This paper examines the growing shift toward qualitative research methodologies in nursing, with a specific focus on their application to diabetes management among elderly patients. It contrasts qualitative and quantitative approaches philosophically and practically, arguing that the holistic, subjective nature of qualitative inquiry is particularly well-suited to understanding the complex self-management challenges faced by older adults with diabetes. Through examples drawn from published studies, the paper demonstrates how in-depth interviews, case study methods, and ethnographic approaches can uncover patient knowledge gaps, dietary management difficulties, and systemic biases such as ageism that quantitative methods alone cannot adequately address.
There has been a notable shift in research methodology preferences in nursing toward a more qualitative rather than quantitative approach. While the professional nurse has always been involved in the application of quantitative research designs and methods, there are indications that the nature of the profession has changed and become more independent, sophisticated, and holistically inclined. The emphasis on a more integrative and holistic trajectory in nursing is not unusual. The ideal of an intimate, holistic, and inclusive caring attitude — which is aligned with qualitative methodologies — has always been a central concern around which nursing was established as a profession.
While quantitative methods and views are certainly accepted and used by nursing professionals, there has been a growing realization that a more open-ended and expansive qualitative approach in research and practice offers a number of positive advantages in the nursing context. Qualitative approaches also carry particular advantages within the contemporary medical and nursing environment. This paper attempts to show, through examples, how qualitative methods can be effective in nursing situations and in research. The focus is on qualitative approaches to diabetes management in older people.
A common definition of qualitative research is "…any kind of research that produces findings not arrived at by means of statistical procedures or other means of quantification" (Strauss and Corbin, 1990, p. 17). A working definition of quantitative research, by contrast, describes it as research aimed at "…determining the relationship between one thing (an independent variable) and another (a dependent or outcome variable) in a population" (Hopkins).
The difference between qualitative and quantitative research methodologies implies, in the first instance, an understanding of the philosophical traditions that support these methods (Hussey and Hussey, 1997). The choice of a particular research design is determined by the research theories, presuppositions, and the relevance of the methodology to the issue at stake.
As will be discussed, external and self-management in the case of elderly patients with diabetes is an issue that requires insight into subjective as well as objective aspects. In other words, the nurse must be aware not only of clinical data but also of aspects such as whether the patient has acquired the necessary knowledge and understanding of the disease to manage his or her situation adequately. This implies that a qualitative and more subjective approach is, in certain situations, a more effective method of understanding problems and implementing interventions than quantitative research alone can provide.
Stated simply, a philosophical stance that favors objectivism and scientific verifiability would tend toward quantitative methodology, while constructivist and subjectivist researchers would choose qualitative methods. Vincent Pouliot (2007) has argued that the objectivist, or "experience-distant," form of knowledge should be supported by subjective, "experience-near" knowledge (Pouliot, 2007, p. 359). This suggests the particular value of qualitative research in a field such as nursing, where inter-subjective contact is a priority.
Common examples of qualitative methods include action research, case study research, and ethnography. In general, data and insight are obtained through more open-ended techniques, in contrast to the statistical and measurable data that characterize quantitative methods. Qualitative methods include interviews and questionnaires, analysis of documents and texts, as well as the researcher's own impressions and reactions (Haugh and McKee, 2007, p. 377). In general, the qualitative researcher attempts to understand a situation from a holistic and contextual point of view.
Studies indicate that there is a high rate of diabetes among the elderly in the United States. As one report states, "The prevalence of type 2 diabetes, which represents roughly 90% of all diabetes, increases with age and affects 18–20% of people over age 65 in the United States (with a substantial percentage of these cases being undiagnosed)" (Wallace). Furthermore, it has been shown that people with diabetes who have elevated blood sugar develop senescence-associated disorders at an earlier stage than the general population. This fact suggests that nursing and healthcare organizations should focus research and management efforts on this disease among older patients, and that self-management interventions should be priorities in nursing care.
It is significant that many studies indicate a definite paucity of research in diabetes management — especially with regard to older people (Abbott and Gunnell, 2004). While quantitative research is effective in many respects for the clinical measurement of aspects of this disease, it fails to address the more complex issue of management difficulties and the way that elderly patients perceive and understand the necessary processes of management responsibility.
A key research question in this context is: to what extent are elderly patients aware of self-management techniques, and to what extent are they cognizant of the responsibilities associated with managing this disease? This also involves a related factor with bearing on the treatment of the elderly: the aspect of cognitive functioning and possible impairment, and how this relates to management issues.
A qualitative methodological approach has been shown in a number of studies to be particularly effective for management interventions and understanding — especially through the use of in-depth, open-ended interviewing techniques. This methodology has been shown to be more effective than quantitative methods for investigating these issues, as it allows patients to explore their own personal situations and to respond in more open and subjective ways that cannot be achieved through quantitative methodologies or the synthesis of hard data.
An example of this methodology in practice is a study entitled "Older People's Experiences of Diabetes Care" by Stephen Abbott and Caroline Gunnell (2004). This exploratory study used a structured interview format aimed at establishing key themes. The central problem being investigated was that "One of the biggest challenges for health care providers today is how to address the continued needs and demands of individuals with chronic illnesses like diabetes" (Abbott and Gunnell, 2004). The intention of the study was to ascertain to what extent patients had the necessary skills to effectively manage their diabetes.
The results indicate that in most cases, "…respondents did not generally report finding self-care difficult, as the requisite procedures were easily explained, whether this had been done orally by healthcare staff or in written form" (Abbott and Gunnell, 2004). However, a central area of concern was the management of dietary issues, which are critically significant for these patients:
"Almost all respondents said that they should avoid sugar, and some said that they should avoid fat or oil. Most reported that they had seen a dietitian at some point, often when first diagnosed, but some were uncertain about what to do" (Abbott and Gunnell, 2004).
The qualitative methods employed in this case were thus useful in isolating specific areas of concern in the management of the disease — information that nurses can use in developing management protocols for these patients.
Another study using the interview technique examined self-monitoring of blood glucose in patients with type 2 diabetes. The study, "Self-Care Coping Strategies in People with Diabetes: A Qualitative Exploratory Study" (Collins et al., 2009), found that the "…role of the health professional is crucial to patient understanding of their blood glucose fluctuations and whether or not the patient responds to a high blood glucose reading with an appropriate self-care action." This study made use of in-depth interviews that were tape-recorded and transcribed. It found that perceptions of self-care varied considerably among those interviewed, leading the authors to describe three types of patients according to their level of management knowledge — a finding that provided a framework for more effective management and nursing intervention.
Qualitative in-depth interviews have been successfully implemented in many other diabetic studies and have shown positive results in improving patient care and management. It is therefore clear that in situations where self-help and care are problematic, the interview as a qualitative technique is capable of revealing issues that may not have been evident through a more quantitative methodology.
While the interview is an effective qualitative technique, a more in-depth approach is the case study. A case study is generally defined as a form of empirical inquiry that "…investigates a contemporary phenomenon within its real-life context, especially when…the boundaries between phenomenon and context are not clearly evident" (Myers, M.D.).
"Case studies uncover complex management variables"
"Ethnography exposes ageism in diabetic patient care"
The above discussion demonstrates the value of various qualitative methodologies in the nursing profession and in relation to understanding and addressing diabetic management issues among the elderly. What is also evident is that certain qualitative methods are more appropriate in certain situations. For instance, the choice between an in-depth interview and a case study would depend on the specific aims and intentions of the research. It should also be noted that in many cases researchers find that a combination of qualitative and quantitative research methodologies can be extremely effective in understanding and addressing healthcare issues — each approach complementing the other's limitations.
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