recommend that recovery is underpinned by good practice and to deter it from being the buzz word as it is not fully supported because the systems are under developed.

Readability
This article is straight forward to read. It has displayed its text clearly and with understandable graphs. It describes complex issues of services development, the needs of CMHN’s and services in a clear and understood format. However, it does appear to lack any sort of insight into the way the nurses themselves feel, as qualitative tries to give an understanding in trying to be that person almost, even though the method might be some what complex.

Practice Implications
The study offered insight into the lack of training for CMHN’s. It also goes on to report the lack of unified assessment tools used throughout this CMHT.
This writer feels the article is relevant to nursing and highlights how important training and evidence based practice are. However quite a big percentage felt confident without suitable training in the field of schizophrenia. The article does not definitely state the reason why CMHN’s felt so confident without suitable training.

Why CMHN,s feel so confident in their abilities despite any supporting evidence remains a mystery and the authors do not address this important issue. Perhaps a quantitative approach is not suitable to address it anyway. Quantitative research has uncovered an interesting phenomenon that could be followed through with the phenomenological approach and thus yield very valuable information which may help training practice and ultimately patients themselves. A phenomenological approach might yield important information in exploring the feelings of skilled adequacy despite there being little evidence for holding such views of competency. One could say there is room for both here.

REFLECTION
The qualitative article is a confusing article of mixed patients stories and unclear research findings that do not progress to a clear or even easily understood conclusion. The pre-conclusion discussion consolidates this information with its description of ‘a resilience continuum’ and the schizophrenia self. However, the quantitative paper clearly and simply sets purpose and study context. It progresses informatively, presenting results in easily understood graphs and charts, underpinning discussion topics within the article with reasonable argument and evidence based information. The author’s recommendations are realistic and reflect both the needs of the clients and the service.

REFERRENCES

Barker, D.Trenchard, S. (2005) Positive Practice and Psychosis care. Mental Health Nursing, l (24), 4-8.

Cormack, D. (2000) The Research Process in Nursing, Black Well Science.

Geanello, R. (2005) Adversity as opportunity : Living with schizophrenia and developing a resilient self. International Journal of Mental Health Nursing, 14, 7-15.

Laverty, S. M. (2006) The University of Calgary, Calgary, AB. Hermeneutic Phenomenology and Phenomenology: A comparison of Historical and Methodological Consideration.
HYPERLINK "http://www.ualberta.ca/~iiqm/backissues/2_3final/htmal/laverty.htmal" http://www.ualberta.ca/~iiqm/backissues/2_3final/htmal/laverty.htmal . 16/09/2006

LoBiondo-Wood, et al. (2002) Nursing Research Methods, Critical Appraisal and Utilization. 5th Edition. Mosby Publishing’s.

Macleod Clark, J and Hockey, L. (1989) Cited in Cormack, D. (2000). The Research Process in Nursing, 4th Edition. Black Well Science.

Nursing and Midwifery Council (2002) Code of Professional Conduct. 8 6.1

Parahoo, K. (1997) Nursing Research. Principles, Process and Issues. Palgrave Macmillan publishing.

The National; Service Framework (DOH 1999), as cited in Article 540. Stevenson, C, Fletcher, E (2002) The Tidal Model: the questions answered. Mental Health Practice. 5, 8, 29-38 The Oxford Dictionary, (1984). Oxford University Press.

Rees, C. (2001). An Introduction to Research for Midwives. Chapter 4, page 44.

Spinelli, E. (1992). The Interpreted World: An Introduction to Phenomenological Psychology. London, Sage Publishing.

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